ChanBeDu/relevant_section_length · Datasets at Hugging Face

72,526

146,284

42416

Discharge summary

report

Admission Date: [**2191-2-8**] Discharge Date: [**2191-2-10**] Date of Birth: [**2117-5-10**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 613**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: (per son) 73 yo F with history of seizure disorder and bipolar disorder who had viral syndrome 2 weeks ago, possibly stopped taking POs and stopped her pills (seizure meds), who has been increasingly confused and altered x 2 days. 2 days ago, son noticed her mother was acting different on the phone, confused, but still able to hold a conversation. Today, VNA evaluated pt, noted her to be markedly more confused, told her to see her PCP. [**Name10 (NameIs) **] PCP office pt was seen to be more confused (usually high functioning, does her own bills), she was AO to person, place and knew the president. SHe reported increased urinary frequency, admitted to not taking her medicatiosn recently. She notes that she is drinking a lot of iced tea. AMS work up at [**Location (un) 2274**] with negative rectal exam, negative CXR, Na of 128, bicarb 20, K 3.3, Cl 99, Cr 1.7, ALT 15, and WBC 14, Hb 11, HCT 34, PLY 260. Pt was sent to the ED for workup. . In the ED inital vitals were, 98.5 72 189/88 20 99% In [**Name (NI) **], pt was more confused, muttering non sensical words, oriented to person only. During evaluation, she had fine tremor tonic movements and what appeared to be a seizure (triggered), so was given ativan 2mg IV. Labs notable for Na 119->121 (Na 128->119 in 4 hrs->121)., K 3.1, Cl 85, HCO3 13, AG 17->23, BUN 37, Cr 1.3, trop 0.01. Ca 8.2, Mg 1.5, P 3.1, Serum OSM 252. WBC 15, HCT 32, PLT 299, MCV 80. Urine lytes: Urea 249, Cr 17, Na 24, K 9, Cl 28, Osm 176. SG 1003, pH 5. Appeared euvolemic on exam. Given 40 KCL PO, lorazepam 2mg IV x1. GIven 1.5 L NS. CXR unremarkable. Admit to MICU for seizure activity, hyponatremia, hypertonic saline. CT head was unremarkable. Vitals: HR 76, 100% face-mask, 135/68, 76 hr, 98% RA . On arrival to the ICU, pt is somnolent but arrousable, has a fine tremor that loooks like a seizure but pt can awake and converse while shaking. Comfortable, will not answer where she is and states she wants to sleep. SOn says she had similar episode just like this 1 year ago when she was found to have a UTI, then admitted to [**Hospital 1191**] hospital for 30 days. Past Medical History: Bipolar disorder chronic kidney disease hypertension hyperlipidemia memory disorder Seizure disorder: follows Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 69344**], epilepsy, seizures since age 64, cplex partial. Initialy on lamictal 300mg [**Hospital1 **], zonadran 100 [**Hospital1 **], prozac 60. In [**2188**]: saw Dr [**First Name (STitle) **] from neuro at [**Hospital1 112**] and then Dr [**First Name4 (NamePattern1) 16284**] [**Last Name (NamePattern1) **] and had EEG and mRI. Social History: non smoker (smoked when young), occ social ETOH, lives alone, not working, 2 children Family History: no FH of seizure disorder, "healthy family: per son Physical Exam: Admission PE: Vitals:T 97, BP 147/73, HR 75, RR 21, 97%RA General: somnolent, arrousable, oriented to self, tremor HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, 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 Pertinent Results: Pertinent Admission Labs: [**2191-2-8**] 04:05PM BLOOD WBC-15.1* RBC-4.04* Hgb-11.1* Hct-32.4* MCV-80* MCH-27.5 MCHC-34.2 RDW-13.2 Plt Ct-299 [**2191-2-8**] 04:05PM BLOOD Neuts-77.9* Lymphs-13.9* Monos-6.7 Eos-0.9 Baso-0.5 [**2191-2-8**] 04:05PM BLOOD PT-10.3 PTT-26.7 INR(PT)-0.9 [**2191-2-8**] 04:05PM BLOOD Glucose-113* UreaN-38* Creat-1.3* Na-119* K-3.2* Cl-84* HCO3-18* AnGap-20 [**2191-2-8**] 05:30PM BLOOD Glucose-136* UreaN-37* Creat-1.3* Na-121* K-3.1* Cl-85* HCO3-13* AnGap-26* [**2191-2-8**] 11:14PM BLOOD Glucose-91 UreaN-30* Creat-1.0 Na-128* K-3.7 Cl-99 HCO3-19* AnGap-14 [**2191-2-9**] 04:26AM BLOOD Glucose-88 UreaN-26* Creat-1.1 Na-136 K-4.1 Cl-105 HCO3-19* AnGap-16 [**2191-2-9**] 08:52AM BLOOD Glucose-94 UreaN-24* Creat-1.1 Na-136 K-4.2 Cl-107 HCO3-21* AnGap-12 [**2191-2-9**] 11:58AM BLOOD Glucose-149* UreaN-22* Creat-1.1 Na-139 K-3.8 Cl-108 HCO3-21* AnGap-14 [**2191-2-8**] 04:05PM BLOOD Calcium-8.2* Phos-3.1 Mg-1.5* [**2191-2-9**] 08:52AM BLOOD Calcium-8.6 Phos-4.1 Mg-3.2* [**2191-2-8**] 04:05PM BLOOD cTropnT-<0.01 [**2191-2-8**] 04:05PM BLOOD Osmolal-252* [**2191-2-8**] 11:14PM BLOOD Osmolal-267* [**2191-2-8**] 11:14PM BLOOD Prolact-27* TSH-0.83 [**2191-2-9**] 04:26AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2191-2-8**] 05:55PM BLOOD Na-121* K-2.9* [**2191-2-8**] 07:54PM BLOOD Na-120* K-3.6 calHCO3-18* MICRO: Blood cultures: pending Urine cultures: pending IMAGING: CT Head non-con ([**2-8**]): IMPRESSION: WET READ Severely limited evaluation due to motion artifact. No acute intracranial process. CXR ([**2-8**]): WET READ No acute cardiothoracic process. Brief Hospital Course: 73 yo F with history of seizure disorder and bipolar disorder who presents with altered mental status, hyponatremia, ?seizure activity, in setting of not taking medications and increased tea consumption, patient was admitted to the ICU and was stabilized. . ?Seizure/Seizure disorder: Unknown if pt had recent seizure activity. On the ICU floor, pt has a fine intermittent tremor that stops upon arrousing patient, making this unlikely a seizure. That being said, pt is altered and looked post-ictal on admission, but improved significantly (near baseline) by the morning. Etiology for seizure in this pt includes not taking her seizure meds/hyponatremia. Withdrawel from benzos (takes ativan 0.5mg [**Hospital1 **] usually and has not been taking her meds recently) also possible in pt with tremor and ?seizure activity. CT head unremarkable.Initially patient was not awake enough to take her home zonisamide 200mg [**Hospital1 **] or ativan 0.5mg [**Hospital1 **]. gave ativan IV 0.25 BID standing for now until taking POs. No further seizure activity. . Hyponatremia: Pt was 128 earlier today at PCP [**Last Name (NamePattern4) **] 1pm. Na 119 at 4pm->121 at 6pm. Given 1.5 L NS in the ED. Appears euvolemic on exam. ADH mediated etiology is considered since serum Osm is 250, however, urine Osm is lower at 170, suggesting this is not ADH mediated, and perhaps more likely psychogenic polydipsia, esp in setting of recent large quantities of tea consumption and increased urination. UNa is in the 20s, suggesting that she is in a euvolemic state, as confirmed by physical exam. Also in the differential is beer potomania (although pt drinks socially, not frequently), hypothyroidism, ACE-I also known to cause hyponatremia, although not as commonly as other meds such as HCTZ. Na 121 right now and pt possibly has symptomtic hyponatremia possibly contributing to seizures/AMS, on 3% sodium drip at 40/hr. In the ICU, gave normal saline at 30-40cc/hr. Did serial Na in ICU, and hyponatremia resolved and stabilized at 136. Once she was transferred to the medical floor, Na remained stable and was 145 on the day of discharge. . Anion gap: AG 23. Unclear etiology, normal lactate, Cr at baseline, no ketones in urine, starvation ketosis is possible but pt appears euvolemic on exam and no ketones, ETOh ketoacidosis is considered but again no ketones in urine, would consider ethylene glycol, salicylate and methanol toxicity in pt with psych condition. checked Osm gap= -6 so unlikely methanol or ethylene glycol tox. Anion gap resolved. . Bipolar disorder: Takes olanzepine 2.5mg q 6hr PRN at home for bipolar. held while not able to take POs, restarted after POs given. When transferred to medical floor, she was appropriate, without evidence of mania or major depression. Memory appears impaired. . HTN: Amlodipine 2.5mg PO Daily, Lisinopril 40mg PO QAM . Medications on Admission: -olanzapine 2.5mg daily - Amlodipine 2.5mg PO Daily - Lisinopril 40mg PO QAM - Atorvastatin 40mg PO QHS - Gabapentin 300mg PO TID - Ativan 0.5m PO BID - Zonisamide 200mg PO BID Discharge Medications: 1. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. zonisamide 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for agitation. 7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times a day. Discharge Disposition: Home With Service Facility: Nizhoni Home Care Discharge Diagnosis: 1. hypovolemic hyponatremia with acute seizure 2. seizure disorder 3. viral syndrome 4. bipolar disorder 5. hypertension 6. hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the ICU with a low sodium level which led to a probable seizure. You reported flu-like symptoms prior to admission and may not have been taking your medications as directed. Your sodium was corrected and you had no further seizure activity. Your other medical conditions were stable. Followup Instructions: Name: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 91852**], MD Location: [**Location (un) 2274**] Post Office Square -Behavioral Health Address: [**Street Address(2) 642**], [**Location (un) **],[**Numeric Identifier 643**] Phone: [**Telephone/Fax (1) 90304**] Appt: Monday [**2-14**] at 1pm Name: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 62417**] (works with Dr [**Last Name (STitle) 3100**] Location: [**Location (un) 2274**] Post Office Square -Internal Medicine Address: [**Street Address(2) 642**], [**Location (un) **],[**Numeric Identifier 643**] Phone: [**Telephone/Fax (1) 644**] Appt: [**2-16**] at 11am [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2191-2-10**]

[ "276.1", "288.60", "296.80", "345.90", "585.3", "345.10", "276.2", "403.90", "V15.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9042, 9090

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324, 330

9273, 9273

3752, 3762

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3127, 3180

8503, 9019

9111, 9252

8301, 8480

9424, 9730

3195, 3733

263, 286

358, 2477

3779, 5385

9288, 9400

2499, 3008

3024, 3111

7,542

186,653

6421

Discharge summary

report

Admission Date: [**2155-3-2**] Discharge Date: [**2155-3-7**] Date of Birth: [**2079-7-31**] Sex: F Service: [**Hospital Unit Name 196**] HISTORY OF PRESENT ILLNESS: Patient is a 75-year-old woman with coronary artery disease status post coronary artery bypass graft in [**2149**], diabetes mellitus type 2, gout who presented with several hours of shortness of breath and epigastric/lower sternum discomfort which developed while the patient was sleeping. Denied any other associated symptoms. The discomfort was pressure like and improved with nitroglycerin spray. Patient has had no chest pain since then but continued subjective shortness of breath although satting well on room air. Denies edema. Also, patient with upper respiratory infection over the past few days. Also with right great toe pain identical to previous gout episodes. The patient is followed by numerous doctors [**First Name (Titles) **] [**Hospital6 1708**]. PAST MEDICAL HISTORY: 1. Diabetes mellitus type 2. 2. Coronary artery disease status post coronary artery bypass graft in [**2149**]. 3. Gout. 4. Chronic renal insufficiency. SOCIAL HISTORY: Previous tobacco smoker; quit 25 years ago. Lives alone, but her daughter lives in same building and attends to her care. Daughter is a nurse. ALLERGIES: No known drug allergies. HOME MEDICATIONS: 1. Atenolol 50 once a day. 2. Amlodipine 10 once a day. 3. Enalapril 10 once a day. 4. Zocor 5 once a day. 5. Nephrocaps one tab once a day. 6. Aspirin 325 once a day. 7. Calcium supplement. 8. Lasix 80 once a day. 9. Epogen q. Saturday. PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.0, heart rate 65, pressure 140/49, satting 99% on room air. Physical examination: Pleasant, elderly woman in no apparent distress. Heart with a soft systolic murmur. Lungs with bibasilar crackles approximately one-third of the way up. Remainder of physical examination within normal limits, however, notable for only trace pulses in the bilateral lower extremities as well as only trace edema in the bilateral lower extremities. DIAGNOSTIC DATA ON ADMISSION: Per the patient she had a treadmill exercise stress test with imaging in [**3-/2154**] which was reportedly normal. Echocardiogram done at [**Hospital6 1708**] [**2154-3-22**] with ejection fraction of 40 to 45%, akinesis in the distal anterior septum, mild to moderate mitral regurgitation, hypokinesis in inferior and posterior walls, hypokinesis in the inferior septum. CBC on admission: White blood count 15 with 80% neutrophils, 0 bands, hematocrit 34, platelets 270. Chemistries within normal limits except for BUN and creatinine of 62/2.2. Troponin of 0.39, CK of 84. Chest x-ray with bilateral pleural effusions and prominent pulmonary vasculature consistent with left ventricular heart failure. ECG with normal sinus rhythm at 65 beats per minute, normal intervals, [**Street Address(2) 4793**] elevations at III, 0.[**Street Address(2) 18425**] depressions in I and aVL, less than 0.[**Street Address(2) 1755**] depressions in V4 to 6 all unchanged from the previous ECG from [**Hospital6 **] dated 04/[**2153**]. CONCISE SUMMARY OF HOSPITAL COURSE: Patient is a 75-year-old woman with coronary artery disease status post coronary artery bypass graft as well as diabetes who presented with shortness of breath and lower chest/epigastric pain which resolved. 1. Coronary artery disease: Patient's ECG without significant changes. Patient's creatinine kinases flat and not consistent with current myocardial infarction. Patient's troponins likely elevated related to her renal insufficiency but may represent older myocardial ischemia from several days prior to admission. Patient was initially started on Heparin drip in the Emergency Room, but this was discontinued after approximately six hours as the patient was entirely symptom free and patient's enzymes were largely flat. Patient underwent Persantine MIBI stress test on [**2155-3-3**] which showed mild to moderate lateral reversible perfusion defect as well as moderate fixed anterior wall defect with an estimated ejection fraction of 42%. Based on this information and after weighing the pros and cons of possible renal effects of catheterization and after extensive discussions with the family and medical team, decision was made for patient to undergo catheterization, which she underwent on [**2155-3-5**], which showed 20% left main, 100% proximal left anterior descending, 80% left circumflex, 70% obtuse marginal 1, 100% mid right coronary artery, occluded saphenous vein graft to posterior descending artery graft, patent left internal mammary artery graft to left anterior descending graft. Patient's left circumflex lesion was thought to be the likely culprit for her symptoms and was status post angioplasty with good TIMI 3 flow afterwards. However, this area was not able to be stented due to the anatomy. Patient did not have any further episodes of chest pain throughout her hospital stay and tolerated procedure well. The patient was continued on aspirin as well as Lipitor throughout hospital stay. Patient was on Metoprolol initially which was held peripost catheterization due to hemodynamic reasons and then restarted and titrated up to, which the patient tolerated well. Patient was also started on Plavix, which she should probably be on for life. Patient to follow up with her outpatient cardiologist for further management. 2. Congestive heart failure/pump: Patient with significant shortness of breath and chest x-ray and clinical findings consistent with congestive heart failure at admission. Patient was diuresed gently on the floor. At Catheterization hemodynamics revealed an elevated right and left pressure including PA pressure of 60/25, mean wedge of 32, LVEDP of 35, and cardiac index of 2.2. Echocardiogram on [**2155-3-6**] showed an ejection fraction of 30 to 35% with 3+ mitral regurgitation and left ventricular hypertrophy. Patient continued low-sodium diet and weighed daily with close ins and outs. Patient's angiotensin-converting enzyme inhibitor was held and instead Hydralazine and Isordil were used for after load reduction. This was due to the patient's high creatinine, which was at her baseline, and pericath with the dye load. Due to the elevated filling pressures seen on catheterization, the patient had an intra-aortic balloon pump placed. Patient was also started on Dobutamine drip. Patient was admitted to the Coronary Care Unit overnight due to these interventions and she was stable throughout her Coronary Care Unit time. The intra-aortic balloon pump was removed and the patient was off of Dobutamine within 12 hours of those being started. Patient remained hemodynamically stable throughout this time. At the time of discharge the patient was satting very well on room air, as well as ambulating. Was restarted on her home Lasix dose of 80 once a day. Close outpatient follow up for this. 3. Rhythm: Patient in sinus rhythm obtained on telemetry throughout her hospital stay. 4. Diabetes: Patient maintained with regular insulin sliding scale throughout her hospital stay. 5. Renal: Patient's baseline creatinine in the low to mid 2 range per outpatient cardiologist. Patient also has an outpatient nephrologist who presumably has done some workup for the patient's renal insufficiency. Patient was given Mucomyst peri cardiac catheterization. Patient's SPEP and UPEP were also sent, and at the time of discharge the UPEP came back normal and SPEP was still pending. Plan outpatient follow up. 6. Anemia: Patient received one unit packed red blood cells on [**2155-3-6**] for a hematocrit of 27. Patient was asymptomatic at this time with no signs or symptoms of active bleed. Patient's hematocrit increased appropriately once stable throughout the end of her hospital stay. 7. Gout: Patient was initially placed on Colchicine for likely gouty flare in her right great toe. However, this was discontinued and patient was given three days of Prednisone 20 q.d. for this flare. Patient also given Percocet p.r.n. 8. Previous diarrhea/hematochezia: Patient did not have either of these in house. Patient's daughter reports that patient underwent virtual colonoscopy at [**Hospital6 **] just prior to presenting to [**Hospital6 2018**]. As the patient was entirely asymptomatic, planned outpatient follow up for this. 9. Fluid, electrolytes, nutrition: Patient begun on low salt diet with fluid restriction. 10. Prophylaxis: Patient begun on subcutaneous Heparin and proton pump inhibitor throughout hospital stay. 11. Code status: Patient is a Full Code, which was confirmed with the patient as well as her family at admission. DISCHARGE CONDITION: Stable. DISPOSITION: To home with physical therapy visiting. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post angioplasty to the left circumflex coronary artery. 2. Congestive heart failure. 3. Diabetes mellitus. 4. Chronic renal insufficiency. 5. Gout. MEDICATIONS ON DISCHARGE: 1. Nephrocaps one once a day. 2. Aspirin 325 once a day. 3. Plavix 75 once a day. 4. Trazodone 25 mg q. h.s. p.r.n. 5. Lipitor 80 once a day. 6. Toprol XL 75 mg once a day. 7. Famvir 60 once a day. 8. Hydralazine 20 q. 6 hours. 9. Lasix 80 once a day. DISCHARGE INSTRUCTIONS: 1. Patient to follow up with her outpatient primary care physician. 2. Patient to follow up with cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 24731**]). 3. Patient to follow up with Dr. [**First Name4 (NamePattern1) 8369**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 20035**]). Patient to call to make her own appointments, however, was instructed to see her doctors within one to two weeks. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) **] Dictated By:[**Name8 (MD) 6906**] MEDQUIST36 D: [**2155-3-7**] 16:18 T: [**2155-3-9**] 09:09 JOB#: [**Job Number 24732**]

[ "401.9", "414.02", "428.0", "274.9", "414.01", "593.9", "285.9", "250.00" ]

icd9cm

[ [ [] ] ]

[ "36.01", "37.61", "88.56", "37.64", "99.20", "37.23" ]

icd9pcs

[ [ [] ] ]

8773, 8837

8858, 9047

9073, 9335

9359, 10051

1357, 1626

3188, 8751

184, 959

2514, 3159

981, 1139

1156, 1339

45,985

163,987

18994

Discharge summary

report

Admission Date: [**2145-1-27**] Discharge Date: [**2145-1-31**] Date of Birth: [**2077-10-26**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Exertional angina Major Surgical or Invasive Procedure: [**2145-1-27**] Aortic Valve Replacement(23mm Pericardial Valve) and Three Vessel Coronary Artery Bypass Grafting(left internal mammary artery to left anterior descending, with vein grafts to diagonal and obtuse marginal. History of Present Illness: Mr. [**Known lastname 51902**] is a 67 year old male with known severe aortic stenosis. He recently underwent cardiac catheterization for increasing exertional dyspnea and chest heaviness. Angiography was notable for an 80% ostial left anterior descending artery lesion. He was therefore admitted for aortic valve replacement and coronary artery bypass grafting surgery. Past Medical History: -Hyperlipidemia -Anemia -Non-Hodgkins Lymphoma (marginal zone) -Stage I left renal carcinoma, status post left radical nephrectomy, adrenalectomy, and regional lymphadenectomy by Dr. [**Last Name (STitle) **] in [**2139-12-7**]. -Prostate carcinoma, s/p radical prostatectomy [**2132**]. -Obstructive sleep apnea. -Status post right ulnar neurolysis as management for an ulnar neuropathy by (Dr. [**Last Name (STitle) **] in [**2143-8-7**]) Social History: The patient is married and lives in [**Location **] MA. He works part-time at a local sports stadium. He denies IVDU /illicit drug hx, but admits to prior severe alcoholism up until [**2137**] when he stopped drinking ETOH after diagnosis of NHL. He states he now drinks 1-2 drinks every few months at holidays. Smoked ~[**1-10**] PPD from age 28-38yo. Family History: He states he has 6 siblings and all of them have been diagnosed with high cholesterol but none have had NSTEMI/MIs or CVAs. One brother with recent stent placed. Father with lung cancer and mother had CVA at age 84 and HTN. Physical Exam: Vitals: 98.2, 105/53, 77SR, 20, 98%RA General: NAD HEENT:unremarkable Neck:supple Lungs:CTAB Heart:RRR Abdomen:+BS, soft, non-tender, non-distended Extremities:warm, well-perfused, 2+pitting edema Neuro:intact Wounds:sternotomy without erythema or drainage, EVH/open GSV harvest site all c/d/i without erythema or drainage Pertinent Results: [**2145-1-27**] Intraop TEE PRE-CPB: No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve is bicuspid. 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 structurally normal. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. POST-CPB: Preserved biventricular systolic function. Intact aorta. The examination is unchanged. Bioprosthesis in aortic poistion. Well seated and good leaflet excursion. There is trace aortic regurgitation. [**2145-1-31**] 04:13AM BLOOD Hct-23.8* [**2145-1-31**] 04:13AM BLOOD Glucose-122* UreaN-22* Creat-1.4* Na-135 K-4.6 Cl-101 HCO3-30 AnGap-9 Brief Hospital Course: Mr. [**Known lastname 51902**] was admitted and taken directly to the operating room where Dr. [**First Name (STitle) **] performed an aortic valve replacment and coronary artery bypass grafting surgery. For surgical details, please see operative note. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics and transferred to the SDU on postoperative day one. Beta blockade was advanced as tolerated and he remained in a normal sinus rhythm. Preoperative medications were resumed. He continued to make clinical improvements with diuresis and was medically cleared for discharge to home on postoperative day 4. Medications on Admission: Simvastatin 20 qd, Toprol XL 50 qd, Gabapentin 300 qam, 600qpm, Bactrim DS one tab every Mon, Wed, Friday, Valtrex 500 [**Hospital1 **], Aspirin 81 qd, Folate 2mg qd, MVI, Colace prn, MVI, Omega 3 Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 7. Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO Q 12H (Every 12 Hours). Disp:*60 Tablet(s)* Refills:*0* 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X WEEK START POD#2 (). Disp:*15 Tablet(s)* Refills:*0* 10. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO three times a day. Disp:*90 Capsule(s)* Refills:*2* 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily) for 1 months. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*0* 13. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO once a day for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks. Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 15. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Coronary Artery Disease, Aortic Valve Stenosis - s/p AVR/CABG Hypertension Dyslipidemia Non-Hodgkins Lymphoma History of Renal Cell Carcinoma Chronic Renal Insufficiency Obstructive Sleep Apnea 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. [**First Name (STitle) **] in [**4-11**] weeks, call for appt Dr. [**Known firstname **] [**Last Name (NamePattern1) **] in [**2-9**] weeks, call for appt Dr. [**Last Name (STitle) **] in [**2-9**] weeks, call for appt [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2145-1-31**]

[ "424.1", "327.23", "V45.73", "413.9", "V10.46", "V10.52", "202.80", "585.9", "272.4", "414.01", "285.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6388, 6443

3541, 4295

339, 563

6681, 6688

2397, 3518

7200, 7545

1814, 2039

4542, 6365

6464, 6660

4321, 4519

6712, 7177

2054, 2378

282, 301

591, 963

985, 1427

1443, 1798

11,859

150,062

30968

Discharge summary

report

Admission Date: [**2155-6-18**] Discharge Date: [**2155-7-1**] Date of Birth: [**2097-6-15**] Sex: F Service: UROLOGY Allergies: Ciprofloxacin / Percocet Attending:[**First Name3 (LF) 1232**] Chief Complaint: Hematuria Major Surgical or Invasive Procedure: Radical nephrectomy with IVC thrombectomy ([**6-25**]) History of Present Illness: Ms [**Known lastname 1024**] is a 58 year-old woman with recent diagnosis of renal cell carcinoma with IVC infiltration who was transferred from an OSH with hematuria and anemia. Patient states that 3 weeks ago she started noticing hematuria with clots. She thought she had a UTI, went to the Er and had a CT scan at that time. CT scan showed and a renal mass invading the IVC. She was seen by two urologists who did not think she was a surgical candidate. 4 days ago she started having frank hematuria and felt lightheaded and nauseous (she vomited x 1 the night before). She also noted that the clots transiently obstructed her ability to urinate and caused suprapubic pain. She was taken to [**Hospital3 15286**] on [**2155-6-14**]. A d/c summary was not sent with her but it appears upon arrival there her hct was 24.5 and it only bumped to 27.6 after 2 units. She received a total of 4 units PRBCs and was treated with dilaudid and zofran. She did not have a foley placed and continued to have transient obstructions in her urinary stream. She believes her hematuria has decreased. She denies fevers or dysuria. She has had chills and urinary frequency. Past Medical History: Diabetes with retinopathy . ONCOLOGIC HISTORY: Renal cell carcinoma with invasion of the IVC diagnosed by CT 3 weeks ago after patient noted hematuria. She has been evaluated for surgery at [**Hospital3 **] and [**Hospital1 2025**] but was not thought to be a surgical candidate. Social History: Registered RN not currently working Divorced with one daughter who lives in Europe but just moved back here after pt's diagnosis. She now resides with daughter and 8 month old grandchild. Smoked 1 ppd till 6 months ago (previously smoked on and off for 40 yrs) Denies drug use, has occasional ETOH use Family History: Grandmother with pancreatic cancer mother with abdominal cancer aunt had lung cancer Physical Exam: VS: T 100.0 HR 90 BP150/70 RR 18 Sat 97% RA HEENT: anicteric sclera, MMM Neck: supple, no LAD Pulm: CTAB Cardio: RRR, 2/6 systolic murmur loudest at LUSB, nl S1 S2 Abdomen: soft, NT, ND, +BS, no hepatosplenomegaly Ext: no edema, 2+ DP pulses Neuro: Cn 2-12 intact, PERRL, muscle strength 5/5 in upper and lower extremities, sensation to light touch intact Skin: few petechia on LLQ of abd Back: no point tenderness, no CVA tenderness Pertinent Results: CT chest/abdomen from [**2155-6-2**] at OSH per reports: multiple b/l pulmonary nodules compatible with metastatic diseaes and the renal mass with filling defect involving the right renal vein into the vena cava but not the right atrium . Bone scan from OSH: no evidence of bony metastases . MRI ABDOMEN [**2155-6-19**]: [**Hospital 93**] MEDICAL CONDITION: 58 year old woman with presumed new diagnosis of metastatic renal cell CA with PROBABLE IVC involvement (per report from CT at OSH) REASON FOR THIS EXAMINATION: assess extent of tumor burden, IVC involvement, vascularity of malignancy CONTRAINDICATIONS for IV CONTRAST: None. INDICATIONS: Presumed new diagnosis of metastatic renal cell carcinoma, probable IVC involvement at outside hospital. Assess extent of tumor burden and IVC involvement. TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5- Tesla magnet including dynamic 3D images acquired prior to, during, and after the uneventful intravenous administration of 0.1 mmol/kg gadolinium-DTPA. Multiplanar 2D and 3D reformatted images were made and analyzed independently on an adjacent workstation. COMPARISON: None. FINDINGS: There is a very large, irregular, infiltrative mass occupying and expanding the entire upper pole of the right kidney measuring up to 10.1 x 8.9 x 8.6 cm. Heterogeneous areas of internal signal intensity on both T1- and T2-weighted images are present. No definite fat-containing areas are present internally, but there are likely areas of central necrosis. There is expansion and invasion of the right renal vein by tumor thrombus which extends into the IVC and extends cranially to a point approximately 17 mm below the intrahepatic segment of the IVC. There is no evidence of extension into the right atrium. There is one main right renal artery, but multiple arterial collaterals are seen surrounding the right kidney. There is distention of the lower pole collecting system, which is filled with low signal intensity material on T2- weighted images. There is thickening and enhancement along the proximal right ureter. This is seen adjacent to areas where there is extensive heterogeneity in signal in the perirenal fat as well as multiple parasitized vessels crossing the right ureter. The right adrenal gland is incompletely imaged, and areas of stranding/infiltration in the perinephric fat are present up to the expected position of the adrenal gland. There is no evidence of tumor in the left kidney or left adrenal gland. There is a single left renal artery and a conventional left renal vein which is anterior to the aorta. There is a tiny well-circumscribed lesion in the inferior right lobe of the liver (segment VI) which is of high signal intensity on T2-weighted images, and is likely a cyst with rim enhancement. There has been prior cholecystectomy. The spleen is unremarkable. There is a rounded 14-mm focus of high signal intensity on T2-weighted images within L1 which is most likely a hemangioma. Multiplanar 2D and 3D reformations and subtraction sequences were essential in evaluating vascular structures. IMPRESSION: 1. Large infiltrative mass occupying and expanding entire upper pole of right kidney measuring up to 10.1 cm. Presence of renal vein/IVC invasion is suggestive of a clear cell renal carcinoma. 2. Tumor thrombus extending through the right renal vein into IVC. Craniocaudal extent is to within 17 mm of the intrahepatic segment of the IVC. 3. Single main right renal artery. Multiple additional collateral parasitized vessels. 4. Clot distending right renal pelvis and collecting system. Delayed excretion from lower pole calices indicates obstruction. Thickening and enhancement along proximal right ureter is most likely secondary to venous/lymphatic engorgement and multiple crossing parasitized vessels. MIcroinvasion of tumor is considered less likely. 5. Diffuse stranding in retroperitoneal fat about kidney extending up to right adrenal gland. Tumor involvement in the right adrenal gland cannot be excluded. . CT HEAD [**2155-6-24**]: There is no intra- or extra-axial hemorrhage, mass effect, enhancing mass lesions, shift of normally structures, or hydrocephalus. The density values of the brain parenchyma appears unremarkable. The paranasal sinuses and mastoid air cells are clear. The soft tissues appear unremarkable. IMPRESSION: No evidence of intracranial metastatic disease. . .....MICRO: URINE CULTURE (Final [**2155-6-28**]): STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S NITROFURANTOIN-------- <=16 S OXACILLIN------------- 0.5 S PENICILLIN------------ =>0.5 R . Blood Cultures **FINAL REPORT [**2155-6-28**]** AEROBIC BOTTLE (Final [**2155-6-28**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2155-6-28**]): NO GROWTH. Brief Hospital Course: A/P: 58 yo female with newly diagnosed RCC with infiltration into the IVC and likely lung mets who presents with hematuria with transient urinary obstruction [**3-7**] clots and anemia. . 1) Hematuria: Patient with newly diagnosed renal cell carcinoma complicated by frank hematuria requiring transfusion at outside hospital. She arrived without a foley, but continued to pass frequent blood clots and ultimately became obstructed with urinary retention. A 22 french foley catheter was placed, and continuous bladder irrigation was initiated. Due to her high clot volume and resulting bladder spasms, the foley became obstructed on multiple occasions, and occasionally was propelled out of the bladder due to spasms. It required frequent manual irrigation to flush clots, in addition to continuous bladder irrigation. Her hematocrit continued to drop, and she was transfused 5 units of blood in the pre-operative period. Of note, CT of the chest at an outside hospital showed multiple pulmonary nodules consistent with mesastatic disease. A CT of the head was negative and an MRI of the abdomen showed extension of tumor into the IVC. . *RCC: Given her symptomatic hematuria and hemodynamic instability, Urology was consulted for a nephrectomy during this hospitalization. She underwent a radical nephrectomy with IVC thrombectomy with Dr. [**Last Name (STitle) 261**] on [**6-25**]. Of note during the procedure her EBL was 2L and she received 5units of pRBCs with 6L of crystalloid. She tolerated the procedure well and remained intubated post-op because of the large amount of fluid resucitation. She was transferred to the SICU where she was extubated on POD1. Her pain was then controlled with toradol and a dilaudid PCA. Of note, her urine output was normal, her creatinine was at baseline, and no active bleeding was seen in the urine. On POD2 she was transferred out of the ICU and her chest tube was removed as no pneumothorax was seen on CXR. Her hematocrit was noted to be down to 25 on POD 2 and she was transfused with 2 units pRBCs. Her post-transfusion hematocrit on POD 3 was noted to be 30. She remained NPO secondary to a prolonged ileus. She had no active emesis but did feel nauseated. On POD 4 she started having flatus late in the day. On POD 5 her diet was advanced to clears, which she tolerated, and then to regular, which she tolerated as well. She was converted to all PO medications. On POD 6 she was doing well, her foley was d/ced and she was discharged home in good condition with clear discharge and follow up instructions. . *Fevers: Current temp 100.7. Patient has had cough for several months, urinary urgency and chills. Likely d/t UTI or URI. -check bcx, ucx, CXR -Urine culture was positive for MSSA and an alpha hemolytic gram positive bacteria. She was treated with 2 days of bactrim preop and 3 days of ceftriaxone postop. . *DM: type 2, now insulin dependent. -cont home regimen of 30 NPH [**Hospital1 **] -SSI and qid FS -postoperatively her blood sugars were stable with half doses of NPH while NPO. She was restarted on her home regimen when tolerating POs. Medications on Admission: zofran, SSI Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take for constipation while taking percocet. Disp:*60 Capsule(s)* Refills:*2* 2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain: please do not drive while taking this medication. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Metastatic renal cell carcinoma Postop ileus Postop anemia Diabetes mellitus Discharge Condition: good Discharge Instructions: You were in the hospital for a radical nephrectomy with IVC thrombectomy. Please call your doctor or come to the emergency room if you notice wound redness, swelling, purulent discharge, have a fever greater than 101.5, severe pain not controlled by medications or for any other concerns. Please do not drive while taking pain medications. Please resume taking your home medications as prior to admission. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 275**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 277**] Call to schedule appointment next week. Completed by:[**2155-7-1**]

[ "250.50", "362.01", "997.4", "560.1", "198.89", "599.60", "V16.1", "189.0", "V16.0", "V15.82", "599.0", "285.1", "197.0", "599.7" ]

icd9cm

[ [ [] ] ]

[ "38.93", "38.07", "55.51", "99.04" ]

icd9pcs

[ [ [] ] ]

11856, 11862

8289, 11418

293, 350

11983, 11990

2739, 3060

12445, 12634

2183, 2269

11480, 11833

3097, 3229

11883, 11962

11444, 11457

12014, 12422

2284, 2720

244, 255

3258, 8266

378, 1543

1565, 1847

1863, 2167

59,199

141,687

38305+58204

Discharge summary

report+addendum

Admission Date: [**2111-5-18**] Discharge Date: [**2111-5-24**] Date of Birth: [**2044-5-17**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1406**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2111-5-18**] Cardiac Catheterization [**2111-5-19**] s/p Coronary artery bypass graft surgery x 3 (left internal mammary artery > left anterior descending, saphenous vein graft > posterior descending artery, saphenous vein graft > obtuse marginal) History of Present Illness: 66 year old male admitted to outside hospital on [**5-16**] after [**3-5**] days of increased shortness of breath and right sided chest pain. Shortness of breath primarily while lying flat. He ruled in for Non ST elevation myocardial infarction with CK 780 peak and troponin 11.6 Cardiac surgery consulted for coronary revascularization. Past Medical History: none Social History: Lives alone, has girlfriend Bartender part-time Tobacco history: 40 pack year history currently smoking ETOH: 3 beers 2x per week Family History: non contributory Physical Exam: Pulse: 82 Resp: O2 sat: 95% on 3 l NC B/P Right: Left: 123/56 Height: 5'[**11**]" Weight: 93.4 kg General: no acute distress Skin: Dry [x] intact [x] dry flaky skin bilateral LE, surgical scar right side abdomen HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur none Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] large, no palpable masses Extremities: Warm [x], Edema trace Neuro: alert and oriented x3 non focal unable to assess gait on bedrest Pulses: Femoral Right: cath site Left: +1 DP Right: Doppler Left: Doppler PT [**Name (NI) 167**]: Doppler Left: Doppler Radial Right: Doppler Left: Doppler Carotid Bruit Right: + bruit Left: + bruit Pertinent Results: [**2111-5-21**] 05:15AM BLOOD WBC-11.8* RBC-3.36* Hgb-10.3* Hct-31.4* MCV-93 MCH-30.8 MCHC-33.0 RDW-14.7 Plt Ct-157 [**2111-5-18**] 01:50PM BLOOD WBC-13.9* RBC-4.31* Hgb-13.3* Hct-39.6* MCV-92 MCH-30.9 MCHC-33.6 RDW-15.1 Plt Ct-271 [**2111-5-19**] 12:58PM BLOOD PT-13.9* PTT-31.7 INR(PT)-1.2* [**2111-5-18**] 01:50PM BLOOD PT-13.2 PTT-24.5 INR(PT)-1.1 [**2111-5-21**] 05:15AM BLOOD Glucose-155* UreaN-20 Creat-1.0 Na-137 K-4.9 Cl-100 HCO3-28 AnGap-14 [**2111-5-18**] 01:50PM BLOOD Glucose-191* UreaN-24* Creat-1.0 Na-136 K-5.0 Cl-102 HCO3-22 AnGap-17 Brief Hospital Course: Transferred [**2111-5-18**] from outside hospital for cardiac catheterization which revealed severe left main disease. He was admitted to the intensive care unit and underwent preoperative workup. On [**2111-5-19**] he was brought to the operating room for coronary artery bypass graft surgery. See operative report for further details. He received vancomycin for perioperative antibiotics since he was in hospital greater than twenty four hours. He was transferred to the intensive care unit for post operative management. He waoke neurologically intact and was weaned from the ventilator and extubated. On POD#1 he was transferred fromt he ICU to the stepdown unit for ongoing care. He was started on betablockers, diuretic and statin therapy. His chest tubes and wires were removed per cardiac surgery protocol. He was evaluated by physical therapy for strength and conditioning and on POD#5 he was cleared for discharge to home with VNA services by Dr. [**Last Name (STitle) **]. He is new to statin therapy and will need to have his LFT's checked in one month. Medications on Admission: None at home Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain/fever. 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*65 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 10. Outpatient Lab Work Liver function tests to be checked in one month 11. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp:*60 Tablet Sustained Release(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: Coronary artery disease s/p CABG x3 Non ST elevation myocardial infarction Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with ultram Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. No Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **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 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2111-6-17**] 1:15 Primary Care Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 25693**] [**Telephone/Fax (1) 25694**] [**6-2**] at 1015 am ( you need your liver function tests checked in one month ) Cardiologist Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2111-6-3**] at 11:20 am **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:[**2111-5-24**] Name: [**Known lastname 13522**],[**Known firstname **] H Unit No: [**Numeric Identifier 13523**] Admission Date: [**2111-5-18**] Discharge Date: [**2111-5-24**] Date of Birth: [**2044-5-17**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 135**] Addendum: Mr. [**Known lastname **] was treated for acute systolic CHF with betablockers and diuretics. Discharge Disposition: Home With Service Facility: [**Location (un) 2333**] Area VNA [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**] Completed by:[**2111-7-1**]

[ "414.01", "410.71", "250.00", "416.8", "788.20", "305.1", "443.9", "272.4", "491.21", "285.9", "401.9", "424.0", "428.0", "428.21" ]

icd9cm

[ [ [] ] ]

[ "37.23", "39.61", "36.12", "88.56", "36.15" ]

icd9pcs

[ [ [] ] ]

7446, 7666

2593, 3666

341, 594

5261, 5481

2018, 2570

6237, 7423

1158, 1176

3729, 5056

5163, 5240

3692, 3706

5505, 6214

1191, 1999

282, 303

622, 964

986, 992

1008, 1142

20,453

121,513

20340

Discharge summary

report

Admission Date: [**2173-6-7**] Discharge Date: [**2173-6-14**] Date of Birth: [**2094-1-28**] Sex: F Service: CSURG Allergies: Codeine Attending:[**First Name3 (LF) 1505**] Chief Complaint: 79 y/o W female s/p stent with sharp, substernal chest pain. Major Surgical or Invasive Procedure: CABGx3 [**2173-6-8**] History of Present Illness: This 79 year old, white female has a history of coronary artery disease and is s/p Taxus stent to the RCA in [**2-21**]. She presented with severe exertional angina and was admitted for r/o MI. her cath in [**2-21**] revealed 3 vessel coronary artery disease with an LVEF of 55%. Past Medical History: S/P bilateral TKR 10 years ago. S/P bladder suspension HTN hypercholesteremia OA of back and shoulders S/P R LE vein stripping. S/P TAH Social History: Cigs: none ETOH: none Lives alone. Family History: unremarkable Physical Exam: General: Well developed, well nourished eldery female in NAD HR: 66 R: 20 BP: 124/54 Afeb HEENT: NC/AT, EOMI, PERLA, oropharynx benign Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids 2+= w/out bruits Lungs: Clear to A+P CV: RRR w/out R/G/M, nl. s1, s2 Abd: soft, nontender, w/out masses or hepatosplenomegaly, +BS Extremities: w/out clubbing, cyanosis, or edema. Pulses: 2+= bilat. except 1+ PT and DP bilat. Neuro: nonfocal Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2173-6-11**] 07:30AM 10.1 3.13* 9.1* 28.4* 91 29.2 32.2 12.9 225 BASIC COAGULATION (PT, PTT, PLT, INR) Plt Ct [**2173-6-11**] 07:30AM 225 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2173-6-12**] 04:44AM 99 14 0.4 139 4.4 103 32* 8 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2173-6-12**] 04:44AM 8.5 2.1* 2.8* Brief Hospital Course: The patient was admitted on [**2173-6-7**] and underwent cardiac catheterization which revealed a diffusely diseased LMCA, severe diffuse disease with serial 90% lesions of the LAD, 80% lesion of the non-dominant LCX, and the dominant RCA was widely patent. Dr. [**Last Name (STitle) **] was consulted and on [**2173-6-8**] the patient underwent CABGx3 with LIMA to the LAD and SVG to the diagonal and the obtuse marginal. The cross clamp time was 45 minutes and the total bypass time was 62 minutes. She tolerated the procedure well and was transferred to the CSRU in stable condition on Neo and Propofol. She was extubated on the post op night and was transferred to the floor. Her chest tubes and epicardial pacing wires were d/c'd on POD#2. She was diuresed with Lasix and started on Lopressor. She continued to progress and was discharged to rehab in stable condition on POD# 4. Medications on Admission: Plavix 75 mg. PO qd ASA 325 mg. PO qd Lipitor 20 mg. PO qd Lopressor 25 mg. PO qd HCTZ 25 mg. PO qd Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 7. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 8. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 **] TCU Discharge Diagnosis: Coronary artery disease. Hypertension Hypercholesteremia Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 3 months. You should shower, let water flow over wounds, pat dry with a towel. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 6707**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) 4469**] for 2-3 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Completed by:[**2173-6-14**]

[ "272.0", "411.1", "412", "414.01", "V43.65", "V45.82", "401.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

3748, 3795

1857, 2745

325, 349

3896, 3903

1379, 1834

4146, 4393

887, 901

2895, 3725

3816, 3875

2771, 2872

3927, 4123

916, 1360

225, 287

377, 660

682, 819

835, 871

82,100

127,908

34094

Discharge summary

report

Admission Date: [**2175-2-10**] Discharge Date: [**2175-2-21**] Date of Birth: [**2106-2-14**] Sex: M Service: MEDICINE Allergies: Adhesive Attending:[**First Name3 (LF) 12174**] Chief Complaint: confusion Major Surgical or Invasive Procedure: PICC line placement Packed red blood cell transfusion x3 History of Present Illness: 68 year old male with PMH of cirrhosis of unclear etiology, SBP in [**4-28**] on levofloxacin prophylaxis, gastropathy and esophageal varices, initially admitted to MICU on [**2175-2-10**] for altered mental status and lethargy. . On the morning of admission, Mr. [**Known lastname **] was noted to be confused and barely arousable with only yes/no answers. EMS was called and he was transferred to an OSH. He vomited once upon transfer and again at OSH, both of which were reportedly negative for blood/coffee grounds. His wife reports that he had no F/C, HA, abd pain, URI symptoms, cough, HA, BRBPR, melena and was at his recent baseline health with + fatigue. At OSH he was uncooperative and disoriented. Transferred to [**Hospital1 18**] given that is where his hepatologist is. . In the MICU, NGT was placed and lactulose administered for presumed hepatic encephalopathy. Diagnostic paracentesis was negative for SBP. Blood cultures grew [**1-25**] coagulase negative staphylococcus and he was started on vancomycin on [**2175-2-11**]. Has was also started on ceftriaxone initially for concern of UTI, then pneumonia, which was changed to zosyn on [**2-12**] due to concern of worsening respiratory status on ceftriaxone. Also found to have ARF on admission which resolved to baseline but has since been mildly increasing over the last two days. Receiving albumin 50 g IV 1-2 times daily. Other MICU issues have included hypercalcemia (tx fluids and lasix) and hypernatremia. Past Medical History: 1. Cirrhosis. NASH vs autoimmune vs alcohol related per biopsy at outside hospital. He also has heterozygote related to hemachromatosis gene mutation. His biopsy results demonstrate hemosiderin deposits. 2. History of spontaneous bacterial peritonitis in [**2174-4-21**]. 3. History of GI bleed in [**2174-7-22**] secondary to portal gastropathy as well as esophageal varices. 4. Peripheral arterial disease status post stent to superficial femoral artery approximately 10 years ago. 5. Hypertension. Social History: Former smoker, 20-pack-year history, quit [**2146**]. Prior social EtOH drinker, none in 5 years. No h/o IVDU or other drugs. No tatoos or piercings. Retired Home Care and Home Oxygen company co-partner. Married x 42 years. Family History: Mother d. age 51 from leukemia. Father d. age 59 from gastric cancer, and he had stomach ulcers and CAD. Brother d. age 51 from alcohol, ? cirrhosis. Sister d. age 61 from cervical and ovarian cancer. Physical Exam: GEN: Pale with distended abdomen. HEENT: EOMI, PERRL, pale conjunctiva, +scleral icterus NECK: supple CHEST: CTAB, no w/r/r CV: RRR, S1S2, no m/r/g ABD: protuberant abdomen, nontender with umbilical hernia, reducible EXT: 4+ bilateral pitting edema to thighs SKIN: No rashes, no jaundice Neuro: opens eyes to voice and stimulation. Moves all extremities. Pertinent Results: ADMISSION LABS: . CBC: [**2175-2-10**] 11:38AM BLOOD WBC-11.9* RBC-2.39* Hgb-7.8* Hct-23.3* MCV-98 MCH-32.7* MCHC-33.5 RDW-19.2* Plt Ct-298# [**2175-2-10**] 11:38AM BLOOD Neuts-75.5* Bands-0 Lymphs-14.6* Monos-6.2 Eos-3.5 Baso-0.2 . COAGS: [**2175-2-10**] 11:38AM BLOOD PT-20.6* PTT-42.2* INR(PT)-1.9* . CHEMISTRIES: [**2175-2-10**] 11:38AM BLOOD Glucose-107* UreaN-82* Creat-2.5*# Na-130* K-5.0 Cl-101 HCO3-19* AnGap-15 . LFTs: [**2175-2-10**] 11:38AM BLOOD ALT-34 AST-57* LD(LDH)-339* AlkPhos-123* TotBili-6.6* . Blood Gas: [**2175-2-10**] 04:18PM BLOOD Type-ART pO2-109* pCO2-23* pH-7.52* calTCO2-19* Base XS--1 Comment-SPECIMEN > [**2175-2-10**] 04:18PM BLOOD Lactate-2.8* . Urine Analysis: [**2175-2-10**] 05:16PM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2175-2-10**] 05:16PM URINE RBC->50 WBC-21-50* Bacteri-FEW Yeast-NONE Epi-0-2 . MICROBIOLOGY: . Urine Cx [**2-10**]: NEG BLOOD Cx [**2-10**]: STAPHYLOCOCCUS, COAGULASE NEGATIVE BLOOD Cx 2/21,22,24,25: NEG Peritoneal Fluid Cx [**2-10**]: NEG ---------- . PATHOLOGY: Peritoneal Fluid [**2175-2-10**]: NEG for malignant cells ---------- IMAGING STUDIES: . CXR [**2175-2-10**]: IMPRESSION: 1. Left basilar opacity slightly obscuring left hemidiaphragm probably representing atelectasis; consolidation at the left base cannot entirely be excluded. 2. Within the limits of a motion limited study, no gross free air is seen under the hemidiaphragms. . TTE [**2175-2-10**]: IMPRESSION: Mild mitral regurgitation with normal valve morphology. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Dilated ascending aorta. Brief Hospital Course: This is a 68 year old male with PMH of cryptogenic cirrhosis, portal gastropathy, who was initially admitted to the MICU for management of altered mental status most likely from hepatic encephalopathy whose course has been complicated by developing pneumonia, bacteremia and acute on chronic renal failure. . # Hepatic Encephalopathy: His symptoms improved with administration of lactulose and rifaximin. He did not have evidence of SBP on diagnostic paracentesis. Possible that infection from pneumonia and bacteremia may have also contributed to his mental status change. With continued rifaximin, lactuolse and antibiotics for infection hisencephalopathy resolved. . # Coagulase Negative Staphylococcus Bacteremia: He was started on Vancomycin on [**2175-2-11**]. Serial blood cultures remained negative and he remained afebrile and hemodynamically stable. PICC line placed and patient discharged home on remaining 5 of 14 day course. . # Pneumonia: Chest xray on [**2-10**] showed left lower lobe opacity. Patient initially started on ceftriaxone which was switched to zosyn and then to levaquin. Patient completed a total of a 7 day course of medications. Respiratory status remained stable and patient was breathing comfortably at rest and with ambulation on room air at time of discharge. . # Acute on Chronic Renal failure: On admission creatinine was 2.5 up from a baseline of around 1.4-1.7. Cr initially improved to baseline and then began trending up. Patient was treated with albumin [**Hospital1 **] and then daily which did not improve renal function so he was started on a course of midodrine and octreotide for suspected hepatorenal syndrome. After 3 days of midodrine/octroetide Cr improved to around 1. Midodrine and octreotide were stopped. He was restarted on a low dose of diuretics (furosemide 20 and spironolactone 50 daily), and his creatinine rose to baseline levels 1.5-1.6. We decided to stop the fursoemide; however, he will continue to take spironolactone at a reduced dose of 50 mg daily. He will have labs checked three days following discharge and again three days after that. . # Cryptogennic Cirrhosis: He was admitted with encephalopathy and may have also developed HRS as described above. Nadolol was held while he was on midodrine and octreotide but restarted after these medications were stopped. Patient was also restarted on a SBP prophylactic dose of levaquin. Patient is currently awaiting liver [**Hospital1 **]. . # Anemia: Patient's hematocrit 20 on admission felt to be secondary to slow blood loss from known portal gastropathy. Patient was transfused a total of 3 units of packed red blood cells during this admission and hematocrit remains stable. . # Hypercalcemia: Patient was noted to have elevated calcium on admission with normal PTH. Calcium has since normalized. A PTHrP is still pending at time of discharge. . # Interstitial Pulmonary Fibrosis: Stable during this admission. Patient is followed by pulmonology as an outpatient. . Patient was a FULL code during this admission. Medications on Admission: MEDS AT HOME: cholestryramine-aspartame 4g tid prn clotrimazole troches 5x/day lasix 40 qday (stopped [**2-7**]) levofloxacin 250mg qday megestrol 40mg/ml 20mL qday nadolol 20mg qday omeprazole 20mg [**Hospital1 **] spironolactone 100mg qday (stopped [**2-7**]) carafate 1g 4x/day ergocalciferol 1000U qday ferrous gluconate 325 qday . MEDS ON TRANSFER: Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Insulin SC sliding scale Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Lactulose 60 mL PO QID Nadolol 20 mg PO DAILY Pantoprazole 40 mg IV Q12H Piperacillin-Tazobactam Na 4.5 g IV Q8H Rifaximin 400 mg PO TID Sucralfate 1 gm PO QID Vancomycin 1000 mg IV Q 24H Discharge Medications: 1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day. 4. Megestrol 400 mg/10 mL Suspension Sig: 20mL PO once a day. 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 6. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours. 7. Cholestyramine-Aspartame 4 gram Packet Sig: One (1) PO three times a day as needed for itching. 8. Ergocalciferol (Vitamin D2) Oral 9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 10. Lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO QID (4 times a day). 11. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush: Per PICC line care protocol at [**Location (un) 511**] Home Therapies. Disp:*qs qs* Refills:*0* 13. Saline Flush 0.9 % Syringe Sig: Ten (10) ML Injection every six (6) hours: Per PICC line care per protocol at [**Location (un) **] Home Therapies. Disp:*qs qs* Refills:*0* 14. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day. 15. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO three times a day. Disp:*180 Tablet(s)* Refills:*2* 16. Vancomycin in Normal Saline 1 gram/250 mL Solution Sig: One (1) GM Intravenous once a day for 5 days. Disp:*5 qs* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary: Hepatic encephalopathy, acute on chronic renal failure, pneumonia, coagulase negative staphylococcus bacteremia, anemia secondary to blood loss . Secondary: Cryptogenic cirrhosis, interstitial pulmonary fibrosis Discharge Condition: Stable. Discharge Instructions: You were admitted to the hospital with confusion which we felt was likely hepatic encephalopathy. We gave you medications for the encephalopathy and your confusion resolved. During this hospital stay you were also found to have pneumonia and an infection in the blood for which you were treated with antibiotics. You also developed worsening kidney function and were treated with medications which improved this condition. . Medication Changes: 1. Vancomycin was added. Please complete a 14-day course that will end on [**2-26**]. 2. Lasix was stopped. Please do not take this medicine until you speak with Dr. [**Last Name (STitle) 497**]. 3. Spironolactone was decreased from 100 mg to 50 mg once daily. 4. Rifaximin was added. Please take at a dose of 400 mg three times daily. . If you experience confusion, abdominal pain, fevers, chest pain or shortness of breath please contact your primary care provider or go to the emergency department for evaluation. Followup Instructions: The following appointments were already scheduled: Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2175-3-1**] 1:20 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2175-2-24**] 10:15 Provider: [**Name10 (NameIs) 7548**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2175-2-24**] 2:20 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2175-5-17**] 9:30 Completed by:[**2175-2-21**]

[ "572.2", "280.0", "537.89", "287.5", "790.7", "486", "275.42", "443.9", "789.59", "571.5", "599.0" ]

icd9cm

[ [ [] ] ]

[ "54.91" ]

icd9pcs

[ [ [] ] ]

10208, 10257

4931, 7970

280, 338

10522, 10532

3224, 3224

11542, 12071

2631, 2833

8671, 10185

10278, 10501

7996, 8332

10556, 10981

2848, 3205

11001, 11519

231, 242

366, 1849

3240, 4380

1871, 2373

2389, 2615

8350, 8648

4397, 4908

71,233

127,018

6156

Discharge summary

report

Admission Date: [**2192-3-15**] Discharge Date: [**2192-3-19**] Service: MEDICINE Allergies: Lisinopril Attending:[**First Name3 (LF) 2108**] Chief Complaint: angioedema Major Surgical or Invasive Procedure: none History of Present Illness: This is a 87 year-old [**Location 7972**] male with a history of afib who presents with fall 2 days ago in BR that was unwitnessed. Per nephew who lives with the pt, he got up from bed and in the BR became dizzy and had a LCO. He was recent admitted for a LGI bleed on [**2192-3-8**] thought to be from diverticulosis. He was started on lisinopril 5mg and flomax during that admission. In his fall he hit his left face and sinc then has been having increaseing swelling. He did not want to seek care at that time. He has no SOB. No diffictuly swallowing. He has pain along his right cheek and left eye and inner lower lip. He thinks he is starting to feel better since his ER presentation. He also feels like he has something in the back of his throat that he can not clear. . In the ED, 10 97.5 72 133/61 16 96%. He had edema of face on exam with concern for angioedema. Pt was given solumederol 125, benadryl 25, famotidine. CT head and neck with small fx, unclear age. ENT not consulted in ER. Pt was admitted to [**Hospital Unit Name 153**] for airway monitoring. On transfer VS were0 HR 70 146/62 12 97%RA. Pt has PIV 18 and 20 G. . ROS: no CP, no SOB, no cough. Chronic RUQ pain for 2 months, not associated with meals, no hematuria. no dysuria. Past Medical History: -Rectal bleeding, from diverticulosis -Adenomas on colonoscopy [**2-21**] -CAD s/p BMS LAD and RPDA -Hypertension -Dyslipidemia -Paroxysmal atrial fibrillation -s/p CVA -Asthma/COPD -Urinary retention -Orthostatic hypotension: admit for syncope in [**5-19**] and for hypotension in [**10-19**]. Initial work-up consistent with medication induced orthostasis, also had formal autonomic testing and in [**10-19**] was started on florinef and midodrine (see d'c summary from [**10-19**] for details). These medications were subsequently stopped by pcp due to hypertension -Paranoid schizophrenia: diagnosed 5-10 years ago admitted [**12-19**] x 2 weeks at [**Hospital 1263**] hospital; [**Date range (3) 24050**] [**Hospital1 18**] admit for psychosis after stopping risperidone for orthostatic hypotension- Outpt Psychiatrist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24051**] at [**First Name8 (NamePattern2) **] [**Doctor Last Name **] -Impaired glucose tolerance Social History: Tob: 2ppd, quit [**2186**] No alcohol in [**7-17**] years No other drug use. Born and raised in [**Country 3587**]. Previously worked on his father's farm, states he did not attend school. Emigrated to US in [**2168**], 3 children and 2 brothers in [**Name (NI) 86**] area. Never married. Worked in housekeeping in US. Lives with his nephew. Family History: Mother - Schizophrenia Brother - Depression Physical Exam: Vitals: 96.9 79 143/73 10 96%RA GEN: [**Location 7972**] speaking, Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, swelling of right lower jaw and lips, bruising around left eye, cut on inner lower lip, tongue not swollen, OP visible, MMM NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline, no stridor COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: some mild wheezes, intermitent ABD: Soft, mild RUQ pain, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, CN II ?????? XII grossly intact. Moves all 4 extremities. SKIN: No jaundice, cyanosis, or gross dermatitis. Facial ecchymoses. Pertinent Results: [**2192-3-16**] 04:30AM BLOOD WBC-18.3*# RBC-3.77* Hgb-10.2* Hct-30.4* MCV-81* MCH-27.1 MCHC-33.7 RDW-13.0 Plt Ct-240 [**2192-3-15**] 05:25AM BLOOD WBC-9.2 RBC-4.08* Hgb-11.2* Hct-32.8* MCV-80* MCH-27.4 MCHC-34.0 RDW-13.3 Plt Ct-249 [**2192-3-15**] 05:25AM BLOOD Neuts-58.6 Lymphs-26.3 Monos-6.5 Eos-8.0* Baso-0.7 [**2192-3-16**] 04:30AM BLOOD PT-12.4 PTT-23.6 INR(PT)-1.0 [**2192-3-15**] 05:25AM BLOOD ESR-11 [**2192-3-15**] 05:25AM BLOOD Glucose-106* UreaN-14 Creat-1.2 Na-129* K-4.4 Cl-94* HCO3-28 AnGap-11 [**2192-3-16**] 04:30AM BLOOD Glucose-111* UreaN-17 Creat-1.1 Na-132* K-4.8 Cl-102 HCO3-22 AnGap-13 [**2192-3-15**] 05:25AM BLOOD ALT-27 AST-28 LD(LDH)-155 AlkPhos-88 TotBili-0.3 [**2192-3-15**] 05:25AM BLOOD cTropnT-<0.01 [**2192-3-16**] 04:30AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.3 [**2192-3-16**] 04:30AM BLOOD VitB12-437 [**2192-3-15**] 05:25AM BLOOD CRP-1.2 [**2192-3-15**] 05:25AM BLOOD C3-107 C4-23 RPR non reactive cxr [**2192-3-15**]: FINDINGS: There is suggestion of COPD. There is a linear opacity at the left mid lung likely small atelectasis. There are bibasilar atelectasis. There is probable RML atelectasis. There is no pneumonia. There is no pleural effusion or pneumothorax. Hilar silhouette is normal. There is tortuosity of thoracic aorta. Mild cardiomegaly with a left ventricular configuration. IMPRESSION: No pneumonia. No pneumothorax. [**2192-3-15**] ct c spine: IMPRESSION: 1. Multilevel degenerative changes in the cervical spine with fusion of C3-C4 and posterior osteophytes at C4-C5 and C6-C7 impinging on the thecal sac anteriorly and placing the cord for higher risk of injury in appropriate mechanism. 2. Small osseous fragment superior and posterior of C3 vertebral body could be a small fracture fragment of uncertain chronicity. Correlate with point tenderness. Comparison with prior imaging, if available, would be beneficial. If clinical concern, MRI of the spine can be done for evaluation. [**2192-3-15**] ct sinus: 1. No evidence of fracture. 2. Mild mucosal thickening in bilateral maxillary sinuses and sphenoid sinus. 3. Left preseptal small hematoma. [**2192-3-15**] ct head without contrast: FINDINGS: There is no evidence of hemorrhage, infarction, or masses. There is no shift of midline structures. Ventricles and sulci are normal in size and configuration. There is no evidence of fracture. There is a left preseptal hematoma. IMPRESSION: No acute intracranial process. Brief Hospital Course: This is a 87 year-old male with a history of orthostatic hypotension and recent fall c/b trauma to face who presents with facial swelling and ?angioedema. Facial swelling: possibly angioedema given recent initiation of ACEi but also possibly related to the fall and trauma. At this point will avoid ACEi or [**Last Name (un) **] and have placed lisinopril on his allergy list. SYNCOPE / AUTNOMIC DYSFUNCTION: symptoms of presyncope chronically (for 2 years) and a formal diagnosis of autnomic dysfunction has been made with tilt table testing here at [**Hospital1 18**] in [**2190**]. He had previously been on midodrine and florinef but was hypertensive so these were discontinued. He has most recently been on flomax and lisinopril and was more orthostatic. For now I have changed his regimen to norvasc 2.5mg po daily and thigh high TEDS stockings. In addition given his CT C spine findings and his recurrent falls I feel that it would be dangerous for him to ambulate without an assist device. I have recommended a walker with a seat so that he can sit down immediately should he feel lightheaded, I have strongly urged he use this at all times given his high risk to fall, and have suggested if this is ineffective he may at somepoint be committed to a wheelchair given his severe autnomic dysfunction. In addition he will have a home safety evaluation by VNA. He had no acute fractures as a result of his fall. I have also checked a B12 which was 400 and an RPR which was non reactive given that he had a + romberg sign suggestive of posterior column spinal cord disease. Medications on Admission: 1.fluticasone-salmeterol 250-50 mcg/dose Disk [**Hospital1 **] 2.haloperidol 2.5 mg Tablet PO HS 3.tamsulosin SR 0.4 mg PO HS (nephew thinks this is new for last 3 days, but it was on his older non-confimed med list) 4.tiotropium bromide 18 mcg DAILY 5.atorvastatin 80 mg PO HS 6.lisinopril 5 mg PO DAILY 7.senna 8.6 mg Tablet PO twice a day prn 8.omeprazole 20 mg Capsule, PO once a day. 9.aspirin 325 mg Tablet, PO once a day. 10.citalopram 10 mg Tablet PO once a day. Discharge Medications: 1. ROLLATER WALKER one rollater walker (walker with seat) 2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. haloperidol 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 5. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. TEDS STOCKINGS SMALL TEDS STOCKINGS, ABOVE THE KNEE 11. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: Multicultural VNA Discharge Diagnosis: PRIMARY DIAGNOSIS: angioedema from lisinopril autonomic dysfunction complicated by falls 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 after a fall and had lip swelling. Your fall was likely related to your chronic lightheadedness. You will need to wear the TEDS stockings and use a rolling walker with a seat, if you feel lightheaded please sit down immediately. MEDICATION CHANGES: STOP taking LISINOPRIL (you may be allergic to this medication) STOP taking FLOMAX (prostate medication) START taking NORVASC (AMLODIPINE) Followup Instructions: Department: SURGICAL SPECIALTIES When: THURSDAY [**2192-3-29**] at 9:00 AM With: PELVIC FLOOR UNIT [**Telephone/Fax (1) 274**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital1 7975**] INTERNAL MEDICINE When: MONDAY [**2192-4-9**] at 10:45 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7976**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site

[ "995.1", "285.1", "276.1", "780.2", "401.9", "337.9", "414.01", "272.4", "295.32", "493.20", "427.31", "E942.9", "584.9", "E885.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9191, 9239

6143, 7733

229, 235

9372, 9372

3687, 6120

9973, 10587

2908, 2954

8258, 9168

9260, 9260

7759, 8235

9523, 9789

2969, 3668

9809, 9950

179, 191

263, 1518

9279, 9351

9387, 9499

1540, 2531

2547, 2892

3,100

160,426

53789

Discharge summary

report

Admission Date: [**2118-8-29**] Discharge Date: [**2118-9-2**] Date of Birth: [**2066-10-13**] Sex: F Service: MEDICINE Allergies: Ace Inhibitors / Lisinopril Attending:[**First Name3 (LF) 5827**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Intubation on [**2118-8-30**] for increased PCO2 and somnolence Extubation on [**2118-8-31**] History of Present Illness: HPI: This is a 51 y.o. Spanish-speaking female with COPD, OSA, diabetes insipidus, ?Down's Syndrome, hypothyroid, ?pan-hypopituitary, who presented to ED with dyspnea, fever headache and abdominal pain and was later admitted to the MICU for hypotension. On presentation to the ER, she was febrile 101.5, HR 76, BP 99/59, RR 16, 95% RA. She desaturated with ABG 7/32/78/46 and was placed on 31% ventimask. She received Ceftriaxone and Azithromycin and 4mg of Dexamethasone. She then became hypotensive (BP 60/30), received 2L NS with improvement (BP 96/50), but was transferred to the MICU. While in the unit, her BP improved with fluids and dexamethasone and remained stable. It was thought that the hypotension was due to adrenal insufficiency as well as her DI in the absence of her DDAVP since she her hourly urine output was >300cc/hour during her transfer from the ED to the unit. Her hyponatremia and ARF resolved and because of her sleep apnea, she was started on BIPAP at night with weaning during the day. She was maintained on Albuterol/Atrovent for COPD. Her initial complaint of LUQ pain was worked up with an abdominal CT which showed a right adnexal mass with a fluid attenuation mass inferiorly and cardiomegaly with a right-sided predominance. A pelvic US and echo were both suggested. Pt. was also found to be thrombocytopenic, which is her baseline, etiology unknown. On [**2118-8-30**], she was intubated because of increased PCO2, somnolence and concerns for airway protection, but she has known sleep apnea and was extubated successfully on [**2118-8-31**] and trasferred to the floor. Past Medical History: 1) HTN 2) Hypothyroidism: TSH [**1-2**] 0.87 3) OSA: on BiPAP 16/10 at home - was supposed to also be on 2L NC at home 4) Restrictive lung disease - [**4-2**] PFTs: FVC 39%, FEV1 37%, FEV1/FVC 96%, TLC 59%, DLCO markedly reduced. Consistent with moderate restrictive ventilatory defect 5) Pulmonary artery hypertension: attributed to COPD/OSA 6) ASD with shunt: shunt study demonstrated R-> L shungt with 12% shunt fraction (precluding meaningful repair) 7) Central diabetes insipidis - ? pan- hypo pit: on prednisone 5 mg daily, levothyroxine, desmopressin 8) Down Syndrome 9) h/o CHF - [**1-1**] TTE: LVEF >55%, RV dilated, abnl septal motion c/w right ventricle pressure/volume overload, 2+ MR, 3+ TR, moderate pulmonary systolic hypertension, ASD vs stretched PFO on bubble study Social History: Lives with daughter, who is her primary care-giver and 2 grand children. Prior 45 pk-yr smoking history, quit [**2112**]. No EtOH or other drug use. Family History: NC Physical Exam: PE Vitals: HEENT: NC/AT, EOMI, PERRLA, nares with no secretions, OP nonerythematous Neck: supple, no lymphadenopathy Chest/CV:S1, S2 heard, II/VI holosystolic murmur heard best at LUSB Lungs: Diffuse wheezing, no WOB, bibasilar crackles Abd: soft, NT, ND, + BS Ext: no c/c/ trace edema Neuro: grossly intact Pertinent Results: [**2118-8-28**] 07:00PM PLT COUNT-102* [**2118-8-28**] 07:00PM HYPOCHROM-3+ ANISOCYT-1+ MACROCYT-1+ [**2118-8-28**] 07:00PM NEUTS-55.3 LYMPHS-34.0 MONOS-7.0 EOS-1.9 BASOS-1.8 [**2118-8-28**] 07:00PM WBC-10.7 RBC-4.19* HGB-12.2 HCT-39.5 MCV-94 MCH-29.3 MCHC-31.0 RDW-16.7* [**2118-8-28**] 07:00PM CK-MB-1 proBNP-569* [**2118-8-28**] 07:00PM cTropnT-<0.01 [**2118-8-28**] 07:00PM CK(CPK)-44 [**2118-8-28**] 07:00PM GLUCOSE-68* UREA N-4* CREAT-1.3* SODIUM-145 POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-34* ANION GAP-13 [**2118-8-28**] 07:07PM TEMP-38.6 PO2-46* PCO2-78* PH-7.32* TOTAL CO2-42* BASE XS-9 [**2118-8-28**] 09:14PM LACTATE-1.6 [**2118-8-28**] 10:09PM LACTATE-0.9 [**2118-8-28**] 10:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2118-8-28**] 10:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.002 [**2118-8-28**] 10:56PM LACTATE-1.0 [**2118-8-29**] 12:01AM LACTATE-0.8 [**2118-8-29**] 12:01AM COMMENTS-GREEN TOP [**2118-8-29**] 02:15AM PT-14.1* PTT-29.9 INR(PT)-1.3* [**2118-8-29**] 02:15AM PLT COUNT-78* [**2118-8-29**] 02:15AM WBC-5.6 RBC-3.63* HGB-10.9* HCT-34.3* MCV-95 MCH-30.2 MCHC-31.9 RDW-16.2* [**2118-8-29**] 02:15AM OSMOLAL-318* [**2118-8-29**] 02:15AM ALBUMIN-3.3* CALCIUM-7.6* PHOSPHATE-4.2# MAGNESIUM-2.2 [**2118-8-29**] 02:15AM ALT(SGPT)-20 AST(SGOT)-26 LD(LDH)-264* ALK PHOS-69 AMYLASE-64 TOT BILI-0.5 [**2118-8-29**] 02:15AM GLUCOSE-103 UREA N-4* CREAT-1.0 SODIUM-157* POTASSIUM-3.8 CHLORIDE-118* TOTAL CO2-35* ANION GAP-8 [**2118-8-29**] 03:18AM O2 SAT-97 [**2118-8-29**] 03:18AM TYPE-ART PO2-115* PCO2-94* PH-7.20* TOTAL CO2-39* BASE XS-5 [**2118-8-29**] 03:18AM O2 SAT-97 [**2118-8-29**] 04:45AM LACTATE-1.0 [**2118-8-29**] 04:45AM TYPE-ART PO2-48* PCO2-92* PH-7.21* TOTAL CO2-39* BASE XS-4 [**2118-8-29**] 05:55AM freeCa-1.17 [**2118-8-29**] 05:55AM GLUCOSE-134* LACTATE-1.0 K+-4.4 [**2118-8-29**] 05:55AM TYPE-ART PO2-55* PCO2-85* PH-7.25* TOTAL CO2-39* BASE XS-6 [**2118-8-29**] 06:31AM URINE OSMOLAL-69 [**2118-8-29**] 06:31AM URINE HOURS-RANDOM UREA N-23 CREAT-12 SODIUM-22 [**2118-8-29**] 06:31AM CALCIUM-8.4 PHOSPHATE-4.1 MAGNESIUM-2.4 [**2118-8-29**] 06:31AM GLUCOSE-140* UREA N-4* CREAT-1.1 SODIUM-162* POTASSIUM-4.5 CHLORIDE-122* TOTAL CO2-36* ANION GAP-9 [**2118-8-29**] 09:52AM TSH-2.1 [**2118-8-29**] 09:52AM CALCIUM-8.3* PHOSPHATE-3.9 MAGNESIUM-2.4 [**2118-8-29**] 09:52AM GLUCOSE-173* UREA N-4* CREAT-1.0 SODIUM-162* POTASSIUM-4.4 CHLORIDE-122* TOTAL CO2-36* ANION GAP-8 [**2118-8-29**] 09:52AM GLUCOSE-173* UREA N-4* CREAT-1.0 SODIUM-162* POTASSIUM-4.4 CHLORIDE-122* TOTAL CO2-36* ANION GAP-8 [**2118-8-29**] 10:36AM TYPE-ART TEMP-37.0 PO2-70* PCO2-90* PH-7.22* TOTAL CO2-39* BASE XS-5 INTUBATED-NOT INTUBA [**2118-8-29**] 01:53PM OSMOLAL-338* [**2118-8-29**] 01:53PM GLUCOSE-184* UREA N-4* CREAT-0.9 SODIUM-160* POTASSIUM-4.4 CHLORIDE-121* TOTAL CO2-37* ANION GAP-6* [**2118-8-29**] 03:16PM PLT COUNT-85* [**2118-8-29**] 03:16PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL STIPPLED-OCCASIONAL [**2118-8-29**] 03:16PM NEUTS-91.0* BANDS-0 LYMPHS-7.8* MONOS-1.0* EOS-0 BASOS-0.1 [**2118-8-29**] 03:16PM WBC-9.7# RBC-4.03* HGB-11.8* HCT-38.9 MCV-97 MCH-29.4 MCHC-30.4* RDW-16.7* [**2118-8-29**] 03:16PM FREE T4-0.4* [**2118-8-29**] 03:16PM TSH-1.8 [**2118-8-29**] 06:15PM CALCIUM-8.3* PHOSPHATE-3.5 MAGNESIUM-2.4 [**2118-8-29**] 06:15PM UREA N-5* CREAT-0.9 SODIUM-158* POTASSIUM-4.3 CHLORIDE-119* TOTAL CO2-37* ANION GAP-6* [**2118-8-29**] 09:17PM PLT COUNT-77* [**2118-8-29**] 09:17PM WBC-7.5 RBC-3.61* HGB-10.8* HCT-34.5* MCV-96 MCH-29.8 MCHC-31.2 RDW-16.2* [**2118-8-29**] 09:17PM GLUCOSE-174* UREA N-5* CREAT-0.9 SODIUM-155* POTASSIUM-4.5 CHLORIDE-117* TOTAL CO2-34* ANION GAP-9 [**2118-8-29**] 09:32PM TYPE-ART TEMP-35.8 RATES-14/ TIDAL VOL-400 PEEP-5 O2-40 PO2-65* PCO2-68* PH-7.33* TOTAL CO2-37* BASE XS-6 -ASSIST/CON INTUBATED-INTUBATED Brief Hospital Course: 51F Spanish speaking h/o COPD, OSA, diabetes insipidus, ? Down's syndrome, hypothyroid, ?pan-hypopituitary xferred to the MICU after being admitted for abdominal pain, then developed hypotension and hypercarbic respiratory failure, now resolved. Patient's blood pressure stabilized in the MICU and was thought to be due to adrenal insufficiency. While in the MICU, patient went into hypercarbic respiratory failure of unclear etiology (apnea?) and was intubated, but successfully extubated the next day and transferred to the floor. The following issues were investigated during her admission: . # Hypoxia - The differential in the MICU included angioedema [**3-3**] Lisinopril use vs. hypercarbic respiratory failure from underlying COPD exacerbated by insufficient corticosteroid usage, pan-hypopituitarism). On the floor, she was weaned to room air with 94-96% oxygen saturation. Pulmonology consulted and said that she should be maintained on room air unless she desaturated and in that case should be titrated to 90-93% on nasal canula oxygen since she has a COPD-like picture. . # Apnea - Pt. was initially ordered for BiPAP for improved ventilation over CPAP at night, but has not been on CPAP at home for a extended period of time because of a non-functioning apparatus. In a previous hospitalization as well as this one, the pt. was shown to become hypercarbic on CPAP for unclear reasons. For this reason, no BiPAP was ordered. Pt. will follow up in pulmonology clinic with Dr. [**Last Name (STitle) 20063**] at [**Hospital1 **] for a better characterization of her lung process. . # Hypotension: Patient became acutely hypotensive in ED without tachycardia and improved with iv hydration. There was no evidence of end-organ damage. Findings were most consistent with adrenal insufficiency as patient responded to iv fluids and dexamethasone. On the floor, the patient actually became hypertensive and was maintained on Valsartan 80 mg qd, which was increased to Valsartan 160 mg qd. The patient was not restarted on her outpatient dose of Lisinopril since she has a history of angioedema on that medication. . # Fever/Abdominal Pain: The DDx of the fever included pneumonia, bronchitis and aspiration pneumonitis although there was no evidence on CXR. Gastroenteritis, or other another intrabdominal process were included in the DDX and she received Levoquin and Flagyl for one day. The abdominal CT showed no source of the fever but was significant for a right adnexal mass and cardiomegaly. Pt. was afebrile for the remainder of the hospital course and blood and urine cultures showed no growth. Incidental abdominal findings will need outpatient follow up. . # Acute renal failure: This was resolved with IVF hydration and her creatinine normalized (.8 on discharge). . # Hypothyroid: Pt. was maintained on outpt. dose of Levothyroxine # FEN: Hypernatremia in the setting of central diabetes insipidus was corrected with DDAVP. Pt's Na was 133 on discharge. . # Access: peripheral Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Desmopressin 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Respiratory Failure Discharge Condition: Stable Discharge Instructions: 1. Please take all of your medications as directed 2. Please make all of your appointments 3. Call your doctor or go to the ER for any of the following: shortness of breath, fever, chills, chest pain or any other concerning symptoms Followup Instructions: 1. Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20063**] in pulmonology clinic at [**Hospital1 69**], the [**Hospital Ward Name 23**] Building (on the [**Hospital Ward Name **]) on [**2118-10-13**] at 1:30 PM. 2. You will be contact[**Name (NI) **] next week by Dr.[**Name (NI) **] office to arrange a home visit. 3. Please have your potassium checked by VNA (visiting nursing assistance) on [**Last Name (LF) 766**], [**2118-9-5**]. If VNA does not come, call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5351**] at [**Telephone/Fax (1) 608**]

[ "493.20", "253.2", "327.23", "253.5", "276.2", "255.4", "789.01", "276.0", "584.9", "428.30", "518.82", "780.6", "758.0", "416.8", "428.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "93.90", "38.93", "96.71", "38.91" ]

icd9pcs

[ [ [] ] ]

11182, 11239

7412, 10410

296, 392

11303, 11312

3369, 7389

11594, 12226

3021, 3025

10433, 11159

11260, 11282

11336, 11571

3040, 3350

249, 258

420, 2030

2052, 2838

2854, 3005

8,447

136,971

22885+57324

Discharge summary

report+addendum

Admission Date: [**2133-7-19**] Discharge Date: [**2133-7-30**] Date of Birth: [**2084-11-21**] Sex: F Service: MEDICINE Allergies: Optiray 320 Attending:[**First Name3 (LF) 1055**] Chief Complaint: Endocarditits Major Surgical or Invasive Procedure: Hickman central line on right. Hemodialysis Transesophageal echocardiagram History of Present Illness: 48 y.o. female with DM type1, HCV, ESRD recently started on HD ([**3-7**]) presents with weakness and fatigue after recent admission for change of Hickman catheter. Pt states that her Hickman fell out on [**2133-7-16**] and she returned to the ED where they replaced the Hickman. The Hickman was removed and the tip was cultured and blood cultures were drawn. Since then the patient reports worsening weakness and fatigue. Cultures from the prior Hickman came back positive for enterococcus, pan-sensitive. 2/2 bottles positive for enterococcus from [**2133-7-16**]. No recorded fevers and no chills. She has had some nausea and vomiting with poor PO intake. No hematemasis. Pt has diarrhea at baseline. Denies SOB/ CP/ abd pain. Pt states that her fingerstick at home have been as high as 400 over the past two weeks. Past Medical History: DM- poorly controlled Hypercholesterolemia, elevated triglycerides HTN ESRD Recent HTNive urgency PSH: TAH s/p HD cath [**2133-3-13**] s/p L forearm AV fistula [**2133-3-20**] Social History: Denies and EtOH and drug use. Smoked [**1-4**] ppd x 33 yrs but says she has cut down recently to several cigs/day. She lives in [**Location **]. She is unemployed. Family History: She has biological siblings but does not know about them or her parents because she is adopted. Physical Exam: Vitals: 97.6, HR: 98, BP: 123/79, RR 16, O2 98% RA GEN: Chronically ill appearing woman, but currently appears comfortable. No tachypnea, responds to all questions appropriately. Alert and oriented x3. HEENT: EOMI, PERRL, anicteric, MM dry, + thrush, JVP at 8-9cm, no LAD, neck with full ROM. CV: RRR, 3/6 systolic murmur heard best at LUSB with radiation to carotids. Resp: Decreased BS at b/l bases with rales above. No rhonchi and no wheezes appreciated. Abd: Soft, non-tender, normoactive BS. No organomegally appreciated. Ext: warm, no edema. Pulses 2+ x4. L arm with healing wound, no warmth to tough, palpable thrill and bruit. Neuro: No focal findings, no asterixis. Pertinent Results: [**2133-7-19**] 10:27PM GLUCOSE-606* [**2133-7-19**] 10:00PM GLUCOSE-634* UREA N-28* CREAT-3.3* SODIUM-126* POTASSIUM-3.7 CHLORIDE-91* TOTAL CO2-22 ANION GAP-17 [**2133-7-19**] 07:59PM GLUCOSE-702* LACTATE-1.7 [**2133-7-19**] 07:55PM GLUCOSE-726* UREA N-28* CREAT-3.4*# SODIUM-125* POTASSIUM-4.2 CHLORIDE-87* TOTAL CO2-17* ANION GAP-25* [**2133-7-19**] 07:55PM WBC-17.5* RBC-5.18 HGB-13.1 HCT-44.5 MCV-86 MCH-25.4* MCHC-29.6* RDW-16.6* [**2133-7-19**] 07:55PM NEUTS-78.7* BANDS-0 LYMPHS-19.4 MONOS-1.4* EOS-0.2 BASOS-0.2 [**2133-7-19**] 07:55PM PLT COUNT-171 . . ECG: NSR, diffuse T wave flattening. No changes from old. CXR: IMPRESSION: Findings consistent with moderate pulmonary edema. [**2133-7-16**] 9:45 am BLOOD CULTURE VENOUS SIDE OF DIALYSIS CATH. **FINAL REPORT [**2133-7-18**]** AEROBIC BOTTLE (Final [**2133-7-18**]): REPORTED BY PHONE TO DR [**First Name (STitle) **] [**Name (STitle) **] AT 1:41A [**2133-7-17**]. ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES. HIGH ________________________________________________________ ENTEROCOCCUS FAECALIS | AMPICILLIN------------ <=2 S LEVOFLOXACIN---------- 1 S PENICILLIN------------ 2 S VANCOMYCIN------------ <=1 S ANAEROBIC BOTTLE (Final [**2133-7-18**]): ENTEROCOCCUS SP.. IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE. TEE: 1.The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. 2. There is moderate symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). 3.Right ventricular chamber size and free wall motion are normal. 4. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. 5.There are three aortic valve leaflets. No aortic valve abscess is seen. There is a moderate-sized vegetation on the aortic valve. The vegetation is attached to the ventricular side of the noncoronary aortic valve cusp, is irregular in shape, and measures 0.7 x 1.1 cm in its greatest dimension. There is no aortic valve stenosis. Moderate (2+) aortic regurgitation is seen emanating from under the noncoronary cusp. 6.The mitral valve leaflets are mildly thickened, but no mass or vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is seen. 7. No vegetation/mass is seen on the pulmonic or tricuspid valves. 8. There is no pericardial effusion. Brief Hospital Course: 48 y.o. female with type 1 DM, ESRD and HCV presents with line infection and DKA. . 1) DKA/DM: Etiology likely line infection. Pt has been bacteremic since [**7-16**]. Pt was given IVF and insulin. DKA resolved over 36 hours. Pt returned to home regimen of glargine at night and RISS. . 2) Enterococcal endocarditis, line infection: Pan-sensitive enterococcus bacteremia (likely source is Hickman) with moderate sized vegetation of aortic valve by TTE (exam with new murmur). Hickman line pulled. Initially covered with levoquin. ID consulted, recommended PCN and gentamycin X 4 weeks. (+) for enterococcus. TEE showed moderate vegetation, AR and TR, no abscess. CT surgery consulted and felt no surgery indicated at this time. She will f/u with CT surgery as an outpatient. -Antibiotics to continue until [**2133-8-17**] - check gent levels after HD and redose when <1- dose to give when level <1 is 60mg. - monitor ECG daily for PR pronlongation no changes seen to date (aortic root abscess . 3) Coagulopathy: Pt had extensive bleeding after line pulled. Thought to be secondary to uremic platelets but coags drawn and showed INR 3.4. Pt with known hx of HCV however, no biopsy. Viral load 479,000. Liver was consulted and will follow up as an outpatient. . 4) ESRD: Received HD on T,R,and S. AV fistula not yet mature so tunneled hickman catheter placed by IR. R carotid artery ws punctured during procedure however no sequela developed. Patient will continue on Dialysis Tuesday, Thursday, and Saturday. She will have Gentamicin levels checked at all dialysis visits, with Gemtamicin to be dosed with level < 1 at 60mg. . 5) CHF: Fluid status managed with HD during this admission. Restarted ACEI, beta blocker,and statin. . 6) Diarrhea: During her hospitalization, patient developed diarrhea in the setting of remaining afebrile. C-diff was negative times 1 and 2nd c-diff was pending at time of discharge. However, it was felt that diarrhea likely secondary to antibiotic effect rather than c-diff. Hence, patient started in imodium. Once diarrhea resolves- this should be discontinued. Additionally, if diarrhea continues- further c-diff toxin may need to be sent. . 7) HCV: found during workup for renal transplant. Pt was in the process of having this worked up. Will need biopsy. Pt has never had abnormal LFT's. Has follow uo with Liver in 4wks. . 8)Gastroparesis - stable. patient continued on reglan until she developed diarrhea. Patient's c-diff negative times 1 and 2nd c-diff pending at time of discharge. Reglan stopped while having diarrhea, and may need to be restarted (10mg QID- qith meals) once diarrhea resolves. Tolerating [**Doctor First Name **] diet with sugar free boost supplements. . 9) PPx: Protonix, Pneumoboots. . 10) Access: Hickman,PICC, PIV. Pt has fistula placed on [**7-1**]. Not yet mature. . 11) Code: FULL Medications on Admission: 1. Escitalopram Oxalate 10 mg QD 2. Atorvastatin Calcium 20 mg QD 3. Lisinopril 5 mg QD 4. Loperamide HCl 2 mg QID PRN 5. Acetaminophen 325 mg PRN 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 7. Docusate Sodium 100 mg PO BID 8. Travatan 0.004 % Drops gtt Ophthalmic at bedtime. 9. Reglan 5 mg PO TID. 10. PhosLo 667 mg PO TID w/ MEALS. 11. Lantus 12. Toprol XL 50 mg PO QD Discharge Medications: 1. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day): give till diarrhea resolves. Capsule(s) 2. Travoprost 0.004 % Drops Sig: One (1) Ophthalmic QD (). 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 11. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO DAILY (Daily) for 6 days. 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 14. Insulin Glargine 100 unit/mL Solution Sig: Seven (7) units Subcutaneous at bedtime. 15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 16. Penicillin G Potassium 5,000,000 unit Recon Soln Sig: 1,000,000 units Injection Q4H (every 4 hours). 17. Gentamicin 10 mg/mL Solution Sig: Six (6) Intravenous after dialysis. 18. Insulin Regular Human 500 unit/mL Solution Sig: One (1) as directed Injection four times a day: as directed per attached sliding scale. as directed Discharge Disposition: Home With Service Facility: [**Doctor Last Name 792**]VNA Discharge Diagnosis: Endocarditis Discharge Condition: hemodynamically stable, tolerating POs, afebrile. Discharge Instructions: Please take all medications as prescribed. Please return to PCP or Emergency department for fever, chest pain, shortness of breath, abdominal pain, nausea, vomiting, or diarrhea. Followup Instructions: Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2133-8-20**] 11:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4340**], MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2133-8-25**] 10:30 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2133-9-16**] 10:00 Completed by:[**2133-7-29**] Name: [**Known lastname 10864**],[**Known firstname 6758**] Unit No: [**Numeric Identifier 10865**] Admission Date: [**2133-7-19**] Discharge Date: [**2133-7-30**] Date of Birth: [**2084-11-21**] Sex: F Service: MEDICINE Allergies: Optiray 320 Attending:[**First Name3 (LF) 1852**] Addendum: Pt has decided not to go to rehab facility. She will be discharged to home with help provided by her sister. She will receive 60mg IV gentamycin after each dialysis session three times a week. She does not need dialysis today and may resume her normal Tuesday, Thursday, Saturday schedule this Saturday [**2133-8-1**]. Discharge Disposition: Home With Service Facility: [**Doctor Last Name 6720**]VNA [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 692**] MD [**MD Number(2) 693**] Completed by:[**2133-7-30**]

[ "276.1", "787.91", "998.2", "396.3", "790.7", "070.54", "496", "996.62", "250.40", "272.0", "E878.8", "421.0", "397.0", "398.91", "250.10" ]

icd9cm

[ [ [] ] ]

[ "45.13", "38.93", "39.95", "88.72" ]

icd9pcs

[ [ [] ] ]

11634, 11852

4980, 7835

287, 364

10075, 10126

2420, 4957

10354, 11611

1612, 1709

8325, 9935

10039, 10054

7861, 8302

10150, 10331

1724, 2401

234, 249

392, 1212

1234, 1413

1429, 1596

41,315

104,605

36870

Discharge summary

report

Admission Date: [**2130-6-9**] Discharge Date: [**2130-6-15**] Date of Birth: [**2057-8-18**] Sex: M Service: CARDIOTHORACIC Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 165**] Chief Complaint: Shortness of breath, chest pressure Major Surgical or Invasive Procedure: coronary artery bypass grafting x 2 (LIMA-LAD, SVG-OM) [**2130-6-11**] History of Present Illness: This is a 72 year old male with past medical history significant for angioplasty and stenting of his circumflex artery, posterior left ventricular artery and right coronary artery in [**2129-7-11**]. He returned to the cath lab later that month due to recurrent angina and underwent stenting of his left anterior descending artery. He was doing well until this past [**Month (only) 958**] when he developed chest pressure with associated shortness of breath while carrying trash up a flight of stairs. He has also noted some mild chest pressure when he is on the treadmill during cardiac rehab sessions, this also resolves when he either slows his pace or stops walking. A stress test was performed on [**2130-5-3**] which showed inferolateral ischemia and was stopped due to fatigue. He underwent a cardiac catheterization which revealed single vessel coronary artery disease involving the left main coronary artery and proximal left anterior descending artery detected by IVUS. The former left anterior decending, circumflex and right coronary artery stents were widely patent. Given the anatomy of his disease, he has been referred to Dr. [**Last Name (STitle) **] for surgical evaluation. Past Medical History: Coronary artery disease s/p multiple drug eluting stents in [**7-19**] Hypertension Hypercholesterolemia gastroesophageal reflux History of Basal Cell Carcinoma Social History: Occupation: Pastor at a church in [**Location 15289**]. Tobacco: Quit [**2090**] ETOH: one drink daily. Family History: [**Name (NI) **] brother with HTN. Most of his family died early, but of cancer. No premature coronary disease. Physical Exam: admission: temp 98, HR 82, BP 154/77, RR 16, 98%RA Height: 66" Weight: 155 General: Elderly male in no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] - poor dentition Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur - none Abdomen: Softly distended; asymetrical - larger on left than right; non-tender [x] bowel sounds+ [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 2 Left: 2 **bilateral femoral bruits** DP Right: 2 Left: 2 PT [**Name (NI) 167**]: 2 Left: 2 Radial Right: 2 Left: 2 Carotid Bruit Right: none Left: none Pertinent Results: [**2130-6-14**] 10:53AM BLOOD UreaN-21* Creat-1.1 K-4.5 [**2130-6-13**] 03:21AM BLOOD WBC-12.0* RBC-3.62* Hgb-11.4* Hct-33.4* MCV-92 MCH-31.4 MCHC-34.1 RDW-13.8 Plt Ct-221 [**2130-6-11**] 10:16AM BLOOD PT-13.8* PTT-32.8 INR(PT)-1.2* [**2130-6-13**] 03:21AM BLOOD Glucose-122* UreaN-16 Creat-1.0 Na-138 K-4.2 Cl-103 HCO3-28 AnGap-11 [**2130-6-12**] 03:28AM BLOOD Glucose-103* UreaN-18 Creat-1.1 Na-140 K-4.5 Cl-107 HCO3-25 AnGap-13 [**2130-6-14**] 10:53AM BLOOD WBC-9.2 RBC-3.84* Hgb-12.1* Hct-35.7* MCV-93 MCH-31.5 MCHC-33.9 RDW-14.0 Plt Ct-291 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT BP (mm Hg): 110/75 Wgt (lb): 155 HR (bpm): 81 BSA (m2): 1.80 m2 Indication: Coronary artery disease. ICD-9 Codes: 786.05, 786.51 Test Information Date/Time: [**2130-6-11**] at 09:24 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW001-0:00 Machine: ie33 Echocardiographic Measurements Results Measurements Normal Range Findings LEFT ATRIUM: Normal LA and RA cavity sizes. No spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. Mild mitral annular calcification. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions Pre-bypass: The left atrium and right atrium are normal in cavity size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are 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 and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is no pericardial effusion. Post-bypass: The patient is receiving no inotropic support post-CPB. Biventricular systolic function is preserved. There is 1+ tricuspid regurgitation. The aorta is intact post-decannulation. All findings communicated to the surgeon intraoperatively. Brief Hospital Course: The patient was brought to the Operating Room on [**2130-6-11**] where he underwent coronary artery bypass grafting x 2 with Dr. [**First Name (STitle) **]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Vancomycin was used for surgical antibiotic prophylaxis given the patient's inpatient stay of 24hours preoperatively. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Fr. [**Known lastname 60285**] was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued in a timely fashion, without complication. The patient was evaluated by the Physical Therapy service for assistance with strength and mobility. By the time of discharge on POD# the patient was ambulating freely, the wounds were healing well and pain was controlled with oral analgesics. Fr.[**Known lastname 60285**] was cleared by Dr.[**First Name (STitle) **] for discharge to home on POD# 4 in good condition with appropriate follow up instructions advised. Medications on Admission: Amlodipine 2.5mg qd Plavix 75mg daily- LAST DOSE [**2130-6-4**] Imdur 60mg Daily Lopressor 50mg twice daily Sublingual nitroglycerin as needed 0.3mg Benicar 20/12.5mg daily zantac 150mg [**Hospital1 **] Crestor 20mg daily Aspirin 325mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. Rosuvastatin 20 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 for pain. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. Disp:*50 Tablet(s)* Refills:*0* 7. Zantac 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: coronary artery disease s/p Coronary artery bypass grafting x 2 (LIMA-LAD, SVG-OM) [**2130-6-11**] s/p multiple drug eluting stents in [**7-19**] Hypertension Hypercholesterolemia gastroesophageal reflux History of Basal Cell Carcinoma Left shoulder arthritis Past Surgical History: Resection of skin cancers Discharge Condition: Alert and oriented x3, nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2130-7-17**] 1:45 Please call to schedule appointments PCP/Cardiologist Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 8725**] in [**2-11**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2130-6-15**]

[ "530.81", "401.9", "716.91", "V10.83", "413.9", "272.0", "285.9", "V45.82", "414.01" ]

icd9cm

[ [ [] ] ]

[ "36.11", "39.61", "38.93", "36.15" ]

icd9pcs

[ [ [] ] ]

8736, 8791

5901, 7223

315, 388

9145, 9302

2807, 5878

10004, 10584

1933, 2047

7516, 8713

8812, 9073

7249, 7493

9326, 9981

9096, 9124

2062, 2788

240, 277

416, 1610

1632, 1795

1811, 1917

72,921

130,549

36515

Discharge summary

report

Admission Date: [**2130-3-29**] Discharge Date: [**2130-4-7**] Date of Birth: [**2078-7-5**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3645**] Chief Complaint: s/p fall off ladder Major Surgical or Invasive Procedure: [**2130-3-31**]: T12 decompression, T10-L2 PSIF [**2130-4-4**]: Nasogastric tube placement for ileus (at bedside) History of Present Illness: Mr. [**Known lastname **] is a 51[**Hospital **] transferred to the [**Hospital1 18**] ED from an outside hospital after a 15-20ft fall off a ladder. He denied LOC and c/o pain in his mid-back and some tingling sensations over the right anterior thigh. Denied numbness or tingling in the toes. He was hemodynamically stable on presentation. CXR, CT head & CT Cspine all revealed no acute pathology. CT Torso revealed a T12 Burst Fracture with involvement of the posterior elements, 5-mm retropulsion into spinal canal and an associated paravertebral hematoma with thickening of R diaphragmatic crus. A small chip fracture off the anterior L1 vertebral body with a right L1 TP fracture was also noted. Incidental finding of renal and hepatic cysts was also made. He was admitted to the TSICU for close observation given the high energy mechanism and for serial neurologic examinations. The Orthopaedic Spine Service was consulted for management of his spinal injuries. Past Medical History: 1. s/p CABG [**2126**] 2. HTN 3. Hyperlipidemia 4. s/p RTC repair 5. DM Social History: N/C Family History: N/C Physical Exam: AVSS Well appearing, NAD, comfortable BUE: SILT C5-T1 dermatomal distributions BUE: [**4-18**] [**Doctor First Name **]/Tri/Bic/WE/WF/FF/IO BUE: tone normal, negative [**Doctor Last Name 937**], 2+ symmetric DTR bic/bra/tri All fingers WWP, brisk capillary refill, 2+ distal pulses TTP over thoracolumbar junction BLE: SILT L1-S1 dermatomal distributions, abnormal but intact sensation over right anterior upper thigh c/w L2-L3 dermatome BLE: [**4-18**] IP/Qu/HS/TA/GS/[**Last Name (un) 938**]/FHL/Per BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle All toes WWP, brisk capillary refill, 2+ distal pulses Abdomen, soft, nontender. No guarding. Minimal bowel sounds. Pertinent Results: [**2130-3-31**] 02:42PM BLOOD WBC-16.9* Hct-27.8* Plt Ct-288 [**2130-3-30**] 12:15AM BLOOD WBC-12.6* Hct-34.2* Plt Ct-292 [**2130-3-29**] 07:30PM BLOOD WBC-13.8* Hct-36.1* Plt Ct-292 [**2130-3-31**] 07:30AM BLOOD PT-13.3 PTT-24.7 INR(PT)-1.1 [**2130-3-31**] 02:42PM BLOOD UreaN-14 Creat-0.9 Na-137 K-4.4 Cl-104 HCO3-25 [**2130-3-30**] 12:15AM BLOOD UreaN-17 Creat-1.0 Na-139 K-4.3 Cl-104 HCO3-24 [**2130-3-29**] 07:30PM BLOOD UreaN-20 Creat-1.0 Na-138 K-4.2 Cl-102 HCO3-23 [**2130-3-31**] 02:42PM BLOOD Calcium-7.7* Phos-3.4 Mg-1.9 [**2130-3-30**] 12:15AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.8 Brief Hospital Course: Mr. [**Known lastname **] was admitted to the TSICU on [**2130-3-29**]. He was kept on bedrest with logroll precautions and an MRI of the spine was performed and demonstrated some degree of compression/indentation on the spinal cord, with contusion/edema and displacement of PLL with small focus of discontinuity likely related to ligamentous injury. Also identified was marrow edema in T11, L1 vertebral bodies. He remained otherwise stable and no new injuries were identified. On [**2130-3-31**] he was taken to the Operating Room for the above procedure performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**]. Please refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. He was transferred to the Orthopaedic Spine Surgery Service postoperatively. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with a PCA. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#2. He was transfused 2U RBC on POD#3 for HCT 25. Post-transfusion HCT was appropriately elevated. On POD#3 he was noted to be hiccupping with significant distension of his abdomen. Imaging revealed significant small and large bowel dilatation with air-fluid levels and he was made NPO w/ IVF for bowel rest. Narcotics were decreased. He was having bowel movements and flatus at that time therefore his symptoms were felt to be c/w ileus and not concerning for SBO. When he failed to improve clinically after 24hrs a repeat KUB was performed and showed worsening bowel dilatation. An NGT was placed on [**2130-4-4**] and position was confirmed in the stomach by Xray. IVF, NGT, NPO were all continued until his abdominal distension resolved and KUB normalized. Electrolytes were followed daily while NPO. The patient's abdominal distention and nausea improved significantly with placement of the NGT. On POD# 6, the NGT was clamped and residual output was minimal so the tube was removed and the patient was started slowly on a clear liquid diet. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: 1. Lipitor 2. Lopressor 3. ASA Discharge Disposition: Home Discharge Diagnosis: T12 Burst Fracture Discharge Condition: Stable Discharge Instructions: You have undergone the following operation: Spinal Decompression With Fusion T10-L2 Immediately after the operation: - Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. - Rehabilitation/ Physical Therapy: o 2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. o Limit any kind of lifting. - Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. - Brace: You do not need a brace. - Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. - You should resume taking your normal home medications. - You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Followup Instructions: SPINE: o Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. o At the 2-week visit we will check your incision, take baseline X-rays and answer any questions. We may at that time start physical therapy. o We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. PRIMARY CARE MD: Please follow up with your primary doctor [**First Name (Titles) **] [**Last Name (Titles) 24226**]g of the kidney and liver cysts identified on CT scan.

[ "401.9", "997.4", "805.4", "E881.0", "278.01", "573.8", "V45.81", "E878.8", "250.00", "272.4", "721.3", "753.10", "560.1", "806.25" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5513, 5519

2923, 5432

337, 453

5582, 5591

2307, 2900

7427, 7990

1583, 1588

5540, 5561

5458, 5490

5615, 5700

1603, 2288

5962, 6298

5734, 5944

278, 299

6310, 7404

481, 1451

1473, 1546

1562, 1567

152

117,181

25761

Discharge summary

report

Admission Date: [**2145-7-22**] Discharge Date: [**2145-8-3**] Date of Birth: [**2065-11-11**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 60889**] is a 79-year-old male who was recently discharged from [**Hospital1 18**] preoperatively after being referred to Dr. [**Last Name (STitle) **] for coronary artery bypass grafting. He has a history of hypertension, angina, abdominal aortic aneurysm, hypercholesterolemia and was recently discharged from [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1281**] Hospital prior to his admission last week at [**Hospital3 **] for lithotripsy and bladder calculi. He presented with an episode of nausea and vomiting, weakness and chest discomfort. He had known renal and bladder calculi as well as an incidental finding of a 4.4-cm abdominal aortic aneurysm by report from his outside hospital. He developed hematuria and was transferred from [**Hospital **] hospital to [**Hospital1 **] the week prior to this admission. Please refer to the discharge summary dated [**2145-7-18**]. On the way home from the hospital in [**Location (un) **], he had developed vertigo, nausea and vomiting. He was then transferred in to our institution for work-up for cardiac disease preoperatively to his abdominal aortic aneurysm repair or possible stenting. PAST MEDICAL HISTORY: 1. Myocardial infarction [**2120**]. 2. Hypertension. 3. Angina. 4. BPH. 5. Bladder calculi and renal calculi. 6. Abdominal aortic aneurysm. 7. Hypercholesterolemia. PAST SURGICAL HISTORY: Includes open cholecystectomy. He was evaluated by cardiology and was allowed to return home to get urology clearance from his primary care physician and the urologist who had treated him the week prior in [**Hospital **] hospital and to return for surgery on [**2145-7-22**] with Dr. [**Last Name (STitle) **]. LABORATORY DATA: EKG showed normal sinus rhythm with occasional PVCs, normal PR and Q-waves in leads II, AVR and AVF and question of Q-wave inversion in lead III. Persantine MIBI was performed which showed a moderate, partially- reversible inferior wall perfusion defect and ejection fraction of 55%. Echocardiogram performed prior to this admission showed an ejection fraction of 55% or greater, 1+ MR and no pericardial effusion. Please refer to the echo report. A CT of the abdomen done on [**7-13**] prior to this admission also showed extensive atherosclerotic changes with associated 5.4-cm infrarenal abdominal aortic aneurysm with no evidence of rupture. The left common iliac was also aneurysmal and total occlusion of the right common iliac with reconstitution of the right internal iliac and femoral arteries. It also showed massive prostatic enlargement and a right-sided posterior diaphragmatic hernia containing mesenteric and omental fat. Repeat CT of the abdomen was done the following day which also showed a simple, multiple renal cyst bilaterally. Chest x-ray done on [**7-15**] showed no evidence of free intraperitoneal air and small bilateral pleural effusions with some mild pulmonary vascular congestion. Cardiac catheterization performed also showed a right dominant system with a left main 30% lesion, a diffusely-diseased LAD with a 90% mid-vessel stenosis, a 99% OM1 lesion and a totally-occluded proximal RCA. EF was 60% at catheterization with no mitral regurgitation. Carotid Dopplers also performed showed less than 40% stenosis on both the right and left internal carotid arteries. The patient was allowed to return to home for urology clearance and was readmitted to the hospital on [**7-22**] for coronary artery bypass grafting. He also had been treated for urinary tract infection over the weekend. He was seen by urology who recommended continuous bladder irrigation which we were unable to perform in the OR so the decision was made to keep the patient in-house for several days to wait until his gross hematuria cleared. He was admitted on the 7th and followed by our service. On hospital day 2, he had some supraventricular tachycardia with activity. His EKG showed no ischemic changes and he had no chest pain. His hematuria continued to resolve. Preop labs were as follows: White count 7.1, hematocrit 34.8, platelet count 272,000, sodium 140, K 3.9, chloride 103, bicarbonate 29, BUN 18, creatinine 1.1, blood sugar of 117, PT 13.8, PTT 27.8, ALT 52, AST 32, alkaline phosphatase 59, amylase 35, total bilirubin 0.8, lipase 34. He was started on ciprofloxacin 500 mg p.o. twice a day and continued with Lopressor beta blockade and continue also with aspirin and Finasteride. His pressure was 152/74 that morning. He was in sinus tachycardia at 52 with respiratory rate of 20 and saturating 99% on room air. IV nitroglycerin was started briefly for blood pressure control and the plan was to continue to irrigate him over the weekend for his hematuria, and bring him back to the OR on Monday. On [**7-26**], he underwent coronary artery bypass grafting x3 by Dr. [**Last Name (STitle) **] with a LIMA to the LAD, a vein graft to the PDA and a vein graft to the OM. He was transferred to cardiothoracic ICU in stable condition on titrated Propofol and phenylephrine drips. He was also seen by urology who cleared him for CABG prior to the procedure. On postop day 1, his index was 2.6. He remained stable in the cardiothoracic ICU. Postop labs were as follows. White count 12.7, hematocrit 32, K 4.4, BUN 12, creatinine 1.0. His sugars were covered by sliding scale insulin. He was seen by Dr. [**Last Name (STitle) **], his cardiologist. He was on insulin drip at 3 units an hour and lidocaine drip at 2 mg per minute. On postoperative day 2, he went into atrial fibrillation with a ventricular response rate of 129. He maintained good blood pressure of 114/52. His chest tubes were pulled. His atrial fibrillation was treated. He received magnesium repletion also. His creatinine remained stable at 1.2 and his exam was unremarkable. When he was weaned from his drips, he was transferred out to the floor and was seen and evaluated by urology and by physical therapy to start working on ambulation with the nurses and the therapists. On the 13th, his urine was clear. He was managing his pain control with p.o. medications. He was in sinus rhythm with some PVCs. He was restarted on his cholesterol medicines. He was continued with IV diuresis with Lasix. His blood pressure was 145/69 so his blood pressure was titrated up. He did have some complaints of nausea but this was not overwhelming. His pacing wires were discontinued. On postoperative day 4, he had another event of atrial fibrillation overnight with a blood pressure of 132/68. His Foley was discontinued per urology. His exam was unremarkable. Incisions were clean, dry and intact. He was alert and oriented with a nonfocal neurological exam. His lungs were clear bilaterally. He was also seen by social work. The following morning he was back in sinus rhythm again with a good blood pressure. He continued his diuresis with Lasix and continued to increase his ambulation and his activity tolerance level. On the 17th, he went back into atrial fibrillation and heparin was started as a possible bridge to Coumadin. His exam was unremarkable. He was saturating well on 2 liters nasal cannula. His heparin was discontinued per Dr. [**Last Name (STitle) **]. His pressure came down to 101/54. On the 19th, amiodarone was started for his atrial fibrillation at 400 mg p.o. twice a day. He was doing very well, ambulating with minimal support. His creatinine was stable at 1.2. His exam was unremarkable, clean, dry and intact incisions. The central venous line had been removed. He continued on Proscar 5 mg p.o. once a day for his enlarged and somewhat raw prostate. His urine was clear. His beta blockade had been increased to 75 mg p.o. three times a day and he was discharged to home in stable condition with VNA services, with the following discharge diagnoses. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Status post coronary artery bypass grafting x3. 3. Hypertension. 4. Status post myocardial infarction [**2120**]. 5. Abdominal aortic aneurysm. 6. Hyperlipidemia. 7. Renal and bladder calculi, status post lithotripsy [**Month (only) **] [**2145**]. It was recommended that he followup with Dr.[**Name (NI) 5572**] service for postop surgical visit in the office at 4 weeks, to see Dr. [**First Name4 (NamePattern1) 1158**] [**Last Name (NamePattern1) 64178**], his primary care physician, [**Last Name (NamePattern4) **] 2 weeks, to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], his cardiologist, in 2 weeks, and to see Dr. [**Last Name (STitle) **], his urologist at the outside hospital, after his discharge. DISCHARGE MEDICATIONS: 1. Proscar 5 mg p.o. once daily 2. Colace 100 mg p.o. twice a day 3. Zantac 150 mg p.o. twice a day 4. Enteric-coated aspirin 81 mg p.o. once a day 5. Crestor 5 mg p.o. once daily 6. Metoprolol 75 mg p.o. three times a day 7. Amiodarone 200 mg p.o. once a day 8. Coumadin 1 mg p.o. with no dose to be taken on the evening of [**8-3**]. INR check was scheduled with blood draws on [**8-4**], the day after discharge, with results to go to Dr. [**First Name4 (NamePattern1) 1158**] [**Last Name (NamePattern1) 64178**], his primary care physician, [**Name10 (NameIs) **] therapeutic INR dosing with Coumadin. The patient had been started on Coumadin the evening prior to discharge. Again, the patient was discharged to home in stable condition on [**2145-8-3**]. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2145-8-18**] 11:47:57 T: [**2145-8-18**] 12:49:09 Job#: [**Job Number 64184**]

[ "997.5", "401.9", "441.4", "272.0", "V13.01", "600.00", "997.1", "427.31", "788.20", "412", "414.01" ]

icd9cm

[ [ [] ] ]

[ "89.68", "88.72", "36.12", "39.61", "97.64", "36.15" ]

icd9pcs

[ [ [] ] ]

7981, 8757

8780, 9794

1563, 7960

165, 1349

1371, 1539

77,259

132,359

40778

Discharge summary

report

Admission Date: [**2149-7-15**] Discharge Date: [**2149-7-21**] Date of Birth: [**2097-8-26**] Sex: F Service: MEDICINE Allergies: Penicillins / Prednisone / Codeine / gabapentin Attending:[**Doctor First Name 3290**] Chief Complaint: headache, vision changes, confusion, and tremor Major Surgical or Invasive Procedure: None. History of Present Illness: [**Known firstname **] [**Known lastname **] is a 51 year old right handed woman with admission in early [**Month (only) 116**] for unreponsiveness. Workup at that time was suggestive of possible PRES. She was readmitted on [**7-15**] for evaluation of complaints of worsening of headache, visual acuity, tremors and imparied cognition. MRI was repeated which showed resolution of the previously seen deficits. She had an episode of hypoxia and was transferred to the MICU on [**7-17**]. On arrival to the MICU, the patient was minimally responsive and able to follow some commands but was largely unable to cooperate with history and physical. 10-20 minutes after receiving a second dose of Narcan in the MICU, the patient had an episode of rhythmic twitching which did not appear to be tonic-clonic accompanied by tachypnea in the high 30's, arching her back, and worsening mental status with confusion and minimal response/cooperation. The episode lasted less than 20 minutes prior to spontaneous resolution. The patient remained confused and somnolent for 30 minutes following her episode. A Narcan drip was given to reverse effects of methadone which was causing apnea/hypoventilation/hypoxia. She was placed on biPAP during this period and her mental status improved dramatically. She has been off of biPAP for 24 hours. She also had an episode of hypotension to the 80s with fever to 101.3 which improved with a fluid bolus and was started on vancomycin & cefepime on [**7-17**]. Past Medical History: - COPD, history of multiple exacerbations and recent hospitalization with intubation - Hypothyroidism - Depression Social History: The patient lives in [**Hospital1 **], MA. She lives by herself but her mother, sister, and brother live in an apartment downstairs from her. She has two daughters (23 and 17 years old). She quit tobacco 3 years ago after smoking 2 packs a day for approximately 35 years (70 pack year history). She denies alcohol use and drug use, although she does have a distant drug abuse history (reports that she quit 16 years ago). Family History: The patient's mother had an extensive tobacco history and had lung cancer and lymphoma. The patient reports heart disease on her father's side. Her older brother died suddenly approximately 3 years ago with no autopsy performed. Her maternal grandmother suffered from a stroke. Physical Exam: VS: 98.6 118/80 86 18 93%2L GEN: awake, alert, oriented x 3 HEENT: PERRL, EOMI/no nystagmus, sclerae anicteric CV: RRR, nl S1 and S2, no m/r/g RESP: Poor air movement b/l, minimal scattered wheezes b/l, no rales, minimal rhonchi ABD: Soft, NT/ND, +b/s, +BS EXT: No c/c/e, WWP, 2+ DP b/l. SKIN: No rashes/no jaundice/no splinters NEURO: A&Ox3, CN II-XII intact, no asterixis, strength 5/5 throughout, gait not observed Pertinent Results: LABORATORY DATA -Admission Labs [**2149-7-15**] 01:50PM BLOOD WBC-8.0 RBC-4.58 Hgb-13.0 Hct-38.3 MCV-84 MCH-28.3 MCHC-33.8 RDW-14.9 Plt Ct-143*# [**2149-7-15**] 01:50PM BLOOD Neuts-50.3 Lymphs-40.6 Monos-5.7 Eos-1.3 Baso-2.2* [**2149-7-15**] 01:50PM BLOOD Glucose-78 UreaN-14 Creat-0.9 Na-140 K-4.0 Cl-103 HCO3-26 AnGap-15 [**2149-7-15**] 01:50PM BLOOD ALT-17 AST-18 AlkPhos-76 TotBili-0.2 [**2149-7-15**] 01:50PM BLOOD Albumin-4.2 Calcium-8.6 Phos-3.2 Mg-1.9 [**2149-7-15**] 01:50PM BLOOD T4-9.7 -Discharge Labs [**2149-7-21**] 05:16AM BLOOD WBC-5.5 RBC-3.93* Hgb-11.0* Hct-32.2* MCV-82 MCH-27.9 MCHC-34.1 RDW-14.9 Plt Ct-111* IMAGING: [**7-17**] CXR (Portable): FINDINGS: As compared to the previous radiograph, there is no relevant change. Atelectasis at both lung bases. No overt pulmonary edema. Moderate cardiomegaly. No newly appeared focal parenchymal opacities. No pneumothorax. [**7-20**] CHEST, SINGLE AP VIEW. Rotated positioning. A right subclavian PICC line is present -- the tip overlies the distal SVC. There is mild cardiomegaly and minimal atelectasis at left-greater-than-right bases. There is patchy increased retrocardiac density, probably unchanged allowing for technique. No CHF, frank consolidation, or gross effusion. MICROBIOLOGY: [**7-15**] URINE CULTURE (Final [**2149-7-16**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [**7-16**] URINE CULTURE (Final [**2149-7-17**]): NO GROWTH. [**7-16**] Blood Cultures, Routine (Final [**2149-7-22**]): NO GROWTH. Brief Hospital Course: 51 yo F with history of COPD requiring intubation in the past and recent admission for PRES who was admitted to the Neurology service for multiple complaints including headache, vision changes, confusion, and tremor, then transferred to the MICU for hypoxia secondary to apnea, likely a central process related to methadone use as it reversed after administration of Narcan. # Neurologic Symptoms: Neurology was evaluating her for a primary neurologic process; MRI head was unrevealing. EEG did not have evidence of seizure activity. Patient will follow up with neurology as an outpatient regarding headaches, confusion, and short term memory impairment. She continued aspirin 81mg for stroke prevention. # Hypoxia: Improved, patient was back to room air at discharge and back to her baseline supplemental home O2 as needed. Possibly related to decreased respiratory drive from additive effects of opiates and benzodiazepenes. Underlying COPD likely contributes to baseline hypoxia as well. Additionally, there is concern that patient might have central sleep apnea given witnessed episodes of apnea; she has been ordered for a sleep study and will need to set up a sleep consultation appointment. # RLL PNA: Patient was started on vancomycin & cefepime empirically on [**7-17**] after having spiking a fever in the MICU. Had PICC line placed and was discharged with a plan to complete an 8-day course of vancomycin and cefepime. # Depression/Anxiety: Stable. Restarted alprazolam at lower dose (1mg TID with 0.5mg [**Hospital1 **]:PRN). Patient is tolerating this well although she is still very anxious about her sister. She was also continued on Prozac. # Chronic Pain: Patient is prescribed Methadone by her PCP for chronic neck and back pain. Restarted it at lower dose (30mg [**Hospital1 **]), which was discussed with her PCP. # Hypothyroidism: Neurology recommended lower levothyroxine dose on admission due to tremor. TSH was lower limit of normal. She was discharge on levothyroxine at lower dose of 75 mcg/day (was previously 88mcg daily). # Thrombocytopenia: Patient was thrombocytopenic on admission, but platelet count was stable. Hematocrit was also lower than baseline. Possibly has an element of marrow suppression in the context of multiple metabolic insults in the past 2-3 months (including infection, intubation & PRES). PCP will follow up and refer to hematology as needed. # Flushing: Earlier in the admission and prior to admission, patient had episodes of flushing, diaphoresis, and hot flashes, observed recently to be accompanied by significant hypertension at [**Hospital **] Hospital per her sister. In the setting of history of frequent headaches, this is concerning pheochromocytoma. Can consider further workup as an outpatient, however symptoms did not recur while patient was on the medical floor. Patient's verapamil was initially held as she had an episode of hypotension in the MICU, however, her pressures were stable thereafter and verapamil was restarted. # DVT Prophylaxis: Patient received heparin products during this admission. # Code: Full code. Medications on Admission: - Fluoxetine 20 mg: 3 Capsules PO DAILY - Tiotropium bromide 18 mcg Capsule Inhalation DAILY - Levothyroxine 88 mcg PO DAILY - Methadone 10 mg: 6 Tablets PO QAM - Methadone 10 mg/mL: Five (5) PO QPM - Alprazolam 2 mg PO TID - Alprazolam 1 mg PO DAILY PRN anxiety - Advair Diskus Inhalation - Verapamil 120 mg Extended Release PO Q24H - Dexamethasone 2 mg: 2 Tablet PO Q8H for 12 days through [**6-17**] - Aspirin 325 mg PO DAILY Discharge Medications: 1. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 4 days: Last dose on the evening of [**7-24**] to complete total 8-day course of antibiotics. Disp:*7 gram* Refills:*0* 2. cefepime 2 gram Recon Soln Sig: Two (2) grams Injection Q12H (every 12 hours) for 4 days: Last dose on the evening of [**7-24**] to complete total 8-day course of antibiotics. Disp:*14 grams* Refills:*0* 3. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for tension headache. Disp:*90 Capsule(s)* Refills:*0* 4. fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily): For a total dose of 60mg daily. 5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 6. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for Hypothyroidism. Disp:*30 Tablet(s)* Refills:*0* 7. methadone 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 10. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 11. verapamil 120 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q24H (every 24 hours). 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary diagnoses: # Hypoxia # Altered mental status # Chronic obstructive pulmonary disease # Anxiety Secondary diagnoses: # Hypothyroidism # Posterior reversible encephalopathy syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: # You were admitted to the Neurology service for multiple complaints including headache, vision changes, confusion, and tremor. They recommended decreasing your dose of levothyroxine to see if it would reduce the tremor (from 88mcg daily to 75mcg daily). They also recommended starting gabapentin for your tension headaches. While you were on their service, you had an episode of unresponsiveness and hypoxia (low oxygen saturation) and you were transferred to the MICU. # While you were in the MICU, you received Narcan (naloxone), which reverses the effects of methadone. After receiving Narcan, your mental status improved, which leads us to believe that your episode of unresponsiveness & hypoxia was related to apnea (not breathing) in part related to excessive methadone. Additionally, you take Xanax (alprazolam), which can also suppress your drive to breathe. We stopped both of these medications and your mental status and oxygen saturation improved back to normal by the time of discharge. # In addition to the methadone & your COPD contributing to your low oxygen saturation, it appears that you might also have periods of apnea (not breathing) at night. We ordered a sleep study for you, but it is very important that you call the [**Hospital1 18**] Sleep Disorders Center (tel: [**Telephone/Fax (1) 89121**]) and schedule a Sleep Consultation appointment. # We restarted your methadone and Xanax (alprazolam) at lower doses than your home doses. It is important that you discuss the dosing of these medications with your PCP and whether they need to be increased. # Your platelets were low on admission. It is possible that this related to your recent illness; your PCP should recheck [**Name Initial (PRE) **] blood count in [**3-7**] weeks. If it is not improving, you should consider seeing a hematologist (blood specialist). # We made the following changes to your medications: - DECREASED methadone dose - DECREASED alprazolam dose - DECREASED levothyroxine dose - DECREASED aspirin dose - STARTED gabapentin - STARTED vancomycin & cefepime (antibiotics for your pneumonia; the last day of your 8-day antibiotic course is [**7-24**]) # It is important that you take all of your medications as prescribed and keep all of your follow up appointments. Followup Instructions: **You will need to call the [**Hospital1 18**] Sleep Disorders Center (tel: [**Telephone/Fax (1) 6856**]) to schedule a Sleep Consultation appointment. A sleep study has already been ordered for you. Your PCP will need to follow up the results of the sleep study until you have a sleep doctor. Name: NP [**First Name9 (NamePattern2) **] [**Last Name (un) 35646**] Address: [**Street Address(2) 84438**], [**Location **],[**Numeric Identifier 84439**] Phone: [**Telephone/Fax (1) 13553**] Appointment: Wednesday [**2149-7-23**] 2:30pm **This is a follow up appointment of your hospitalization. You will be reconnected with your primary care physician after this visit. Department: NEUROLOGY When: TUESDAY [**2149-7-29**] at 2:30 PM With: DRS. [**Name5 (PTitle) **]/VANHAERENTS [**Telephone/Fax (1) 44**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2149-8-15**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

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357, 364

10125, 10125

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Discharge summary

report

Admission Date: [**2156-11-2**] Discharge Date: [**2156-11-10**] Date of Birth: [**2115-4-22**] Sex: F Service: MEDICINE Allergies: cefepime Attending:[**First Name3 (LF) 5606**] Chief Complaint: respiratory distress/hypoxia Major Surgical or Invasive Procedure: Intubation PICC placement History of Present Illness: 41F with no PMH who presented to [**Hospital1 **] [**Location (un) 620**] [**10-29**] c/o high spiking fevers (104 tmax)and joint pain, achyness, rigors, no swelling. She c/o frontal HA not relieved by tylenol and motrin. Eventually she became overwhelmed with cough, weakness, and fatigue and presented to [**Location (un) 620**] ED. She also c/o corryza, increased mucousy phlegm and DOE. She had poor PO intake. ROS was positive for 10lb weight loss. She denied rashes, travel. . Outpatient lyme and flu were sent and were negative. She did not have a flu shot this year or ever. . In the [**Location (un) 620**] ER, initial vital signs were 103.1, 100, 108/70, 18 and 95% room air. She received 5 liters of normal saline with approximately 500 mL of urine output. CXR was performed and revealed an RLL and she received Robitussin AC and Levaquin 750 mg IV. While in the ER, her saturation dropped to 91% on room air and with supplemental 2 liters of oxygen it came up to 96%. Initial laboratory eval was notable for pancytopenia, with 18% bands and 65% neutrophils. ESR was 14, CRP was 108. She was started on Ceftriaxone and azithromycin. . . Hospital course: CT chest was performed revealing extensive dense consolidation predominantly involving the right lower lobe and in decreasing order of severity at the left lower lobe, and left upper lobe. Essentially multifocal pneumonia without lung abscess and no PE. Suggestion of pulmonary arterial hypertension. Oxygen requirements never exceded 6L to maintain 95%. . Blood cultures from the ER eventually returned 3/4 bottles Staph Epi, pan sensitive which cleared on HD#2. No further surveilance cultures were performed. She is being treated with vancomycin for this. ID recomended echocardiogram which is being preliminarily read as ?mitral valve endocarditis. . On the day of transfer creatinine was noted to be 2.4 from 0.7 3 days after CTA and RTC ibuprofen. Per report urine output remained "good." . Past Medical History: Anxiety and depression. History of C-section. Social History: Lives at home with her husband. Independent of ADL. No smoking or drug abuse. Occasionally drinks alcohol. Works as a jewelry buyer for MFA. Family History: noncontributory Physical Exam: ADMISSION EXAM: Vitals: T: BP:117/71 P:88 R: 40 O2: 91-99% on high flow oxygen General: Alert, oriented, tachypneic, anxious though this is likely [**1-21**] respiratory distress HEENT: Sclera anicteric, Dry MM greenish discoloration, oropharynx clear Neck: supple, Carotid hyperdynamic JVP not elevated, no LAD Lungs: Right base to right mid back rhonchorous, Left base rhonchourous. no wheezes, rales 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 . Pertinent Results: ADMISSION LABS: [**2156-11-2**] 02:23PM BLOOD WBC-8.1 RBC-4.58 Hgb-13.9 Hct-39.1 MCV-86 MCH-30.3 MCHC-35.5* RDW-11.8 Plt Ct-249 [**2156-11-2**] 02:23PM BLOOD Neuts-81.0* Lymphs-12.1* Monos-6.1 Eos-0.5 Baso-0.3 [**2156-11-2**] 02:23PM BLOOD PT-13.3 PTT-30.9 INR(PT)-1.1 [**2156-11-2**] 02:23PM BLOOD Glucose-98 UreaN-25* Creat-2.7* Na-142 K-4.2 Cl-110* HCO3-20* AnGap-16 [**2156-11-2**] 02:23PM BLOOD ALT-55* AST-120* LD(LDH)-555* CK(CPK)-112 AlkPhos-95 TotBili-0.3 [**2156-11-2**] 02:23PM BLOOD Albumin-2.7* Calcium-8.2* Phos-5.6* Mg-2.3 [**2156-11-5**] 03:17AM BLOOD Ret Aut-0.6* [**2156-11-5**] 10:27AM BLOOD Hapto-325* [**2156-11-2**] 02:23PM BLOOD ANCA-NEGATIVE B GLOMERULAR BASEMENT MEMBRANE <1.0 TEE: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 40 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve or chordae. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: Normal valve morphology without echo evidence of discrete vegetation/abscess or pathology flow. CXR: FINDINGS: As compared to the previous radiograph, the extent of the pre-existing pleural effusions has slightly decreased but parenchymal opacities with air bronchograms are still visible at both lung bases. Moderate areas of atelectasis at both lung bases. The patient has been extubated and the nasogastric tube has been removed, explaining in part for the slightly lower lung volumes. Unchanged size of the cardiac silhouette. Blood CX, BAL CX, stool CX, resp viral culture NGTD BRONCHIAL WASHINGS: [**2156-11-4**] 2:54 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE . GRAM STAIN (Final [**2156-11-4**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2156-11-6**]): NO GROWTH, <1000 CFU/ml. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2156-11-4**]): TEST CANCELLED, PATIENT CREDITED. This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (7-2306). Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2156-11-5**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2156-11-5**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): No Cytomegalovirus (CMV) isolated. [**2156-11-4**] 2:54 pm Rapid Respiratory Viral Screen & Culture BRONCHIAL LAVAGE . **FINAL REPORT [**2156-11-7**]** Respiratory Viral Culture (Final [**2156-11-7**]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [**Telephone/Fax (1) 6182**] within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final [**2156-11-5**]): Less than 60 columnar epithelial cells;. Specimen inadequate for detecting respiratory viral infection by DFA testing. Interpret all negative results from this specimen with caution. Negative results should not be used to discontinue precautions. Refer to respiratory viral culture results. Recommend new sample be submitted for confirmation. Reported to and read back by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 91500**] [**2156-11-5**] 1145. [**2156-11-8**] 9:34 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FECAL CULTURE (Pending): CAMPYLOBACTER CULTURE (Pending): CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2156-11-8**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). Time Taken Not Noted Log-In Date/Time: [**2156-11-5**] 4:10 pm BLOOD CULTURE BLOOD CULTURE ISOLATE FROM [**Location (un) **] [**Hospital1 **] FOR ID/S. **FINAL REPORT [**2156-11-7**]** ISOLATE FOR MIC (Final [**2156-11-7**]): STAPHYLOCOCCUS EPIDERMIDIS. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS EPIDERMIDIS | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN-------------<=0.25 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 2 S ISOLATE FOR MIC (Final [**2156-11-8**]): PSEUDOMONAS FLUORESCENS. sensitivity testing performed by Microscan. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS FLUORESCENS | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CEFTRIAXONE----------- <=4 S CIPROFLOXACIN--------- <=0.5 S GENTAMICIN------------ <=1 S IMIPENEM-------------- 8 I LEVOFLOXACIN---------- <=1 S MEROPENEM------------- 4 S PIPERACILLIN---------- 16 S PIPERACILLIN/TAZO----- <=8 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- S Legionella Urinary Antigen (Final [**2156-11-3**]): 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. Brief Hospital Course: 41 Yo F previously healthy presented with multifocal pneumonia requiring intubation; also with staph epidermidits and staph capitis bacteremia. # Acute Resp Failure/Multifocal Pneumonia: Patient was admitted with hypoxia and found to have multilobar pneumonia on chest xray. She was initially started on vanc/ceftriaxone/azithro for empiric coverage, however this was changed to vanc/cefepime/cipro when sputum cultures from [**Location (un) 620**] grew pseudoamonas florescans. All cultures here have been negative to date. Patient also had bronch to evaluate for possible other etiologies. All cultures from bronch are negative to date as well. The patient was extubated and transferred to the floor. While on the floor the patient developed a rash, thus her antibiotics were changed to vanco/cipro. The rash was presumably due to cefipime. The patient's antibiotics were discontined on [**2156-11-9**](10 days course). She should follow up with her PCP regarding pneumonia resolution. She will be discharged on albuterol and mucinex for symptomatic relief for her cough. . # Bacteremia: Cultures on presentation to [**Location (un) 620**] grew staph capitis and staph epidermidis. She had a TTE at [**Location (un) 620**] which suggested a vegetation on the chordae of the mitral valve. However, repeat TEE here not c/w endocarditis. All cultures here have been negative. She was continued on vancomycin for a total of 10 days. It is unclear whether the staph epidermidits and capitis were true infection or contaminant. ID followed the patient and initially recommended 14 days of antibiotics but given that overall it appeared that the patient had a superimposed pneumonia on top of a viral illness, that treating for a pneumonia for 10 days was adequate and that 14 days was not necessary. . #Drug rash The patient intially had a rash developed on her left inner thigh which was treated with miconazole. This rash progressed on [**2156-11-8**] to her abdomen as erythematous macules that coalesced the following day and spread to her chest arms and legs. She intermitently complained of pruritis which was treated with benadryl and [**Doctor First Name 130**]. She had some hoarseness on [**11-9**] but no SOB or other respiratory issues. She was observed for 24 hours and remained stable prior to discharge. . # Acute Renal Failure: Pt had sudden increase in creatinine from baseline 0.6 to 2.5 prior to transfer here. Creatinine continued to increase for several days before trending down. Her acute kidney injury was likely contrast nephropathy c/b NSAID overuse in setting of hypovolemia. Her urine output remained good, 50-75cc/hr. FeNa is 2.7% which is consistent with ATN/intrinsic process. Urine eosinophils negative. Her antibiotics were renally dosed. Her Cr trended down by discharge. She will need follow up Creatinine. . # Metabolic acidosis: Mixed gap and non-gap acidosis, likely secondary to renal failure and NaCl resuscitation. This has been improving and gap has closed. . # Anemia, NOS: Pt was noted to have hct decrease from 39 to 32 on admission, likely hemodilutional in setting of fluid resuscitation and possible marrow suppresion from infection. She remained stable with no signs of active bleeding. No signs of active bleeding. Trending down slowly presently. . # Anxiety/depression: pt was continued on home dose of wellbutrin . # Liver lesions incidentally noted on CT chest: likely simple cysts given hounsfield units similar to water, however her LFTs remain midly elevated. Pt should have outpatient work-up for etiology of elevated LFTs and liver lesions with imaging once her renal function recovers. . Pt was full code. Addendum: ID recommended one more dose of vancomycin IV today prior to discharge so she received 11 days of vancomycin. Medications on Admission: Wellbutrin 100 SR [**Hospital1 **] Discharge Medications: 1. bupropion HCl 100 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO BID (2 times a day). 2. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day): to groin. Disp:*1 bottle* Refills:*0* 3. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as needed for sob/cough. Disp:*30 puffs* Refills:*0* 5. Guaifenesin DM 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. Disp:*100 ML(s)* Refills:*0* 6. Outpatient Lab Work please draw a CBC and basic metabolic panel prior in 1 week and fax to Dr. [**Last Name (STitle) **] Discharge Disposition: Home Discharge Diagnosis: Multifocal pneumonia Respiratory failure Acute Kidney Injury/ATN Acidosis Liver lesions of unknown significance cefipime induced drug rash Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with multifocal pneumonia causing respiratory failure and requiring intubation. You also had a bacteremia. With antibiotics your symptoms have improve. You will stop your antibitoics prior to discharge. Your kidneys were also injured during your illness and will need close monitoring to ensure proper recovery. Please do NOT use NSAID medications during this time. You also developed a antibiotic induced drug rash. This shoudl improved over time. You should not take keflex or other antibiotics in that family again. Finally, you were found to have liver lesions of unknown significance. Once your kidneys recover, we recommend CT scan to further evaluate. Medication changes: Miconazole powder to groin four times per day until rash resolves [**Doctor First Name 130**] prn albuterol prn guafenesin prn Followup Instructions: PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 6715**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 31529**] - as soon as possible Follow up with Liver specialist following repeat imaging of liver

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icd9cm

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icd9pcs

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27360+57538

Discharge summary

report+addendum

Admission Date: [**2201-3-31**] Discharge Date: [**2201-4-4**] Date of Birth: [**2148-1-2**] Sex: M Service: CARDIOTHORACIC Allergies: Statins-Hmg-Coa Reductase Inhibitors Attending:[**First Name3 (LF) 1505**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Coronary artery disease s/p Cornary artery bypass graftx4 (LIMA-LAD, SVG to diagonal, obtuse marginal, posterior diagonal; mitral valve repair. History of Present Illness: History of Present Illness: 53 year old male with progressive anginal symptoms (chest pain with walking) and history of coronary disease. In [**2193**] he had a ST elevation myocardial infarction which was treated with TNK and received a bare metal stent in the LAD. In [**2195-5-19**] he underwent placement of drug-eluting cypher stents in the diagonal branch of LAD, proximal circumflex and distal RCA. He has also undergone ballon angioplasty of totally occluded distal circumflex. He has done well until recently developing symptoms and stress test in [**2200-9-18**] revealed new area of inferoseptal ischemia. Cath revealed three vessel coronary disease and he was referred for surgical management. Past Medical History: Past Medical History -Coronary artery disease with ST elevation myocardial infarction [**2193**] (bare-metal stent in LAD) and cypher stents to diagonal branch of LAD, prox circumflex, distal RCA and PTCA of totally occluded LCX in [**2194**] -Hyperlipidemia -Right knee pain with torn ACL Past Surgical History: -Right knee surgery Social History: Race: Caucasian Last Dental Exam: 1 month ago Lives with: Wife (divorced after 20 years and remarried) Occupation: Engineer with GE Tobacco: never smoked ETOH: occ. use ([**2-19**]/wk) Enrolled in any clinical/research study? Family History: Family History: Father died of MI at age 51. Physical Exam: Review of Systems General: Weight changes Skin: Eczema [X] Psoriasis [] Skin Cancer [] Other: Denies[] HEENT: Hearing aide(s) [] Glasses [] Other: Denies[X] Respiratory: Asthma [] COPD [] Pneumonia [] Cough [] Sputum [] Other: Denies [X] Cardiac: Chest pain [X] SOB [] DOE [X] Orthopnea [] PND [] Other: admits to chest pain at rest GI: Nausea [] Vomiting [] Diarrhea [] Constipation [] Heartburn/GERD [] Other: Denies [X] GU: Dysuria [] Frequency [] Prostate [] GYN [] other: Denies [X] Musculoskeletal: Arthritis [] Other: Denies [X] Peripheral Vascular: Claudication [] Other: Denies [X] Psych: anxiety [] depression [] Other: Denies [X] Endocrine: Diabetes [] thyroid [] Other: denies [X] Heme/ID: Denies [X] Neuro: TIA [] CVA [] Neuropathy [] Seizures [] Other: Denies [X] Physical Exam Pulse: 59 Resp: 16 O2 sat: 99% B/P Right: 124/85 Left: 132/88 Height: 6'2" Weight: 265 lbs General: well-developed male in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema: none Varicosities: superficial bilateral 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: none Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 8021**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 67038**] (Complete) Done [**2201-3-31**] at 3:36:38 PM PRELIMINARY 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: [**2148-1-2**] Findings LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PFO is present. Left-to-right shunt across the interatrial septum at rest. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild regional LV systolic dysfunction. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal aortic arch diameter. Focal calcifications in aortic arch. Normal descending aorta diameter. Focal calcifications in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with focalities in the inferior wall. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on Mr.[**Known lastname **] before CPB. Post_Bypass: 1. Preserved biventricular systolic function 2. Intact aorta 3. No other change [**2201-4-4**] 06:40AM BLOOD WBC-8.2 RBC-4.28* Hgb-12.6* Hct-36.7* MCV-86 MCH-29.5 MCHC-34.5 RDW-12.9 Plt Ct-289 [**2201-4-4**] 06:40AM BLOOD Glucose-96 UreaN-17 Creat-1.1 Na-139 K-4.4 Cl-98 HCO3-30 AnGap-15 Brief Hospital Course: Mr. [**Known lastname **] was admitted on [**2201-3-31**] and taken to the operating room for revascularization. See operative note for details. Immediately post-operatively he remained intubated and was admitted to the ICU for ongoing post-operative care. He awoke neurologically intact was weaned from the ventilator and extubated on the evening of POD#0. He remained hemdynamically stable and was started on betablocker, lasix and statin therapy. He was transferred to the step down unit for ongoing post-operative care. His Lasix was discontinued due to autodiuresis. His chest tubes and temporary pacing wired were removed per protocol. Lopressor was titrated up. Mr. [**Known lastname **] was evaluated by physical therapy for strength and conditioning. At the time of discharge he was tolerating a full oral diet, his incisions were healing well and he was ambulating well. He was cleared for discharge to home with visiting nurse services by Dr. [**Last Name (STitle) **] on POD#4. Medications on Admission: Medications at home: Plavix 75mg qd (stopped 2 weeks ago) Aspirin81 mg qd Lisinopril 2.5mg qd Toprol XL 50mg qd Lopid 600mg [**Hospital1 **] Multivitamins Plavix - last dose: stopped 2 weeks ago Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever. 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: [**12-20**] Tablets PO Q6H (every 6 hours) as needed for pain: do not exceed six tablets in 24 hours. Disp:*30 Tablet(s)* Refills:*0* 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1376**] Discharge Diagnosis: Coronary artery disease -s/p multiple stents and now Cornary artery bypass graftx4 (LIMA-LAD, SVG to diagonal, obtuse marginal, posterior diagonal; mitral valve repair, hyperlipidemia, Right knee surgery Discharge Condition: alert and oriented ambulatory pain controlled with Darvocet/Ultram PRN Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Please call to schedule appointments Primary Care Dr. [**Last Name (STitle) **] in [**12-20**] weeks Cardiologist Dr [**First Name (STitle) **] [**Name (STitle) **] in [**12-20**] weeks Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Completed by:[**2201-4-4**] Name: [**Known lastname 1193**],[**Known firstname **] Unit No: [**Numeric Identifier 11629**] Admission Date: [**2201-3-31**] Discharge Date: [**2201-4-4**] Date of Birth: [**2148-1-2**] Sex: M Service: CARDIOTHORACIC Allergies: Statins-Hmg-Coa Reductase Inhibitors Attending:[**First Name3 (LF) 741**] Addendum: Discharge summary ammended to read that surgery undertaken on [**2201-3-31**] was Coronary artery disease s/p Cornary artery bypass graftx4 (LIMA-LAD, SVG to diagonal, obtuse marginal, posterior diagonal). Chief Complaint: chest pain Major Surgical or Invasive Procedure: Coronary artery disease s/p Cornary artery bypass graftx4 (LIMA-LAD, SVG to diagonal, obtuse marginal, posterior diagonal History of Present Illness: 53 year old male with progressive anginal symptoms (chest pain with walking) and history of coronary disease. In [**2193**] he had a ST elevation myocardial infarction which was treated with TNK and received a bare metal stent in the LAD. In [**2195-5-19**] he underwent placement of drug-eluting cypher stents in the diagonal branch of LAD, proximal circumflex and distal RCA. He has also undergone ballon angioplasty of totally occluded distal circumflex. He has done well until recently developing symptoms and stress test in [**2200-9-18**] revealed new area of inferoseptal ischemia. Cath revealed three vessel coronary disease and he was referred for surgical management. Past Medical History: Past Medical History -Coronary artery disease with ST elevation myocardial infarction [**2193**] (bare-metal stent in LAD) and cypher stents to diagonal branch of LAD, prox circumflex, distal RCA and PTCA of totally occluded LCX in [**2194**] -Hyperlipidemia -Right knee pain with torn ACL Past Surgical History: -Right knee surgery Social History: Race: Caucasian Last Dental Exam: 1 month ago Lives with: Wife (divorced after 20 years and remarried) Occupation: Engineer with GE Tobacco: never smoked ETOH: occ. use ([**2-19**]/wk) Family History: Family History: Father died of MI at age 51. Physical Exam: Pulse: 59 Resp: 16 O2 sat: 99% B/P Right: 124/85 Left: 132/88 Height: 6'2" Weight: 265 lbs General: well-developed male in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema: none Varicosities: superficial bilateral Neuro: Grossly intact [X] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) **]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right/Left: none Pertinent Results: [**Hospital1 8**] ECHOCARDIOGRAPHY REPORT [**Known lastname 1193**], [**Known firstname **] [**Hospital1 8**] [**Numeric Identifier 11630**] (Complete) Done [**2201-3-31**] at 3:36:38 PM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 8**], Division of Cardiothorac [**Hospital Unit Name 11631**] [**Location (un) 42**], [**Numeric Identifier 5891**] Status: Inpatient DOB: [**2148-1-2**] Age (years): 53 M Hgt (in): 75 BP (mm Hg): 100/80 Wgt (lb): 260 HR (bpm): 50 BSA (m2): 2.46 m2 Indication: coronary artery disease ICD-9 Codes: 402.90 Test Information Date/Time: [**2201-3-31**] at 15:36 Interpret MD: [**Name6 (MD) 5893**] [**Name8 (MD) 5894**], MD Test Type: TEE (Complete) Son[**Name (NI) 5895**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5894**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW04-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.6 cm <= 4.0 cm Left Atrium - Four Chamber Length: 4.6 cm <= 5.2 cm Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 45% >= 55% Left Ventricle - Stroke Volume: 49 ml/beat Left Ventricle - Cardiac Output: 2.47 L/min Left Ventricle - Cardiac Index: *1.00 >= 2.0 L/min/M2 Aorta - Ascending: 3.4 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 13 Aortic Valve - LVOT diam: 2.2 cm Findings LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PFO is present. Left-to-right shunt across the interatrial septum at rest. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild regional LV systolic dysfunction. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Focal calcifications in ascending aorta. Normal aortic arch diameter. Focal calcifications in aortic arch. Normal descending aorta diameter. Focal calcifications in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. The patient appears to be in sinus rhythm. Resting bradycardia (HR<60bpm). Results were personally reviewed with the MD caring for the patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: The left atrium is normal in size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with focalities in the inferior wall. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on Mr.[**Known lastname **] before CPB. Post_Bypass: 1. Preserved biventricular systolic function 2. Intact aorta 3. No other change I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [**Name6 (MD) 5893**] [**Name8 (MD) 5894**], MD, Interpreting physician Brief Hospital Course: Mr. [**Known lastname **] was admitted on [**2201-3-31**] and taken to the operating room for revascularization. See operative note for details. Immediately post-operatively he remained intubated and was admitted to the ICU for ongoing post-operative care. He awoke neurologically intact was weaned from the ventilator and extubated on the evening of POD#0. He remained hemdynamically stable and was started on betablocker, lasix and statin therapy. He was transferred to the step down unit for ongoing post-operative care. His Lasix was discontinued due to autodiuresis. His chest tubes and temporary pacing wired were removed per protocol. Lopressor was titrated up. Mr. [**Known lastname **] was evaluated by physical therapy for strength and conditioning. At the time of discharge he was tolerating a full oral diet, his incisions were healing well and he was ambulating well. He was cleared for discharge to home with visiting nurse services by Dr. [**Last Name (STitle) **] on POD#4. Medications on Admission: Plavix 75mg qd (stopped 2 weeks ago) Aspirin81 mg qd Lisinopril 2.5mg qd Toprol XL 50mg qd Lopid 600mg [**Hospital1 **] Multivitamins Plavix - last dose: stopped 2 weeks ago Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever. 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: [**12-20**] Tablets PO Q6H (every 6 hours) as needed for pain: do not exceed six tablets in 24 hours. Disp:*30 Tablet(s)* Refills:*0* 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 3546**] Discharge Diagnosis: Coronary artery disease -s/p multiple stents and now Coronary artery bypass graftx4 (LIMA-LAD, SVG to diagonal, obtuse marginal, posterior diagonal; hyperlipidemia, Right knee surgery Discharge Condition: alert and oriented ambulatory pain controlled with Darvocet/Ultram PRN Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 1477**] Followup Instructions: Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 1477**] Please call to schedule appointments Primary Care Dr. [**Last Name (STitle) 11632**] in [**12-20**] weeks ([**Telephone/Fax (1) 11633**] Cardiologist Dr [**First Name (STitle) **] [**Name (STitle) 11634**] in [**12-20**] weeks ([**Telephone/Fax (1) 11635**] Wound check appointment - [**Hospital Ward Name **] 6 ([**Telephone/Fax (1) 2440**]) - your nurse will schedule [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2201-4-4**]

[ "272.4", "412", "413.9", "V45.89", "V45.82", "414.01", "787.02" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

19836, 19887

17467, 18464

10624, 10748

20116, 20190

12793, 16046

20672, 21244

12048, 12079

18690, 19813

19908, 20095

18490, 18667

20214, 20649

7366, 7543

11791, 11813

16095, 17444

12094, 12774

10574, 10586

10776, 11456

11478, 11768

11829, 12016

9,517

118,208

10691

Discharge summary

report

Admission Date: [**2116-5-11**] Discharge Date: [**2116-5-16**] Date of Birth: [**2049-11-28**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: aortic valve replacement (tissue) via redo sternotomy [**2116-5-11**] History of Present Illness: Mr. [**Known lastname 35028**] is a 66-year-old male who, 5 years earlier, underwent a triple vessel bypass for coronary artery disease. He has been suffering worsening symptoms of shortness of breath and chest tightness, and underwent evaluation that showed that critical aortic stenosis. Cardiac catheterization confirmed patent grafts with confirmation of the aortic stenosis. He is presenting for redo surgery and aortic valve replacement. Past Medical History: CAD s/p CABG '[**10**] ([**Doctor Last Name **]) with RLE SVG to OM s/p PCI stent '[**11**] DM type 2 HTN hyperlipidemia hypothyroid anemia rheumatoid arthritis R knee DJD s/p R nephrectomy '[**03**] s/p appendectomy s/p colon polypectomy Social History: retired buyer, lives with wife. former tobacco, 1ppd x20years, quit 20y ago. Denies alcohol. Family History: Father died from MI at 67yo Physical Exam: Pre-op: 61, 156/65, 19. 5'6", 210 lbs. WD WN in NAD HEENT unremarkable CTAB, no wheezes RRR. + murmur. + L carotid bruit. soft, NT, ND, +BS WWP, no C/C/E. DP 1+ BL. Pertinent Results: [**2116-5-11**] 11:59AM BLOOD WBC-21.3*# RBC-2.17* Hgb-7.2* Hct-21.8* MCV-100* MCH-33.1* MCHC-33.0 RDW-17.6* Plt Ct-117* [**2116-5-11**] 12:52PM BLOOD WBC-39.7*# RBC-3.14*# Hgb-10.6*# Hct-30.1*# MCV-96 MCH-33.7* MCHC-35.1* RDW-17.9* Plt Ct-105* [**2116-5-12**] 03:13AM BLOOD WBC-26.3* RBC-3.35* Hgb-11.1* Hct-31.3* MCV-93 MCH-33.0* MCHC-35.4* RDW-18.6* Plt Ct-103* [**2116-5-15**] 03:15AM BLOOD WBC-14.4* RBC-3.20* Hgb-10.3* Hct-29.7* MCV-93 MCH-32.1* MCHC-34.5 RDW-17.8* Plt Ct-143* [**2116-5-11**] 11:59AM BLOOD Plt Ct-117* [**2116-5-15**] 03:15AM BLOOD Plt Ct-143* [**2116-5-11**] 11:59AM BLOOD PT-19.7* PTT-38.5* INR(PT)-1.9* [**2116-5-14**] 02:12AM BLOOD PT-13.1 PTT-29.9 INR(PT)-1.1 [**2116-5-11**] 06:10PM BLOOD Glucose-179* UreaN-32* Creat-1.4* Na-141 K-5.0 Cl-111* HCO3-19* AnGap-16 [**2116-5-13**] 12:50AM BLOOD Glucose-125* UreaN-47* Creat-2.7* Na-139 K-4.6 Cl-108 HCO3-22 AnGap-14 [**2116-5-14**] 02:12AM BLOOD Glucose-104 UreaN-42* Creat-2.1* Na-138 K-4.0 Cl-105 HCO3-22 AnGap-15 [**2116-5-16**] 05:05AM BLOOD Glucose-112* UreaN-42* Creat-2.0* Na-138 K-4.9 Cl-102 HCO3-28 AnGap-13 Brief Hospital Course: 66yo M admitted to cardiac surgery service after undergoing AVR with 21mm pericardial valve via redo sternotomy on [**2116-5-11**]; please see operative note for details. Post-operatively the pt was brought to the CSRU intubated, with chest and mediastinal tubes in place, epicardial pacing wires, on low-dose pressors. That evening he was successfully extubated and weaned off pressors. The chest tubes were removed on POD 1 as the output volume was suffuciently low. The creatine peaked on POD 2 at 2.7 and gradually declined over the remainder of the admission. Two units of blood transfusion were needed on POD 2 for symptomatic anemia, and diuretics were maintained with caution. The swan-ganz catheter was able to be removed when no longer needed, and the patient was transferred to the floor on telemetry on POD 3 after the pacing wires were removed per protocol. Both beta- and calcium-channel blockers were initiated for hypertensive control. Atrial fibrillation with stable hemodynamics occurred on POD 4 and was treated with amiodarone with successful cardioversion. The patient was tolerating a regular diet with good hyperglyemic control with oral agents, was voiding on his own, and participated with physical therapy for cardiac rehab at the time on discharge on POD 5. Medications on Admission: ecotrin 325' zocor 20' atenolol 50' levothyroxine 100' glyburide 2.5' methotrexate 10qwk leucovorin 10 12h post-methotrexate folate humira injection coenzyme q10 Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation: while taking narcotics to prevent constipation. Disp:*60 Capsule(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Glyburide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Methotrexate 2.5 mg Tablet Sig: Four (4) Tablet PO 1X/WEEK (MO). Disp:*30 Tablet(s)* Refills:*2* 9. Leucovorin Calcium 5 mg Tablet Sig: Two (2) Tablet PO 12 HOURS AFTER METHOTREXATE (). Disp:*30 Tablet(s)* Refills:*2* 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 6138**] Home Care Services Discharge Diagnosis: aortic stenosis atrial fibrillation coronary atherosclerotic disease diabetes mellitus type 2 rheumatoid arthritis hyperlipidemia hypothyroid chronic renal insufficiency Discharge Condition: stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) You may wash incision and gently pat dry. No swimming or bathing until [**Location (un) **] has healed. No lotions, creams or powders to incision until it has healed. 5) No driving for 1 month. 6) No lifting greater then 10 pounds for 10 weeks. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 4 weeks. Call [**Telephone/Fax (1) 170**] for an appointment. Follow-up with your primary care physician and cardiologist in 2 weeks. Call for an appointment.

[ "714.0", "396.2", "414.00", "244.9", "403.91", "250.00", "V45.81", "V10.53", "427.31", "272.4", "285.9" ]

icd9cm

[ [ [] ] ]

[ "88.72", "99.04", "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

5764, 5838

2622, 3914

342, 414

6052, 6061

1504, 2599

6563, 6775

1275, 1304

4126, 5741

5859, 6031

3940, 4103

6085, 6540

1319, 1485

283, 304

442, 887

909, 1149

1165, 1259

11,881

168,185

26492

Discharge summary

report

Admission Date: [**2136-12-20**] Discharge Date: [**2136-12-23**] Date of Birth: [**2072-4-16**] Sex: M Service: MEDICINE Allergies: Bactrim Ds / Blood-Group Specific Substance Attending:[**First Name3 (LF) 6169**] Chief Complaint: transfer from OSH for DLI infusion. History of MRSA bacteremia, [**Hospital 16486**] transferred to [**Hospital Unit Name 153**] overnight for stabilization, being transferred back after improvement in heart rate. Major Surgical or Invasive Procedure: DLI Blood transfusions Platelet transfusions History of Present Illness: Mr. [**Known lastname **] is a 64 y/o man with relapsed AML, s/p allo-BMT in [**5-26**] who presented to OSH on [**12-17**] with shaking chills which started abruptly during the day. No c/o HA, cough, N/V. + diarrhea, bleeding from nares/hemorrhoids. Temp was 102 on admission, spiked as high as 103.7. Started on Imipenem/Azithromycin on admission. On [**12-18**], found to be growing GPC in [**2-23**] blood cultures from admission, started on Vancomycin that day. Evidence of pneumonia on CXR, which intervally improved during the hospital course. Developed Afib with RVR in 160s, shortness of breath which responded well to diltiazem drip. ECG showed Afib with RVR and cardiac enzymes have been negative. . Hydrea was started on [**12-17**] for elevated WBC. Blasts 97%. . On review of systems, the patient denies any chest pain, shortness of breath, night sweats, fevers, chills, weight loss, headaches, dizziness, blurred vision, sore throat, nausea, vomiting, abdominal pain, any new rashes, denies dysuria, hematuria, increased urgency, diarrhea, constipation, hematochezia, melena, epistaxis. All other systems reviewed in detail and negative except for what has been mentioned above. . He was transferred to the [**Hospital Unit Name 153**] for stabilization overnight with heart rate unresponsive to dilt drip and worsening tachypnea. He was diuresed with lasix and transitioned to PO metoprolol with some improvement. Creatinine has increased slightly to 1.9 . On arrival to the floor, he was not significantly short of breath, and was feeling better than when he go to the hospital. Past Medical History: Onc Hx: [**11/2135**]: slow onset of dyspnea and fatigue, with 1 mo of easy bruisability. No focal bony tenderness. Routine CBC, showed thrombocytopenia (25,000) & anemia. WBC was 5300 with 26% blasts. BM biopsy showed markedly hypercellular marrow with undifferentiated blast forms, expressing CD 34, and HLA-DR. [**Last Name (STitle) **] negative for CD 13 and 33. Chromosome analysis revealed trisomy 8. No adenopathy or splenomegaly. [**12/2135**]: Admitted to [**Hospital6 16029**] for induction chemotherapy with 7+3 (idarubicin). Day #14 bone marrow was aplastic. Course c/b coag neg staph line infection [**2136-1-25**]: BM biopsy showed complete remission. [**2-27**]: 1st cycle ara-C consolidation; course c/b line infection and bacteremia, and c. difficile collitis [**3-26**]: 2nd cycle ara-C consolidation; course c/b c. difficile collitis and prolonged hospitalization, followed by viral gastroenteritis. . PMHx: AML as above CAD s/p MI 5 yrs ago with stent placement GERD BPH s/p L4/5 discectomy with persistent radiculopathy (L) h/o A fib without recurrence (2 years ago) seasonal allergies Social History: Married with 2 sons ages 35 and 37; lives with wife outside of [**Name (NI) 5583**]. They have a 9 yr old [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Terrier that is a yard and house dog. Works as a VP for [**Hospital1 11485**] Physicians' organization. He was formerly in the military where he worked as an ordinance officer and was exposed to nuclear weapons. No tobacco, occasional EtOH. No other drug use. Family History: No family history of hematologic malignancy. Physical Exam: VS: T: 99.8 HR: 111 BP: 115/70 RR: 28 Sat: 97 on 10L face mask Gen: Appears in mild distress, tachypneic HEENT: NCAT, PERRL, Sclera anicteric, No ulcers, oropharynx otherwise clear, throat with no erythema or exudates, no thrush, no cervical lymphadenopathy, JVP is elevated CV: tachycardic, irregularly irregular, difficult to assess S1/S2, no tenderness to palpation of precordium, PMI non-displaced Lungs: Diffuse rhonchi Abdomen: Soft, nontender, nondistended, normoactive bowel sounds, no hepatosplenomegaly, pitting edema in flanks Ext: 1+ peripheral edema, no clubbing, cyanosis, no calf pain, DP pulses are 2+ bilaterally, petechiae on lower extremities Neuro: A + O x 3, CN II-XII grossly intact, Motor [**5-25**] both upper and lower extremities, Sensation grossly intact to light touch, DTR 2+ throughout, Toes downgoing Skin: pink, warm, no rashes Pertinent Results: [**2136-12-20**] 09:59PM TYPE-ART RATES-/36 PO2-52* PCO2-25* PH-7.47* TOTAL CO2-19* BASE XS--2 [**2136-12-20**] 09:59PM LACTATE-0.9 [**2136-12-20**] 07:34PM URINE HOURS-RANDOM CREAT-75 SODIUM-42 POTASSIUM-19 CHLORIDE-69 TOT PROT-89 PROT/CREA-1.2* [**2136-12-20**] 07:34PM URINE OSMOLAL-408 [**2136-12-20**] 07:34PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005 [**2136-12-20**] 07:34PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2136-12-20**] 07:34PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [**2136-12-20**] 07:34PM URINE EOS-NEGATIVE [**2136-12-20**] 07:09PM GLUCOSE-105 UREA N-28* CREAT-1.8* SODIUM-127* POTASSIUM-3.4 CHLORIDE-98 TOTAL CO2-19* ANION GAP-13 [**2136-12-20**] 07:09PM estGFR-Using this [**2136-12-20**] 07:09PM ALT(SGPT)-13 AST(SGOT)-12 LD(LDH)-367* ALK PHOS-30* TOT BILI-0.7 [**2136-12-20**] 07:09PM ALBUMIN-3.1* CALCIUM-8.0* PHOSPHATE-3.0 MAGNESIUM-2.0 URIC ACID-5.4 [**2136-12-20**] 07:09PM WBC-22.8*# RBC-2.64* HGB-7.9* HCT-22.5* MCV-85# MCH-30.0 MCHC-35.2* RDW-16.9* [**2136-12-20**] 07:09PM NEUTS-1.0* LYMPHS-1.0* MONOS-1.0* EOS-0 BASOS-0 BLASTS-97.0* [**2136-12-20**] 07:09PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2136-12-20**] 07:09PM PLT SMR-VERY LOW PLT COUNT-10* [**2136-12-20**] 07:09PM PT-13.4* PTT-27.4 INR(PT)-1.2* . Admission CXR: : Bibasilar opacities, which may represent atelectasis, although pneumonia cannot be excluded. Brief Hospital Course: This is a 64 year old man with relapsed [**Hospital **] transferred to [**Hospital1 18**] from OSH after being admitted for febrile neutropenia, found to have MRSA bacteremia, pneumonia, course complicated by Afib with RVR, acute renal failure, short course in the MICU. . # AML relapse: Very high blast count (95-98%), received DLI on [**2136-12-21**]. He was started on hydroxyurea as well as stress dose steroids, which should be continued at the discretion of his outpatient oncologist. He was transfused as needed for blood and platelets. He was also continued on allopurinol and hydroxyurea. His uric acid was low at time of discharge. . # Bacteremia/Pneumonia: MRSA bacteremia, still febrile on broad spectrum antibiotics, vancomycin, imipenem and azithromycin. Caspofungin was started ([**2136-12-20**]) to cover for fungal source of the fever. Vancomycin was renally dosed. He was started on standing tylenol 1g q6h to prevent fever and subsequent afib with rvr. Ativan prn for shortness of breath. Blood and urine cultures with no growth to date at time of discharge. . # Acute Renal Failure: Likely [**2-23**] Afib/flutter with RVR causing CHF with poor forward flow. Minimized fluids, patient was given blood in lieu of fluids. He was given IV Lasix, to help with diuresis, and his creatinine was monitored closely. It was increasing at the time of discharge, but it was felt that given his tenuous breathing situation, diuresis was important. . # A.fib/flutter: Initally, patient was on a diltiazem drip on admission, which had controlled his rate during his past hospitalization. Initally it was controlling his rate, but then he was persistently in the 140s near the limit of diltiazem. He was transitioned to an esmolol drip, and then eventually to metoprolol PO, which helped maintain his heart rate in the 110. However, his rate climbed into the 150's the following day, so he was sent back to the ICU where he was loaded with amiodarone and also started on a diltiazem drip. With the amio load, diltiazem drip, and maximum doses of metoprolol 100 TID, his rates came down to 94. . # CAD: Concern for tachycardia induced ischemia, titrate heart rate to < 90. Holding aspirin as he is thrombocytopenic. His Ck and Troponin did not bump. . # Diarrhea: History of C. diff, send stool for C. diff. - Still pending. . # FEN: neutropenic cardiac diet. . # Code: DNR/DNI, confirmed with Dr. [**First Name (STitle) 1557**] and patient . # Communication: With patient and wife. . # Dispo: transfer to [**Last Name (LF) 11485**], [**First Name3 (LF) **] Dr. [**Last Name (STitle) 65448**] [**Telephone/Fax (1) 65449**]. Medications on Admission: Ursodiol OxyContin acyclovir fluconazole metoprolol nifedipine Anusol prednisone 10 mg p.o. daily Flonase temazepam danazol 200 mg p.o. b.i.d. Levitra p.r.n. Pentamidine Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO EVERY OTHER DAY (Every Other Day). 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 3. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal QD PRN (). 4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Caspofungin 50 mg IV Q24H 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 8. Hydrocortisone Na Succ. 100 mg IV Q8H 9. Meropenem 1000 mg IV Q12H 10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 11. Morphine Sulfate 1-2 mg IV Q4-6H:PRN Hold for sedation or RR < 12. 12. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous daily as needed for Dose for Level < 20. 13. Diltiazem HCl 5 mg/mL Solution Sig: One (1) Intravenous INFUSION (continuous infusion). 14. Amiodarone 50 mg/mL Solution Sig: One (1) Intravenous INFUSION (continuous infusion) for 18 doses: please continue for 12 more hours for a total of 18 hours. 15. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 17. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Discharge Diagnosis: 1. Fever/Neutropenia 2. MRSA bacteremia 3. Acute Renal Failure 4. Atrial fibrillation/flutter with rapid ventricular rate Discharge Condition: Stable Discharge Instructions: You were admitted for breathing fast and increasing blast count. We have increased the dose of your beta blocker, put you on an amio load and a diltiazem drip and started a new antibiotic. . Please call your doctor if you are having chest pain, shortness of breath, abdominal pain, bleeding from nose or stools, palpitations, inability to urinate. Followup Instructions: Please make an appointment to follow up with your primary oncologist within the next three days.

[ "284.8", "272.0", "518.81", "V09.0", "250.00", "414.00", "E878.0", "600.00", "205.00", "780.6", "486", "996.85", "530.81", "790.7", "427.31", "288.00", "787.91", "584.9", "428.0", "041.11" ]

icd9cm

[ [ [] ] ]

[ "99.05", "99.04" ]

icd9pcs

[ [ [] ] ]

10688, 10703

6302, 8941

521, 567

10869, 10878

4732, 6279

11274, 11374

3790, 3836

9161, 10665

10724, 10848

8967, 9138

10902, 11251

3851, 4713

267, 483

595, 2193

2215, 3324

3340, 3774

20,698

176,962

10886

Discharge summary

report

Admission Date: [**2183-4-21**] Discharge Date: [**2183-4-23**] Date of Birth: [**2121-9-5**] Sex: F Service: NSU HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old woman with a history of right internal carotid artery stenosis of 75 to 80 percent, and left internal carotid artery stenosis of 65 to 70 percent, and an aneurysm of 3.5 mm from the anterior communicating artery which she had coiled in [**2183-2-10**]. She comes in now for left internal carotid artery stent placement for carotid stenosis. PHYSICAL EXAMINATION: The patient was in no acute distress. Mental status revealed she was pleasant, cooperative, and attentive. Cardiovascular examination revealed a regular rate and rhythm with a 3 plus carotid bruit on the right. The chest was clear to auscultation with fine crackles at the base which cleared with cough. The abdomen was soft and nontender. Extremities revealed no edema. The pulses were dopplerable. The pupils were equal, round, and reactive to light. The face was symmetric. Right lip decreased with smile. The tongue was midline. SUMMARY OF HOSPITAL COURSE: The patient was admitted status post left carotid artery stent placement without intraoperative complications. She was monitored in the Intensive Care Unit overnight. She had sheaths in place that were removed on post procedure day one with no groin hematoma. Her vital signs remained stable. She had no changes in mental status. She was transferred to the regular floor on post procedure day one in stable condition. DISCHARGE DISPOSITION: Discharged to home on post procedure day two with a prescription for Plavix and aspirin as well as follow up with Dr. [**Last Name (STitle) 1132**] in two weeks. CONDITION ON DISCHARGE: Stable at the time of discharge. Her groin site was clean, dry, and intact. [**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], MD [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 6583**] MEDQUIST36 D: [**2183-4-23**] 16:54:30 T: [**2183-4-24**] 12:08:08 Job#: [**Job Number 35427**]

[ "433.10", "295.62", "496", "414.01", "530.81", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "39.90", "39.50" ]

icd9pcs

[ [ [] ] ]

1578, 1742

1130, 1554

559, 1101

163, 536

1767, 2101

2,807

151,250

12686

Discharge summary

report

Admission Date: [**2175-8-15**] Discharge Date: [**2175-9-6**] Date of Birth: [**2108-8-31**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 301**] Chief Complaint: left-lower quadrant hernia, symptomatic Major Surgical or Invasive Procedure: laparoscopic converted to open ventral hernia repair, small bowel resection for incarcerated ischemic small bowel with primary anastamosis, and component release of anterior abdominal wall, [**2175-8-15**]. percutaneous tracheostomy [**2175-8-21**] broncheoalveolar lavage [**2175-8-25**] History of Present Illness: 67yo F reports undergoing multiple repairs of ventral hernias throughout her abdomen over the past ten years, including left-upper quadrant, umbilical, and midline. She has had symptoms from the left lower quadrant, where a hernia was appreciated during an outpatient referral measuring ~10x15cm on exam. She presents for elective repair of these symptomatic hernias. Past Medical History: COPD/emphysema from smoking IDDM depression s/p ventral hernia repair, open, with mesh, multiple. s/p appendectomy s/p TAH/BSO Social History: + tobacco, 1ppd Physical Exam: In clinic: A&Ox3, NAD. VSS supple neck coarse BS decreased at bases BL RRR, no M/G. soft, NT, no R/G. large reducible hernias in LLQ, largest 10x15cm. FROM x4 extremities, nl gait and station. Pertinent Results: [**2175-9-6**] 06:05AM BLOOD WBC-6.4 RBC-3.41* Hgb-9.7* Hct-31.0* MCV-91 MCH-28.4 MCHC-31.2 RDW-15.0 Plt Ct-454* [**2175-9-6**] 06:05AM BLOOD Glucose-43* UreaN-16 Creat-0.6 Na-142 K-4.1 Cl-102 HCO3-32 AnGap-12 [**2175-9-6**] 06:05AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.4 [**2175-9-5**] 05:33AM BLOOD Type-ART pO2-94 pCO2-54* pH-7.41 calHCO3-35* Base XS-7 Brief Hospital Course: 67yo female was admitted to the Minimally Invasive Surgiery (MIS) service post-operatively on [**2175-8-15**]. Please see operative report for details. In brief, laparoscopic hernia repair was attempted but converted to open repair due to incarcerate small bowel in the hernia. After dissection of the incarcerated bowel off the mesh, an area of ischemic bowel was appreciated, resected, and anastamosed primarily. Plastic surgery consult was obtained intra-operatively for assistance with closure and a component release procedure was performed. 2 JP bulbs were left in as drains. Neuro: initially on propofol while intubated, subsequently treated with morphine and later roxicet. Occassional agitation was treated with haldol. Cardiovascular: HTN treated with lopressor and hydralazine. After a desaturation episode, an EKG was suspicious for ST changes but cardiac enzymes were cycled and negative. Respiratory: Post-operatively the pt remained in the PACU and intubated. She was successfully extubated on POD 1 but subsequently developed respiratory distress on POD 2 and was re-intubated. She was then transferred to the SICU and followed with the ICU team. She proved very difficult to wean off the ventilator, probably due to her smoking history and COPD/emphysema, and ultimately underwent a percutaneous tracheostomy on [**2175-8-21**], POD 6. Ultimately she was able to tolerate a vent wean bu POD 18, remained on trach collar x48h, and was transferred to the floor. There an episode of respiratory distress, tachypnea, and desaturation was relieved with suctioning, presumably due to mucous plug, and she was returned to the ICU. Vent supported overnight and returned to trach collar by the next day. A pulmonary consult was also obtained. She continued to receive chest pt, inhalers and nebulizers. A speech/swallow consult provided a Passy-Muir valve and she successfully passed a bedside swallow evaluation. GI/FEN: initially kept NPO but diet was later begun with promote with fiber, advanced easily to goal, via a dobhoff nasogastric tube. After passing swallow exam, begun on PO diabetic diet. GU: Foley d/c'd on POD 20 and pt voided successfully. UTI treated with levaquin. Heme: Progressive hematocrit fall down to 24, treated with transfusion to maintain Hct > 30. No evidence for any bleeding was found. Hematology consult was obtained although hemolysis work-up was negative and deemed possibly secondary to chronic disease and phlebotomy. ID: A fever spike on POD 9 prompted a pan-culture, which revealed a UTI, and broncheoalveolar lavage, which demostrated HFlu pneumonia. Levaquin was started for 14days beginning POD 11. Although she continued to have secretions, no further fevers or elevated WBCs were observed. Wound: Plastic surgery continued to follow the patient post-operatively. JP drains were maintained with plan to remove once the output was zero; drain #1 was removed on POD 22 while drain #2 remains in place with scant daily output. Wound necrosis between the paramedian incision and her prior midline occurred and was treated with wet-to-drys and later with silvadene cream. Endo: RISS well controlled and added NPH upon initiation of TF and diet. Rehab: Underwent evaluation by PT/OT services and received care throughout her hospital stay. Prophylaxis: received pneumoboots, sq heparin, and GI prophylaxis throughout the hospital stay. On POD 21 the patient was transferred from the ICU to the floor after remaining on trach collar successfully for 24 hours. She did well overnight and was planned for discharge to vent rehab on POD 22. Medications on Admission: Paxil 30' Avapro 150' Humulin 34units qam, 34units qpm Novalog sliding scale Discharge Medications: 1. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 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 Q4H (every 4 hours). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical TID (3 times a day): apply to necrotic wound. 6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed for pain. 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days: final dose on [**2175-09-08**]. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal once a day as needed. 11. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 12. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscell. Q4-6H (every 4 to 6 hours) as needed. 13. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): hold for SBP < 100 or HR < 60. 15. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed. 16. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection HS (at bedtime) as needed. 17. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty Eight (28) units Subcutaneous twice a day: can titrate dose as transition to bolus tube/po feedings. 18. Insulin Regular Human 100 unit/mL Solution Sig: qs units Injection four times a day: as directed by accompanying sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: s/p open ventral hernia repair [**2175-8-15**] for incarcerated ventral hernia with concurrent small bowel resection, component release by plastic surgery. respiratory distress, reintubation. respiratory failure, ventilator dependence, percutaneous tracheostomy [**8-21**] COPD, smoker IDDM depression PNA with H.Flu UTI, morganella Discharge Condition: stable, on trach collar. Discharge Instructions: continue trachostomy site care. continue tracheal suction as needed. continue medications as directed. continue vent wean. strip and record JP drains qshift. continue dressing changes with silvadene to necrotic area of wound Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **], General Surgery, 1 week from discharge. Call [**Telephone/Fax (1) 2723**] for an appointment time. Follow-up with Dr. [**First Name (STitle) 3228**], Plastic surgery, 1 week from discharge. Please call [**Telephone/Fax (1) 5343**] for appointment.

[ "568.0", "285.1", "458.29", "518.83", "482.2", "552.29", "V64.41", "309.9", "496", "276.0", "401.9", "293.0", "933.1", "599.0", "250.00", "709.2", "518.5", "305.1" ]

icd9cm

[ [ [] ] ]

[ "54.59", "96.56", "45.02", "86.28", "33.21", "31.1", "99.04", "83.14", "96.04", "45.62", "93.90", "96.72", "53.69", "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

7514, 7586

1833, 5500

352, 643

7963, 7990

1453, 1805

8264, 8563

5627, 7491

7607, 7942

5526, 5604

8014, 8241

1240, 1434

273, 314

671, 1042

1064, 1192

1208, 1225

25,645

120,718

3888

Discharge summary

report

Admission Date: [**2189-8-6**] Discharge Date: [**2189-8-13**] Date of Birth: [**2137-4-27**] Sex: F Service: PLASTIC SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old with a history of asthma, hypothyroidism, and lobular carcinoma in situ who was referred to Dr. [**First Name (STitle) **] for reconstruction after a planned bilateral mastectomy. PAST MEDICAL HISTORY: Significant for asthma, hypothyroidism, gastroesophageal reflux disease, fibromyalgia, and scoliosis. PAST SURGICAL HISTORY: Includes breast biopsy x 2 in [**2182**] and [**2185**], partial thyroidectomy in [**2177**], bilateral tubal ligation and sinus surgery in [**2186**]. HOME MEDICATIONS: Include Levoxyl 112 mcg per day, Prevacid, albuterol as needed, and Nasonex as needed. ALLERGIES: Include penicillin, Duricef and Keflex. PHYSICAL EXAMINATION: Her preadmission physical examination revealed a chest which was clear to auscultation bilaterally. Breast examination revealed status post biopsy with no masses, discharge or retraction. Cardiac examination: Regular rate and rhythm. Abdomen: No pain, mass or hernia. LABORATORY DATA: White blood cell count 6.0, hemoglobin 11.8, hematocrit 34.0, platelet count 293. PT 12.5, INR 1.1, PTT 28.4. Sodium 141, potassium 3.7, chloride 100, bicarbonate 27, BUN 17, creatinine 0.6, glucose 79. She had an ALT of 28, an AST of 27, alkaline phosphatase 60, total bilirubin 0.8, total protein 7.1, albumin 4.1. HOSPITAL COURSE: Procedure: Bilateral mastectomy by Dr. [**Last Name (STitle) 11635**] of General Surgery and reconstruction on the right-hand side with a free TRAM flap, and on the left with a pedical TRAM flap by Dr. [**First Name (STitle) **] of Plastic Surgery. Intraoperative ins and outs: Total in was 11,600. She received two units of autologous red blood cells. Her output included an estimated blood loss of 800 ml, and urine output of 800 ml, for a total output of 1600 ml. Her postoperative hematocrit was 26.2. Postoperative antibiotics: Vancomycin. Deep venous thrombosis prophylaxis included SCG boots and subcutaneous heparin. Pain control was managed with morphine as needed. Of note, the patient experienced some airway edema and was sent to the Trauma Surgical Intensive Care Unit, intubated and on a ventilator postoperatively to manage her airway. On postoperative day one, her examination revealed an alert and oriented, extubated patient, without complaints. Overnight she had a fever to 102.4 maximum temperature. Vital signs were otherwise stable. Urine output was adequate. [**Location (un) 1661**]-[**Location (un) 1662**] drains were putting out between 60 and 170 cc. Her right breast incision was clean, dry and intact. There was no evidence of erythema. Minimal serosanguinous drainage. Sensation was intact. This breast was the free flap, which had capillary refill of less than three seconds, a Dopplerable pulse, continuous venous Doppler signal. Drains were patent, with serosanguinous fluid in the left breast, which is the pedicle flap. The incision was clean, dry and intact. There was no erythema, minimal serosanguinous drainage. Sensation was intact. The flap was warm and well perfused. Capillary refill less than three seconds. Drains were patent, draining serosanguinous fluid. Abdominal incision was clean, dry and intact, without evidence of erythema. The morning's laboratories included a white count of 6.7, hematocrit 24.7, platelets 179. Sodium 137, potassium 3.9, chloride 107, bicarbonate 25, BUN 13, creatinine 0.5, glucose 118. On postoperative day two, the patient was transferred to the Vascular Intensive Care Unit. She was without complaints, although it was noted that her right Cook monitor was malfunctioning. Both flaps were viable at that time. Vital signs were stable. She continued to be febrile to 102, and defervesced to 99.7. Postoperative day three revealed a stable patient who remained slightly febrile but started to defervesce from 101.7 maximum to 100, and otherwise had no complaints. It was noted later in the day that she had fine crackles on her physical examination. She began to fell unwell, complained of malaise, and had a rattling cough. At that time, a full fever workup, including chest x-ray, blood cultures, sputum cultures and urine cultures were ordered. In addition, in association with this cough, she lowered her oxygen saturation on room air to 88 to 90. The chest x-ray was suggestive for pneumonia with left basilar and right basilar infiltrates. It was also noted that the patient was approximately 11 liters positive fluid balance since admission, though she continued to diurese well. Five mg of lasix was administered intravenously, with good effect. The following morning, on postoperative day four, the patient stated that she was feeling much better, with decreasing shortness of breath. She was saturating 94% on 2 liters nasal cannula. Her bilateral breast flaps continued to do very well, without any signs of infection. The [**Location (un) 1661**]-[**Location (un) 1662**] drains were patent and continued to drain minimal serosanguinous fluid. Levofloxacin was begun on postoperative day four to treat presumptive pneumonia. Postoperative day five revealed a patient without complaints, who was afebrile, with a maximum temperature of 99.2, and oxygen saturation of 95% on room air. The [**Location (un) 1661**]-[**Location (un) 1662**] drains continued to decrease their output to between 50 and 95 cc/day. Physical examination continued to be good, without evidence of infection and with viable flaps. Her lung examination showed decreasing crackles in the left and right, improving from prior days. Postoperative day six revealed the patient without complaints, was afebrile for 24 hours, saturating 92% on room air, with a continuing improvement in her respiratory examination, and no evidence of infection in any of her surgical sites. She was stable. A repeat chest x-ray was obtained, which revealed improvement over the prior x-ray, and evidence of pneumonia with some persistent bilateral pleural effusions. The patient was discharged on [**2189-8-13**]. Her discharge examination revealed a stable patient with flaps warm and in good condition. Her drains x 4 were discontinued, and she was scheduled to follow up next week in Plastic Surgery Clinic. CONDITION AT DISCHARGE: Patient discharged to home. DISCHARGE STATUS: Patient stable. DISCHARGE MEDICATIONS: 1. Percocet 325 mg/5 mg one to two tablets by mouth every four to six hours as needed for pain 2. Levofloxacin 500 mg by mouth once daily for seven days FOLLOW-UP PLAN: The patient is to follow up with Dr. [**First Name (STitle) **] in the Plastic Surgery Outpatient Clinic next week. The patient is to call [**Telephone/Fax (1) 17373**] to schedule an appointment. Her discharge instructions include maintaining the incisions clean and dry at all times. The patient may shower, but should pat the wounds dry afterwards. No bathing or swimming for four to six weeks. She is not to drive while on pain medications. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8332**], M.D. [**MD Number(1) 8333**] Dictated By:[**Last Name (NamePattern1) 17374**] MEDQUIST36 D: [**2189-8-13**] 22:55 T: [**2189-8-14**] 00:19 JOB#: [**Job Number 17375**]

[ "737.30", "493.90", "244.9", "401.9", "250.00", "233.0", "E878.8", "V50.41", "997.3" ]

icd9cm

[ [ [] ] ]

[ "85.7", "93.90", "85.42" ]

icd9pcs

[ [ [] ] ]

6520, 7423

1501, 6417

536, 689

708, 849

872, 1483

6432, 6497

176, 386

409, 512

1,970

144,456

25234

Discharge summary

report

Admission Date: [**2164-9-4**] Discharge Date: [**2164-10-9**] Date of Birth: [**2123-11-10**] Sex: M Service: MEDICINE Allergies: Compazine / Oxacillin Attending:[**First Name3 (LF) 1377**] Chief Complaint: chest pain/v-fib arrest Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 40 yo M unknown past med hx, presented to [**Hospital **] hospital with chest pain. He was evaluated at 11:45 pm. No ECG changes, negative cardiac enzymes. The patient reported constant substernal chest pressure for 1-2hrs. He was given azithromycin for PNA (LLL infiltrate on CXR), and the chest pain resolved after nitro. The pt signed out AMA sometime after midnight. Had a ventricular fibrillation arrest in the car ride home, witnessed by his girlfriend who started CPR and called EMS. He was shocked x 3 and loaded with amiodarone. He was taken back to the [**Hospital **] hospital, arriving just before 2am. ECG showed NSR with RBBB, ST elevations in II, III, and aVF, and V5-V6, ST depressions v1-v3. Heparin, integrelin, ASA, plavix, and metoprolol were started. He was intubated at the OSH for airway protection, and since he was agitated and combative in the CT scan, he was given ativan and succinylcholine and intubated, per OSH records. The pt was transferred to [**Hospital1 18**] for cardiac catheterization, where he arrived at 4:30 am. Thrombolytics were considered, although not given in part because chest compressions had been administered. At catheterization, there was a totally occluded OM1 stented with cypher. Past Medical History: no previous MI. no previous medical history. Social History: Soc Hx: tobacco. Family History: non-contributory Physical Exam: Vitals: Pertinent Results: Cath [**2164-9-4**]: RHC: PA 35/23. PCWP 19. CVP 17 CO/CI 3.2/1.5 R dominant system. RCA: 20% diffuse LAD: 20% diffuse. 60% ramus LCX: proximal patent. OM1 100% cypher. _______________________________________ [**2164-9-4**] 04:41AM HGB-20.1* calcHCT-60 O2 SAT-95 [**2164-9-4**] 04:41AM TYPE-ART RATES-/16 TIDAL VOL-700 O2-100 PO2-278* PCO2-38 PH-7.35 TOTAL CO2-22 BASE XS--3 AADO2-416 REQ O2-70 INTUBATED-INTUBATED [**2164-9-4**] 07:33AM PLT COUNT-328 [**2164-9-4**] 07:33AM WBC-16.3* RBC-5.18 HGB-17.6 HCT-50.1 MCV-97 MCH-34.0* MCHC-35.2* RDW-12.5 [**2164-9-4**] 07:33AM CALCIUM-8.7 PHOSPHATE-2.0* [**2164-9-4**] 07:33AM CK-MB-GREATER TH cTropnT-11.36* [**2164-9-4**] 07:33AM CK(CPK)-[**Numeric Identifier 63202**]* [**2164-9-4**] 07:33AM GLUCOSE-174* UREA N-17 CREAT-1.0 SODIUM-136 POTASSIUM-5.1 CHLORIDE-106 TOTAL CO2-19* ANION GAP-16 [**2164-9-4**] 07:43AM LACTATE-2.0 [**2164-9-4**] 07:43AM TYPE-ART RATES-16/ TIDAL VOL-700 PEEP-5 O2-100 PO2-474* PCO2-33* PH-7.38 TOTAL CO2-20* BASE XS--4 AADO2-225 REQ O2-44 -ASSIST/CON INTUBATED-INTUBATED [**2164-9-4**] 12:29PM URINE RBC-21-50* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2164-9-4**] 12:29PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.036* [**2164-9-4**] 02:22PM PLT COUNT-327 [**2164-9-4**] 02:22PM HCT-50.7 [**2164-9-4**] 02:22PM URIC ACID-5.6 [**2164-9-4**] 02:22PM CK-MB-485* MB INDX-3.5 [**2164-9-4**] 02:22PM CK(CPK)-[**Numeric Identifier 63203**]* [**2164-9-4**] 02:22PM POTASSIUM-4.5 [**2164-9-4**] 11:50PM TYPE-ART PO2-161* PCO2-35 PH-7.42 TOTAL CO2-23 BASE XS-0 _ _ _ _ ________________________________________________________________ MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Reason: stroke protocol, DWI [**Hospital 93**] MEDICAL CONDITION: 40 year old man s/p MI with vfib arrest with residual neurological deficits REASON FOR THIS EXAMINATION: MRI and MRA of head, stroke protocol, DWI CLINICAL INFORMATION: Patient with atrial fibrillation and subdural neurologic deficit for further evaluation. TECHNIQUE: T1 sagittal, and FLAIR, T2 susceptibility and diffusion axial images of the brain were acquired. 3D time-of-flight MRA of the circle of [**Location (un) 431**] was obtained. FINDINGS BRAIN MRI: The diffusion images demonstrate no evidence of slow diffusion to indicate acute infarct. There is no evidence of corpus territorial infarcts or significant subcortical white matter disease seen. No evidence of mass effect or midline shift is identified. There are extensive soft tissue changes seen in the bilateral maxillary and sphenoid as well as ethmoid sinuses. IMPRESSION: No evidence of acute infarct or mass effect. Soft tissue changes in the paranasal sinuses. MRA OF THE HEAD: The head MRA demonstrates normal flow signal within the arteries of anterior and posterior circulation. IMPRESSION: Normal MRA of the head. DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**] Approved: SAT [**2164-9-8**] 7:53 PM Brief Hospital Course: 40 y/o male with presented to OSH with Pulseless VFib after Acute MI (STEMI) now s/p Cypher stent of totally occuded OM1 with anoxic brain injury from being pulseless for ~15 mins with slow neurological recovery. . Hospital course is reviewed below by problem: . 1. Neuro: s/p Anoxic brain injury. Head MRI showed no evidence of ischemic insult. Per neuro, the pathology is probably deep cortical anoxic injury difficult to trace on EEG. Patient is minimally communicative, mental status waxes and wanes, but is able to follow commands and respond somewhat appropriately. He does not speak well. Per neuro, arm shaking was felt to be a component of the anoxic brain injury not requiring additional therapy at this time. With time, arm shaking has resolved, but the patient has developed increased tone in his bilat UE and bilat LE. Baclofen was started and the rigidity improved especially in his lower extremities. He was able to ambulate with assistance and has worked with PT and OT and made some progress in being functional. He did continue to get agitated overnight, trying to get out of bed, and had to be given ativan PRN for sleep and relief of anxiety. When his fiancee was in the room with him, the problems have been significantly reduced. In additon, during his hospital stay, patient experience a "roll-out fall" from his [**Female First Name (un) **] chair while trying to get up and go to the bathroom. He did not sustain any injuries, just minor abrasions and complained of no residual pain. It is to be noted that giving the patient Ambien made him more agitated or sedated and should be avoided. . 2. Elevated LFTs. The patient was noted to have elevated LFTs upon checking baseline to start the statin treatment. He was started on a statin s/p MI and was started on a course of oxacillin for coag negative staph bacteremia that he developed during his course. The pattern was not consistent with shock liver or liver failure, as INR and albumin stayed WNL. Hepatology was consulted and determined that the LFT elevations were probably due to the combination of statin and oxacillin treatments. Therefore, the statin was d/c'ed and the course of oxacillin was completed. He was also discovered to have Hep C positivity with a viral load of 81,800 IU/mL. This was thought NOT the cause of his LFT elevations, likely an incidental finding, and no acute inpatient treatment was recommended. Liver recommended to follow LFT's until they trend down, and arrange for a follow-up at the [**Hospital1 18**] liver center as an outpatient ([**Telephone/Fax (1) 2422**]). During the hospital course, the patient's LFTs trended down, with the latest labs being: ALT: 215 AP: 180 Tbili: 0.8 AST: 67 LDH: 204 [**Doctor First Name **]: 46 Lip: 19 . 3. Acute MI: STEMI with totally occuded OM1, s/p Cypher stent with resolution of ST elevations. Patient was started on aspirin, plavix, metoprolol and statin per post-MI managment. Statin was d/c'ed as per discussion above, and patient should be re-challenged with statin as an outpatient. During the entire hospital course, the patient remained chest pain free, NSR w/o ectopy on his EKG. Aspirin and plavix should be continued indefinitely and metoprolol may be increased as blood pressure tolerates. . 4. HTN: His hypertension has been well controlled on metoprolol during the hospitalization. . 5. Urinary retention: The patient had a foley placed on admission, and discontinuation of the foley catheter was initially limited by urinary retention. This was thought to be secondary to his cognitive status, and it resolved with time. Since his foley catheter has been discontinued, he has been incontinent but has had good urinary output. . 6. Back pain: He had an episode of back pain in the hospital that was thought to be secondary to musculoskeletal pain from his fall and from awkward transport between chair and bed while assisted by his girlfriend. [**Name (NI) **] had no neurological changes attributable to the pain, and it resolved with minimal intervention (pain management with small amounts of tylenol). . 7. F/E/N: The patient has good PO intake, and has been able to eat on his own, though he may need some help at times. . 8. Ambulation: the patient has been ambulating with assistance from physical therapy. . Medications on Admission: none prior to admission Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Bisacodyl 10 mg Suppository Sig: [**1-1**] Suppositorys Rectal [**Hospital1 **] (2 times a day) as needed for constipation. 3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Primary: 1. Anoxic brain injury 2. Acute coronary syndrome 3. status post ventricular fibrillation arrest 4. status post cardiac catheterization and stent placement Secondary: 1. Transaminitis 2. Urinary incontinence Discharge Condition: Improved mental status, ambulating with assistance, chest pain free. Discharge Instructions: Please take all your medications as directed, especially aspirin and plavix. You will need intensive physical therapy and range of motion exercises of your upper extremities. Please follow up with your PCP and the Liver Center as detailed below. Call your doctor or go to the emergency room if you have any chest pain, difficulty breathing, acute change in your level of awareness, nausea, vomiting, lightheadedness, or other concerning symptoms. Followup Instructions: Please call [**Telephone/Fax (1) 250**] to make an appointment with a new primary care provider once your free care application has been approved. Please follow up in the liver center, please call [**Telephone/Fax (1) 2422**] to make an appointment once your free care application has been approved. Please have your primary care provider set up appointments with cardiology and neurology for follow-up of your heart attack and anoxic brain injury. Please have your primary care provider check your liver function tests and add on a medication called 'a statin' in the next 30 days if appropriate. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

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icd9cm

[ [ [] ] ]

[ "96.72", "88.56", "00.45", "99.20", "00.66", "03.31", "96.6", "36.07", "00.40" ]

icd9pcs

[ [ [] ] ]

9702, 9775

4811, 9112

306, 332

10036, 10107

1777, 3510

10602, 11325

1716, 1734

9186, 9679

3547, 3623

9796, 10015

9138, 9163

10131, 10579

1749, 1758

243, 268

3652, 4487

360, 1597

4505, 4788

1619, 1666

1682, 1700

53,596

153,510

1295

Discharge summary

report

Admission Date: [**2161-9-10**] Discharge Date: [**2161-9-15**] Date of Birth: [**2086-7-20**] Sex: M Service: MEDICINE Allergies: Penicillins / Cephalothin / Trazodone / Avelox Attending:[**First Name3 (LF) 3991**] Chief Complaint: urosepsis; possible bleed Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 8004**] is a 75 yo M with h/o DVT/PE on warfarin and h/o spinal lymphoma causing paraplegia with neurogenic bladder necessitating chronic indwelling foley. He went to [**Hospital1 **] on [**2161-9-9**] for a routine catheter change. The change was done by urology with some difficulty and he subsequently went to the ED for a foley change. There he developed hypotension with SBP reportedly in the 70's with associated rigors. He was admitted, received fluid bolus with initially unresponsive SBP then improvement to SBP 90-100. He was started on gentamycin in the ED and then zosyn. His blood and urine cultures grew GNR. . Hemoglobin dropped initially from 12 to 8, thought to be both from blood losses with the foley change as well as dilutional with 3L IVF given over the 24 hours. . On arrival to the MICU after transfer, he denies pain, HA, fever, chills, but endorses abdominal bloating and discomfort from bacterial overgrowth (for which he is completing a course of [**Date Range 8005**]). Past Medical History: 1. Large B cell lymphoma with metastasis to spinal cord with resultant paraplegia - [**10-14**] (followed per Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital3 328**]) 2. Prior L4 compression fracture s/p posterior fusion 3. Hypertension 4. History of C.diff 5. Large basal cell carcinoma of L upper eyelid s/p Mohs excision 6. h/o DVT, PE after surgery in [**10-14**] 7. Spinal myoclonus and tremor 8. Anxiety/Depression 9. Chronic Nephrolithiasis 10. Dyslipidemia 11. h/o UTIs 12. L retina surgery [**63**]. Osteoporosis Social History: denies tobacco, ETOH and IVDU. Lives in [**Hospital3 **] with aides. Wheelchair-bound. Family History: per prior DCS "Father had a tremor and he believes his paternal GF also had a tremor. No lymphoma. No PD." Physical Exam: VS on arrival: T 101.4, P 98, BP 100/48, 97% RA GENERAL: elderly, chornically ill appearing, but conversant and in NAD; has foley catheter draining clear urine, no gross hematuria HEENT: OP clear, MMM, poor dentition LUNGS: crackles at bases that clear with coughing CARDIO: RR, fast, no murmurs appreciated ABD: + BS, distended but relatively soft, no roebound or guarding EXT: no [**Location (un) **], legs somewhat WTT with fever but no signs of cellutlits SKIN: no rashes NEURO: AA, Ox3, high frequency resting tremor in all limbs, slight ptosis of right eye lid but otherwise no CN abnormalities; moves upper extrmeitie sonly; gait deferred On Discharge VS: T 96.9, BP 102/66, P 71, RR 17, O2sat 99%RA GENERAL: Chronically ill appearing man in NAD HEENT: OP clear, MMM, poor dentition LUNGS: Limited exam but clear CARDIO: RRR, S1-S2+ ABD: + BS, distended but soft, no rebound or guarding EXT: No LE edema GU: Foley in place SKIN: No rashes NEURO: AAOx3, resting tremor in all extremities, slight ptosis, gait not assessed Pertinent Results: ADMISSION LABS: [**2161-9-10**] 10:58PM BLOOD WBC-9.0# RBC-2.95*# Hgb-7.4*# Hct-21.8*# MCV-74* MCH-25.0* MCHC-33.8 RDW-18.4* Plt Ct-230 [**2161-9-10**] 10:58PM BLOOD Neuts-85* Bands-1 Lymphs-11* Monos-2 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2161-9-10**] 10:58PM BLOOD PT-27.3* PTT-34.1 INR(PT)-2.7* [**2161-9-10**] 10:58PM BLOOD Glucose-108* UreaN-17 Creat-1.1 Na-137 K-3.4 Cl-104 HCO3-24 AnGap-12 [**2161-9-10**] 10:58PM BLOOD Calcium-7.7* Phos-2.2* Mg-1.9 URINALYSIS: [**2161-9-10**] 10:58PM Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-MOD RBC-9* WBC-20* Bacteri-NONE Yeast-NONE Epi-0 MICROBIOLOGY: [**2161-9-10**] Urine cultures: No Growth [**2161-9-10**] Blood cultures: No Growth Chest X-Ray [**9-14**]: There is a left subclavian line with tip in the right atrium. In addition, there is a radiopaque line projecting partially over the course expected for PICC line, but than a less radiopaque catheter is seen coiled in the left neck. This finding was communicated to the IV access team at the time of dictating this report at 9:15 a.m. There is no pneumothorax. There is some plate-like atelectasis in the left lower lung. Spinal fixation device projects over the lower thoracic spine. Brief Hospital Course: Mr. [**Known lastname 8004**] is a 75 yoM with neurogenic bladder s/p paraplegia from lymphoma involving his spinal cord in [**2157**]. He was admitted with gram negative rod bacteremia and positive urine culture after foley manipulation at OSH. Patient was started on zosyn empirically given prior UTI's with zosyn-sensitive Proteus species. . #. GRAM NEGATIVE ROD BACTEREMIA, SEPSIS: Patient presents from OSH with hypotension and blood and urine cultures positive for Serratia marcesens after manipulation of foley catheter. He was started empirically on Zosyn at the OSH and due to clinical improvement was continued on this medication in the [**Hospital1 18**] ICU. Blood pressure improved with IV fluids and did not require pressors. He had intermittent hypotension over the next two days that responded well to small boluses of IV fluids. He was subsequently transferred to the general medicine floor. He was discharge on IV Zosyn for a total 14 days with an end date of [**9-25**]. His antibiotics were to be given through his portacath. #. ABDOMINAL DISTENSION: Patient with chronic abdominal bloating of unclear [**Name2 (NI) 8006**]. He is being treated for presumed bacterial overgrowth by his Gastroenterologist Dr. [**First Name (STitle) 572**]. He finished his course of [**First Name (STitle) 8005**] on [**2161-9-11**]. He admits to some improvement in constipation with the antibiotic course but no improvement in bloating. He was continued on a gluten-free, lactose-free diet during his admission. He was started on scheduled miralax for constipation and high dose simethicone. He was discharged on high dose simethicone however his symptoms persisted. #. ANEMIA: He has a baseline anemia with an acute on chronic Hct drop noted in the MICU. This was likely due to blood loss from traumatic foley change and had an appropriate response to 1 unit pRBC. #. TREMOR: Unclear the etiology of the tremor. Based on Dr. [**Name (NI) 8007**] note on [**7-/2161**] it was felt that his tremor was more consistent with a familial essential tremor rather that parkinsonian tremor. During his admission his Sinemet was decreased and he was restarted on propranolol 20mg tid. He was told to follow up with his PCP if the tremor got any worse. Medications on Admission: HOME MEDICATIONS: Alendronate 70 mg Qweek Baclofen 20 mg TID Carbidopa-levodopa 25-100 mg ? 2 tablets PO TID Citalopram 20 mg Qd Vit D2 50,000 Qweek Erythromycin 0.5% ointment, 1 drop in eyes at bed Fludrocortisone 0.1 mg QHD Lasix 20 mg [**Hospital1 **] Gabapentin 600 mg TID Omeprazole 20 mg QD Propanolol 20 mg TID Seroquel 12.5 mg QHS [**Hospital1 **] 550 mg TID Warfarn 2.5-7.5 mg QHS Tylenol Bisacodyl Calcium carbonate - Vitamin D3 Cranburry Colace Acidophilus . MEDICATIONS ON TRANSFER: Celexa colace Coumadin 5 pm Florinef 0.1 mg QD Gentamicin 120 mg given on [**9-9**] Propanolol 20 mg TID held today Lotrimin for scrotum MOM Neurontin [**Name (NI) **] protonix Seroquel Sinemet Tylenol Zosyn 3.375 mg QID Discharge Medications: 1. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 10 days: Stop date [**9-23**]. Disp:*41 * Refills:*0* 2. Heparin Flush 10 unit/mL Kit Sig: One (1) Intravenous once a day for 10 days. Disp:*10 * Refills:*0* 3. Sodium Chloride 0.9 % 0.9 % Syringe Sig: One (1) Injection twice a day for 10 days. Disp:*22 * Refills:*0* 4. Portacath Kit Sig: One (1) PRN. Disp:*3 * Refills:*0* 5. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever, HA. 8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Carbidopa-Levodopa 10-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 11. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 12. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 14. Erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) Ophthalmic HS (at bedtime). 15. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day. 16. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 17. Propranolol 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 18. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 19. [**Month/Year (2) **] 550 mg Tablet Sig: One (1) Tablet PO three times a day. 20. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 22. Acidophilus Capsule Sig: One (1) Capsule PO once a day. 23. Simethicone 80 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO QID (4 times a day). Disp:*180 Tablet, Chewable(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: 1. Serratia urinary tract infection 2. Serratia sepsis from urine source 3. Neurogenic bladder 4. Abdominal distension 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 transferred from [**Hospital3 **] for further treatment of a Serratia infection in your urine and blood. You were treated with IV antibiotics, initially in the ICU and then on the medical floor as you improved clinically. You will be discharged to complete a total 14 day of intravenous antibiotics via your accessed portacath. During this hospitalization, we restarted you on low dose propanolol and down-titrated your Cinemet per Dr.[**Name (NI) 8008**] prior recommendations regarding your tremor. Please discuss with Dr. [**Last Name (STitle) **] whether you may have further benefit with additional increase of propanolol and decrease of Cinemet as tolerated. Medication changes: IV Zosyn for a total 14 days (End [**9-25**]) Propanalol restarted Cinemet decreased Simethicone started Followup Instructions: Please schedule follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], within 1 to 2 weeks. Please also follow up with Dr. [**Last Name (STitle) **]. Previously scheduled appointments: Department: [**Hospital3 249**] When: THURSDAY [**2161-11-12**] at 3:40 PM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3990**], [**First Name3 (LF) **] [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: GASTROENTEROLOGY When: THURSDAY [**2161-10-8**] at 2:20 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD [**Telephone/Fax (1) 463**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: SURGICAL SPECIALTIES When: WEDNESDAY [**2161-10-7**] at 2:00 PM With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3990**] DO 12-BJM

[ "781.0", "599.71", "285.29", "787.3", "110.3", "592.0", "E879.6", "785.59", "344.1", "996.64", "790.01", "733.00", "202.80", "599.0", "V62.84", "V10.83", "344.61", "272.4", "300.4", "038.44", "564.00", "E928.9", "995.91", "867.0" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

9748, 9819

4606, 6867

334, 340

9982, 9982

3277, 3277

10986, 12362

2103, 2212

7634, 9725

9840, 9961

6893, 6893

10158, 10837

2227, 3258

6911, 7363

10857, 10963

268, 296

368, 1397

3293, 4583

9997, 10134

7388, 7611

1419, 1980

1996, 2087

18,500

143,786

28079

Discharge summary

report

Admission Date: [**2200-10-3**] Discharge Date: [**2200-10-21**] Date of Birth: [**2120-10-7**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: Pedestrian struck Major Surgical or Invasive Procedure: [**10-3**] Exploratory laparotomy with repair of left hemidiaphragm Dr. [**Last Name (STitle) **] Trauma Surgery [**10-4**] 1. Closed reduction of right glenohumeral joint dislocation. 2.Closed treatment of both bone forearm fracture with manipulation and anesthesia Dr. [**Last Name (STitle) **] Orthopedic Surgery [**10-9**] 1. Open tracheostomy. 2.Percutaneous endoscopic gastrostomy. 3.Right femoral [**Location (un) 260**] inferior vena caval filter. Dr. [**Last Name (STitle) **] Trauma Surgery [**10-14**] 1. Closed reduction right glenohumeral joint. 2. ORIF right both bone forearm fracture. 3. Closed treatment right fibula shaft fracture. 4. ORIF left medial malleolar fracture. 5. Closed treatment left proximal fibula fracture. Dr. [**Last Name (STitle) **] Orthopedic Surgery [**10-14**] 1. Fusion of C7 to T9. 2. Total laminectomy of T3. 3. Reduction of posterior fracture-dislocation. 4. Instrumentation of C7 to T9. 5. Autograft. Dr. [**Last Name (STitle) 363**] Ortho Spine History of Present Illness: 80 yo female who while crossing the street was struck by a car. Reportedly she was thrown approx 15-20 feet; + LOC and multiple gross deformities of upper and lower extremities. She arrived to the ED intubated and upon examination was found to be pulseless; CPR was initiated; vital signs were re-established within ~1 min. Social History: Supportive family Family History: Noncontributory Pertinent Results: Upon admission: [**2200-10-3**] 11:22PM TYPE-ART PO2-358* PCO2-44 PH-7.24* TOTAL CO2-20* BASE XS--8 INTUBATED-INTUBATED [**2200-10-3**] 11:22PM GLUCOSE-163* LACTATE-2.4* NA+-138 K+-3.5 CL--117* [**2200-10-3**] 11:22PM calcHCT-26 [**2200-10-3**] 08:43PM HGB-8.7* calcHCT-26 O2 SAT-32 CARBOXYHB-0.8 MET HGB-1.1 [**2200-10-3**] 08:36PM UREA N-28* CREAT-1.3* [**2200-10-3**] 08:36PM CK(CPK)-408* AMYLASE-100 [**2200-10-3**] 08:36PM CK-MB-13* MB INDX-3.2 cTropnT-0.10* [**2200-10-3**] 08:36PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2200-10-3**] 08:36PM HCV Ab-NEGATIVE [**2200-10-3**] 08:36PM WBC-11.7* RBC-3.05* HGB-9.3* HCT-27.2* MCV-89 MCH-30.6 MCHC-34.2 RDW-13.5 [**2200-10-3**] 08:36PM PLT COUNT-175 [**2200-10-3**] 08:36PM PT-12.7 PTT-43.3* INR(PT)-1.1 [**2200-10-3**] 08:36PM FIBRINOGE-129* CT HEAD W/O CONTRAST Reason: R/O BLEED, TRAUMA [**Hospital 93**] MEDICAL CONDITION: 75 year old woman s/p ped v auto REASON FOR THIS EXAMINATION: eval for trauma CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Pedestrian struck by motor vehicle. COMPARISON: None. TECHNIQUE: Non-contrast head CT. CT HEAD WITHOUT IV CONTRAST: There is subarachnoid hemorrhage within the right temporoparietal region and the left parietal region, and within the right frontal region. Additionally, there is intraventricular hemorrhage, greater within the left lateral ventricle. There are several foci of increased density consistent with intraparenchymal hemorrhage and contusion within the left frontal lobe. There may be a focus of intraparenchymal hemorrhage within the right cerebellum as well. Additionally, there is an area of increased density likely intraparenchymal hemorrhage within the medial aspect of the right temporal lobe. The basilar cisterns are patent. The fourth ventricle and foramen magnum are widely patent. There is no evidence of mass effect. The [**Doctor Last Name 352**]-white matter differentiation is otherwise preserved. No fractures are identified. A small amount of fluid is seen within the maxillary sinuses bilaterally. The mastoid air cells and middle ear cavities are well aerated. Possible bilateral basal ganglia dystrophic calcifications vs shear hemorrhages. IMPRESSION: Multiple areas of intracranial hemorrhage are seen, as described above. No fractures are seen. CT CHEST W/CONTRAST [**2200-10-3**] 8:56 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Reason: TRAUMA Field of view: 36 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 75 year old woman s/p ped v auto REASON FOR THIS EXAMINATION: eval for trauma CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 75-year-old woman status post pedestrian and auto accident, evaluate for trauma. COMPARISON: None. TECHNIQUE: Contiguous axial images were obtained from the thoracic inlet to the pubic symphysis with multiplanar reformatted images. Additionally, delayed images through the pelvis were also obtained. CONTRAST: 130 cc of IV Optiray contrast was administered. CT OF THE CHEST WITH IV CONTRAST: There is an ET tube, with the tip positioned within the right main stem bronchus. There is a right chest tube positioned with the tip located in the posterior pleural space. The sidehole of the right chest tube is not positioned within the hemithorax, and is positioned in the adjacent subcutaneous tissues. There is a left chest tube, with the tip positioned near the lung apex, and the tip courses adjacent to the aorta. The sidehole of the chest tube appears to be positioned within the left hemithorax. There is adjacent subcutaneous air adjacent to both chest tube insertion sites. There are foci of subcutaneous air in the superior mediastinum, and tracking along the posterior mediastinum. There is a soft tissue hematoma and stranding in the mediastinum adjacent to the anterior aspect of the T3 vertebral body, which demonstrates a fracture. The aorta demonstrates normal caliber and contour throughout its course, there is no definite wall abnormality or evidence of injury. The heart and pericardium are within normal limits. Lung window images demonstrate several scattered areas of ill-defined opacity within the right upper lobe, which likely represent areas of contusion. Additionally, there is a left diaphragmatic injury, and herniation of almost the entire stomach into the left hemithorax. There is associated collapse of the entire right lower lobe and displacement of this superiorly. There is a small left apical pneumothorax. There are tiny foci of air within the tissues posterior to several thoracic vertebral bodies, and a tiny focus of air within the spinal canal at the T2 level. There is a hypodensity within the right thyroid lobe, which likely represents a nodule. CT OF THE ABDOMEN WITH IV CONTRAST: The liver, spleen, pancreas, adrenal glands, and gallbladder are within normal limits. There are several hypodensities within the kidneys, most of which are too small to characterize. There is a larger hypodensity within the right kidney measuring 2.3 x 2.9 cm, which demonstrates a density of 37 Hounsfield units, which is indeterminately characterized. The pancreas is within normal limits. There is a tiny focal hypodensity within the uncinate process which may represent fatty infiltration. The aorta demonstrates normal caliber and contour throughout its visualized course. There is no evidence of filling defects. There is some stranding around the aortocaval region adjacent to and superior to the third portion of the duodenum. Additionally, there is a tiny linear area of increased density on the arterial phase, which is not completely characterized. There is equivocal minimal stranding within the mesentery (series 2, image 67), which may reflect motion, though a small amount of mesenteric fluid is not excluded. The bowel is fluid filled, but there is no evidence of focal free intraperitoneal air or bowel wall thickening. The patient is status post resection of the distal sigmoid colon, and there is a colostomy in the left anterior abdominal wall. Additionally, there is a stomal hernia with a small loop of small bowel at the ostomy site. CT OF THE PELVIS WITH IV CONTRAST: A catheter is seen within the bladder. There is a hematoma from adjacent fracture sites. On delayed images, no definite contrast extravasation is seen from the bladder, though the bladder is not completely distended. There is soft tissue within the presacral region which likely represents post-surgical change from patient's prior surgery. There is a soft tissue hematoma within the right lateral anterior abdominal wall, with several tiny foci of increased density on arterial phase images, which demonstrate dilution on delayed images, and may reflect small arterial bleeding. Additionally, there is soft tissue hematoma within the posterior soft tissues overlying the left iliac crest, and the left anterior abdominal wall extending inferiorly to the inguinal region. BONE WINDOWS: There is complete anterior dislocation of the right shoulder. Additionally, there are fractures of the posterior aspect of the left first rib at the uncovertebral junction, of the left fifth rib adjacent to the chest tube insertion site, and nondisplaced fractures of the anterior aspects of the right fourth through seventh ribs. There is a fracture of the anteroinferior aspect of the T3 vertebral body, likely reflecting a hyperextension injury, with associated mild retrolisthesis. There is adjacent anterior soft tissue hematoma in this region. There is a fracture of the right sacrum. Additionally, there are comminuted fractures of the bilateral superior and inferior pubic rami. There is also a comminuted fracture of the left acetabulum including the roof and medial wall, with a protrusio type deformity of the left femoral head. There is comminuted fracture of the left iliac [**Doctor First Name 362**]. The fracture fragments of the left iliac [**Doctor First Name 362**] are positioned very close to the left external iliac vessels, though no definite vascular injury is identified. There is a large amount of soft tissue hematoma adjacent to the comminuted fractures of the iliac [**Doctor First Name 362**]. Additionally, posterior to the left iliac bone (series 2, image 80), there is a tiny focal hyperdensity which demonstrates dilution on delayed images, and likely represents a small focus of contrast extravasation. CT RECONSTRUCTIONS: Multiplanar reconstructions were essential in delineating the anatomy and pathology. Specifically, they were essential in evaluating the thoracic and lumbar vertebral spine. IMPRESSION: 1. The ET tube is positioned within the right main stem bronchus. There are bilateral chest tubes, of which the right chest tube side port is positioned outside the right hemithorax. The left chest tube tip is positioned near the aorta. There is subcutaneous emphysema along the left chest wall in the region of chest tube insertion. 2. Small left pneumothorax. 3. There are foci of air in the superior mediastinum, posterior to the trachea, and along the right pleural space. The etiology of this is unclear, and tracheal or esophageal injury is not definitely excluded. 4. Scattered contusions within the right lung. 5. Left diaphragmatic injury with herniation of the entire stomach into the left hemithorax and associated left lower lobe collapse. 6. There is soft tissue stranding and increased focus of density on the arterial phase in the aortocaval region, and a possible small vessel or duodenal injury is not excluded. 7. The patient is status post sigmoidectomy and colostomy, with a small bowel containing stomal hernia. 8. Several small foci of increased density posterior to the left ilium and in the right lateral abdominal wall, suggestive of arterial extravasation. 9. Vague stranding in the small bowel mesentery, which may be related to motion, though mesenteric fluid is not definitely excluded. 10. Multiple fractures involving the pubic rami bilaterally, the left iliac [**Doctor First Name 362**], the right sacrum, and several ribs and the T3 vertebral body with associated hematomas, as described in detail above. 11. Right anterior shoulder dislocation 12. Indeterminant mass in the right kidney, not compatible with a simple cyst. Further characterization with MRI or renal mass CT is recommended to exclude malignancy in a nonemergent basis. Sinus tachycardia. Diffuse non-diagnostic T wave flattening. Compared to the previous tracing of [**2200-10-5**] no major change. Intervals Axes Rate PR QRS QT/QTc P QRS T 110 132 76 294/359 65 -2 87 CHEST (PORTABLE AP) [**2200-10-19**] 4:11 PM CHEST (PORTABLE AP) Reason: For 4pm today please. Eval. for PTX s/p CT pull [**Hospital 93**] MEDICAL CONDITION: 75 year old woman pedestrian stuck by car with multiple injuries s/p CT pull. REASON FOR THIS EXAMINATION: For 4pm today please. Eval. for PTX s/p CT pull CLINICAL HISTORY: Struck by car with multiple injuries, chest tube removed. Evaluate for pneumothorax. CHEST: The left chest tube has been removed. There is no evidence for pneumothorax. Right effusion is again seen. There is a dislocation of the right shoulder anteriorly. No failure or infiltrates are present. CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2200-10-17**] 4:23 PM CT SINUS/MANDIBLE/MAXILLOFACIA Reason: Eval for sinus disease or periorbital changes. [**Hospital 93**] MEDICAL CONDITION: 80 year old woman with fever, R periorbital swelling REASON FOR THIS EXAMINATION: Eval for sinus disease or periorbital changes. CONTRAINDICATIONS for IV CONTRAST: None. CT OF THE SINUSES MAXILLOFACIAL WITHOUT CONTRAST DATED [**2200-10-17**]. HISTORY: 80-year-old woman with fever, right periorbital swelling; evaluate for sinus disease or "periorbital changes." TECHNIQUE: Helical 2.5-mm axial tomographic sections were obtained through the paranasal sinuses, coronal reformations were prepared, and all images reviewed in bone and soft tissue window on a workstation. FINDINGS: The study is compared with the recent NECT of the head, dated [**2200-10-10**]. As on that study, there is circumferentially lobulated mucosal thickening involving both maxillary antra, with probable small mucous retention cysts in their floors, with no fluid level. Circumferential mucosal thickening involves the maxillary ostia, bilaterally; however, the large-caliber ostiomeatal complexes are patent, bilaterally (is there a history of previous nasal-antral windows and inferior partial ethmoidectomy?). There is extensive soft tissue opacification of left more than right anterior ethmoid air cells, as well as the frontal-ethmoidal recesses, with near-complete opacification of both frontal sinuses, with hyperattenuating contents in, particularly, the right frontal air cell. Circumferential mucosal thickening also involves both maxillary sinuses, with fluid levels dorsally Fluid appears to layer dependently in the nasopharynx with "trapped" air bubbles; some these findings may relate to dependent positioning and intubation (the patient does not appear to be intubated at this time). Note that the petrous apices are pneumatized, with a small fluid level in the left petrous apex air cell, not clearly present on the [**2200-10-10**] study. Very limited included anterior portion of the brain demonstrates asymmetric prominence of the right frontal extra-axial CSF space, without definite hemorrhage. There is apparent interval clearing of the subarachnoid hemorrhage within the dorsal aspect of the right sylvian fissure and adjacent cortical sulci. IMPRESSION: 1. Extensive pansinus inflammatory changes, particularly involving the frontal sinuses, bilaterally, with hyperdense contents, on the right; while this may represent inspissated secretions, fungal colonization is another concern. 2. Fluid levels in the sphenoid sinuses, bilaterally, which, in this context with layering fluid in the posterior nasopharynx, may, in part, relate to supine positioning. 3. Fluid layering within the pneumatized left petrous apex, definitely not present on the [**10-3**] CT; again, while this may relate to positioning, infectious petrous apicitis cannot be excluded. 4. Very limited depiction of the brain with enlarged bifrontal extra-axial CSF space, unchanged since [**10-10**], but new since the [**10-3**] admission study. There has been apparent interval clearing of the right frontal subarachnoid hemorrhage. 5. Minimal induration in the right periorbital soft tissues, with no evidence of intraconal (post-septal) process. Brief Hospital Course: She was a admitted to the Trauma service. She was taken to the operating room secondary to shock and ruptured diaphragm; underwent exploratory laparotomy and repair of her diaphragmatic injury. She was then transferred to the Trauma ICU where she remained sedated and intubated. A family team meeting was held early on because of the extent of her injuries and to discuss resuscitative measures. The family wished to proceed with ongoing care and subsequently consented for further surgeries. Orthopedic surgery was consulted; she was taken to the operating room on [**10-4**] for Closed reduction of right glenohumeral joint dislocation and closed treatment of both bone forearm fracture with manipulation and anesthesia. She was taken back to the operating room on [**10-14**] for closed reduction right glenohumeral joint; ORIF right both bone forearm fracture; closed treatment right fibula shaft fracture;ORIF left medial malleolar fracture and closed treatment left proximal fibula fracture. Follow up imaging of her right shoulder revealed persistent dislocation; several closed reduction attempts have been made to relocate without success; she will require further follow-up with Dr. [**Last Name (STitle) **] after discharge. She is to be non weight bearing on that extremity. Currently this has not been an issue as patient has remained unresponsive since off sedation. Her right wrist staples and left leg staples will need to be removed on [**2200-10-28**]. Orthopedic spine surgery was consulted because of her spine injuries; she was taken to the operating room for fusion of C7 to T9; total laminectomy of T3; reduction of posterior fracture-dislocation; instrumentation of C7 to T9; and autograft. She was fitted for a TLSO brace which should be worn when out of bed per recommendations of Ortho-spine surgery. She underwent an open tracheostomy; percutaneous endoscopic gastrostomy; right femoral [**Location (un) 260**] inferior vena caval filter. Tube feedings were initiated. She has had intermittent high residuals and was started on Reglan QID. A CT scan of her sinuses and mandible were performed because of unilateral facial swelling in order to rule out any sinus processes (see pertinent results section). The swelling has decreased over the last several days. Her pain was initially controlled with IV narcotics; Morphine and Dilaudid; she did on occassion drop her blood pressure with IV Dilaudid; the dose was decreased. She was eventually changed to Roxicet via her g-tube. Her ventilator was weaned off and she was subsequently transferredto the Step down unit. She did have intermittent fevers and was cultured; her most recent workup was on [**10-16**] WOUND CULTURE (Final [**2200-10-18**]): No significant growth. The anaerobic and aerobic blood cultures are still pending at time of this dictation. Prior to this her sputum culture results were as follows: [**2200-10-12**] 8:24 am SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. NOTE: Delayed transport between collection and receipt in the Laboratory. FASTIDIOUS ORGANISMS [**Month (only) **] NOT GROW. INTERPRET RESULTS WITH CAUTION. **FINAL REPORT [**2200-10-15**]** GRAM STAIN (Final [**2200-10-13**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2200-10-15**]): OROPHARYNGEAL FLORA ABSENT. SERRATIA MARCESCENS. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. Trimethoprim/Sulfa sensitivity testing available on request. MODERATE GROWTH. She has been without fevers, her WB on [**10-16**] was 18/1; it was 12.1 on [**10-19**]. Physical, Occupational therapy; social work; case management; nutrition services and patient care services were all very closely involved in her care throughout her entire hospital stay. Discharge Medications: 1. Acetaminophen 160 mg/5 mL Solution Sig: Twenty Five (25) ML's PO Q4H (every 4 hours) as needed for fever or pain. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose Injection TID (3 times a day). 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose Injection ASDIR (AS DIRECTED) as needed for per sliding scale. 4. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic TID (3 times a day) as needed for dry eyes. 5. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) ML's PO BID (2 times a day). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for HR <60, SBP <110. 7. Ibuprofen 100 mg/5 mL Suspension Sig: Twenty (20) ML's PO Q8H (every 8 hours) as needed for pain, fever: give if Tylenol not effective for reducing fevers. 8. Reglan 5 mg Tablet Sig: One (1) Tablet PO four times a day. 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) dose Inhalation four times a day as needed for shortness of breath or wheezing. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) dose Inhalation four times a day as needed for shortness of breath or wheezing. 11. Roxicet 5-325 mg/5 mL Solution Sig: Five (5) ML's PO every four (4) hours as needed for pain. 12. Colace 150 mg/15 mL Liquid Sig: Fifteen (15) ML's PO twice a day as needed for constipation. 13. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: s/p Pedestrian Struck by auto Left diaphragm rupture Fractures of: 1. right sacrum 2. comminuted iliac [**Doctor First Name 362**] 3. left acetabular roof 4. bilat superior/inferior pubic rami 5. right radius/ulna 6. multiple bialt ribs 7. right fibula 8. left tibia 9. left medial malleolus 10.T3 anterior/inferior vertebral body Right shoulder dislocation Right pulmonary contusion Discharge Condition: Stable Discharge Instructions: Return to the Emergency room if you develop any fevers, chills, severe headaches, dizziness, chest pain, increased shortness of breath, nausea, vomiting and/or any other sympotms that are concerning to you. DO NOT bear any weight on right upper extremity secondary to dislocation. Followup Instructions: Follow up with Orthopedics in [**1-4**] weeks, call [**Telephone/Fax (1) 1228**] for an appointment. Follow up with Orthopedic Spine surgery in 4 weeks, call [**Telephone/Fax (1) 3573**] for an appointment. Follow up in Trauma Clinic in 4 weeks, call [**Telephone/Fax (1) 6429**] for an appointment. Completed by:[**2200-10-21**]

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icd9pcs

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185,983

54396

Discharge summary

report

Admission Date: [**2151-6-30**] Discharge Date: [**2151-7-15**] Service: NEUROLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 2569**] Chief Complaint: Right arm weakness, slurred speech Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 84 year old female nursing home resident with PMH of DVT [**3-4**], HTN, GERD, dermatitis. She awoke this morning at 0540 with right arm weakness, slurred and inappropriate speech and bladder/bowel incontinence. She was noted to have said "I think I'm having a stroke". There was no associated fall or trauma. Was reportedly aphasic and weak in the right upper extremity initially, but these deficits resolved at some point as noted in the OSH records. En route, she reportedly desaturated to 88%, was put on face mask and improved, but required CPR for some reason. It is not known at this time if she was receiving CPR for cardiac arrest or respiratory arrest. . CT at OSH showed Intracranial hemorhhage. INR was found to be 6.4 (takes coumadin for h/o DVT this year). She was given FFP and transferred. . She was electively intubated at the OSH ([**Hospital3 628**]) and arrived here to [**Hospital1 18**] intubated but not sedated. On initial evaluation by neurology ER resident, she was noted to be unresponsive, moving all four extremities spontaneously (L>R), with brain-stem reflexes intact and withdrawing X4 to pain. Repeat INR here at [**Hospital1 18**] at 0830 showed INR of 3.2. Patient was given 2 vials of proplex. 3rd INR is pending at this time. . Past Medical History: DVT [**3-4**], HTN, GERD, Bipolar, Dementia, chronic bladder issues, OA, b/l knee pain with partial knee replacement in past. Dermatitis. Undocumented, but according to son, has history of "golf-ball sized" meningioma in the left part of brain. Was seen by a neurosurgeon last year who did not want to operate. History from chart and partially from son who is unclear on some details of PMH. Social History: NH resident. Son lives nearby. Otherwise unknown. Family History: Unknown Physical Exam: T-97.3 BP-118/78 HR-72 RR-12 (vented) O2Sat: 100% Gen: Lying in bed, intubated, vented, sedated. No spontaneous movements. Left arm slightly more flexed at elbow than right. No posturing. HEENT: NC/AT, moist oral mucosa. Neck: In C-spine hard collar. CV: Distant heart sounds. RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: slight ronchi bilaterally. no crackels/wheezes. aBd: +BS soft, nontender. ext: no edema. no lesions. Neurologic examination: Mental status: Intubated. Off propofol, exam shows no response to voice commands. Withdraws all four extremities to pain (left greater than right) but no localization of pain. No spontaneous movements. PERRLA 2-->1 bilaterally. Dolls eyes difficult to assess as in hard collar. Corneal reflexes present bilaterally. Tone moderately rigid in bilateral upper extremities. Reflexes 2+ at brachrad/biceps/triceps/patella. Plantar response extensor on right, mute on left. . No Adventitious movements. . Pertinent Results: Admission Labs: [**2151-6-30**] 08:30AM URINE RBC-0-2 WBC-21-50* BACTERIA-MANY YEAST-NONE EPI-[**10-18**] RENAL EPI-0-2 URINE HYALINE-0-2 [**2151-6-30**] 08:30AM URINE BLOOD-SM NITRITE-POS PROTEIN-TR GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD [**2151-6-30**] 08:30AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.018 [**2151-6-30**] 08:30AM PT-30.5* PTT-33.8 INR(PT)-3.2* [**2151-6-30**] 08:30AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2151-6-30**] 08:30AM NEUTS-84* BANDS-7* LYMPHS-6* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2151-6-30**] 08:30AM WBC-14.5* RBC-3.82*# HGB-12.3# HCT-33.8*# MCV-88# MCH-32.2* MCHC-36.5* RDW-13.7 PLT COUNT-276 [**2151-6-30**] 08:30AM ACETONE-MODERATE [**2151-6-30**] 08:30AM CALCIUM-9.5 PHOSPHATE-1.4* MAGNESIUM-1.8 [**2151-6-30**] 08:30AM CK-MB-NotDone cTropnT-<0.01 CK(CPK)-42 [**2151-6-30**] 08:30AM GLUCOSE-117* UREA N-25* CREAT-0.7 SODIUM-141 POTASSIUM-3.4 CHLORIDE-102 TOTAL CO2-20* ANION GAP-22* [**2151-6-30**] 09:25AM freeCa-1.19 LACTATE-0.9 [**2151-6-30**] 09:25AM TYPE-ART PH-7.37 INTUBATED-INTUBATED [**2151-6-30**] 12:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2151-6-30**] 12:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012 [**2151-6-30**] 12:30PM PT-13.7* PTT-23.9 INR(PT)-1.2* [**2151-6-30**] 12:30PM ASA-NEG* ETHANOL-NEG ACETMNPHN-9.8 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2151-6-30**] 12:30PM TSH-1.3 ALBUMIN-4.4 [**2151-6-30**] 12:30PM CK-MB-4 cTropnT-<0.01 [**2151-6-30**] 12:30PM ALT(SGPT)-22 AST(SGOT)-61* CK(CPK)-125 ALK PHOS-81 TOT BILI-0.5 [**2151-6-30**] 05:33PM PT-18.0* PTT-29.8 INR(PT)-1.7* [**2151-6-30**] 10:14PM PT-22.8* PTT-35.1* INR(PT)-2.3* [**2151-6-30**] 10:14PM CK-MB-NotDone cTropnT-<0.01 CK(CPK)-72 . Admission CT Head: CT OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST: A large left frontoparietal intraparenchymal hemorrhage is again noted. There is questionable minimal increase in prominence of the caudal portion of the hemorrhage in comparison with the examination of several hours earlier. The degree of hypodensity surrounding the inferior portion of the hemorrhage also appears minimally increased, consistent with slight increase in edema. The degree of left to right subfalcine herniation is unchanged. There is no hydrocephalus or evidence of transtentorial herniation. Bilateral cerebral periventricular white matter hypodensity is consistent with chronic small vessel ischemic change. There is no evidence of extra-axial hemorrhage. . Bone windows demonstrate no evidence of fracture within the surrounding osseous structures. The mastoid air cells and visualized portions of the paranasal sinuses are normally pneumatized. . IMPRESSION: Left frontoparietal intraparenchymal hemorrhage, questionably minimally increased along its caudal aspect, without change in degree of mass effect. . CT C Spine: 1. No fracture or malalignment seen. 2. Extensive degenerative disc disease as well as multilevel DJD. . [**7-1**] follow up CT: Stable left frontoparietal intraparenchymal hemorrhage. No change in degree of mass effect . EEG [**6-30**]: ABNORMALITY #1: Throughout the recording there were frequent bursts of mixed frequency slowing with a generalized distribution. There were also occasional bursts of bitemporal mixed frequency slowing. ABNORMALITY #2: Background rhythm was usually disorganized. It was often somewhat slow, in the [**6-5**] Hz range although there were some faster frequencies. The background did react to external stimuli with some apparent alerting. HYPERVENTILATION: Could not be performed. INTERMITTENT PHOTIC STIMULATION: Could not be performed. SLEEP: No normal waking or sleeping morphologies were seen. CARDIAC MONITOR: Showed a generally regular rhythm. IMPRESSION: Abnormal portable EEG due to the bursts of generalized slowing with additional bitemporal mixed frequency slowing. These findings suggest multifocal subcortical abnormalities. Vascular disease is a relatively common cause of such findings. In addition, the background was disorganized and usually somewhat slow, suggesting a concomitant encephalopathy. There were no areas of prominent and persistent focal slowing, and there were no clear epileptiform features. . Bilateral LENIs: 1. No evidence of acute DVT. 2. Evidence of prior DVT of the left popliteal vein. . MRI/MRA Brain: FINDINGS: As noted on the prior CT, there is an acute 4 cm left frontoparietal intraparenchymal hematoma. There is a small amount of subdural blood present over the anterior left temporal lobe. There is mass effect upon the atrium of the ipsilateral lateral ventricle. However, there is no significant midline shift or herniation. There are no additional foci of abnormal magnetic susceptibility to indicate other microhemorrhages. There are multiple T2 hyperintensities within the subcortical white matter of both cerebral hemispheres due to chronic microvascular infarct. . This study is slightly limited by patient motion artifact. There is no slow diffusion to indicate an acute infarct. . IMPRESSION: Large intraparenchymal left frontoparietal acute hematoma with a tiny amount of subdural blood along the left middle cranial fossa. . There is no evidence of other microhemorrhages. . No acute infarct. Chronic microvascular infarct. . MRA: Normal brain MRA, but limited by motion. . EEG [**7-3**]: TIME SAMPLES: Throughout the recording, there is continuous slowing of the left hemisphere in the mixed [**11-30**] Hz delta and [**3-3**] Hz theta frequency range. There were no clear epileptiform discharges seen throughout the recording. BACKGROUND: Over the left hemisphere is more disorganized and represented a lower voltage gradient. The right hemisphere is mildly disorganized but reaches normal alpha frequency ranges. SLEEP: Normal transitions of the sleep architecture were not seen. CARDIAC MONITOR: Normal cardiac rhythm with a rate of 84 bpm. There was a continuous widespread QRS complex seen. AUTOMATIC SEIZURE DETECTIONS: There were no entries in these files. AUTOMATIC SPIKE DETECTIONS: There were 103 entries in these files. All entries represent movement and muscle artifact. PUSHBUTTON EVENTS: There was one pushbutton at the beginning of the recording which represented a system's test. IMPRESSION: This is an abnormal discontinuous 24-hour long term EEG monitoring due to the presence of continuous slowing over the mixed delta and theta frequency range over the entire left hemisphere. There were no clear epileptiform discharges or seizure activity recorded. A widespread QRS complex was noted. . EEG [**7-4**]: TIME SAMPLES: Throughout the recording, there is a persistent moderate voltage slowing in the [**11-30**] Hz delta frequency range and intermittent theta frequency slowing over the entire left hemisphere with left temporal emphasis. As the study progressed, there are initially isolated sharp features over the left temporal region with phase reversing around T3 and runs of semi-rhythmic 5 Hz theta frequency slowing in the left central region lasting up to 20 seconds. Beginning in the early evening of the recording, there are frequent semi-rhythmic sharp and slow wave and spike slow wave discharges seen phase reversing around F7 and T3, secondarily spreading over the entire left hemisphere. The frequency of these discharges vary between 1 and 2 Hz lasting from 1 a.m. to the end of the recording at 10 a.m. on [**2151-7-4**]. AUTOMATIC SEIZURE DETECTIONS: There are three entries in these files. All events represent fast eye movements. There was no clear seizure activity recorded. AUTOMATIC SPIKE DETECTIONS: There were 79 entries in these files. The majority of these entries represent muscle artifact. There were also a few sharp wave discharges over the left temporal region captured. Please see above. PUSHBUTTONS: There were no entries in this file. SLEEP: Normal transitions of the sleep architecture were not seen. CARDIAC MONITOR: There is a normal cardiac rhythm with a rate of 90 bpm. There are prolonged widespread QRS complexes alternating with normal QRS complexes seen. IMPRESSION: This is an abnormal 24-hour discontinuous EEG telemetry due to the presence of prolonged epileptiform sharp and spike slow wave discharges seen over the left fronto-temporal region spreading over the entire left hemisphere. This finding was persistent for at least nine hours through the end of the recording. Additionally, there is continuous delta frequency slowing over the entire left hemisphere. This finding suggests cortical and subcortical structural abnormalities. Over the 24-hour EEG recording, there are described discharges over the left hemisphere which became more frequent and persistent but there were no clear seizures recorded. Widespread QRS complexes alternating with normal QRS complexes were noted. . EEG [**7-8**]: ABNORMALITY #1: Throughout the recording, there are intermittent bicentral sharp slowing seen independently occasionally followed by a slow wave. ABNORMALITY #2: There is increased voltage gradient over the entire left hemisphere with a diffuse mixed theta and delta frequency slowing. There is no clear anterior-posterior voltage gradient on both hemispheres. The background is slow in the [**5-5**] Hz theta frequency range and disorganized. The superimposed fast activity in the beta frequency range is noted. BACKGROUND: As above. HYPERVENTILATION: Was not performed due to the patient's clinical condition. INTERMITTENT PHOTIC STIMULATION: Was not performed because this was a portable study. SLEEP: Normal transitions of the sleep architecture were not seen. CARDIAC MONITOR: Normal cardiac runs of widespread QRS complexes followed by normal QRS complexes were seen. IMPRESSION: This is an abnormal portable EEG due to the presence of intermittent, independent, bicentral sharp slowing and sharp slow wave discharges and due to slow and disorganized background rhythms with diffuse theta frequency slowing and increased voltage gradient over the entire left hemisphere. The background slowing suggests cortical/ subcortical dysfunctions and a mild encephalopathy. Epileptiform discharges represent most likely cortical dysfunction in central parietal regions. Superimposed fast activity is most likely due to medication effect. Given the patient's clinical history and EEG findings, EEG monitoring might be of benefit. . CT Head [**7-8**]: Comparison with the prior study of [**2151-7-1**], reveals reduction in the density of the large hemorrhage, but negligible change in its degree of mass effect or surrounding edema. Once again, there is considerable compression of the posterior aspect of the body of the left lateral ventricle as well as the atrium. The minimal subfalcine herniation is unaltered. No new area of intracranial hemorrhage is identified. . There is moderate mucosal thickening within the posterior aspect of the left ethmoid sinus, which has evolved since the prior study. The finding likely relates to the intubated status of the patient. . TTE [**7-9**]: The left atrium is mildly dilated. There is mild (non-obstructive) focal hypertrophy of the basal septum. The left ventricular cavity size is normal. There is mild to moderate regional left ventricular systolic dysfunction with akinesis of the mid antero-septum, distal LV and apex. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . Brief Hospital Course: Pt. was admitted to the Neuro ICU. Was intubated at the outside hospital. BP was initially maintained below 140 with Labetalol IV, and repeat imaging showed stability of the hemorrhage. INR was corrected with FFP and proplex. Over the first 24 hours, her exam was felt to be out of proportion with findings on CT. However, she did receive narcotics at the OSH and was found to have UTI on admission both of which could account for a change in neurological status. Propofol was weaned and narcotics held. On day 2 she was noted to be much more awake and following commands. She was able to raise left arm and leg anti-gravity and was noted to be moving all four extremities spontaneously (L>R). Her mental status continued to improve and she was transferred to the floor [**7-4**]. Failed multiple bedside swallow exams and was NPO with NG in place. . On the floor mental status continued to improve, although pt. failed a repeat bedside swallow evaluation. Aspirin was restarted. She finished a 7 day course of Levofloxacin for UTI. . On [**7-7**] had GTC seizure in the early morning hours. Witnessed by physician who reported as upper extremities and face involvement. Received 2mg IV ativan without any change. After another 1mg ativan converted to RUE and face only. GTC portion estimated to have been about 20 minutes. After another 1+1 ativan she gradually slowed the RUE movement but facial twitching continued. Was loaded with 1 gram IV Dilantin and movements ceased after about an hour. Vitals were all initially stable with tachycardia, but became hypotensive in post-ictal period. Patient received 5mg Ativan and 1gram Dilantin in total. She was not on seizure prophylaxis up until this point. Was not following any commands but withdrew all four extremities to noxious stim. Transferred back to ICU for hypotension. Dilantin discontinued as she had cyanotic fingertips which was presumably as a reaction to the Dilantin (purple glove syndrome). Was loaded on Depakote and maintained with IV doses QID. Was following commands at 24 hours although very somnolent. After 48 hours was more awake and near baseline. Was transferred back to the floor [**7-9**]. . On the floor Depakote was continued, and dose titrated up as levels were low. Depakote levels should be checked QOD at rehab and dose titrated accordingly. Pt. worked with PT and OT who recommended acute rehab. She failed another swallow evaluation. Her swallowing was discussed several times with her son and HCP, [**Name (NI) **] [**Name (NI) 111356**], who felt that he did not want to subject his mother to a PEG tube at this juncture, and was hopeful that with more time she would pass a swallow evaluation. We discussed with him that there was a chance that she may not to regain her swallowing abilities, which he understood, but he maintained that he wanted to give her more time before making the decision to proceed with PEG. She should continue to be evaluated by speech and swallow at rehab, and if she continues to fail PEG tube will need to be readdressed with him. . Neuro exam on discharge was significant for diffuse mild L sided weakness ([**3-3**] in all muscles groups), trace movement of R ankle but 0/5 strength of all muscle groups on the right, and some inattention and perseveration, as well as problems following complex commands. . CVS: Cardiovascularly ruled out for MI with serial enzymes. No significant events on Telemetry. Was hypotensive to 80s/50s and initially did not respond to fluid boluses (3 boluses of 500cc NS each). On arrival to ICU received additional 500 cc bolus and pressures corrected to acceptable level. Pressors not initiated. Ruled out again for MI with serial enzymes. Had echo (please see results section) which showed mild to moderate regional left ventricular systolic dysfunction with akinesis of the mid antero-septum, distal LV and apex, EF 35%. She should have a repeat TTE when she is more medically stable to f/u these findings. BP stable for several days with no IV boluses required prior to discharge. . RESP: Intubated at OSH. Extubated after 48 hours without complications. HEME: INR was initially corrected with FFP and proplex. Serial INRs were performed and she required a few additional units of FFP over the first 48 hours. She also received some vitamin K SC. INR was stable at 1.0-1.2 after HOD #3. . GI: Failed multiple swallow evals and NG placed. Received tube feeds throughout hospitalization. PPI for prophylaxis. Decision for PEG . ID: Had UTI on admission which was treated with IV Levaquin for 7 days. . RENAL: No issues this admission. . Medications on Admission: MEDS at NH: Erythromycin ointment to eyes QHS first 5 days of each month Dulcolax Sup PRN Coumadin 4mg PO Daily Namenda 5mg PO Daily MVI Daily Remeron 45mg Daily MOM 30cc daily prn Tyelnol 650mg Daily prn Discharge Medications: 1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): please administer prior to meals per sliding scale attached. 2. Memantine 5 mg Tablet Sig: One (1) Tablet PO daily (). 3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Valproate Sodium 250 mg/5 mL Syrup Sig: 7.5 mL PO Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: 1) Left frontoparietal intraparenchymal hemorrhage 2) Generalized tonic-clonic seizure Discharge Condition: stable, tolerating medications Discharge Instructions: 1) Please return for increasing weakness, trouble speaking, inability to take medications, uncontrolled bleeding, vomiting and fevers. 2) Please attend all appointments 3) Take all medications as prescribed. Followup Instructions: Your PCP will visit you at your nursing home. Please have your nursing home call upon your arrival. . Your have a neurology appointment with Dr. [**Last Name (STitle) **] and his fellow (Dr. [**Last Name (STitle) 70597**] , Wed [**2151-9-8**] at 1pm. [**Hospital3 **] hospital [**Hospital Ward Name 23**] building [**Location (un) **]. For more details can call # [**Telephone/Fax (1) 2574**]. [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**] Completed by:[**2151-7-15**]

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Discharge summary

report

Admission Date: [**2157-10-8**] Discharge Date: [**2157-10-29**] Date of Birth: [**2078-9-11**] Sex: M Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 9569**] Chief Complaint: MRSA sepsis Major Surgical or Invasive Procedure: trans-esophageal echocardiogram dialysis catheter placement History of Present Illness: 79yoM admitted to [**Hospital1 **] [**Location (un) 620**] on [**10-2**] for constipation. This resolved with aggressive bowel regimen. On [**10-5**], became hypotensive to BP in 70s, with unresponsiveness. WBC spiked to 27, fever to 100.1, with AG acidosis. Blood cultures were positive for MRSA. Pt was given vancomycin, dosed by level. He was placed on dopamine and fluid resuscitated; dopamine was switched to levophed secondary to tachycardia; pressors were discontinued on AM of transfer. . Pt had progressively worsening renal function, as well, with baseline BUN almost 100 and Cr 2.6-2.7. This was thought to be due to over-diuresis, perhaps with a component of sepsis. Pt could not be dialyzed due to low MAPs, and was therefore transferred here for CVVH. At OSH, pt also received FFP for elevated INR and DDAVP for bleeding at site of R IJ. . Pt denies chest pressure, SOB, or abdominal pain. No dysuria. No orthopnea, PND, no lightheadedness/dizziness. No headache. + BM in the last 2 days. No changes in color of stool, no BRBPR. Overall feels fatigued, attributes this to lack of sleep. Denies fevers, chills, or sweats. Past Medical History: CAD s/p CABG, multi PCI Ischemic cardiomyopathy(EF<20%) Diabetes, on insulin. Chronic atrial fibrillation, on Coumadin. Status post BIV pacer/ICD Chronic renal insufficiency (Cr 2.7-2.9)complicated by acidosis on Sod Bicarb and hyperkalemia requiring Kayexalate treatments as an outpatient. Gout on Allopurinol Anemia on Procrit Social History: + tob, 15 pack-years, quit [**2122**]; smoked cigars intermittently in 70s. Occasional EtOH, no IVDU. Lives at home with his wife and disabled son in [**Name (NI) 620**]. Family History: Mother - CAD ? age, DM 2 Brother - epilepsy Son - Ischemic cardiomyopathy / congestive heart failure . ALLERGIES: No known drug allergies. Questionable allergy to Morphine (SBP dropped on Morphine administration). Physical Exam: VS: 96.1 89/55 74 18 100% RA Gen: alert, NAD HEENT: PERRL, EOMI, OP clear, MM somewhat dry Neck: no JVD, no carotid bruits Chest: AICD in place, no tenderness, erythema or swelling over pocket CV: RRR, nl S1/S2, no murmurs appreciated Pulm: CTAB, no wheezes or crackles Abd: soft, NT, mildly distended, + ecchymosis at site of heparin injection, + BS Ext: [**2-6**]+ pitting edema in B LE; + ecchymosis on arms bilaterally Pertinent Results: [**2157-10-28**] 07:10AM BLOOD WBC-10.3 RBC-3.06* Hgb-9.4* Hct-31.7* MCV-104* MCH-30.9 MCHC-29.8* RDW-20.9* Plt Ct-135* [**2157-10-9**] 04:00AM BLOOD WBC-12.3*# RBC-3.21* Hgb-10.0* Hct-30.0* MCV-93 MCH-31.1 MCHC-33.3 RDW-19.1* Plt Ct-68*# [**2157-10-25**] 04:10AM BLOOD Neuts-79.6* Lymphs-15.0* Monos-3.4 Eos-1.3 Baso-0.6 [**2157-10-25**] 04:10AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+ Macrocy-3+ [**2157-10-28**] 07:10AM BLOOD Plt Smr-LOW Plt Ct-135* LPlt-8 [**2157-10-28**] 07:10AM BLOOD PT-16.5* PTT-37.0* INR(PT)-1.9 [**2157-10-11**] 02:00PM BLOOD ESR-10 [**2157-10-28**] 07:10AM BLOOD Glucose-103 UreaN-120* Creat-6.4*# Na-150* K-7.2* Cl-113* HCO3-15* AnGap-29* [**2157-10-9**] 04:00AM BLOOD Glucose-102 UreaN-125* Creat-2.8* Na-134 K-4.0 Cl-98 HCO3-21* AnGap-19 [**2157-10-24**] 01:10PM BLOOD ALT-9 AST-20 LD(LDH)-289* AlkPhos-136* TotBili-2.4* [**2157-10-28**] 07:10AM BLOOD Calcium-8.8 Phos-10.5*# Mg-2.8* [**2157-10-27**] 01:30AM BLOOD Calcium-9.7 Phos-6.6* Mg-2.6 [**2157-10-26**] 06:55AM BLOOD Calcium-9.5 Phos-6.2* Mg-2.6 [**2157-10-25**] 04:10AM BLOOD Calcium-9.9 Phos-5.5* Mg-2.3 [**2157-10-24**] 07:45AM BLOOD Calcium-9.4 Phos-4.3 Mg-2.3 [**2157-10-10**] 03:40AM BLOOD Calcium-9.4 Phos-4.0 Mg-2.7* [**2157-10-8**] 10:45PM BLOOD Cortsol-44.4* [**2157-10-8**] 10:15PM BLOOD Cortsol-43.3* [**2157-10-8**] 03:15PM BLOOD Cortsol-28.6* [**2157-10-11**] 02:00PM BLOOD CRP-112.9* [**2157-10-25**] 04:10AM BLOOD Vanco-28.6* [**2157-10-20**] 03:00PM BLOOD Vanco-16.6* [**2157-10-21**] 10:20PM BLOOD Type-ART Rates-/24 FiO2-99 pO2-236* pCO2-29* pH-7.46* calHCO3-21 Base XS--1 AADO2-458 REQ O2-76 Intubat-NOT INTUBA [**2157-10-21**] 10:20PM BLOOD Lactate-2.1* [**2157-10-21**] 10:20PM BLOOD freeCa-1.17 . TTE/chest echo [**10-26**]: Focused study on pacing wires. The inferior vena cava is dilated (>2.5 cm) c/w elevated RA pressure. Catheters/pacing wires are seen in the RA and RAA. No discrete vegetation is identified (Best excluded by TEE). Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated with severe global hypokinesis. The right ventricular cavity is dilated. There is severe global right ventricular free wall hypokinesis. The aortic valve leaflets are moderately thickened. The mitral valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2157-9-23**], the catheters appear similar. 1. No abscess as clinically questioned. 2. Hypoechoic mass present just deep to the left pectoralis muscle. This exam was not done in the radiologic department, it done by the patient's bedside. Further evaluation is recommended with scanning by the radiologist. It is unclear if this represents a solid mass or entity such as a hematoma. . CXR [**10-24**]: 1. Persistent pulmonary edema. 2. Mild cardiomegaly with small bilateral pleural effusions. 3. Biventricular pacer device in good position. . CT abd/pelvis [**10-23**]: 1. Study limited due to lack of IV contrast. No source identified for the patient's MRSA bacteremia by noncontrast CT scan. 2. Small bilateral pleural effusions, left side greater than right. . CT sinus [**10-23**]: Acute right maxillary sinusitis. . upper extr u/s [**10-22**]: No deep venous thrombosis in right or left internal jugular, subclavian, axillary, basilic, brachial or cephalic veins. . bone scan [**10-20**]: In conjunction with the Indium WBC scan performed today, there is no evidence of osteomyelitis within the spine. Increased activity in the clavicle on the wbc scan is not seen on the bone scan. This is unlikely to represent infection, and may represent marrow changes. . CXR [**10-20**]: New parenchymal abnormality in the lower lungs has a similar pattern to that on [**10-12**] which cleared by [**10-13**], suggesting a combination of mild pulmonary edema and atelectasis accompanied by increasing small bilateral pleural effusions. Moderate cardiomegaly is stable. Intended right atrial and left ventricular pacer and right ventricular pacer defibrillator leads are continuous from the left pectoral power pack and project over their expected courses. A right ventricular pacer lead fragment ends in the right chest wall. Right PIC catheter has been removed. . WBC scan [**10-18**]: 1. No abnormal tracer activity within the spine. 2. Increased tracer activity in the medial left clavicle. This may suggest infection or inflammation. The patient is to undergo Tc-99 bone scan and correlation with the bone scan is recommened. 3. Increased activity in the region of the right maxilla. No clear sinusitis is seen on the panorex film. If there is clinical concern for a periodontal process, a CT of the sinuses is recommened with imaging through the mandible. . Echo [**10-12**]: Mildly thickened mitral and tricuspid valves without discrete vegetation seen. Moderate to severe tricuspid regurgitation and mild to moderate mitral regurgitation. Moderately thickened and calcified aortic valve with mild aortic regurgitation but no discrete vegetation. Severely depressed left and right ventricular function. . CXR [**10-12**]: Left lower lobe pneumonia. . CT neck [**10-11**]: Severe atherosclerotic disease. No destructive processes of the osseous structures. No paraspinal soft tissue masses or abscess. . CXR [**10-8**]: Right IJ line in satisfactory position, no other significant change. Stable cardiomegaly. Brief Hospital Course: A/P: 79y/o M with DM2 c/b ESRD with MRSA sepsis . 1. MRSA bacteremia - Patient transferred from OSH w/ MRSA bacteremia (8/31 [**3-9**] MRSA, 9/1 [**3-9**] MRSA, 9/2 [**2-8**] MRSA, [**10-8**] MRSA). Was transiently on pressors for hypotension but was off of these prior to transfer to [**Hospital1 18**]. Unclear source of infection - no evidence of PNA by CXR or symptoms, no open skin lesions. TTE performed at OSH with no evidence of vegetations, but TEE planned to r/o endocarditis. Patient was to have TEE on [**10-11**] but was hypotensive to 90's/40's and procedure postponed. Also, patient was complaining of neck pain and a CT of neck was done to look for epidural abscess/osteomyelitis, etc (no contrast used due to renal function and unable to get MRI due to AICD). Has been on vancomycin since [**10-5**] at OSH. Vancomycin dosing by daily levels, with goal between 15-20. Serial blood cultures consisently grew MRSA, which were all sensitive to vancomycin. TEE performed on [**2157-10-12**]. During procedure, pt became hypotensive (60-70's) and was given dopamine and 500cc fluid. Pt remained assymptomatic during the event. TEE was able to performed and it showed no changes. No signs of thrombosis or vegetative growth. Moderate to severe TR, mild to moderate MR. Vanco was continued. A PICC line was placed on [**10-12**]. Bcx sent on [**10-12**] returned positive for staph infection. CXR was obtained to r/o aspiration PNA. It showed a LLL PNA. Initated levofloxacin x 7 days. On [**2157-10-14**], pt began c/o SOB. Nebulizers were initated. Pt has been coughing up sputum. However, he was able to swallow and eat without any problems. This was once Speech/Swallow evaluated him and set him on a ground diet. Pt continued on IV Vancomycin, with routine trough measurements. BCxs continued to be drawn and showed continued growth. ID consulted and determined that vanco is appropriate treatment (surveillance cultures have all demonstrated sensitivity to vanco). An MRI of the spine was warranted, however, unable to be performed due to AICD. A CT can not be performed due to patients renal issues. A WBC tagged scan was ordered to assess for any sources of possible infection. This test, and a bone scan, did not reveal a source of infection. A right maxillary sinusitis was noted and was confirmed by sinus CT, however, ID thought this was a highly unlikely source of MRSA. Vancomycin was continued however cx remained + for MRSA. Although the serial blood cultures indicated that the MRSA was vanco sensitive, the family requested "other options" for antibiotics, which resulted in a switch to daptomycin/doxycycline/rifampin and d/c of the vancomycin. By the time this regimen was started, the patient was obtunded and anuric, and ID recommended stopping the rifampin to avoid adverse side effects of overdose. The patient was made DNR/DNI, but at the family's request, the ABx were continued until the patient expired on [**10-29**]. . As best as could be determined from the studies obtained, there was no other source of persistent infection other than the pacer wires. Dr. [**Last Name (STitle) **] (from EP), who had originally placed the wires, evaluated the patient for potential wire removal, and after discussion with the family and patient, it was not considered feasible and carried an extremely high mortality with no guarantee of clinical improvement even if the patient tolerated the surgery. . 2. Hypotension - MRSA growing out of blood cultures thought to be the precipitator of hypotension. However, patient was also intravascularly dry after diuresis at OSH. Cortisol and stim test performed with no evidence for adrenal insufficiency (patient was treated with hydrocortisone and fludrocortisone and d/c'd once results of cosynotropin stim test back on [**2157-10-11**]). While patient is total body fluid overloaded, his ECV is down, likely in the setting of decreased cardiac output (EF 10-20%) and infections. On [**10-10**] evening and through night he became hypotensive into 90's and was given gentle fluids and maintained MAPs >60. No need for pressors during ICU stay. As of [**10-12**], no IVF given on the floor. BP remained stable betwen 90-100. Monitored bp when lasix was reinitiated, and pt tolerated it well. On [**10-18**], pt was hypotensive at 80/D. Concern over that pt becomes dazed in mid-conversation. Adjusted his insulin regimen as this may contributing. In order to maintain bp for effective diuresis, Pt. was started on a dopamine drip (administered on a cardiology unit with continuous telemetry monitoring). The patient's SBP was stable in the 100-110 range during the time he received dopamine, and he was able to tolerate IV lasix, to which he diuresed nicely. His Cr was monitored throughout this period to prevent over-diuresis. Dopamine was stopped when the patient appeared euvolemic, and his bp remained stable for several days, but the patient gradually went in to renal failure and became anuric. Dialysis was considered, and a dialysis catheter was inserted by IR, but at this time, the patient was agitated with tremors and hemodynamically unstable, and the recommendation from the renal service was that the patient would likely be unable to tolerate dialysis. At this point, the patient was DNR/DNI, and IV fluids were stopped and the patient remained anuric until he expired. . 3. Acute on chronic renal failure - Baseline Cr 2.6-2.7, but admitted with Cr in low 3's. Patient was transferred to [**Hospital1 18**] in case of need for CVVH, but renal was consulted and found no indication for HD. Patient was total body fluid overloaded (slightly), but not initially to the point of needing dialysis. As described above, following dopamine/lasix diuresis, the patient gradually went into acute renal failure and was not able to undergo dialysis. . 4. Systolic congestive heart failure - Patient with significant systolic CHF (EF 10-20% on recent echo), with no evidence of acute decompensation on exam. Pt. consistently sat'ed well. Patient's lasix and BB were held due to hypotension while in ICU. Pt remained off lasix and BB until after the TEE. Lasix continued to be withheld due to pressure drop during the TEE. on [**10-12**], Lasix increased at slow rate and ASA reinstated. VS remained stable. On [**10-15**], pt was on 20mg PO daily and was changed to 10mgIV on [**10-18**]. Change due to increasing edema of LE. Cardiac function remained poor throughout hospitalization. . 5. Coronary artery disease - Patient has had CABG and cath in 03 and 04, respectively. No symptoms of angina during hospitalization. No evidence of ischemia on ECG, though pt's pacer makes interpretation of ECG limited. Plavix was continued, but this should be addressed with cardiology as it appears he has been on it for >9 months. ASA held in setting of thrombocytopenia and likely uremic plts. BB held in setting of hypotension. On [**10-12**], it was decided that ASA would be reinitiated at low dose, and plavix was continued. . 6. Atrial fibrillation - Pt. was well rate-controlled. While in hospital, coumadin was held in setting of oozing from R IJ catheter. Pt. remained in NSR until he expired. . 7. Thrombocytopenia - Unclear etiology (new since this admission). Platelets that are present likely dysfunctional as BUN > 100. HIT Ab was negative. Avoided heparin while in the hospital. Platelet level continued to steadily increase until Pt. expired. . 8. Anemia - Chronic, due to underlying iron and B12 deficiency. Also chronic kidney disease likely an etiology of anemia. On Epogen 3x/week. Blood levels wer monitored as per routine. . 9) On presentation, pt has back/neck pain. Concern that it was attributed to OM or the bacteremia had spread to his spine. CT was performed and found to be negative for ST disease or bony destruction. Atherosclerosis was noted. Tylenol was given to treat the pain. . 10) DM: Pt was placed on 19NPH at admission. On [**10-18**], notable decrease in blood glucose. D/c NPH to asssess how pt is without it. This was due to his level running very low (32 at 600AM). Decided to monitor for changes. . 11) Code: Pt. was admitted full code. When surgical removal of the pacer wires was deemed not feasible, and when Pt. became anuric and was not considered a candidate for dialysis, several family meetings resulted in a consensus that the Pt. would be DNR/DNI, and treated as comfort measures only. DNR/DNI documentation was signed by [**Name (NI) 1094**] son in presence of wife, daughter, and other son, who were all in agreement. Although Pt. was comfort measures only, antibiotics were continued at family's request, and ativan, valium, and dilaudid were given ad lib. The patient expired pain-free and without incident. Medications on Admission: aspirin 81mg po daily plavix 75mg po daily naproxen 50mg po daily epogen 10,000 units qMWF toprol XL 25mg po daily vitamin B12 100mcg po daily flovent 2 puffs [**Hospital1 **] iron 325mg po daily gemfibrozil 600mg po bid allopurinol 100mg every other day coumadin 3mg po qHS lasix 40mg po daily calcitriol 0.25mg po daily sevelamer 800mg po daily insulin 19 units NPH in AM, 3 units humalog ? NPH/humalog at night Discharge Medications: not applicable. Discharge Disposition: Expired Discharge Diagnosis: MRSA bacteremia Congestive heart failure Acute renal failure Discharge Condition: expired. Discharge Instructions: not applicable. Followup Instructions: not applicable. Completed by:[**2157-10-30**]

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icd9cm

[ [ [] ] ]

[ "38.95", "38.93", "88.72" ]

icd9pcs

[ [ [] ] ]

17558, 17567

8245, 17045

282, 343

17671, 17682

2763, 8222

17746, 17794

2080, 2295

17518, 17535

17588, 17650

17071, 17495

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2310, 2744

231, 244

371, 1521

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1890, 2064

27,362

171,835

33060

Discharge summary

report

Admission Date: [**2179-2-23**] Discharge Date: [**2179-2-26**] Date of Birth: [**2158-5-11**] Sex: F Service: [**Year (4 digits) 662**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: hypertensive urgency Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 20 year old female with MPGN s/p renal transplant ([**7-13**]) and recurrent MPGN who was recently admitted for renal failure as well as hypertensive emergency who re-presents with hypertensive emergency. . She initially presented from [**Hospital1 336**] to [**Hospital1 18**] transfer in [**1-15**] for ARF. She also developed severe HTN to the 200s resulting in adjustment of her BP medications. She was also found to have hemolytic anemia thought [**1-9**] to her malignant HTN according the heme/onc. She was treated supportively with PRBCs as well as plasmapheresis for her MPGN. She also went for embolization of an AVF in her transplant kidney which occurred as a result of her transplant. Though this resulted in an increased Cr, HD was not required and she was discharged with close follow up. However, the patient returned one day later when she was found to have SBPs in the 200s by her PCP. [**Name10 (NameIs) **] was re-admitted to the ICU for BP monitoring and further titration. She was also found to have HTNive retinopathy as well. The decision was made during that admission to start HD which she tolerated well. She did require 1 unit PRBCs for persistent anemia thought [**1-9**] hemolysis. . She was then doing well on HD until the day prior to this admission. On sunday she developed coarse cough we no real productive sputum. She also felt generally unwell but denied overt fever, ST, HA, CP, abd pain, myalgias. Her coughing spells did cause her to have nausea and she vomited at home. She went in to see her PCP on monday who recorded a T 100.8. Rapid strep and flu were negative. CXR was also taken and there was ? of small infiltrate. No antibiotics were given. She then went for a full HD session, continued to feel unwell, and presented to the ED. Of note, her family has been sick with the cold and her mother was diagnosed with the flu. She reports good adherence to her medications, but did not use her clonidine patch this weekend and is unsure if her vomitting prevented good digestion of her pills. . In the ED, T 99.2, HR 92, BP 155/108, RR 16, 100%RA. CXR was done. She was given Levaquin, Vanco. She was noted to have T 99.6, mild HA and nausea. Pt noted to have BP 189/102 at 0515. She was given 25mg Hydralazine. At 0640 BP 210/129. Given Cozaar 50mg, Captopril 25mg, Labetolol 20mg IV. BP did not improve and was started on Labetolol gtt ([**1-11**]). She was started on Nipride at 1015 (3mcg/hr). At 1030 BPs improved to 140-180/74-108. . On arrival to the ICU, she states that she feels about the same. Her eyes are closed. She denies CP, vision changes, HA. . Upon arrival to the floor patient is w/out complaints denies vision changes, back pain, CP, palpitations, SOB, headache, cough, nausea, vomiting, adominal pain. Past Medical History: #)MPGN: Diagnosed age 9 by biopsy. S/p LRRT in 08/[**2175**]. Post transplant pt was doing well, but had rising Cr for two year. On [**6-/2178**], pt presented with uncontrolled BP requiring ICU admission for Isradipine drip. Repeat biopsy showed a type 1 MPGN. Negative HepC,HepB,[**Doctor First Name **], and renal U/S from NMEC showed stable AVF. Her creatinine peaked to 4's and she was started on steroids, prograf and cellcept. In [**1-/2179**], she required 3 sessions of HD through a right upper chest catheter. Creatinine slowly recovered to 3.2. Plasmapheresis was then initiated with plan to then treat with Rituximab. She only underwent 3 sessions of [**Year (4 digits) **]. She is now transferred her care to Dr. [**Last Name (STitle) **] at [**Hospital1 18**] to an adult clinic. #)Peripheral edema and abdominal striae [**1-9**] steroids #)HTN [**1-9**] steroids and renal disease, multiple admissions for Hypertensive Emergency. Most recently one month ago, [**Date range (1) 76875**] #)Hemolytic Anemia - was seen by heme/onc who felt it was [**1-9**] to malignant hypertension #)Migranes Social History: Lives at home with [**Month/Day (2) **], brother and sister, college student at [**Name (NI) 498**] [**Name (NI) 86**] in the health sciences. Denies ETOH, illicit drugs, tobacco. Family History: No history of kidney disease, malignancy, heart disease, or diabetes. Physical Exam: VS: 98.7 112/64 HR 85 RR18 99%/RA GEN: Eyes closed, in NAD, flat affect, detached but cooperative HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear, no pallor or cyanosis of the oral mucosa, no xanthalesma NECK: supple, no LAD, JVD RESP: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. CV: RRR, loud S2, nl S1, 3/6 SEM heard best at LUSB and throughout precordium ABD: Soft, NT, ND, no masses, fluid shifts, guarding EXT: no c/c/e Neuro: not tested SKIN: No rashes or lesions Pertinent Results: ADMISSION LABS [**2179-2-23**] 05:00PM GLUCOSE-116* UREA N-26* CREAT-5.6*# SODIUM-139 POTASSIUM-5.2* CHLORIDE-102 TOTAL CO2-31 ANION GAP-11 [**2179-2-23**] 05:00PM LD(LDH)-480* TOT BILI-0.3 [**2179-2-23**] 05:00PM HAPTOGLOB-LESS THAN [**2179-2-23**] 05:00PM WBC-6.0 RBC-2.40* HGB-6.4* HCT-21.5* MCV-90 MCH-26.8* MCHC-29.8* RDW-20.9* [**2179-2-23**] 05:00PM NEUTS-78.0* LYMPHS-13.0* MONOS-6.3 EOS-2.4 BASOS-0.2 [**2179-2-23**] 05:00PM PLT COUNT-203 [**2179-2-23**] 05:00PM PT-15.3* PTT-25.3 INR(PT)-1.3* [**2179-2-22**] 09:57PM COMMENTS-GREEN TOP [**2179-2-22**] 09:57PM LACTATE-1.0 [**2179-2-22**] 09:45PM GLUCOSE-83 UREA N-22* CREAT-4.3* SODIUM-143 POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-30 ANION GAP-18 [**2179-2-22**] 09:45PM estGFR-Using this [**2179-2-22**] 09:45PM CALCIUM-9.2 PHOSPHATE-3.5 MAGNESIUM-1.4* [**2179-2-22**] 09:45PM WBC-10.5 RBC-2.95* HGB-8.0* HCT-25.8* MCV-88 MCH-27.0 MCHC-30.9* RDW-21.1* [**2179-2-22**] 09:45PM NEUTS-84.9* LYMPHS-8.1* MONOS-5.8 EOS-1.0 BASOS-0.2 [**2179-2-22**] 09:45PM PLT COUNT-236 RADIOLOGY Final Report . CHEST (PA & LAT) [**2179-2-25**] 1:37 PM [**Hospital 93**] MEDICAL CONDITION: 20 year old woman with renal failure, hx of renal transplant, temp 99.9, immunosuppresed. portable this am question infiltrate REASON FOR THIS EXAMINATION: looking for pneumonia HISTORY: Renal failure with renal transplant and fever. . FINDINGS: In comparison with earlier study of this date, there is little change. Stable enlargement of the cardiac silhouette with an ill-defined area of increased opacification at the right base. The left hemidiaphragm is more sharply seen on the current study. . Central catheter extends to the lower portion of the SVC. RADIOLOGY Preliminary Report . [**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) [**2179-2-25**] 1:09 PM . The cephalic and basilic veins are patent bilaterally. In the right upper extremity the cephalic vein diameters range from 0.28 to 0.36 in the forearm and from 0.18 to 0.26 in the upper arm. The right basilic vein diameters range from 0.28 to 0.35 cm in the forearm and from 0.39 to 0.63 cm in the upper arm. . In the left upper extremity cephalic vein diameters range from 0.30 to 0.33 cm in the forearm and from 0.31 to 0.39 cm in the upper arm. The left basilic vein diameters range from 0.19 to 0.46 cm in the forearm and from 0.49 to 0.70 cm in the upper arm. . IMPRESSION: Patent bilateral cephalic and basilic veins with diameters as noted. Brief Hospital Course: 20 yo female with ESRD, h/o MPGN-type 1 s/p transplant now with recurrence of MPGN in transplanted kidney, back on HD since [**2178-11-7**], who was admitted to micu for hypertensive urgency, s/p labetolol drip, back on home meds, on gen med floor. . # Hypertensive Urgency: Patient presented to ED w/ nausea/vomiting, then developed hypertensive urgency, SBP in 230s. Patient was admitted to ICU for blood pressure control. She was started on nipride then on labetolol. Patient remained symptom free during this period of time, No DP, vision changes, No SOB. Patient was transitioned back to home regimen of antihypertensive. Which is as follows Clonidine 0.2 mg/24 hr Patch QWED, Losartan 75 mg PO BID, Hydralazine 50 mg PO every eight (8) hours, Furosemide 80 mg PO BID, Labetalol 800 mg PO TID, Captopril 75 mg PO TID, Isradipine 15 mg PO TID. Patient continued to receive HD, was normotensive for 12 hours prior to discharge. Some concern that ectopic kidney was sensing hemodynamics and causing hyperenemic state and vasoconstriction. Renin levels were pending at discharge. Patient was instructed to measure her blood pressure several times per day and to hold hydralazine depending on her BP measurements. . # Possible Pneumonia: Infiltrate on CXR PA and lateral. It was felt that this opacity was actually atelectasis and not a pneumonia. It was felt that pt did not need a full course of antibiotics. . # ESRD/MPGN: Recurrent MPGN in transplant kidney, currently on HD. During this hospital stay patient was continued on HD through tunneled catheter. She was followed by the transplant team. Venous mapping was done via ultrasound for future access options av fistula vs. graft. Patient was still debating whether to continue on HD or to start peritoneal dialysis. This issue will be readdressed as an outpatient. Transplant team recommends PD as she would then be able to preserve her veins for HD further down the road. Patient was transitioned back to outpatient HD M/W/F. Cont nephrocaps and renally dosed meds. . # Renal Transplant: Failed ectopic kidney, secondary to MPGN-1 recurrence. Patient to have further outpatient discussions as whether or not ectopic kidney should be removed. During this hospitalization Tacrolimus was discontinued. Patient was continued on Cellcept and Prednisone. . # Anemia: Secondary to CKD w/ prior hemolysis. No evidence of hemolysis this hospital stay. Pt came in w/ HCT 21 and was discharged w/ hct of 21. Deferred blood transfusion this hospital stay. Neg guaic. Pt needing anemia follow up at HD> . # Flat affect and anhedonia. Pt spoke with social work during this hospitalization, but refused to speak w/ psychiatry. She believes that she has a strong support network of family and friends and deals with her medical problems well. . # She was discharge home w/ a stable blood pressure of 130-140/80-90. . Follow up as listed in discharge instructions. Medications on Admission: Prednisone 5 mg PO EVERY OTHER DAY, due [**2-23**] Clonidine 0.2 mg/24 hr Patch QWED Losartan 75 mg PO BID Hydralazine 50 mg PO every eight (8) hours: Mycophenolate Mofetil 500 mg PO BID (2 times a day). Furosemide 80 mg PO BID Labetalol 800 mg PO TID Captopril 75 mg PO TID Isradipine 15 mg PO three times Tacrolimus 1 mg PO Q12H Calcium Acetate 667 mgPO TID B Complex-Vitamin C-Folic Acid 1 mg PO DAILY Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). 3. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Losartan 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 6. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 8. Captopril 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 9. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Isradipine 5 mg Capsule Sig: Three (3) Capsule PO TID HTN (). Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Hypertensive Emergency 2. Renal Failure Secondary: 3. Productive cough 4. Headache 5. Nausea Discharge Condition: Stable Discharge Instructions: You were admitted for hypertensive emergency. When you arrived at the [**Hospital1 18**] ED for productive cough, headache, nausea, and vomiting, you were found to be hypertensive. You received hemodialysis to manage volume status and kidney failure. . You are going home on all the same blood pressure medications that you were taking before you came into the hospital. . Before taking captopril and hydralazine please check your blood pressure, do not take these medications if your blood pressure is less than 120. . You have been set up for dialysis Monday Wednesday and Fridays at the [**Hospital1 8**] Dialysis Center. Your next session is on Moday [**2179-3-1**] . During your hospitalization it was the advice from the transplant doctors that [**Name5 (PTitle) **] [**Name5 (PTitle) **] longer take your tacrolimus. . Please call your doctors [**Name5 (PTitle) **] return to the hospital if you experience any concerning symptoms including blood pressure that is too high >150 despite taking your medication or <100, severe headache, confusion, fevers, or any other worrisome symptoms. Followup Instructions: Please attending the following appointments: - Provider VASCULAR STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2179-3-11**] 2:00 - Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2179-3-11**] 2:50 - Provider [**Name9 (PRE) 2105**] [**Name9 (PRE) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2179-3-18**] 9:00 - Your next dialysis has been arranged at [**Hospital1 8**] for Monday. [**2179-3-1**]. Please arrive at 11:00AM . You will be seeing Dr. [**Last Name (STitle) **] weekly for the next several weeks to monitor your blood presssure. Dr.[**Name (NI) 17254**] secretary is working on making you an appointment for next week. Please call the office at [**Telephone/Fax (1) 673**] tomorrow to find out the date and time of the appointment. They are aware that you need an appointment on a Tuesday or Thursday.

[ "E849.9", "996.81", "285.21", "403.01", "E878.0", "582.2", "585.6", "486" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

11890, 11896

7629, 10538

353, 360

12045, 12054

5132, 6253

13198, 14121

4503, 4574

10993, 11867

6290, 6417

11917, 12024

10564, 10970

12078, 13175

4589, 5113

293, 315

6446, 7606

388, 3160

3182, 4289

4305, 4487

11,981

171,600

30487

Discharge summary

report

Admission Date: [**2130-4-15**] Discharge Date: [**2130-5-1**] Date of Birth: [**2074-12-21**] Sex: F Service: MEDICINE Allergies: Nafcillin Attending:[**First Name3 (LF) 30**] Chief Complaint: black stools Major Surgical or Invasive Procedure: debridement of epidural abscess colonoscopy EGD History of Present Illness: 55f who until this year had been fairly healthy but then in [**3-5**] developed worsening lower back pain that progressed and became associated with systemic symptoms until she was found with AMS and LE weakness on [**3-22**], brought to [**Hospital1 18**] where she was found to have MSSA bacteremia with infected left hip replacement, left knee infection, psoas abscesses, epidural abscess, intradural abscess, aortic valve endocarditis with septic emboli to the brain, who underwent a prolonged hospitalization, was discharged [**4-13**], went to rehab, and had an episode of BRBPR, for which she was sent back to [**Hospital1 18**]. The etiology of the bacteremia is not known, though was potentially exacerbated by steroid used to treat her back pain. At the last admit, she had her knee and hip washed out, epidural abscess washed out (intradural was not as was felt the procedure was too high of a risk to cause neurologic compromise). The course was complicated by a demand myocardial infarction, felt to be due to hypotension and tachycardia of sepsis at initial presentation as well as ARF (peak cr 1.9) felt to be due to nafcillin-AIN versus ATN; nafcillin was continued given stable cr and vast superiority of nafcillin to vancomycin in this widespread MSSA infection. She was also grossly volume overloaded from fluids and blood products. Anemia had been a problem during the admit, and she was noted to have brown, guaiac positive stools; her hct was 24 at discharge. GI felt scoping at last admission would've been risky, given multiple comorbidities, especially elevated Tn. She was discharged to rehab on [**4-13**], and once there, felt to be passing tarry stools, clots, and one episode of brbpr; hct was 25, got one unit prbcs, and sent back to [**Hospital1 18**]. She denied LH, chest pain, dyspnea, or n/v/d. In the MICU, she was treated with PPI, and GI scoped pt [**Name (NI) **] and colonoscopy), all of which was normal. Her hct has remained stable this admit without transfusion. Her course has otherwise been notable for worsening renal function, the main ddx of which remains AIN versus ATN. Past Medical History: -MSSA bacteremia with infection of L hip, L knee, spine, aortic valve, psoas and erector spinae muscles, and emboli to brain [**3-15**] -HTN -sciatica (was diagnosed 6-7 years ago, but pt states she has not had any back pain since then until [**3-5**].) -s/p left hip replacement 3 years ago. -h/o cervical cancer s/p XRT 4 years ago. -h/o Barrett's esophagus in the distant past. Social History: Before last hospitalization she lived in [**Hospital1 3597**] with husband and daughter. Denies smoking, ETOH, or drugs. Family History: Father died at 61 with heart disease. Mother is in a nursing home Physical Exam: t 96.5, bp 128/80, hr 88, rr 16, spo2 98%ra gen- anasarcic, lying in bed, poor function, pleasant heent- anicteric, op clear with mmm neck- no jvd, lad, thyromegaly cv- rrr, s1s2, no m/r/g pul- moves air well, no w/r/r abd- soft, nt, nd, nabs extrm- no cyanosis, [**2-11**]+ pitting edema le bilater, hands, warm/dry nails- no clubbing, + [**Doctor First Name **] nails neuro- a&ox3, no cn deficits, good strength distally and proximally in le, sensation intact Pertinent Results: Notable labs on transfer: wbc 7.1, hct 25.1, plt 425, mcv 89, inr 1.5; na 138, k 4.0, cl 107, bicarb 19, bun 28, cr 2.3, glc 144. . Admission labs: [**2130-4-15**] 01:17AM BLOOD WBC-10.4 RBC-3.23* Hgb-9.7* Hct-27.9* MCV-87 MCH-30.1 MCHC-34.8 RDW-18.1* Plt Ct-524* [**2130-4-15**] 01:17AM BLOOD Neuts-86.1* Lymphs-8.8* Monos-2.3 Eos-2.4 Baso-0.3 [**2130-4-15**] 01:17AM BLOOD PT-14.3* PTT-31.7 INR(PT)-1.3* [**2130-4-15**] 01:17AM BLOOD Fibrino-690* [**2130-4-15**] 01:17AM BLOOD FDP-10-40 [**2130-4-15**] 01:17AM BLOOD Glucose-112* UreaN-30* Creat-1.9* Na-140 K-3.4 Cl-109* HCO3-20* AnGap-14 [**2130-4-15**] 01:17AM BLOOD ALT-18 AST-36 LD(LDH)-386* AlkPhos-77 TotBili-0.6 [**2130-4-15**] 01:17AM BLOOD Albumin-2.0* Calcium-7.7* Phos-3.6 Mg-1.8 [**2130-4-15**] 01:30AM BLOOD Lactate-0.9 . Discharge labs: . Micro: C. difficile stool toxin negative x 1 URINE CULTURE (Final [**2130-4-22**]): [**Month/Day/Year **]. 10,000-100,000 ORGANISMS/ML. OF TWO COLONIAL MORPHOLOGIES. [**2130-4-18**] 10:00 am LUMBAR WOUND SWAB SKIN -BACK. GRAM STAIN (Final [**2130-4-18**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2130-4-20**]): 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). GRAM NEGATIVE ROD(S). RARE GROWTH. BEING ISOLATED. STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH. ANAEROBIC CULTURE (Final [**2130-4-22**]): NO ANAEROBES ISOLATED. LUMBAR WOUND TISSUE (Final [**2130-4-21**]): CITROBACTER FREUNDII COMPLEX. RARE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. Trimethoprim/Sulfa sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER FREUNDII COMPLEX | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S TOBRAMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [**2130-4-22**]): NO ANAEROBES ISOLATED. . Studies - ECG: NSR at 87, RBBB (old). No ST/T changes comp to prior. . [**2130-4-15**] CXR: A single AP view of the chest is obtained [**2130-4-15**] at 15:25 hours and is compared with the prior radiograph performed [**2130-4-7**]. Allowing for technical differences, there has been no major change. There is mild cardiomegaly with tortuosity of the aorta. There is increased opacity in the left lower hemithorax consistent with a left pleural effusion. Increased retrocardiac density is seen on the left side consistent with superimposed atelectasis/airspace disease in the left lower lobe. Subsegmental atelectasis is seen in the right base. There is mild pulmonary vascular prominence. A Dobbhoff tube is seen in the stomach. Surgical staples are seen in the upper abdomen. A left-sided PICC line has its tip projected over the area of the cavoatrial junction. The previous IJ line on the right side has been removed. IMPRESSION: Stable appearances. Dobbhoff tube is in the stomach. Pulmonary findings as described above. Brief Hospital Course: 55F with recent MSSA bacteremia complicated by widespread, multi-system involvement including septic emboli to brain, aortic valve endocarditis, epidural and intradural abscesses, erector spinae and psoas abscesses, artificial hip and knee infection as well as NSTEMI and ARF who was at rehab for about a day before coming back with BRBPR and worsening renal failure. . #GI-bleed -- Unclear if she had a bleed or not based on history. Hct was near baseline and the patient felt that she did not have a bleed. Admitted to the ICU where she underwent upper and lower endoscopy which were both normal. Her Hct's remained relatively stable throughout admission requiring 2 units pRBC transfusion. She was guaiac negative and iron studies were consistent with anemia of chronic disease. She was continued on a PPI and started on epogen. Consider outpatient capsule endoscopy if hct continues to trend down. . #ARF -- Likely AIN based on urine and peripheral eosinophilia and rash. Believed less likely to be ATN (although there was some discussion that she became rather hypovolemic during colonoscopy prep). FeNa 4% supporting intrinsic renal etiology. Attempted to perform gallium scan on [**4-21**] as per the Renal consultants, if positive, would support AIN as a diagnosis, however patient unable to lie flat for exam and was therefore cancelled. Given strong evidence of AIN, her antibiotic regimen was changed from nafcillin to vancomycin by ID (dosed by level with goal ~20) and remained afebrile. Creatinine and rash slowly improved after d/c nafcillin. Given atarax, benadryl prn for pruritis. At discharge, Cre 1.8 which may represent new baseline. . #Epidural/intradural abscesses -- s/p OR incision and drainage of lumbar wound on [**4-18**] by the Ortho Spine team at prior epidural abscess site revealed pocket of infection above the fascial plane which was washed out. Drains were placed and then discontinued by the surgical team when output tapered off. Wound cultures grew pan-sensitive citrobacter and the patient was changed to ciprofloxacin from aztreonam which had been started emperically after the cultures returned positive. Pt is to be on Cipro for at least 6 weeks per ID. For her intradural abscess, during prior admission the spine team felt risk of operation too high and therefore was placed on a steroid taper that finished [**4-18**]. Followup with Ortho-Spine in 2 weeks for suture removal and evaluation. . #Metabolic acidosis: Transiently with elevated AG which rapidly closed after starting aztreonam. The patient remained afebrile with a normal lactate. Also with diarrhea and renal failure contributing to low bicarbonate. . #MSSA bacteremia -- Was on naficillin and then changed to vancomycin per ID given AIN. Increased vancomycin dosing to 1gm q24h as renal function improved (goal ~20; fax results to ID team from rehab after discharge per discharge instructions). Pt is to be on Vanc indefinitely per ID. . #Knee and hip infection -- No evidence of recurrence. The affected hip is prosthetic and may require future replacment. The patient has followup on [**2130-5-4**] with Dr. [**Last Name (STitle) **] from Orthopedics. . #Psoas and erector spinae abscesses -- Per ID team, will need re-imaging with contrast-enhanced CT as outpatient after renal function improves. Followup scheduled with Dr. [**Last Name (STitle) 67369**] [**Name (STitle) 3394**]. . #UTI -- Citrobacter sensitive to fluoroquinolones, and the patient completed a course of ciprofloxacin on [**4-20**]. Repeat U/A on [**4-20**] was positive associated with an increasing serum WBC count which then improved after restarting ciprofloxacin and replacing foley catheter. . #Diarrhea/Buttock skin breakdown -- C.diff negative stool samples x 3. Rectal collection system in place (flexiseal) in order to protect sacral skin wounds and using special mixture of cholestyramine, lidocaine, and doubleguard (protective ointment) which should be applied to buttocks prn. Stools continued to be loose. Can consider removing Flexiseal device when more formed. . #Anasarca: Likely from hypoalbuminemia and copious IVF and blood products. Using ACE wraps. Started lasix 20mg po qd after renal function improved for diuresis with daily goal I/O -1L. . #Septic Brain Emboli: Neuro status followed as outpatient with Dr. [**Last Name (STitle) **]. Followup appointment scheduled in 4 weeks. . #NSTEMI: Likely was demand phenomenon during prior admission rathern than ACS. No CP or other concerning symptoms at presentation. Per GI team, restarted on ASA. Also continued metoprolol and simvastatin. . # Anxiety/depression: Patient distressed about diagnosis and poor prognosis. Continued paxil and klonopin tid. Social work followed for support. Remeron started. . # Hyponatremia: Mild and asymptomatic. Free water boluses that were being given during tube feeds were stopped and her sodium normalized. . # Positive blood culture: 1/2 bottles positive for CNS on [**2130-4-28**]. Afebrile with normal WBC count. Most likely a contaminant however the patient has a central line so 2 sets blood cultures drawn from peripheral and PICC line on [**2130-4-30**] and were without growth at the time of discharge. . # Access: PICC (placed [**4-3**]). . # FEN: Very poor nutritional status and caloric intake [**Date range (1) 59224**] only 50% of required 1500 kcal per day so restarted TFs to supplement intake. Her PO intake then improved and given complaints of throat soreness the tube feeds were stopped, Doboff removed, and calorie counts repeated. Supplements were given per Nutrition consult recommendations. . # PPx: Lovenox 30mg sq qd, PPI Medications on Admission: Meds at Rehab (same as on d/c): -simvastatin 80 po daily -miconazole powder prn -heparin SC tid -ASA 325 daily -Paroxetine 20mg po daily -Lansoprazole 30mg po bid -sucralfate 1g po qid -metoprolol 100 po tid -fentanyl 25mcg/hr patch q72 hours -oxycodone 5-10mg po q4-6 prn -prednisone taper (currently on 20mg) -clonazepam 0.5mg po tid -nafcillin 2gm IV q4 -ciprofloxacin 500mg po q12 Discharge Medications: 1. Acetaminophen 325 mg Tablet [**Date range (1) **]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Aspirin 325 mg Tablet [**Date range (1) **]: One (1) Tablet PO DAILY (Daily). 3. Cholestyramine-Sucrose 4 g Packet [**Date range (1) **]: One (1) Packet PO QID (4 times a day) as needed. 4. Clonazepam 0.5 mg Tablet [**Date range (1) **]: One (1) Tablet PO TID (3 times a day). 5. Fentanyl 25 mcg/hr Patch 72 hr [**Date range (1) **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 6. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 7. Hydralazine 10 mg Tablet [**Date range (1) **]: Two (2) Tablet PO Q6H (every 6 hours). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 9. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical QID (4 times a day) as needed. 10. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 11. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed. 12. Camphor-Menthol 0.5-0.5 % Lotion [**Last Name (STitle) **]: One (1) Appl Topical TID (3 times a day) as needed. 13. Simvastatin 40 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 14. Ciprofloxacin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q24H (every 24 hours). 15. Citalopram 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 16. Enoxaparin 30 mg/0.3 mL Syringe [**Last Name (STitle) **]: Thirty (30) mg Subcutaneous Q24H (every 24 hours). 17. Furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 18. Hydroxyzine HCl 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4 times a day). 19. Phenol-Phenolate Sodium 1.4 % Mouthwash [**Last Name (STitle) **]: One (1) Spray Mucous membrane Q4H (every 4 hours) as needed. 20. Mirtazapine 15 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime). 21. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 22. Vancomycin 1000 mg IV Q 24H 23. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: Primary: 1. 15mm x 4mm Aortic Valve Vegetation - Endocarditis. 2. High Grade MSSA Bacteremia, Sepsis, Embolization. 3. L2-S1 Epidural Abscess 4. T3-L3 Intradural Abscess 5. Right psoas, left erector spinae muscle abscesses. 6. Septic Arthritis - Prosthetic Left Hip, Native Left Knee 7. Left Posterior Parietal, Temporal, Occipital Embolic Infarct. 8. Acute Interstitital Nephritis and Renal Failure. 9. Post-operative Spinal Incision Cellulitis - Citrobacter Freundii. 10. Gastrointestinal Bleeding NOS. 11. Blood Loss Anemia. 12. Non-Thrombotic Troponin Elevation. 13. Malnutrition - Severe 14. Volume Overload - Anasarca 15. Citrobacter UTI 16. Morbilliform Drug Rash NOS 17. Partial thickness 2 x 1 cm left gluteal ulcer. Secondary: 1. L1-2 Moderate-to-Severe Spinal Stenosis. 2. Sciatica 3. Hypertension 4. Gastroesophageal Reflux Disease 5. Left Hip Replacement. 6. Cervical Cancer s/p XRT. Discharge Condition: Stable Discharge Instructions: Please take all medications as prescribed. Call your doctor or return to the ED immediately if you experience worsening chest pain, shortness of breath, nausea, vomiting, sweating, fevers, chills, bleeding, or other concerning symptoms. Followup Instructions: You are scheduled for the following appointments. Please contact the [**Name2 (NI) 11686**] provider with any questions or if you need to reschedule. 1. Dr. [**Last Name (STitle) 3394**] from infectious diseases, on [**5-16**] at 9AM, [**Hospital1 **] [**Last Name (Titles) 517**] [**Hospital Unit Name **] Basement, can call [**Telephone/Fax (1) 457**] for directions. This is a very important appointment. Orthopedics: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2130-5-4**] 11:50. You will need to have your hip and knee re-evaluated. Ortho-Spine: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2130-5-11**] 11:40. You will need to have your back wound evaluated and your sutures removed. ID: DR. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2130-5-2**] 11:00 Neurology: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 540**] MD Phone:[**Telephone/Fax (1) 541**] Date/Time:[**2130-5-24**] 3:30 PM You should have outpatient cardiology follow-up and cardiac stress testing.

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6965

Discharge summary

report

Admission Date: [**2130-6-12**] Discharge Date: [**2130-6-25**] Date of Birth: [**2062-11-26**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: aortic valve replacement (#23mm porcine), aortic root enlargement and pericardial patch [**2130-6-12**] History of Present Illness: 67 yo F with h/o aortic stenosis followed by serial echocardiograms with complaints of dyspnea on exertion and occasional dizziness. Past Medical History: 1. aortic stenosis 2. hypertension 3. hypercholesterolemia 4. hypothyroidism 5. s/p incisional hernia repair 6. retroperitoneal mass resected in [**10-17**], found to be a 15cm cystic mass most consistent with paraganglioma on pathology 7. obesity 8. osteoarthritis 9. osteoporosis Social History: Lives with husband. Denies tobacco, alcohol, or IVDU. Family History: Noncontributory Physical Exam: Physical Exam Pulse:75 Resp:14 O2 sat: 97% RA B/P Right:150/81 Left:145/68 Height:5'0" Weight:182 lbs General: Skin: Dry [x] intact [] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [**3-20**] blowing SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] No Edema Varicosities: bilat spider veins and PVD color changes Neuro: Grossly intact [x] Pulses: Femoral Right: cath site Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit: Right: radiated murmur Left: radiated murmur Pertinent Results: [**2130-6-15**] 05:45AM BLOOD WBC-11.6* RBC-2.68* Hgb-8.4* Hct-25.2* MCV-94 MCH-31.3 MCHC-33.3 RDW-15.1 Plt Ct-163 [**2130-6-16**] 05:45AM BLOOD Hct-35.2*# [**2130-6-12**] 12:10PM BLOOD PT-13.4 PTT-39.6* INR(PT)-1.1 [**2130-6-16**] 05:45AM BLOOD Glucose-140* UreaN-29* Creat-0.7 Na-138 K-4.5 Cl-102 HCO3-25 AnGap-16 [**2130-6-16**] 05:45AM BLOOD Mg-2.4 PRE-BYPASS: 1. The left atrium is moderately dilated. Mild spontaneous echo contrast is present in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is critical aortic valve stenosis (valve area <0.8cm2). Mild to moderate ([**12-16**]+) aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. 6. Moderate [2+] tricuspid regurgitation is seen. 7. There is no pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is being A paced. 1. A well-seated bioprosthetic valve is seen in the Aortic position with normal leaflet motion and gradients (mean gradient = 10 mmHg). Trace central aortic regurgitation is seen. 2. Biventricular function is normal. 3. MR appears improved. 4. Other findings are unchanged [**Known lastname 26148**],[**Known firstname **] [**Age over 90 26149**] F 67 [**2062-11-26**] Radiology Report CTA NECK W&W/OC & RECONS Study Date of [**2130-6-17**] 7:33 PM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2130-6-17**] 7:33 PM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # [**Clip Number (Radiology) 26150**] Reason: (L)MCA infarct/(L)ICA embolic occlusion Contrast: OPTIRAY Amt: 80 [**Hospital 93**] MEDICAL CONDITION: 67 year old woman with (R)sided weakness/facial droop/slurred speech REASON FOR THIS EXAMINATION: (L)MCA infarct/(L)ICA embolic occlusion CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: JKSd SAT [**2130-6-17**] 10:09 PM Small amount of contrast now seen in the left common carotid artery, but flow stops at level of carotid canal. Minimal flow in left MCA as before. Bilateral pleural effusions, unchanged. Final Report CT ANGIOGRAPHY OF THE NECK AND HEAD HISTORY: Right-sided weakness, facial droop, and slurred speech. TECHNIQUE: Bolus intravenously enhanced imaging of the neck and head with multiplanar reconstructions. COMPARISON STUDY ON PACS ARCHIVE: CT angiography of the neck and head performed eight hours previously. PRELIMINARY FINDINGS: Provided by Dr. [**Name (NI) 402**] [**Last Name (NamePattern1) **], who indicated "small amount of contrast is now seen in the left common carotid artery, but flow stops at the level of the carotid canal. Minimal flow in left middle cerebral artery as before." FINDINGS: Comparison with the prior CT angiogram does reveal slightly increased quantity of contrast material within the intracervical portion of the left internal carotid artery. Both studies did reveal flow within the left common carotid artery, with essentially complete occlusion suspected on the prior CT angiogram. Upon meticulous review of the source data, the original study revealed the internal carotid artery, but appeared to show negligible flow beyond its origin. The present study appears to show some flow within this vessel extending to the carotid foramen, but again there is negligible flow more distally. The poor flow is substantiated by review of the source images intracranially, with this absence of flow also involving the left internal carotid bifurcation, as well as a portion of the A1 segment of the left anterior cerebral artery and proximal M1 segment of the left middle cerebral artery. Given this pattern of occlusions, flow to the left middle cerebral artery likely depends upon retrograde filling from contiguous vascular territories. There is redemonstration of a moderate right and smaller left-sided pleural effusion, incompletely delineated on this study. CONCLUSION: Some minor improvement in intracervical blood flow in the left internal carotid artery, but continued negligible flow in the intracranial portion of this vessel. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9987**] Approved: SUN [**2130-6-18**] 1:33 PM Imaging Lab Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2130-6-12**] where she underwent aortic valve replacement as well as aortic root enlargement with a pericardial patch as detailed in the operative note. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in critical but stable condition for observation and recovery. At this time hemodynamics were maintained with phenylephrine. She awoke neurologically intact and was extubated without difficulty on POD#1. Pressors were weaned off and Beta- Blocker and diuresis was initiated.All lines and drains were discontinued in a timely fashion. She did develop atrial fibrillation which was rate controlled with amiodarone and lopressor. Physical therapy was consulted for post-operative strength and mobility assistance. On the morning of [**6-17**], she became aphasic with right-sided weakness. Code Stroke was called and she was evaluated by neurology. A CT scan showed [**Doctor First Name 3098**] occlusion and likely embolic CVA. She was transferred back to the CVICU and an IV heparin bridge was initiated per neurology recommendations. She continued to make a good recovery with a slight residual right facial droop and mild right upper and lower extremity weakness. Coumadin was started. She was transferred back to the step down floor on POD #7 to begin increasing her activity level. She went into rapid A Fib on POD #7 and was treated with amiodarone and titrated beta blockade. She was cleared for discharge to home on POD # 13, The first INR blood draw with VNA should be on [**6-26**] with results to be called to the office of Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] at phone ([**Telephone/Fax (1) 1921**]/fax ([**Telephone/Fax (1) 23341**]. The target INR is [**1-17**] per neurology. Pt then set up with [**Hospital 197**] clinic. They will contact her [**6-27**] Medications on Admission: Alendronate 70 mg Tablet once weekly (Not Taking as Prescribed: patient not able to take a full glass of water so has not taken the med for 3 months ) Atorvastatin [Lipitor] 40 mg daily Cyanocobalamin 1,000 mcg/mL Solution IM injection once a month Levothyroxine [Levoxyl] 100 mcg daily Lisinopril 20 mg Tablet TID Calcium Citrate-Vitamin D3 [Calcium Citrate + D] 315 mg-200 unit Tablet 2 Tablet(s) by mouth twice a day Discharge Medications: 1. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day: ING goal is [**1-17**] for afibrillation. [**Hospital 197**] clinic to follow INR. Disp:*60 Tablet(s)* Refills:*2* 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Take 400 [**Hospital1 **] x 1 week, Then 200 [**Hospital1 **] x 1 week, Then 200 qd afterwards. Disp:*120 Tablet(s)* Refills:*2* 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Disp:*30 Suppository(s)* Refills:*0* 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 10. Potassium Chloride 20 mEq Packet Sig: One (1) PO twice a day for 7 days. Disp:*14 20 mEq Packet* Refills:*0* 11. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 12. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week: PER PCP. 13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: prn for pain. Disp:*30 Tablet(s)* Refills:*0* 14. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a month: per PCP. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: aortic stenosis s/p AVR -Left Internal carotid artery embolic occlusion/ left middle cerebral artery infarct postop A Fib HTN hypercholesterolemia hypothyroidism obesity oesteoartritis osteoporosis 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 surgeon) in 4 weeks ([**Telephone/Fax (1) 170**]) Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] (PCP) [**Telephone/Fax (1) 250**] in [**12-16**] weeks. Dr. [**Last Name (STitle) **] (cardiology) in [**1-17**] weeks Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (neurology) follow up in [**1-17**] weeks- please call for appt. Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse ([**Telephone/Fax (1) 3071**]) First INR blood draw with VNA [**6-26**] with results to be called to the office of Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] at phone ([**Telephone/Fax (1) 1921**]/fax ([**Telephone/Fax (1) 23341**]. Plan confirmed with [**Doctor First Name 16883**] on [**6-22**]. Target INR 2-3 per neurology. You will also be contact[**Name (NI) **] by the coumadiinclinic on [**6-27**].. They will then moniter your INR Completed by:[**2130-6-25**]

[ "278.00", "733.00", "401.9", "244.9", "427.31", "272.0", "784.3", "715.90", "997.1", "433.11", "E878.8", "424.1" ]

icd9cm

[ [ [] ] ]

[ "35.21", "39.61", "37.49" ]

icd9pcs

[ [ [] ] ]

10812, 10870

6682, 8629

342, 448

11112, 11119

1789, 3914

11659, 12658

1011, 1028

9100, 10789

3954, 4023

10891, 11091

8655, 9077

11143, 11636

1043, 1770

283, 304

4055, 6659

476, 610

632, 922

938, 995

23,900

110,765

26265+26266

Discharge summary

report+report

Admission Date: [**2142-10-29**] Discharge Date: [**2142-11-6**] Date of Birth: [**2069-5-15**] Sex: M Service: HEPATOBILIARY SURGERY SERVICE HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old male, with a history of peripheral vascular disease, elevated PSA, history of benign prostatic hypertrophy, who went for a routine physical exam and was noted to have elevated liver function tests. This prompted to obtain an ultrasound of the abdomen which was performed on [**2142-9-25**], demonstrating a lobular slight hypoechoic mass in the region of the pancreatic head that measured roughly 3-cm in diameter and was associated with prominent abnormal dilatation of the pancreatic duct which measured 10 to 11-mm in diameter. There was also dilatation of the common bile duct which measured 11 to 12-mm in diameter and was associated with slight intrahepatic ductal dilatation. The remainder of the exam was unremarkable. A CT of the abdomen was performed on [**2142-9-25**] which demonstrated a mild to moderate intrahepatic biliary duct dilatation, as well as dilatation of the common bile duct which measured 1.1-cm at the level of the pancreatic head. There was diffuse dilatation of the pancreatic duct which measured 0.8-cm. There was normal enhancement of the superior mesenteric artery and vein without involvement of the tumor. There was adenopathy noted inferior to the head of the pancreas measuring 1.7 x 1.9-cm. A necrotic mass was seen in the small bowel mesentery on the left at the level of the head of the pancreas measuring 1.6 x 2.9-cm. Patient is completely asymptomatic. Patient is able to tolerate a regular diet, has normal bowel movements. Patient is fully active. He denies any fevers, chills, nausea, vomiting, diarrhea, any weight loss or steatorrhea. PAST MEDICAL HISTORY: Patient has a history of peripheral vascular disease, elevated PSA, benign prostatic hypertrophy, history of bilateral inguinal hernia repair in the [**2106**], status post appendectomy in [**2086**]. ALLERGIES: Allergic to penicillin. MEDICATIONS ON ADMISSION: Flomax 0.4 mg p.o. once daily. SOCIAL HISTORY: He is married and has 3 children. He is a retired managerial psychologist who has a doctorate in psychology, currently working in the service department for the [**Company 65042**] organization. PHYSICAL EXAM: Temperature 97.2, BP 160/80, heart rate 68, respirations 16, height 5-feet 9-1/2-inches, weight 152- pounds. Patient is a well-nourished, well-developed male in no acute distress. Skin normal. HEENT: Pupils equal, round, reactive to light. EOMIs are full. No scleral icterus. MOUTH: Oropharynx clear. Neck supple, no lymphadenopathy, no thyromegaly, carotids 2-plus/4-plus without bruits. Lungs clear to auscultation bilaterally. CV regular rate and rhythm, normal S1, S2, without rub, but he does have a II/VI systolic ejection murmur that is present along the left sternal border. ABDOMEN: Positive bowel sounds, soft, nontender, no hepatosplenomegaly, masses. EXTREMITIES: No C/C/E. Neurologically grossly intact. LABS PRIOR TO ADMISSION FROM [**2142-10-25**]: WBC of 7.3, hematocrit 42.2, PT 12.3, PTT 22.2, INR 1.0, sodium 137, 4.5, 101, 25, BUN and creatinine 16 and 1.2, glucose 122, ALT 125, AST 108, alkaline phosphatase 525, amylase 139, total bilirubin 1.0, lipase 90, total protein 6.9, CEA on [**2142-10-25**], 2.9, AFP 6.1, and CA19-19, 170. HOSPITAL COURSE: On [**2142-10-29**], the patient had surgery in which a pylorus-sparing pancreaticoduodenectomy, cholecystectomy, small bowel resection was performed by Doctors [**Name5 (PTitle) **] and [**Name5 (PTitle) **]. Please see operative note for more details. Patient received 6000-cc of crystalloid, made 485-cc of urine, estimated blood loss was 500-cc. The skin was closed using staples after irrigating the subcutaneous tissue. JP drain was placed posteriorly to the pancreatic anastomosis. Postoperatively, patient went to the SICU. Patient had epidural catheter for pain control. Postop day 1 labs: WBC of 11.7, hematocrit of 32.9. Coags were unremarkable. Electrolytes were unremarkable except for a blood sugar of 202. LFTs: ALT 228, AST 75, alkaline phosphatase 233, total bilirubin 1.1. On [**2142-10-31**], epidural was removed. NG was clamped. JP drain put out 20-cc. Patient was started on IV pain medications. Patient continued to be afebrile, vital signs stable. Diet was advanced. Foley was removed on [**2142-11-2**]. Continued to be n.p.o. until [**11-2**], at which time patient started on sips and was advanced on the 17 to a regular diet. Oncology was consulted on [**2142-11-2**], and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] saw the patient. Path report came back as 1) adenocarcinoma of the pancreas, 2) extensive pancreatic intraepithelial neoplasm with high-grade dysplasia (PanIN III). 3) There were permanent sections. The permanent sections of the pancreatic neck margin showed no dysplasia or carcinoma. 4) Chronic pancreatitis with atrophy and fibrosis. 5) Dilatation of common bile duct without tumor. 6) Duodenal segment within normal limits. Gallbladder demonstrated cholecystic duct lymph node, no tumor, gallbladder within normal limits. Small bowel segment within normal limits. Lymph node superior pancreatic demonstrated metastatic adenocarcinoma. Physical therapy saw patient and felt that he would be able to be discharged to home without services. On postop day 5, the patient had a low-grade fever of 100.9, otherwise doing well. Vital signs were stable. The output of the JP was 60- cc. The patient was ambulating fine without difficulty. Patient had increased stool output which was loose. So, stool culture was sent on [**2142-11-4**] demonstrating positive C. difficile toxin. Patient was started on Flagyl 500 t.i.d. On [**2142-11-6**], JP drain was removed, and a U-stitch was placed. On [**2142-10-29**], he was afebrile, vital signs stable. The dressing was clean, dry and intact. JP drain was removed. Staples intact. Labs on [**2142-11-6**], WBC of 8.3, hematocrit of 26.6 which was repeated which demonstrated 29.5, platelets 531, sodium 142, 3.8, 106, 28, BUN and creatinine of 12 and 1.1, with glucose 106, ALT 58, AST 26, alkaline phosphatase 188. So, patient was discharged from the hospital, in which the patient does live in [**State 108**] and will be residing in a nearby hotel for 1-week. DISCHARGE MEDICATIONS: Tylenol [**11-19**] p.o. q 4-6 h p.r.n., tamsulosin 0.4 mg 1 tab once daily, Percocet [**11-19**] p.o. q. [**2-21**] h p.r.n., Flagyl 500 mg t.i.d. x14 days. Patient is to follow-up with Dr. [**Last Name (STitle) **] on [**2142-11-14**] at 9:40 a.m. Please call [**Telephone/Fax (1) 673**] if there are any questions about the appointment. Patient is to call transplant surgery immediately at [**Telephone/Fax (1) 673**] for any fevers, chills, nausea, vomiting, abdominal pain, any increased redness to incision, sustained decreased appetite, increased bowel movements, or any problems with urination. FINAL DIAGNOSES: Pancreatic carcinoma. SECONDARY DIAGNOSIS: Clostridium difficile, peripheral vascular disease, elevated prostate-specific antigen/benign prostatic hypertrophy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD,PHD[**Numeric Identifier **] Dictated By:[**Last Name (NamePattern1) 4835**] MEDQUIST36 D: [**2142-11-7**] 11:38:35 T: [**2142-11-7**] 12:33:21 Job#: [**Job Number 65043**] Admission Date: [**2142-10-29**] Discharge Date: [**2142-11-6**] Date of Birth: [**2069-5-15**] Sex: M Service: HEPATOBILIARY SURGERY SERVICE HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old male, with a history of peripheral vascular disease, elevated PSA, history of benign prostatic hypertrophy, who went for a routine physical exam and was noted to have elevated liver function tests. This prompted to obtain an ultrasound of the abdomen which was performed on [**2142-9-25**], demonstrating a lobular slight hypoechoic mass in the region of the pancreatic head that measured roughly 3-cm in diameter and was associated with prominent abnormal dilatation of the pancreatic duct which measured 10 to 11-mm in diameter. There was also dilatation of the common bile duct which measured 11 to 12-mm in diameter and was associated with slight intrahepatic ductal dilatation. The remainder of the exam was unremarkable. A CT of the abdomen was performed on [**2142-9-25**] which demonstrated a mild to moderate intrahepatic biliary duct dilatation, as well as dilatation of the common bile duct which measured 1.1-cm at the level of the pancreatic head. There was diffuse dilatation of the pancreatic duct which measured 0.8-cm. There was normal enhancement of the superior mesenteric artery and vein without involvement of the tumor. There was adenopathy noted inferior to the head of the pancreas measuring 1.7 x 1.9-cm. A necrotic mass was seen in the small bowel mesentery on the left at the level of the head of the pancreas measuring 1.6 x 2.9-cm. Patient is completely asymptomatic. Patient is able to tolerate a regular diet, has normal bowel movements. Patient is fully active. He denies any fevers, chills, nausea, vomiting, diarrhea, any weight loss or steatorrhea. PAST MEDICAL HISTORY: Patient has a history of peripheral vascular disease, elevated PSA, benign prostatic hypertrophy, history of bilateral inguinal hernia repair in the [**2106**], status post appendectomy in [**2086**]. ALLERGIES: Allergic to penicillin. MEDICATIONS ON ADMISSION: Flomax 0.4 mg p.o. once daily. SOCIAL HISTORY: He is married and has 3 children. He is a retired managerial psychologist who has a doctorate in psychology, currently working in the service department for the [**Company 65042**] organization. PHYSICAL EXAM: Temperature 97.2, BP 160/80, heart rate 68, respirations 16, height 5-feet 9-1/2-inches, weight 152- pounds. Patient is a well-nourished, well-developed male in no acute distress. Skin normal. HEENT: Pupils equal, round, reactive to light. EOMIs are full. No scleral icterus. MOUTH: Oropharynx clear. Neck supple, no lymphadenopathy, no thyromegaly, carotids 2-plus/4-plus without bruits. Lungs clear to auscultation bilaterally. CV regular rate and rhythm, normal S1, S2, without rub, but he does have a II/VI systolic ejection murmur that is present along the left sternal border. ABDOMEN: Positive bowel sounds, soft, nontender, no hepatosplenomegaly, masses. EXTREMITIES: No C/C/E. Neurologically grossly intact. LABS PRIOR TO ADMISSION FROM [**2142-10-25**]: WBC of 7.3, hematocrit 42.2, PT 12.3, PTT 22.2, INR 1.0, sodium 137, 4.5, 101, 25, BUN and creatinine 16 and 1.2, glucose 122, ALT 125, AST 108, alkaline phosphatase 525, amylase 139, total bilirubin 1.0, lipase 90, total protein 6.9, CEA on [**2142-10-25**], 2.9, AFP 6.1, and CA19-19, 170. HOSPITAL COURSE: On [**2142-10-29**], the patient had surgery in which a pylorus-sparing pancreaticoduodenectomy, cholecystectomy, small bowel resection was performed by Doctors [**Name5 (PTitle) **] and [**Name5 (PTitle) **]. Please see operative note for more details. Patient received 6000-cc of crystalloid, made 485-cc of urine, estimated blood loss was 500-cc. The skin was closed using staples after irrigating the subcutaneous tissue. JP drain was placed posteriorly to the pancreatic anastomosis. Postoperatively, patient went to the SICU. Patient had epidural catheter for pain control. Postop day 1 labs: WBC of 11.7, hematocrit of 32.9. Coags were unremarkable. Electrolytes were unremarkable except for a blood sugar of 202. LFTs: ALT 228, AST 75, alkaline phosphatase 233, total bilirubin 1.1. On [**2142-10-31**], epidural was removed. NG was clamped. JP drain put out 20-cc. Patient was started on IV pain medications. Patient continued to be afebrile, vital signs stable. Diet was advanced. Foley was removed on [**2142-11-2**]. Continued to be n.p.o. until [**11-2**], at which time patient started on sips and was advanced on the 17 to a regular diet. Oncology was consulted on [**2142-11-2**], and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] saw the patient. Path report came back as 1) adenocarcinoma of the pancreas, 2) extensive pancreatic intraepithelial neoplasm with high-grade dysplasia (PanIN III). 3) There were permanent sections. The permanent sections of the pancreatic neck margin showed no dysplasia or carcinoma. 4) Chronic pancreatitis with atrophy and fibrosis. 5) Dilatation of common bile duct without tumor. 6) Duodenal segment within normal limits. Gallbladder demonstrated cholecystic duct lymph node, no tumor, gallbladder within normal limits. Small bowel segment within normal limits. Lymph node superior pancreatic demonstrated metastatic adenocarcinoma. Physical therapy saw patient and felt that he would be able to be discharged to home without services. On postop day 5, the patient had a low-grade fever of 100.9, otherwise doing well. Vital signs were stable. The output of the JP was 60- cc. The patient was ambulating fine without difficulty. Patient had increased stool output which was loose. So, stool culture was sent on [**2142-11-4**] demonstrating positive C. difficile toxin. Patient was started on Flagyl 500 t.i.d. On [**2142-11-6**], JP drain was removed, and a U-stitch was placed. On [**2142-10-29**], he was afebrile, vital signs stable. The dressing was clean, dry and intact. JP drain was removed. Staples intact. Labs on [**2142-11-6**], WBC of 8.3, hematocrit of 26.6 which was repeated which demonstrated 29.5, platelets 531, sodium 142, 3.8, 106, 28, BUN and creatinine of 12 and 1.1, with glucose 106, ALT 58, AST 26, alkaline phosphatase 188. So, patient was discharged from the hospital, in which the patient does live in [**State 108**] and will be residing in a nearby hotel for 1-week. DISCHARGE MEDICATIONS: Tylenol [**11-19**] p.o. q 4-6 h p.r.n., tamsulosin 0.4 mg 1 tab once daily, Percocet [**11-19**] p.o. q. [**2-21**] h p.r.n., Flagyl 500 mg t.i.d. x14 days. Patient is to follow-up with Dr. [**Last Name (STitle) **] on [**2142-11-14**] at 9:40 a.m. Please call [**Telephone/Fax (1) 673**] if there are any questions about the appointment. Patient is to call transplant surgery immediately at [**Telephone/Fax (1) 673**] for any fevers, chills, nausea, vomiting, abdominal pain, any increased redness to incision, sustained decreased appetite, increased bowel movements, or any problems with urination. FINAL DIAGNOSES: Pancreatic carcinoma. SECONDARY DIAGNOSIS: Clostridium difficile, peripheral vascular disease, elevated prostate-specific antigen/benign prostatic hypertrophy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD,PHD[**Numeric Identifier **] Dictated By:[**Last Name (NamePattern1) 4835**] MEDQUIST36 D: [**2142-11-7**] 11:38:35 T: [**2142-11-7**] 12:33:21 Job#: [**Job Number 65043**]

[ "008.45", "790.93", "157.0", "600.00", "196.2", "443.9" ]

icd9cm

[ [ [] ] ]

[ "52.7" ]

icd9pcs

[ [ [] ] ]

13936, 14541

9595, 9627

10933, 13912

9856, 10915

14559, 14582

7691, 9306

14604, 14997

9329, 9568

9644, 9840

2,053

184,822

9349

Discharge summary

report

Admission Date: [**2143-1-28**] Discharge Date: [**2143-2-8**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1974**] Chief Complaint: CC:[**CC Contact Info **] Major Surgical or Invasive Procedure: s/p washout septic knee washout in OR s/p PICC placement s/p GJ placement, IR guided History of Present Illness: . HPI: Patient is an 84 year old male who presented from NH with hypotension. Per records as patient is poor historian d/t dementia. Per the patients family, he was in his USOH until [**3-31**] days ago at [**Hospital1 **] when he was noted to be disoriented/confused. He improved for a day but then became worse last night. Last night he was found to be hypotensive x 2 at the nursing home and was tranferred to [**Hospital1 18**] for further evaluation. He denies cough, URI symptoms, abdominal pain, SOB, or chest pain. + urinary frequency without dysuria. No sick contacts. [**Name (NI) **] has chronic diarrhea which has not worsened. . Until [**Month (only) **], the patient had been living at home with his wife. At that time he began falling (8-10x during [**Month (only) 321**]). He was admitted to [**Hospital3 2568**] on [**12-13**] - 21st for workup of these falls. Per report from the patients son, the patient was found to have elevated cardiac enzymes and a stress/echo that showed an old MI. The CE's were attributed to ARF (thought to be prerenal). He was transferred to [**Hospital1 **] on [**12-18**] and has been there since. Of note, while at [**Hospital3 2568**] the patient was accidently given klonipin instead of clonidine and per family report his mental status deteriorated at that time and has not returned to baseline ( baseline MS - someone checked on 1x per day, son lays out pills, but lived alone with wife). . In the ED, the patient was found to have a temp of 100.2, HR 73, BP 88/41, RR20, O2 sats NRB. lactate was 2.2/WBC 11.4. A code sepsis was called and a right subclavian was placed. He recieved a total of 4 L IVF with response of BP to the 120's. He was treated with a dose of ceftriaxone and vancomycin. Received 1 unit PRBC. Urology was called because of difficulty placing a foley and they were able to place a foley. A UA was grossly positive. A CT abdomen was preformed which showed a AAA as well as + perichol. fluid and GB wall enhancement. Surgery was consulted and an RUQ U/S was performed which did not show evidence of cholcystitis. Per surgery, no active surgical issues. He was admitted the ICU with a diagnosis of sepsis. . Past Medical History: . # Right total hip replacement in [**7-/2136**] # Duodenal ulcer in [**2134**], status post laparotomy # Cataract surgery in [**2130**] # tonsils and adenoids in the [**2066**] # CRI, unclear baseline # knee surgery # silent MI # pacer placed at [**Hospital1 **] [**2140-6-28**] . Social History: . SH: smokes cigars, no cig, quit etoh 10 yrs ago (abuse 10 yrs ago) . Family History: . FH: non-contributory . Physical Exam: . PE: T 97.9, BP 97/51, HR 68, O2 98% on GEN: awake, nad HEENT: poor dentition, dry mmm Cardiac: s1 s2 no m/r/g Lungs: cta x 2 Abd: distended, soft, neg [**Doctor Last Name **] sign Ext: right knee with punctate wound draining wound with surrounding erythema, no c/c/e Neuro: AOx1 GU: blood at tip of penis, foley inserted . Pertinent Results: Studies: CT abd/pelvis: 1. Dilatation of the ascending aorta to 4.5 cm. 2. A 2-mm right middle lobe pulmonary nodule, which can be followed if clinically indicated in one year. 3. Abdominal aortic aneurysm measuring 3.7 cm extending to the common iliac arteries. 4. Polycystic kidney disease. Hyperdense lesions within both kidneys likely represent hemorrhagic cysts, although these cannot be fully evaluated on this examination. 5. Pericholecystic fluid and mild gallbladder wall enhancement. If there is clinical concern for cholecystitis, gallbladder ultrasound can be performed. . CT Head - No hemmorhage or mass effect . CXR - A left side pacemaker is seen with leads in appropriate position. There is mild cardiomegaly. The aorta is tortuous and dilated. The lungs are clear without focal consolidation, effusion, or pneumothorax. The left costophrenic angle is incompletely evaluated. The osseous structures are unremarkable. . Brief Hospital Course: . Assessment/Plan: 84 yo M with h/o CAD s/p pacer placement transferred from MICU after sepsis and hypotension found to have MSSA bacteremia [**3-1**] left knee infection s/p washout in OR. . # Sepsis/Infected Knee Joint - The patient was admitted to the MICU with hypotension and sepsis without elevated WBC or fevers. He was initially started on Vanc/Gent for broad coverage until a source could be isolated. Blood cultures on admission grew coag positive Staph aureus (MSSA) in [**5-1**] bottles. He was found to have a draining knee abscess with fistula tract to the skin which was thought to be the source of his sepsis. He went to the OR with orthopedics who performed a knee washout. Cultures from the knee were found to be coag positive Staph aureus (MSSA). The patient was put on a 6 week course of Nafcillin. He was found to have an appropriate response to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test. An intra-op TEE demonstrated no significant valvular regurgitation, but a possible small echodensity at tip of anterior mitral leaflet. Additionally, hip films from site of prior total hip replacement were unremarkable making infected hardware less likely. Surveillance cultures were monitored and showed no evidence of further MSSA bacteremia. An ID consult was obtained and they recommended reviewing the TEE with cardiology to ensure there was no evidence of vegetations. The patient has a pacemaker with wires but it did not appear that these were seeded given that his bacteremia cleared quickly and his surveillance cultures were negative. During his hospital course, he was found to have some serosanguinous drainage from his knee wound and he was followed closely by ortho. The drainage tapered off and there was no need for further washouts. . # Atrial fibrillation: Patient found to be intermittently in atrial fibrillation during his MICU course. Patient was not previously anticoagulated per OSH records as well as from history from son and daughter, but OSH records indicate history of atrial fibrillation. Was on heparin gtt in the MICU for a-fib. He was seen by cardiology during his MICU course who recommended long term anticoagulation. After receiving 2 doses of Coumadin, the patient's INR climbed rapidly to 11.4 likely due to his very poor nutritional status. The patient required two units of FFP to reverse this INR. He was restarted on Coumadin at a much lower dose, 1mg PO QOD. His INR.. He was maintained on low dose beta blocker for rate control. . # Agitation/Mental status: The patient has dementia at baseline and per his family, this has been worsening over the last year. The patient was intermittently agitated initially from his acute sepsis and bacteremia, as well as from sundowning in setting of acute illness. He was given PRN Haldol for agitation and a 1:1 sitter as necessary. His Aricept for dementia was held initally given his aspiration with plans to restart after obtaining a GJ tube. . # Gallbladder wall thickening - RUQ u/s without evidence of cholecystitis. Per surgery, there was no need for acute surgical intervention. The patient had no evidence of ductal dilation and only mildly elevated AST and alk phos but normal bili. There was no current concern for an obstructive pattern. . # ARF - Patient's creatinine was 3.2 upon admission which improved to 1.5 upon IVF volume resuscitation. Prior creatinine 1.0 in 11/[**2142**]. An FEurea was 58%. Renal U/S demonstrating polycystic kidneys, but no frank hydronephrosis. His medications were renally dosed. His ACEI was held upon admission. His polycystic kidneys can be further evaluated as an outpatient. . # Aspiration: The patient was evaluated by speech and swallow while in the MICU and was found to be aspirating. An NGT was attempted in the MICU but was unsuccessful. The patient was sent to fluoro for NGT placement but fluoro was also unsuccessful in placing the NGT. An IR guided GJ tube was also attempted but was unsuccessful given the patient's unusual anatomy after bowel resection for duodenal ulcer in the past. Surgery placed a J-tube in the OR and the procedure was well tolerated. Tube feeds were initiated as per a nutrition consult. After approximately 14 hours of tube feeds, the patient was found to have bilious emesis with respiratory distress concerning for aspiration. The patient was found to be 85% on RA with ABG showing pH 7.3, CO2 33, O2 37, and HCO3 17. His O2 sat improved with 50% face mask. A chest xray obtained revealed a new left upper lobe consolidation concerning for aspiration. Additionally on CXR, free air was seen in the peritoneum but given the patient's J-tube placement, the free air was thought to be consistent with recent surgical procedure. The patient showed no signs of an acute abdomen. Flagyl was added to the patient's regimen for concern of aspiration. . # Polycystic kidneys: Not known to be on patient's problem list prior to this hospitalization but patient is usually followed at VA. He had an elevated Cr to 3.4 upon admission but currently 1.6 after IVF hydration and resolution of sepsis. Baseline creatinine unclear. [**Name2 (NI) **] will need to have this followed as an outpatient. . # CAD s/p pacer placement: Not clear why patient has pacemaker but thought to be from SSS (placed at [**Hospital1 2025**] in [**2140**]). The patient was found to have mildly elevated troponin (.12) in setting of flat CKs. His troponin trended down. His elevated troponin was thought to be related to his ARF but could also be consistent with demand ischemia in the setting of sepsis. He ruled out for MI by three sets of cardiac enzymes. As an outpatient, he was on simvastatin, felodipine, atenolol, and fosinopril as an outpatient. These were held initially in the setting of aspiration but were restarted after his J-tube was placed. . # Anemia: His anemia was found to be consistent with anemia of chronic disease. He got 1 unit PRBCs for drifting Hct in MICU on [**2142-1-30**]. His hematocrit remained stable after receiving 1 unit PRBCs. . # AAA: 4.5 cm, No concern for rupture or leakage on CT without contrast. There is no prior imaging of the patient's AAA at [**Hospital1 18**]. This will continued to be followed by his outpatient doctor. . # Hypercholesterolemia: Continue Simvastatin when PEG placed . # FENL IVF as above. Not tolerating PO intake [**3-1**] aspiration. NG tube could not be placed by fluoro. GJ tube was obtained for tube feeds and meds. . # PPX - SQ Heparin . # Access - PICC line for 6 weeks of Nafcillin for septic knee . # Code - Full . # Dispo - On the morning of [**2143-2-8**], the patient was seen to have large volume bilious green emesis after tube feeds were started overnight with desaturation to 85% on 3L NC (which improved with non-rebreather). There was concern for aspiration. A chest xray was obtained which revealed a new LUL consolidation concerning for aspiration. Free air in the peritoneum was also seen on CXR but this was consistent with recent PEG tube placement. Additionally, a KUB showed no evidence of SBO. Later in the day, the patient was found to desaturate to the 70s on 50% face mask. An ABG was obtained which showed: pH 7.14, pO2 52, pCO2 44, bicarb 16, lactate 4.4. Given the patient's respiratory distress and ABG, he was transferred to the MICU. He was intubated with repeat ABG showing pH 7.08, pO2 62, pCO2 56, bicarb 18, lactate 6.0. A repeat CXR showed worsening bilateral opacities. The family was contact[**Name (NI) **] and given a decision was made to make the patient CMO. He passed away shortly after. . Medications on Admission: MEDS: simvastatin 20mg QD felodipine 5mg QD atenolol 50mg QD fosinopril 40mg QD zoloft 50mg QD omeprazole 20mg QD calium 500mg [**Hospital1 **] aricept 10mg QD loperamide prn no asa [**1-29**] ibuprofen prn . ALL: NKDA Discharge Disposition: Expired Discharge Diagnosis: Primary: Respiratory failure from aspiration pneumonia Septic shock MSSA bacteremia from knee abscess Open G-tube placement . Secondary: s/p total hip replacement h/o duodenal ulcer Atrial fibrillation CAD ARF on CRI Dementia . Discharge Condition: Expired Discharge Instructions: Not applicable Followup Instructions: Not applicable Completed by:[**2143-2-12**]

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icd9cm

[ [ [] ] ]

[ "96.71", "96.6", "80.76", "46.32", "99.07", "99.04", "96.04", "38.93", "88.72" ]

icd9pcs

[ [ [] ] ]

12298, 12307

4375, 6930

286, 372

12580, 12590

3406, 4352

12653, 12699

3016, 3044

12328, 12559

12055, 12275

12614, 12630

3059, 3387

222, 248

400, 2604

6945, 12029

2626, 2910

2926, 3000

18,082

181,163

11814

Discharge summary

report

Admission Date: [**2156-2-23**] Discharge Date: [**2156-3-29**] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Erythromycin Base / Lactose Intolerance Attending:[**First Name3 (LF) 545**] Chief Complaint: Fever, Delerium, UTI, Pneumonia Major Surgical or Invasive Procedure: tracheal intubation PICC line History of Present Illness: [**Age over 90 **] yo female with frequent UTIs in the past presents with fever and altered mental status for 3 days. She recently discharged from [**Hospital1 18**] on [**1-23**] after PVD/chronic leg ulcer work-up and was found to have an occluded L popliteal artery which was not revascularized due to medical stability and anesthesia. She has been at [**Hospital3 **] center until 3 days prior to re-admission to [**Hospital1 18**]. Her course at [**Hospital1 100**] was complicated by C.diff colitis and was placed on po vancomycin (unclear if she failed Flagyl). Per her daughter [**Name (NI) **], the patient's only symptoms were decreased mental status and fevers. She did not notice any cough until in the [**Hospital1 18**] ED, and pt has not been talking much at all so it has been hard to assess her complaints. Her baseline since the admission in [**1-9**] has been deteriorating. She used to walk and converse, and follwed basic commands, but is now hardly able to follow the simplest commands. . ED COURSE: Initially, in [**Name (NI) **], pt was febrile to 102.2 and hypotensive with a BP of 86/42 and tachypneic to 34 and 93% on 4L via NC. She was given Ceftriaxone 1g for her positive UA and and pneumonia, she also received vancomycin 1gm, and levofloxacin 500mg iv was ordered but not yet received. Pt also received 2L of NS in the ED for Na 152 and hypovolemia. Past Medical History: PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6680**] . 1) Diabetes mellitus (Hgb A1C 5.8% in [**2-8**]) 2) Frequent UTI 3) Gastroesophageal reflux disease 4) S/p CVA w/residual mild R hemiparesis 5) Osteoporosis 6) Depression/Anxiety 7) Osteoarthritis 8) Hypothyroidism (last TSH 2.8 in [**11-7**]) 9) Chronic diarrhea 10) COPD, on night O2 at home (FEV1 0.88 (73% pred), FVC 1.2, elevated EV1/VC ratio in [**1-6**]), no prior intubations, was placed on steroid taper at last admission in [**3-10**]. 11)Diastolic CHF 12)Coronary Artery Disease with cath [**1-8**], no intervention 13)s/p admission for fall at home discharged on [**2155-8-29**] 14)LLE 1st MTP ulcer 15) Traumatic left parietal SDH. 16) HTN 17) Anemia of chronic disease . Allergies: Sulfa (Sulfonamides) / Erythromycin Base Food Allergies: Milk, [**Name (NI) 37325**] (pt lactose intolerant) Social History: Smoked 2ppd until [**2131**]. [**2-4**] glass of wine 3-4x/week. Worked as a secretary. Independent with ADLs, not IADL. Has 24 hour caretaker. [**Name (NI) **] (daughter) is the Healthcare proxy. Family History: Non-contributory Physical Exam: ROS (by report): GEN: + fevers, - Chills, + Weight Loss EYES: - Photophobia HEENT: - Oral/Gum bleeding CARDIAC: - Chest Pain, - Edema GI: - Vomitting, - Diarhea, - Constipation, - Hematochezia, - melena PULM: - Dyspnea, + Cough, - Hemoptysis HEME: - Bleeding, - Lymphadenopathy GU: - Dysuria, - hematuria, - Incontinence SKIN: - Rash ENDO: - Heat/Cold Intolerance MSK: - Myalgia, - Arthralgia, + Back Pain NEURO: - Numbness, - Weakness, - Vertigo, - Headache, + confusion/delerium VSS: 96.4, 102/50, 80, 22, 99%3LNC GEN: confused, minimally responsive HEENT: PERRL, Dry, - OP Lesions PUL: difficult exam, decreased BS in all lung fields COR: RRR, S1/S2, II/VI SEM ABD: NT/ND, + CVAT EXT: - CCE, Heel Ulcer NEURO: confused, responds to painful stimuli Pertinent Results: [**2156-2-23**] 07:15AM BLOOD WBC-19.6* RBC-3.06* Hgb-9.9* Hct-31.6* MCV-103* MCH-32.4* MCHC-31.4 RDW-15.5 Plt Ct-414 [**2156-2-23**] 07:15AM BLOOD Neuts-77.4* Lymphs-17.9* Monos-4.1 Eos-0.4 Baso-0.1 [**2156-2-23**] 07:15AM BLOOD PT-12.4 PTT-25.4 INR(PT)-1.0 [**2156-2-23**] 07:15AM BLOOD Glucose-112* UreaN-45* Creat-0.8 Na-156* K-3.4 Cl-119* HCO3-29 AnGap-11 [**2156-2-23**] 07:15AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.3 [**2156-2-22**] 10:49PM BLOOD Lactate-1.9 . DISCHARGE LABS . MICRO [**2-22**] urine culture Klebsiella pneumoniae URINE CULTURE (Final [**2156-2-28**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | KLEBSIELLA PNEUMONIAE | | AMPICILLIN/SULBACTAM-- 4 S 8 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ 4 S 4 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 256 R 256 R PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S [**2-22**] blood cultures [**3-6**] negative [**2-23**] C difficile toxin assay negative [**2-23**] legionella urinary antigen negative [**2-24**] blood cultures [**3-6**] negative [**2-25**] urine culture yeast [**2-25**] catheter tip culture negative [**3-1**] urine culture negative [**3-1**] blood cultures **** PENDING **** [**3-2**] sputum 2+ GPCs in pairs and clusters, 1+ budding yeast; cultures with staph aureus 2 morphologies **** PENDING **** [**3-2**] catheter tip culture negative . CT HEAD W/O CONTRAST [**2156-2-22**] 11:29 PM IMPRESSION: 1. No evidence of acute intracranial pathology including hemorrhage or edema. 2. Stable changes of age appropriate atrophy and chronic microvascular ischemia. . AP SEMI-UPRIGHT CHEST: A drainage catheter projects over the left upper abdominal quadrant. Several right abdominal surgical clips are seen. Borderline cardiomegaly is unchanged. The aorta is mildly calcified and folded. Increased left retrocardiac peribronchial nodular infiltration may present aspiration or evolving pneumonia. The right lung is grossly clear. There is no pleural effusion or pneumothorax. The osseous structures are stable. IMPRESSION: Increased left retrocardiac peribronchial nodular infiltration, which may represent aspiration or evolving pneumonia. Brief Hospital Course: 1. Altered mental status) According to the patient's daughter, she had been less interactive at rehab prior to admission. She underwent a CT of her head which was unremarkable. Her mental status changes were thought to be multifactorial, likely related to electrolyte disturbance, infection, recent fall with subdural hematoma -- and subsequent to her PEA arrest possibly anoxic injury. 2. PEA arrest) Ms. [**Known lastname 31102**] had a PEA arrest on [**2-24**]. She was treated with epinephrine and atropine a right femoral line was placed, and she was intubated. Food particles were noted in the airway at intubation, suggestive of an aspiration event. She was subsequently transferred to the ICU for further monitoring and evaluation. Her troponins were mildly elevated at 0.13 post resuscitation, thought secondary to chest compressions. LENIs were done as part of PE workup and were negative. 3. Aspiration pneumonia CXR at admission showed possible infiltrate, and she was treated empirically with vancomycin and cefepime. Cefepime was changed to meropenem subsequently on [**3-1**] after she developed a new fever to 101.6. The patient continued to display symptoms of aspiration PNA/hospital-acquired pneumonia during her hospital course for which she was traeted with vancomycin and ceftazadime. 4. Dysphagia)Given her history of dysphagia she was kept NPO and continued tube feeds. Her G tube was replaced on [**3-3**] as her initial tube was no longer flushing. 5. Urinary tract infection) She received ceftriaxone empirically in the ED on [**2-23**] but was subsequently changed to cefepime. Urine cultures from admission came back positive for quinolone resistant Klebsiella pneumoniae. Follow up urine cultures were negative. 6. History of C. difficile colitis) She was continued on PO vancomycin while receiving broad spectrum antibiotics, with no abdominal tenderness or diarrhea. She should continue flagyl for two weeks following the end of broad spectrum therapy to reduce the risk of recurrent C. difficile colitis. 7. Atrial fibrillation with rapid ventricular response) She was administered metoprolol for rate control. She is not an anticoagulation candidate given fall c/b subdural hematoma. 8. CHF, diastolic, chronic) Required lasix diuresis given increased O2 requirements and pulmonary edema. Continued on beta blocker. Dispo) Multiple discussions held with the patient's two daughters. The daughters have repeatedly stated that they want the patient to be full code. In addition, they want her to be discharged to home and not a [**Hospital1 1501**], where she could receive nursing care and suctioning if required. Per the repeat adamant decisions of the patient's daughters, the patient was discharged home with open hospice. Medications on Admission: 1. Levothyroxine 50 mcg po daily 2. Ipratropium Bromide 0.02 % Solution One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 3. Fluoxetine 20 mg/5 mL (20) mg PO DAILY 4. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: [**11-22**] ml PO Q6H (every 6 hours) as needed for pain. 5. Lisinopril 5 mg Tablet One (1) Tablet PO DAILY 6. Metoprolol Tartrate 25 mg Tablet One (1) Tablet PO twice a day 7. Aspirin 81 mg Tablet One (1) Tablet, Chewable PO DAILY (Daily). 8. Cholecalciferol (Vitamin D3) 1,000 unit Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day. 9. Multivitamin Liquid [**Month/Year (2) **]: Five (5) ml PO once a day. 10. Calcium Carbonate 650 (1,625) mg Tablet [**Month/Year (2) **]: One (1) Tablet PO twice a day. 11. Heparin (Porcine) 5,000 unit/mL Syringe [**Month/Year (2) **]: 5000 (5000) units Injection twice a day. 12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day. 14. Omeprazole Oral 15. Humulin R 100 unit/mL Solution [**Month/Year (2) **]: as directed units Injection per sliding scale: Please continue sliding scale insulin according to patient's regimen during her previous stay at [**Hospital 100**] Rehab. 16. vancomycin po unknown dose and frequency, daughter will bring med list which she was discharged with from [**Hospital **] rehab. 17. Nebulizer treatment TID Discharge Medications: 1. Fluoxetine 20 mg/5 mL Solution [**Hospital **]: One (1) PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable [**Hospital **]: One (1) Tablet, Chewable PO DAILY (Daily). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital **]: 2.5 Tablets PO DAILY (Daily). 4. Therapeutic Multivitamin Liquid [**Hospital **]: One (1) Cap PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital **]: One (1) Tablet, Chewable PO TID (3 times a day). 6. Ferrous Sulfate 300 mg/5 mL Liquid [**Hospital **]: One (1) PO DAILY (Daily). 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 8. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) Injection [**Hospital1 **] (2 times a day). 10. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: SEE BELOW Subcutaneous ASDIR (AS DIRECTED). 11. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID (3 times a day) as needed. 12. Nitroglycerin 2 % Ointment [**Hospital1 **]: One (1) TP Transdermal Q8H (every 8 hours) as needed. 13. Levothyroxine 50 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 14. Metronidazole 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day): Continue for 7 days after discontinuation of other antibiotics. Disp:*14 Tablet(s)* Refills:*0* 15. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Hospital1 **]: One (1) neb Inhalation Q4H (every 4 hours). 16. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) neb Inhalation Q6H (every 6 hours). 17. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Hospital1 **]: One (1) neb Inhalation Q2H (every 2 hours) as needed for wheezing or shortness of breath. 18. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 1.5 Tablets PO Q 8H (Every 8 Hours). 19. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Hospital1 **]: One (1) ML Intravenous DAILY (Daily) as needed. Discharge Disposition: Home With Service Facility: Hospice of the Good [**Last Name (un) 3952**] Discharge Diagnosis: Primary 1. PEA arrest 2. Clostridium difficile colitis 3. Urinary tract infection 4. Aspiration pneumonia Secondary 1. Atrial fibrillation with rapid ventricular response 2. Congestive heart failure, diastolic, chronic 3. Diabetes mellitus 4. Coronary artery disease Discharge Condition: Poor, afebrile Discharge Instructions: You were admitted to the hospital because of fevers at your rehab facility. You were being treated for C. difficile diarrhea. You were also found to have a urinary tract infection. While hospitalized, you had an episode of unresponsiveness where your heart had stopped. You also had a pneumonia that was treated with antibiotics. Followup Instructions: Patient's daughters to call and make f/u appt in [**2-4**] weeks with the patient's PCP.

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icd9cm

[ [ [] ] ]

[ "99.60", "96.04", "96.72", "38.93", "44.32", "99.04" ]

icd9pcs

[ [ [] ] ]

12871, 12947

6521, 9294

301, 332

13258, 13275

3681, 6498

13653, 13745

2875, 2893

10740, 12848

12968, 13237

9320, 10717

13299, 13630

2908, 3662

230, 263

360, 1745

1767, 2643

2659, 2859

29,967

123,192

7547+55848

Discharge summary

report+addendum

Admission Date: [**2143-12-21**] Discharge Date: [**2144-1-11**] Date of Birth: [**2071-5-31**] Sex: F Service: SURGERY Allergies: Iodine; Iodine Containing / Gadolinium-Containing Agents Attending:[**First Name3 (LF) 2597**] Chief Complaint: Severe abdominal pain Major Surgical or Invasive Procedure: CT guided drainage of LLQ intra-abdominal abcess [**2143-12-27**] History of Present Illness: 72F Vascular Surgery patient four days s/p thrombectomy, arterioplasty and stenting of her L Ax-BiFem jump graft presents 8 hrs after acute exacerbation of her post-op abdominal pain. Past Medical History: PMH: Afib, RA, CAD, h/o MI, OA, h/o Lung CA-chemo/XRT, GERD, HTN PSH: Left axillary artery angioplasty and jump graft from left ax-fem graft to SFA w/ PTFE ([**2143-10-2**]), Revision of left ax-fem graft w/ jump graft (PTFE) and left to right fem-fem bypass w/ PTFE ([**2143-4-17**]), Left ax to fem-fem bypass graft bypass w/ PTFE ([**2138-11-5**]), R CIA to bifemoral artery bypass w/ Dacron ([**2138-10-1**]), ballon angioplasty x 2 rle [**2129**], rul resection with xrt / chemo, TAH with b/l saplingoopherectomy, Appy, carpal tunnel release x 2 b/l, lipoma removal, [**Hospital Ward Name **] cyst b/l hands Social History: lives at home, uses wheel chair Family History: n/c Physical Exam: PE: 101.4 74 129/68 20 98%/RA Gen: NAD, A&Ox3, MM dry, (-)scleral icterus, Pul: CTAB, L ant chest with port Cor: RRR Abd: soft, mild distention & tympani (+)BLQ/periumbilical tenderness (+)voluntary guarding (-)rebound (+)mult. scars LLQ incision (+)tenderness (-)pus (-)erythema Ano: guaiac(-) per Vascular resident Pertinent Results: [**2143-12-21**] 4:57 PM CT PELVIS/ABDOMEN WITH AND WITHOUT CONTAST IMPRESSION: 1. Thickening and fatty stranding adjacent to the sigmoid colon which is associated with two large extraluminal gas locules suggesting perforated diverticulitis. There is also free intraperitoneal air. These findings are consistent with the perforated diverticulitis. 2. Stable intra- and extra-hepatic bile duct dilatation. 3. Status post axillobifemoral and superficial femoral artery bypass grafting. [**2143-12-26**] CT ABDOMEN WITH AND WITHOUT CONTRAST IMPRESSION: 1. Sigmoid and descending colonic diverticulitis with new gas and possibly oral contrast containing abscess in the left lower quadrant measuring 4.3 cm. [**2144-1-4**] 1:00 AM CT ABDOMEN/PELVIS W/CONTRAST IMPRESSION: 1. Increase in size of extraluminal collection of the left pericolic gutter, consistent with abscess. Pigtail catheter appears in good position. Local inflammatory change has worsened at this site. 2. Persistent sigmoid and descending colonic wall thickening, not appreciably changed. 3. Small low-density peripherally enhancing fluid collection of the deep pelvis, slightly smaller in size. 4. Redemonstration of distal abdominal aortic occlusion. Extra anatomic bypass graft remains patent. [**2143-12-30**] 04:20AM BLOOD WBC-9.3 RBC-3.76* Hgb-11.2* Hct-32.1* MCV-85 MCH-29.7 MCHC-34.7 RDW-14.0 Plt Ct-314 [**2143-12-27**] 12:06PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2144-1-5**] 6:06 pm ABSCESS Source: pigtail drain. GRAM STAIN (Final [**2144-1-5**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): ESCHERICHIA COLI. SPARSE GROWTH. ENTEROCOCCUS SP.. SPARSE GROWTH. Daptomycin AND MINOCYCLINE REQUESTED BY DR.[**Last Name (STitle) **]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ENTEROCOCCUS SP. | | AMPICILLIN------------ 16 I =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R LINEZOLID------------- 1 S MEROPENEM-------------<=0.25 S PENICILLIN------------ =>64 R PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 4 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ =>32 R ANAEROBIC CULTURE (Final [**2144-1-9**]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): [**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. [**2143-12-31**] 03:00AM BLOOD PT-15.9* PTT-32.5 INR(PT)-1.4* Brief Hospital Course: Briefly, Mrs. [**Known lastname **] is a 72 F with recent thrombectomy of jump graft from L. ax [**Hospital1 **]-fem to SFA and stenting of distal anastamosis, who presented to [**Hospital1 18**] on [**2143-12-21**] with severe abdominal pain and was found to have perforated sigmoid diverticulitis by CT. She was admitted to the Vascular Surgery Service. She was followed by Cardiac Surgery, Blue/General Surgery, and [**Last Name (un) **] during this hospital course. Her hospital course is broken down by systems as follows: Neuro Her pain was controlled by fentanyl and lidocaine patches and a PCA; when appropriate, she was transitioned to po pain medications. CV The patient was put on telemetry during her hospital course, and was taken off when appropriate. She was anticoagulated with aspirin, plavix, and was put on lovenox as bridge therapy while she was made therapeutic on coumadin Pulm No issues; the patient worked with physical therapy to get out of bed and ambulate every day, and pulmonary toilet was encouraged. GI Initially her perforated diverticulitis was managed by bowel rest. Her diet was slowly advanced and changed based on her clinical symptoms. TPN was initiated to supplement her caloric requirements. When the patient's nausea and abdominal pain were severe, her diet was held, and the patient was made NPO. Her diet was advanced when appropriate to a low residue diet with good effect. She had several days of loose bowel movements which were c.diff negative, which also resolved. She received intravenous fluids to compensate for her losses. GU She continued to void spontaneously after foley d/c'd on [**2143-12-24**]. Her volume status and urinary output were routinely monitored for changes, and the patient's intravenous fluids were adjusted accordingly. Heme Her INR was elevated on admission. She was placed on a heparin gtt on [**2143-12-22**], which was stopped when the patient was able to take oral medications, and coumadin could be started. At that time, the patient was also put on a bridge therapy of lovenox until she was therapeutic. THe patient's hematocrit was carefully monitored, and she was transfused 1u [**2143-12-22**] for hct 27.8, which increased to 30.4; she was also transfused on [**2143-12-27**] with good result. She will continue lovenox injections 60mg SC bid on discharge, and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], her oncologist will follow up her CBC and coagulation profile on discharge. ID Pt was placed on iv abx including ampicillin, levofloxacin, and flagyl. During her stay, she also briefly received gentamycin and vancomycin for added coverage, and also received gentamycin flushes into her pigtail catheter. These were tailored over the course of her hospital stay, and she was discharged on linezolid and Bactrim. On hospital day 10, the patient had a PICC placed in order for her to received the multiple antibiotics in addition to TPN (through her Port-a-cath) IR placed a pigtail catheter to drain her pelvic collection on HD3. This pelvic collection grew VRE, E. Coli and staph aureus. Please see the results section for more details. Endo The patient was put on an insulin sliding scale, and her blood sugars were carefully monitored especially while on TPN. The remainder of her hospital course was unremarkable with her vital signs and laboratory values within normal limits. She is being discharged home in stable condition. She will have home PT and [**Last Name (NamePattern1) 269**] services to assist her. Medications on Admission: ASA 81, doxepin 25', lipitor 40', meclizine 125', pregabalon 50"', fentanyl patch, lidocaine patch, omeprazole 20', pyridoxine 100', plavix 75', coumadin 2', atenolol 12.5', lasix 20 QOD Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:*10 Patch 72 hr(s)* Refills:*0* 4. Doxepin 25 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Pyridoxine 25 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 weeks. Disp:*56 Tablet(s)* Refills:*0* 12. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous [**Hospital1 **] (2 times a day) for 4 weeks. Disp:*56 syringes* Refills:*1* 13. Outpatient Lab Work CBC, INR on Wednesday or Thursday Please fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 27578**] 14. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 15. Warfarin 2 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 4 weeks. Disp:*25 Tablet(s)* Refills:*2* 16. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea for 4 weeks. Disp:*30 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] [**Location (un) 269**] Discharge Diagnosis: Perforated diverticulitis LLQ abdominal abcess s/p CT guided drainage rheumatoid arthritis CAD s/p MI osteoarthritis lung ca s/p chemo and XRT GERD HTN AFib PVD R. CIA-bifem BPG w/ dacron [**9-17**], L. ax. fem-fem bypass w/ PTFE [**10-18**], revision L. ax-fem w/ jump graft 5/07 L axillary angioplasty and jump graft from L. ax fem to SFA [**9-22**] S/P hrombectomy of jump graft with stenting of distal anastamosis [**2143-12-16**] Discharge Condition: Stable Discharge Instructions: NUTRITION: - You will continue a low residue diet - Call the General Surgery team for worsening abdominal pain, vomiting or nausea/diarhea and high fever. FOLLOW-UP: - Keep your follow-up appointments Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in [**12-18**] weeks; call ([**Telephone/Fax (1) 4336**] to schedule an appointment. Please call Dr.[**Name (NI) 5695**] assistant, [**Doctor First Name 25812**], at [**Telephone/Fax (1) 1237**] for Date & Time for follow-up in [**3-22**] weeks Provider: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 27579**], MD (Primary Care Physician) Phone:[**Telephone/Fax (1) 8363**] call for a post hospitalization follow-up Please call to schedule an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 27580**] or [**Telephone/Fax (1) 27581**] in [**12-18**] weeks. Dr. [**Last Name (STitle) **] will follow your INR for your coumadin dosing as well as blood counts. Name: [**Known lastname 4761**],[**Known firstname **] Unit No: [**Numeric Identifier 4762**] Admission Date: [**2143-12-21**] Discharge Date: [**2144-1-11**] Date of Birth: [**2071-5-31**] Sex: F Service: SURGERY Allergies: Iodine; Iodine Containing / Gadolinium-Containing Agents Attending:[**First Name3 (LF) 1546**] Addendum: TO NOTE: On arrival to ED she was significantly dehydrated (UO=10cc/hr); While she has in the ED, she received 3500cc IVF, Her urine output increased ~450cc. Her creatinine on her previuos admission to days prior was 1.5. On arrival to the ER her creatinine was 2.2. With the bolus of fluid and hydration while in the hospital her creatinine improved to 1.1. Pt does has CRI, with a baseline creatinine between 1.1-1.5, Because of her acute rise in creatinine to 2.2. Pt experienced acute renal failure. Discharge Disposition: Home With Service Facility: [**Location (un) 42**] VNA [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**] Completed by:[**2144-2-4**]

[ "569.5", "585.9", "V12.72", "041.4", "041.04", "V10.11", "V58.61", "562.11", "V43.4", "276.51", "412", "584.9", "530.81", "427.31", "790.92", "414.01", "V15.3", "041.11", "403.90", "V15.82", "714.0", "715.90" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.15", "99.07", "99.04", "54.91" ]

icd9pcs

[ [ [] ] ]

12644, 12857

4668, 8228

339, 406

10667, 10675

1697, 3362

10927, 12621

1324, 1329

8466, 10088

10209, 10646

8254, 8443

10699, 10904

1344, 1678

4512, 4645

278, 301

434, 619

641, 1258

1274, 1308

3397, 4476

18,965

103,819

2474

Discharge summary

report

Admission Date: [**2154-6-13**] Discharge Date: [**2154-6-15**] Date of Birth: [**2100-4-27**] Sex: M Service: OTOLARYNGOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 12657**] Chief Complaint: CSF leak, AD otorrhea Major Surgical or Invasive Procedure: [**2154-6-13**] repair of CSF leak History of Present Illness: 54 yo M with chronic CSF leak Past Medical History: HTN, CAD s/p NSTEMI, and stents x 2 Social History: +tobacco, +etoh Physical Exam: Afebrile VSS AD dressing changed. Would flat, no otorrhea Facial function intact and symmetric Pertinent Results: [**2154-6-14**] 02:00AM BLOOD WBC-13.0* RBC-4.44* Hgb-13.4* Hct-37.6* MCV-85 MCH-30.2 MCHC-35.6* RDW-13.8 Plt Ct-291 [**2154-6-14**] 02:00AM BLOOD Plt Ct-291 [**2154-6-14**] 02:00AM BLOOD Glucose-247* UreaN-14 Creat-0.8 Na-139 K-4.2 Cl-105 HCO3-23 AnGap-15 [**2154-6-14**] 02:00AM BLOOD Calcium-9.2 Phos-2.8 Mg-1.9 Brief Hospital Course: Initially monitored in ICU setting. Vitals remained stable. ECG was normal. Transferred to floor on POD 1. Ambulated and tolerated PO's. No clear fluid drainage or swelling of incision site. Received IV ceftriaxone while an inpatient. Lovenox held for 48 hours, and restarted on POD 2. Medications on Admission: Metoprolol, Aspirin, Valsartan, ativan, lovenox, omeprazole, zocor Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. Tablet(s) 2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 3. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate Oral 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Lovenox 1.5 mg/kg SC QD 8. Keflex 500 mg Po QID x 7 days Discharge Disposition: Home Discharge Diagnosis: CSF leak Discharge Condition: Good Discharge Instructions: Light activity, no straining or bending over. Call the office if develop neck stiffness, light bothering eyes, or high fevers. Followup Instructions: Dr. [**Last Name (STitle) 3878**], 1 week-call office to schedule Completed by:[**2154-6-15**]

[ "V45.82", "305.1", "412", "414.01", "733.99", "414.8", "388.61", "401.9" ]

icd9cm

[ [ [] ] ]

[ "02.12", "02.04" ]

icd9pcs

[ [ [] ] ]

2007, 2013

1002, 1294

344, 380

2066, 2073

663, 979

2249, 2346

1411, 1984

2034, 2045

1320, 1388

2097, 2226

546, 644

283, 306

408, 439

461, 498

514, 531

56,552

190,327

47851

Discharge summary

report

Admission Date: [**2150-4-6**] Discharge Date: [**2150-4-16**] Date of Birth: [**2077-3-23**] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 12**] Chief Complaint: Unresponsive episode at dialysis. Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [**Known lastname 100984**] is a 73yo M w/hx of NHL on Bendamustine (C3D17) and ESRD [**2-16**] DM on HD who was recently hospitalized multiple times for pneumonia. On [**2150-4-6**] he was found unresponsive near the end of his scheduled dialysis session. It is unclear if he had a fever at that time. He eventually regained consciousness. He denied any prodromal symptoms, including lightheadedness, palpitations, chest pain/discomfort, and blurry vision. CXR showed a new LLL infiltrate. Past Medical History: PAST MEDICAL HISTORY: ==================== Non-Hodgkin's Lymphoma (follicular low-grade B-cell NHL grade I, diagnosed in [**2142**]), on Bendemustine Adriamycin cardiomyopathy EF 30% Aortic Stenosis End-stage kidney disease on HD MWF Type 2 diabetes mellitus Gout Meningioma Spinal stenosis- s/p surgery [**51**] yrs ago Osteoarthritis of the hips s/p b/l THR PAST ONCOLOGIC HISTORY: ====================== He was diagnosed in the year [**2141**] when biopsy of a cervical node revealed follicular low-grade B-cell NHL grade I. He has required treatment off and on throughout the ensuing years with multiple regimens including Leukeran, R-CVP, R-CHOP, and most recently weekly Adriamycin. His total dose never exceeded 450/sq meter but in [**12/2148**] he had shortness of breath on exertion. His ejection fraction was 30%. Adriamycin was discontinued. He saw Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] from cardiology and was placed on lisinopril and Toprol-XL. His dyspnea is improved when he has had dialysis [**Doctor Last Name **] to removal of fluid but he develops hypotension and therefore this approach has its limitations. . Two months ago [**Known firstname **] was found to have a thrombosis in the A-V fistula in his left arm. Her now has a right IJ line in place. Social History: The patient is married and lives in [**Location 1439**], [**State 350**]. He has four children. He quit smoking cigarettes 38 years ago after 80 pack yrs. He does not drink alcohol and denies the use of illicit or illegal drugs. He works as a kosher butcher in [**Location (un) **]. Family History: Mother had diabetes mellitus and died at the age of [**Age over 90 **] years. Father died at the age of [**Age over 90 **] years. He has three brothers and three sisters who are basically healthy. There is no family history of sudden death or premature atherosclerotic cardiovascular disease Physical Exam: Vitals - T: 100.0 BP: 109/77 HR: 99 RR: 22 02 sat: 94% 3L . GENERAL: well-appearing man, NAD, breathing comfortably SKIN: warm and well perfused, no excoriations or lesions, no rashes; HD catheter site without erythema or fluid pockets HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no mrg LUNG: LLL crackles, diffuse wheezes and rhonchi scattered throughout ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXT: trace edema in ankles, shins bilaterally PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, [**5-19**] muscle strength, no sensory deficits Pertinent Results: Admission labs: [**2150-4-6**] 12:55PM BLOOD WBC-2.3* RBC-3.16* Hgb-10.8* Hct-32.6* MCV-103* MCH-34.2* MCHC-33.2 RDW-16.4* Plt Ct-76* [**2150-4-6**] 12:55PM BLOOD Neuts-67.5 Lymphs-19.0 Monos-11.3* Eos-1.9 Baso-0.3 [**2150-4-7**] 02:30AM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-OCCASIONAL Macrocy-1+ Microcy-OCCASIONAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**2150-4-6**] 12:55PM BLOOD PT-14.0* PTT-26.8 INR(PT)-1.2* [**2150-4-6**] 12:55PM BLOOD Glucose-126* UreaN-32* Creat-3.7* Na-139 K-4.1 Cl-97 HCO3-30 AnGap-16 [**2150-4-6**] 12:55PM BLOOD Calcium-8.9 Phos-1.9* Mg-1.5* [**2150-4-6**] 01:05PM BLOOD Lactate-1.4 . Cardiac Enzymes [**2150-4-6**] 12:55PM BLOOD CK(CPK)-21* [**2150-4-6**] 12:55PM BLOOD CK-MB-NotDone cTropnT-0.16* [**2150-4-6**] 08:01PM BLOOD CK(CPK)-21* [**2150-4-6**] 08:01PM BLOOD CK-MB-NotDone cTropnT-0.11* [**2150-4-7**] 02:30AM BLOOD CK(CPK)-34* [**2150-4-7**] 02:30AM BLOOD CK-MB-NotDone cTropnT-0.25* . Other labs [**2150-4-8**] 05:00AM BLOOD IgG-150* [**2150-4-8**] 05:00AM BLOOD calTIBC-109* VitB12-1371* Folate-GREATER TH Hapto-296* Ferritn-GREATER TH TRF-84* [**2150-4-8**] 05:00AM BLOOD LD(LDH)-177 TotBili-0.4 [**2150-4-8**] 05:00AM BLOOD Ret Aut-1.1* [**2150-4-9**] 03:14AM BLOOD Gran Ct-550* . Urine studies [**2150-4-6**] 07:31PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007 [**2150-4-6**] 07:31PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2150-4-6**] 07:31PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1 TransE-<1 . Microbiology [**2150-4-6**] MRSA screen neg [**2150-4-6**] Urine legionella ag neg [**2150-4-6**] Urine Cx: Coag neg staph 10,000-100,000 organisms [**2150-4-8**] Urine Cx: neg [**2150-4-8**] Sputum: contaminated [**4-6**], [**4-7**], [**4-8**], [**4-9**] Blood Cx: No growth to date . CXR [**2150-4-6**]: 1. Interval development of left perihilar opacity likely in the left lower lobe concerning for pneumonia. Followup to resolution. 2. Persistent reticular nodular opacity in the right lower lung which likely represents persistent or recurrent airway infection. . ECHO [**2150-4-6**]: The left atrium is dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2149-7-17**], mitral regurgitation appears similar, aortic valve gradient is similar (valve area was underestimated in the prior report), estimated pulmonary artery systolic pressure is now lower, left ventricular ejection fraction appears similar although today's images are technically suboptimal. . CHEST CT [**2150-4-7**]: 1. Interval development of dense consolidation in the left lower lobe with air bronchograms and surrounding ground-glass halo, which raises the concern for bacterial or fungal infection. 2. Bronchovascular opacity and consolidation in the right lower lobe shows some interval improvement consistent with resolving right lower lobe pneumonia. . CXR [**2150-4-7**]: In comparison with study of [**4-6**], the opacification at the left base is somewhat less. Streaks of atelectasis are seen at the right base and there is blunting of both costophrenic angles. Minimal residual engorgement of the pulmonary vessels. Central catheter remains in position. . CXR [**2150-4-9**]: No significant interval change with consolidation at the left greater than right base consistent with known pneumonia. Brief Hospital Course: Mr. [**Name14 (STitle) 100985**] is a very nice 73 YO gentleman with NHL (C3D17) on Bendemustine (last dose [**2150-3-25**]), ESRD on HD, who presented with fever and LLL infiltrate on CXR and CT. Also hypotensive on pressors in the MICU with concerns for pneumosepsis. Now off pressors for > 24 hours. . 1. LLL Pneumonia: Patietn was admitted to the floor with presumntive bacterial community acquired pneumonia and then triggered for hypotension and was transfered to the MICU. He was started on Levophed for BP, Vanc, Zosyn and Azithromycin (Azithro was discontinued after 2 days) for hospital acquired pneumonia in a patient with an indwelling hemodialysis line. MICU course complicated by tachycardia with HD, fevers (last on [**2150-4-8**]), neutropenia with ANC of 590 after chemotherapy, and hypotension on Levophed, which was stopped on [**2150-4-8**]. He was able to maintain remarkably clear sensorium and remained symptoms free even when his blood pressures dipped into 70s systolic. We were unable to identify an organism, despite multiple sputums that had only contamintants. Her MRSA screen was negative. The most likely organism was pneumococcus, but unfortunately in the settinf of immunosupression it could have been other bacteria that we were able to isolate. Infectious disease service was consulted and recommended 7-days of Vanc/Zosyn, which he completed in the hospital. He was given a course of 7-days of levofloxacin 250 mg PO QOD. His SpO2 was stable in the medical floor after the ICU and patient was able to walk short distances without any SOB or O2 requirements. . 2. Hypotension: Pt has low baseline but etiologies initially considered were sepsis and cardiogenic shock. Echo from [**2150-4-6**] is not markedly changed from prior but [**Last Name (un) 22975**] EF of 35% and 3+ MR as well as AS with [**Location (un) 109**] of 1.0cm. Patient required pressor support as above and improved ans the pneumonia improved. It was thought that patient was in septic shock with very poor cardiac reserve due to chronic systolic heart failure. His medications were held in the ICU and re-started in the floor (coreg and spironolactone) and patient was able to tolerate them adequately. . 3. Chronic Kidney Disease: on HD. Patient with HD at [**Location (un) **] [**Location (un) **] on MWF schedule (Dr. [**Last Name (STitle) **] is his nephrologist). His phosphate binders were continued, he was put on [**Last Name (STitle) **] diet and required extra HD sessions for fluid management. Upon discharge he was back in his MWF schedule tolerating HD without complications.. 4. Type II DM: pt reports episode of hypoglycemia at home with FSBS of 40s week prior to admission. At home, on Glipizide 5mg PO BID. - hold glipizide, HISS, monitor sugars . 5. Pancytopenia: s/p Bendemustine C3D17, which normally has its nadir in the third week (where he was on admission). He was put on neutropenic precautions and his counts were trended. They improved and he was no longer neutropenic upon discharge. . 6. NHL. S/p Bendemustine (last dose [**2150-3-25**]) which is an alkylating [**Doctor Last Name 360**]. It causes pancytopenia with [**Last Name (un) 12899**] at 3 weeks ([**2150-4-15**]). Also can cause hypotension in 6% of patients. He will receive further treatment as outpatient and had follow up arranged with Dr. [**Last Name (STitle) **]. . 7. Acute on chronic heart failure - Patient had multiple episode of atrial fibrilation with his heart with poor reserve. He also had a difficult ICU course, which could precipitated his heart failure. He had bibasilary crackles and SOB in the medicine floor after the ICU. He had HD and his rate was controlled with his coreg. He was sent home with follow up with cardiology. He was discharged with coreg, spironolactone, ACEI, statin. . 8. Atrial Fibrillation - Patient had multiple episodes of atrial fibrillation that lasted few minutes. He had no history of prior AFib. Since he has no history of AFIb, it could have been provoqued by the ICU course, fluid shifts and lung infection. His RA is only midlry enlarged (4.5 cm). However, he has cardiomyopathy and chronic heart failure with poor EF. He was started on coumadin and rate-controlled with beta-bloker. Follow up for coumadin was arranged Monday with his PCP, [**Name10 (NameIs) 1023**] is aware. He has PCP follow up arranged. . 8. FEN: regular [**Name10 (NameIs) **] diet, repleted electrolytes. . 9. Prophylaxis: pneumoboots given thrombocytpenia, bowel regimen. . 10. Access: peripherals, right tunneled HD line, right port-a-cath. . 11. Code: full, confirmed with patient on admission. Wife [**Name (NI) **]: [**Telephone/Fax (1) 100986**] (H); [**Telephone/Fax (1) 100987**] (C) . 12. Dispo: Home with Heme-onc, PCP, [**Name10 (NameIs) **] and cardiology follow up. Medications on Admission: Carvedilol 12.5 mg [**Hospital1 **] Lisinopril 5 mg daily Spironolactone 25 mg daily B Complex-Vitamin C-Folic Acid daily Calcium Acetate 667 mg Capsule PO TID with meals Glipizide 5 mg Tablet [**Hospital1 **] Digoxin 125 mcg daily Guaifenesin 600 mg [**Hospital1 **] Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Coreg 12.5 mg Tablet Sig: One (1) Tablet PO twice a day. 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 3 days. 6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day: Follow your INR Monday at Dr.[**Hospital1 6460**] office. 8. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing for 10 days. Disp:*1 Inhaler* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: New Paroxismal Atrial Fibrilations Community acquired bacterial pneumonia unable to isolated bacteria Acute on Chronic Systolic Heart Failure . Secondary Diagnosis: Non-Hodgkin's Lymphoma (follicular low-grade B-cell NHL grade I, diagnosed in [**2142**]), on Bendemustine Adriamycin cardiomyopathy EF 30% Aortic Stenosis End-stage kidney disease on HD MWF Type 2 diabetes mellitus Discharge Condition: Stable, tolerating PO, ambulating, breathing comfortably on room air. Discharge Instructions: You were seen at the [**Hospital1 18**] for shortness of breath. You were found to have a pneumonia on chest x-ray and CT scan and were started on antibiotics. You needed to be transfered to the ICU, because problems with your blood pressure. The infectious disease doctors helped [**Name5 (PTitle) **] with the antibiotics and infection control and you finished a course of IV antibiotics and will need to finish another course of oral antibiotics. . While your blood pressure was low, your Coreg and Spironolactone were held. Then you had rapid heart rate with a rhythm called atrial fibrillation. For these reason, to avoid clots and stroke, we started you on an anti-coagulant on a medication that is called coumadin or warfarin (same thing). It can cause bleeding, so if you have black stools, blood on stools or anything else that concerns you call your PCP. [**Name10 (NameIs) **] [**Name11 (NameIs) **] your coreg and took care of your heart rhythm. Your blood preasure tolerated it. You will need to follow your coumadin level closely with your PCP and will need an INR next Monday at your PCPs office. You have appointment to follow up with Dr. [**First Name (STitle) 437**] (cardiology). . You will need to follow with Dr. [**Last Name (STitle) **] at your HD tomorrow. Followup Instructions: Dr. [**First Name (STitle) 1313**] Thursday [**2150-4-20**] 9:30 AM. You will need your INR checked next Monday and Dr. [**First Name (STitle) 1313**] will follow them. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4286**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2150-4-29**] 12:00 Provider: [**Name10 (NameIs) 5338**] [**Name8 (MD) 5339**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2150-4-29**] 1:00 Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2150-5-18**] 10:00

[ "284.1", "428.0", "425.4", "427.31", "288.00", "250.40", "V45.11", "482.9", "995.92", "785.52", "428.23", "424.1", "202.88", "585.6", "403.91", "038.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "39.95" ]

icd9pcs

[ [ [] ] ]

13617, 13623

7541, 12350

299, 307

14066, 14138

3539, 3539

15467, 16085

2487, 2780

12668, 13594

13644, 13644

12376, 12645

14162, 15444

2795, 3520

226, 261

335, 831

13828, 14045

3555, 7518

13663, 13807

875, 2171

2187, 2471

5,513

111,557

50785

Discharge summary

report

Admission Date: [**2180-11-15**] Discharge Date: [**2180-11-21**] Date of Birth: [**2129-7-12**] Sex: F Service: MEDICINE Allergies: Demerol Attending:[**First Name3 (LF) 6994**] Chief Complaint: Right knee pain Major Surgical or Invasive Procedure: right total knee arthroplasty History of Present Illness: 51 yo woman complaining of right knee pain. Patient had traumatic MCl tear to right knee 21 years ago. Patient has had increasing pain in right knee since injury. Pain is now affecting daily activities. Past Medical History: Osteoarthritis Hypertension Social History: Etoh-occasional TOB-denies IVDA-denies Physical Exam: Gen-A&Ox,NAD VS-HR-51 SpO2-100%RA CV-RRR S1/S2 Lungs-CTA Abd-Soft NT/ND Ext-no club/cyanosis/edema, decreased ROM right knee secondary to pain. Pertinent Results: CT angiogram: Tiny filling defect in a segmental right upper lobe pulmonary artery is most likely representative of streak artifact. No evidence of occlusive thrombus. EEG: This is a mildly abnormal portable EEG due to the presence of delta with mixed theta frequency slowing seen over the left temporal and parietal regions. This finding suggests subcortical dysfunction in these areas and is a relatively non-specific finding with regard to an evaluation for seizures. No epileptiform abnormalities were seen. brain MRI: heterogenous left temporal lobe mass with calcification and/or blood products without distinct enhancement. No significant surrounding edema. The differential diagnosis includes cavernous malformation however given the irregular distribution of the blood products, the appearance is not typical. CT R knee: Status post right total knee replacement with complex postoperative flusion. Otherwise unremarkable examination. [**2180-11-15**] 12:34PM GLUCOSE-94 UREA N-13 CREAT-0.8 SODIUM-145 POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-30* ANION GAP-13 [**2180-11-15**] 12:34PM CALCIUM-8.9 PHOSPHATE-4.0 MAGNESIUM-1.9 [**2180-11-15**] 12:34PM WBC-4.6 RBC-3.38* HGB-11.6* HCT-31.7* MCV-94 MCH-34.3* MCHC-36.5* RDW-12.7 [**2180-11-15**] 12:34PM PLT COUNT-201 [**2180-11-17**] 01:53AM BLOOD Glucose-178* UreaN-9 Creat-0.8 Na-123* K-2.9* Cl-86* HCO3-22 AnGap-18 [**2180-11-17**] 06:05AM BLOOD Glucose-140* UreaN-9 Creat-0.6 Na-120* K-2.9* Cl-84* HCO3-30* AnGap-9 [**2180-11-17**] 11:22AM BLOOD UreaN-8 Creat-0.6 Na-127* K-3.0* Cl-91* HCO3-28 AnGap-11 [**2180-11-17**] 03:45PM BLOOD UreaN-8 Creat-0.6 Na-136 K-3.7 Cl-99 HCO3-26 AnGap-15 [**2180-11-17**] 07:58PM BLOOD Na-138 K-3.7 [**2180-11-17**] 11:51PM BLOOD Creat-0.6 Na-140 K-4.0 Cl-105 HCO3-26 AnGap-13 [**2180-11-17**] 01:53AM BLOOD WBC-20.9*# RBC-2.38* Hgb-8.1* Hct-22.0* MCV-93 MCH-34.2* MCHC-36.9* RDW-12.5 Plt Ct-195 [**2180-11-17**] 06:05AM BLOOD WBC-18.7* RBC-2.30* Hgb-8.0* Hct-20.8* MCV-90 MCH-34.5* MCHC-37.4* RDW-12.5 Plt Ct-193 [**2180-11-21**] 07:15AM BLOOD WBC-8.3 RBC-3.09* Hgb-9.5* Hct-27.6* MCV-89 MCH-30.7 MCHC-34.4 RDW-14.7 Plt Ct-290 Brief Hospital Course: 1. right total knee arthroplasty - patient had been followed by Dr.[**Last Name (STitle) **] in [**Hospital 6669**] clinic prior to her admission for an elective total knee arthroplasty. Consent was obtained in clinic, medical clearance was also obtained prior to surgery. Patient was admitted on [**2180-11-15**] for an elective right total knee arthroplasty. Surgery was without complication, please see op-note [**2180-11-15**]. On post-op check patient was doing well. Patient was afebrile/vital signs stable. Dressing had moderate amount of drainage, dressing was reinforced and ice applied to incision. Pt developed a hematoma around the area of the joint but there was no evidence of local infection, through to the day of discharge. She was sent home with Percocet for pain relief, and VNA was arranged to help with dressing changes and physical therapy. She was given IV Ancef while in the hospital, and sent out on a 5-day course of Keflex to prevent wound infection. She will also remain on Lovenox for 4 weeks after discharge. She will follow up with Dr. [**Last Name (STitle) **] in clinic. 2. postoperative seizure - Pt was stable immediately post op until 2:30AM then she was noted to have generalized tonic-clonic seizures witnessed by RN, followed by brief periof of post ictal confusion. At the time, the eyes rolled back into head, arms extended and shaking and mouth twitching. The episode lasted [**1-14**] minutes, no tongue biting or incontinence. Pt became tachycardic to 114 during the seizure but did not desat. Following seizure event, the patient had a brief period where she was "speaking non-sense" which subsequently resolved. Pt was transferred to the [**Hospital Unit Name 153**]. Sodium dropped as low as 120 (down from 145 on [**2180-11-15**]), Hct 22 (from 31.7 on [**2180-11-15**]), K was 2.9, and INR was 1.5. CT angio showed no PE. Head CT showed a small lesion with calcifications in left inferior temporal lobe. Of note, pt has been receiving continuous D5 1/2NS, poor PO intake except for water and juice with significant pain in the postoperative period. Pt did not have any recurrent seizures, and her hyponatremia corrected overnight with hypertonic saline initially, and then NS. It is thought that pain and postoperative hypotonic fluids caused her hyponatremia. However, due to the presence of the L temporal lobe lesion, neurology consult was called. An EEG was performed to evaluate for the likelihood that this mass was the etiology of the seizure. There was some slowing over the L temporal and parietal regions, but this was thought to be nonspecific and not necessarily consistent with epileptiform abnormalities. Pt transferred to the floor with a stable sodium. 3. left temporal lobe lesion - After the CT scan showed this left temporal lobe mass, an MRI was done to further evaluate the lesion. This showed a heterogenous left temporal lobe mass with calcification and/or blood products without distinct enhancement. No significant surrounding edema. The differential diagnosis includes cavernous malformation however given the irregular distribution of the blood products, the appearance is not typical. Per neurology, this was likely a lesion that was fairly stable and not extremely likely to bleed, and with careful consideration, it was decided that the benefits of anticoagulation would outweigh the risk of intracerebral bleeding, given the appearance of this lesion on imaging studies. An EEG was performed, which did not particularly point to the lesion as the etiology of seizures. An LP was performed, mainly for cytologic analysis. Pt will follow up with Dr. [**Last Name (STitle) 4253**] in a few weeks, where she will receive the results of the LP. The MRI reviewed by neurology and neuroradiology, and it was recommended that pt also be followed up in neurosurgery clinic, as there were some atypical features of this likely cavernoma, and surgical intervention may be indicated if there are multiple feeding vessels, which would increase her lifetime risk of hemorrhage. 4. Anemia - most likely due to bleeding into leg. Pt was given lovenox after recent surgery and developed a significant hematoma with a tense thigh, but did not develop compartment syndrome. CT scan showed edema with small hematoma (<100c), which did not explain a large Hct drop. Pt was given 2 units PRBC, 1 unit FFP, and hematocrit held steady. 5. Fevers - pt developed low grade temps the day prior to discharge. As pt was also tachycardic, she underwent CXR, which was negative for pneumonia, blood cultures, which are no growth to date, a urine culture, which was negative, and a CT angiogram to look for a PE. This, too, was negative. It is likely that her fevers are from postoperative atelectasis, or perhaps associated with the large hematoma at the site of her surgery. Pt was clinically stable and feeling well, and was therefore discharged the following day. Of note, the site of her incision was not consistent with any local infectious process. 6. Hypertension - pt's HCTZ and lisionpril were initially held when pt developed hypokalemia. They were restarted 2 days prior to discharge, with good control of her blood pressure. Medications on Admission: Lisionpril 20 HCTZ 25 Protonix 40 Naproxen MVI Darvocet Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Lovenox 40 mg/0.4mL Syringe Sig: Forty (40) mg Subcutaneous once a day for 4 weeks. Disp:*QS * Refills:*0* 3. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO every three hours as needed for pain. Disp:*60 Tablet(s)* Refills:*1* 4. Keflex 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 5 days. Disp:*15 Tablet(s)* Refills:*0* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): while taking percocet. Disp:*60 Capsule(s)* Refills:*0* 6. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): until pain resolves. Disp:*240 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Right knee osteoarthritis hyponatremia hypokalemia Discharge Condition: stable Discharge Instructions: Please cont with weight bearing as tolerated right leg. Lovenox 40mg once a day x4weeks for anti-coagulation. Oral pain medication as needed. Please cont with physical therapy. Please keep incision clean/dry. Please call/return if any fevers/increased discharge from incision or trouble breating. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Where: [**Hospital6 29**] ORTHOPEDICS Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2180-11-27**] 2:40 Provider: [**Name10 (NameIs) 5005**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Where: [**Hospital6 29**] NEUROLOGY - this is on the eighth floor Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2180-12-1**] 3:30 You will be contact[**Name (NI) **] in the next few days about a neurosurgery appointment, likely with Dr. [**First Name (STitle) **]. If you do not hear from them, call the neurosurgery clinic at ([**Telephone/Fax (1) 88**].

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icd9cm

[ [ [] ] ]

[ "03.31", "81.54" ]

icd9pcs

[ [ [] ] ]

9267, 9325

2990, 8215

286, 318

9420, 9428

836, 2967

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8321, 9244

9346, 9399

8241, 8298

9452, 9750

672, 817

231, 248

346, 550

572, 601

617, 657

25,808

129,120

51578

Discharge summary

report

Admission Date: [**2140-9-20**] Discharge Date: [**2140-9-27**] Date of Birth: [**2066-2-19**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This 74 year old white male has a past medical history of hypertension, hypercholesterolemia and was referred from an outside hospital after developing ST depressions and 2 to 1 block during a stress test. The patient had exertional chest pain with radiation to the left arm and hand. He currently denies pain. He has been having pain at rest five to six times per day and denies shortness of breath, paroxysmal nocturnal dyspnea or edema. He recently was seen at [**Hospital1 69**] Emergency Room and ruled out for a myocardial infarction and was referred for the stress test. PAST MEDICAL HISTORY: Significant for history of hypertension; history of hypercholesterolemia; history of hiatal hernia and history of anxiety. MEDICATIONS ON ADMISSION: Aspirin one p.o. q. day. Accupril 40 mg p.o. q. day. Hydrochlorothiazide 25 mg p.o. q. day. Lipitor 10 mg p.o. q. day. Nexium 40 mg p.o. twice a day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He drinks four drinks per week and has a distant smoking history. FAMILY HISTORY: Unremarkable. REVIEW OF SYSTEMS: Unremarkable. PHYSICAL EXAMINATION: On physical examination, he is a well developed, elderly, white male in no apparent distress. Vital signs stable. Afebrile. HEAD, EYES, EARS, NOSE AND THROAT: Normal cephalic, atraumatic. Extraocular movements intact. Oropharynx benign. Neck was supple. Full range of motion. No lymphadenopathy or thyromegaly. Carotids 2+ and equal bilaterally without bruits. Lungs clear to auscultation and percussion. Cardiovascular examination: Regular rate and rhythm, normal S1 and S2 with no murmurs, rubs or gallops. Abdomen was soft, nontender with positive bowel sounds, no masses or hepatosplenomegaly. Extremities were without clubbing, cyanosis or edema. Neurological examination was nonfocal. He underwent cardiac catheterization on [**2140-9-21**] which revealed left main and a tight right coronary artery lesion. He had an intra-aortic balloon pump placed. Cardiac surgery was consulted and on [**9-21**], he underwent a coronary artery bypass graft times two with left internal mammary artery to the left anterior descending; reversed saphenous vein graft to the posterior descending artery and obtuse marginal. He was transferred to the CSRU in stable condition. He was extubated on postoperative day number one. He had an intra-aortic balloon pump discontinued and he was transfused one unit of blood. On postoperative day number two, he had some sanguinous drainage from his chest tube. A hematocrit was changed and it was 21. He did remain hemodynamically stable but he had to have his chest tube elevated. He remained in bed that day. On postoperative day number three, he was stable and transferred to the floor. His chest tube remained in and on postoperative day number four, they were discontinued without incident. He continued to have a stable postoperative course. He had his epicardial pacing wires discontinued on postoperative day number three. On postoperative day number five, he was discharged to home in stable condition. LABORATORY DATA: Hematocrit of 29.5; white count 8,900; platelets 177; sodium of 141; potassium of 4.3; chloride of 104; C02 of 33; BUN 17; creatinine 0.9; blood sugar of 95. MEDICATIONS ON DISCHARGE: Ecotrin 325 mg p.o. q. day. Colace 100 mg p.o. twice a day. Lipitor 10 mg p.o. q. day. Hydrochlorothiazide 25 mg p.o. q. day. Tylenol #3 one to two p.o. every four to six hours prn for pain. Lopressor 25 mg p.o. twice a day. Ibuprofen 600 mg p.o. q. eight hours. Nexium 20 mg p.o. twice a day. FOLLOW-UP: He will be followed by Dr. [**Last Name (STitle) 2204**] in one to two weeks and by Dr. [**Last Name (STitle) 70**] in six weeks. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Name8 (MD) 106902**] D: [**2140-9-27**] 06:33 T: [**2140-9-27**] 18:46 JOB#: [**Job Number 106903**]

[ "401.9", "411.1", "414.01", "300.00", "553.3", "272.0" ]

icd9cm

[ [ [] ] ]

[ "88.56", "36.15", "88.72", "88.53", "39.61", "97.44", "37.61", "36.12", "37.22" ]

icd9pcs

[ [ [] ] ]

1204, 1219

3445, 4161

914, 1103

1277, 3419

1239, 1254

160, 741

764, 888

1120, 1187

1,313

104,742

45487

Discharge summary

report

Admission Date: [**2169-6-17**] Discharge Date: [**2169-6-27**] Date of Birth: [**2092-11-3**] Sex: M Service: MEDICINE Allergies: Neosporin / Latex Attending:[**First Name3 (LF) 477**] Chief Complaint: fever, delta MS, incontinence Major Surgical or Invasive Procedure: PICC line placement [**2169-6-21**] History of Present Illness: HPI obtained from wife due to change in pts mental status. 76 yo with poorly differentiated lung carcinoma (likely small cell) on etoposide and carboplatin, recurrent sternal wound osteo/infection requiring debridements and flaps, s/p CABG in [**2166**], CAD s/p MI and CABG, DMII, HTN, COPD who presents after being discharged from [**Hospital1 **] rehab yesterday with fever. The pt was admitted to [**Hospital1 18**] in [**4-17**] and underwent sternal wound debridement on [**2169-4-26**] with tx for MRSA infection. He was then sent to rehab on 6 weeks of Vancomycin and a Vac dressing (recently d/c'd). The pt went home [**6-15**] and was without complaints until [**6-16**] when his wife took his temp and noted it to be 105. The wife gave him 2 tylenol at that time and noted him to have "shaking chills". He then became incontinent of urine and became "short" with her. His wife notes that he becomes confused every time he has a fever, and states he was admitted in [**3-20**] with fever and confusion. She also notes he was intermittently febrile at rehab as well as 2 days prior to his discharge. He denied cough, SOB, ab pain, d/c, n/v to his wife prior to admission. The pt states that during other febrile/delta MS episodes in the past, she has never seen him this somnolent. . The pt was seen by thoracic surgery in the ED and it was felt the pt has a chronic chest fistula. He received Linezolid 600 mg IVx1, lopressor 50 mg po x1, ativan 1mg pox1, levoflox 500 mg IVx1, and flagyl 500 mg IVx1. CT of the chest showed no drainable collections. . Of note, the pt started etoposide and carboplatin while at rehab on [**2169-5-9**]. His first cycle was complicated by neutropenic fever, although he was receiving neupogen daily. The pt reportedly had insomnia and sundowning at OSH with a negative head CT. Past Medical History: Onc Hx per OMR: In [**1-16**] pt was in the doctor's office for routine checkup and was noted to have hemoptysis at that time. He therefore had a chest x-ray that showed a right upper lobe mass which was followed by a CAT scan that showed a 2.2 x 1.9 cm right upper lobe nodule as well as a 7.5 x 4.4 x 6-cm soft tissue lesion in the anterior right chest wall anterior to the right clavicle, also diffuse moderate emphysema. This was followed by a PET scan on [**2169-3-2**], which revealed an FDG-avid nodule in the right upper lobe with a maximal SUV of 24.6 that measured 2.2 x 1.9 cm, also a right hilar 9 mm lymph node with an SUV of 8.9 as well as increased activity in the sternal area in the surgically created muscle flap at the patient's sternal resection site. He then underwent mediastinoscopy on [**2169-3-6**] with bronchial washings, which were negative, and also had an I&D and sternal debridement. He was presumed to have nonsmall cell lung cancer and went in for a fiducial placement in the right upper lobe mass for CyberKnife. At the same time they did an FNA of the nodule which was consistent with poorly differentiated carcinoma with features of small cell. Pt was started on etoposide and carboplatin in [**4-17**] with last dose [**2169-6-1**]. --CAD - IMI in [**2165**], s/p CABGx4 in [**2166**], which was complicated by mediastinitis and sternal osteomyelitis and MRSA wound infection. sternal wound infection requiring sternal debridement and omental flap reconstruction. He subsequently developed multiple sinus tracts emanating from osteo.He had a pec flap repair on [**5-16**]. --incisional hernia -- s/p repair and recurrence --COPD/emphysema on home night time O2 --T2DM - controlled by meds and diet --HTN --hypercholesterolemia --GERD --anemia - monthly procrit --hyperlipidemia --prior right frontal lobe and left caudate infarct --h/o confusion, fever, urinary incontinence on admission [**3-20**] Social History: Married for 52 years; taken care by wife at home. Former smoking of cigar x 20yrs, and 10ppy hx of cigarettes; quit 30 years ago. No EtOH. Family History: FH: no h/x of cancer or CAD Physical Exam: PE: Vitals: T 102.6 P 115 BP 120/78 R 24 Sat 96% 3LNC GENERAL: overweight elderly male, lying on his side, A and Ox2-->somnolent, not answering most questions HEENT: bilateral esotropia, PERRL, conjunctivae noninjected/anicter NECK: No LAD, supple CARDIOVASCULAR: Tachycardic. No murmurs, rubs, or gallops LUNGS: Clear to auscultation bilaterally with distant breath sounds; noted by resident to have Cheynne [**Doctor Last Name **] respirations ABDOMEN: Soft, nontender, protuberant, normoactive bowel sounds with a reducible ventral hernia. EXTREMITIES: no c/c/e, wwp, 1+ dp/pt pulses bilaterally, R PICC line site without erythema STERNUM: 2 sinus tracts (one on each chest wall) which are non erythematous, no purulence, nontender, no fluctuance, no warmth, good granulation tissue NEURO: a and ox2 Pertinent Results: [**2169-6-17**] 06:02PM TYPE-ART PO2-73* PCO2-34* PH-7.43 TOTAL CO2-23 BASE XS-0 [**2169-6-17**] 06:02PM GLUCOSE-139* LACTATE-1.0 NA+-134* K+-4.0 CL--103 TCO2-23 [**2169-6-17**] 06:02PM freeCa-1.19 [**2169-6-17**] 04:33AM LACTATE-1.2 [**2169-6-17**] 12:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.039* [**2169-6-17**] 12:30AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2169-6-17**] 12:30AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [**2169-6-16**] 10:05PM LACTATE-1.3 [**2169-6-16**] 10:00PM GLUCOSE-112* UREA N-20 CREAT-1.0 SODIUM-135 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-22 ANION GAP-16 [**2169-6-16**] 10:00PM ALT(SGPT)-34 AST(SGOT)-21 ALK PHOS-81 AMYLASE-32 TOT BILI-0.3 [**2169-6-16**] 10:00PM LIPASE-24 [**2169-6-16**] 10:00PM ALBUMIN-4.0 [**2169-6-16**] 10:00PM WBC-3.7* RBC-3.88* HGB-10.9* HCT-31.6* MCV-82 MCH-28.1 MCHC-34.5 RDW-17.6* [**2169-6-16**] 10:00PM NEUTS-58 BANDS-1 LYMPHS-17* MONOS-20* EOS-4 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2169-6-16**] 10:00PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL [**2169-6-16**] 10:00PM PLT SMR-NORMAL PLT COUNT-249# . CT Chest [**2169-6-16**]: FINDINGS: The soft tissue mass in the posterior segment of the right upper lobe previously measuring 3.2 x 1.8 cm is almost completely resolved, now 0.5 x 1 cm with a fiducial marker in it. Right hilar adenopathy seen just below the first mass (I 2:23) has resolved. A 1 x 0.8 cm right middle lobe nodule, 3:36, is new. A 1.3x1.3 cm LLL nodule with calcification within it is stable or even smaller. Bilateral basal atelectasis, left greater than right, is grossly stable. Prominent centrilobular emphysema involves mostly the upper lobes. The patient had CABG and sternectomy for osteomyelitis. The omental flap contains new areas of induration adjacent to the previous fluid collection in the sternotomy bed which is now a large thick walled cavity with a far wider connection to the surface, perhaps due to debridement. It still has a long extent long contiguity with pericardium but there is no pericardial effusion or other fluid collection in the mediastinum. The presternal lymph nodes are stable. Heterotopic bone formation around the sternal excision margins is stable. Several, enlarged mediastinal lymph nodes measuring up to 1 x 2 cm, are stable. Some of the bilateral asbestos pleural plaques are calcified. There is no pleural effusion. The imaged portion of the abdomen does not reveal any pathology within the liver, kidneys, spleen, pancreas and adrenals. Several large gallstones are stable, with no evidence of cholecystitis. IMPRESSION: 1. Almost complete resolution of right lung mass and hilar adenopathy. 2. New right middle lobe nodule, could be tumor or infection. 3. Unchanged left lower lobe nodule and bilateral lower lobe atelectasis. 4. Large, infectious cavity in the sternal bed, with large percutaneous fistula or tract formation. . MRI Chest [**2169-6-20**]: FINDINGS: There has been no significant change from prior chest CT dated [**2169-6-16**]. The patient is status post sternectomy with flap repair. Two large fistulae tracks are identified within the anterior chest wall at the sternectomy defect. There is significant soft tissue enhancement in this region, consistent with underlying infection. However, the pericardial fat remains normal in signal and this anterior chest wall infection does not appear to communicate with the mediastinum. A few subcentimeter lymph nodes are seen inferior to the two fistulae. Limited imaging through the upper abdomen demonstrates no significant abnormality. The aorta is normal in caliber, with mild atherosclerotic disease. Visualized portions of the great vessels are unremarkable. IMPRESSION: No significant change from prior CT examination dated [**2169-6-16**]. Two large fistulae within the anterior chest wall at the sternectomy defect with significant soft tissue enhancement consistent with infection. No communication to the pericardium or mediastinum. Evaluation of the reformatted images on a separate workstation were valuable in delineating the anatomy. . PICC line placement [**2169-6-21**]: PROCEDURE/FINDINGS: The procedure was performed by Dr. [**First Name (STitle) 379**] [**Name (STitle) **] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12166**]. Dr. [**Last Name (STitle) 12166**], the attending radiologist, was present and supervising throughout the procedure. The patient was placed supine on the angiographic table. The left arm was prepped and draped in the standard sterile fashion. Ultrasound confirmed the left basilic vein was patent and compressible. 5 cc of 1% lidocaine were applied for local anesthesia. Under ultrasonographic guidance, a 21-gauge needle was used to access the left basilic vein. Ultrasound films were taken before and after the venous access was achieved. A 0.018 guide wire was advanced through the needle under fluoroscopic guidance with the tip in the superior vena cava. The needle was exchanged for a 4-French peel-away sheath. The length of the PICC line was measured at 46 cm depending on the [**Last Name (STitle) **] on the wire. After inner dilator was removed, a double-lumen PICC line was placed over the wire under fluoroscopic guidance with the tip in the superior vena cava. The peel-away sheath and the wire were removed. Two lumens were flushed and the line was secured with skin with StatLock. The patient tolerated the procedure well and there were no immediate complications. IMPRESSION: Successful placement of a 46-cm, double-lumen PICC line through left basilic vein with the tip in the superior vena cava. The line is ready to use. . Brief Hospital Course: Briefly, this is a 76 yo with poorly differentiated lung carcinoma (likely small cell) on etoposide and carboplatin, recurrent sternal wound osteo/infection with MRSA requiring debridements and flaps, s/p CABG in [**2166**], CAD s/p MI and CABG, DMII, HTN, COPD who presented after being discharged from [**Hospital1 15454**] rehab the day prior to admission with fever and mental status changes. On arrival to the floor the pt was tachy to 110s, somnolent, noted to have some Cheynne [**Doctor Last Name **] respirations, febrile to 102.6. Pts PICC line was attempted to be pulled, however it started to heavily bleed and attempt was stopped. Pt was started on broad spectrum abx with Vanc, Ceftaz, and Flagyl. He was taken for US of his RUE to eval his PICC line, and head CT. ABG:7.43/34/73 with lactate 1.0 on 3L NC. The pt was transferred to the ICU overnight for neurologic monitoring. His fever diminished on the night of admission, his delta ms resolved, and he was transferred back to the floor the following day. . #Fever: The pt was admitted with fever of 102.6, RR 24, tachy to 110s, concerning for impending sepsis. His SBP however was stable in the 120s with a lactate of 1.0. Given the pts somnolence and mental status changes, the pt was tranferred to the ICU as per above on the night of admissin. DDX included sternal wound infxn, UTI, line infxn, PNA, meningitis. CT of torso and CXR were unrevealing of any clear source of infxn but large soft tissue collection in anterior chest was visualized and read as a possible abscess vs iatrogenic tract formation. The pt was seen by Thoracics who felt the pts sternal fistulas are not infected. Pt received Vancomycin and Levo/flagyl in ED. Given his mental status changes, the pt was started on Vanc/Ceftaz (to cover pseudomonas) and Flagyl on the floor. These were discontinued the day after admission. The pts PICC line was pulled on admission. Head CT was negative for any acute change on admission. In the ICU, the pts mental status rapidly improved overnight to alert and oriented x 3 the following day. The pt also became afebrile overnight in the ICU. On transfer to the floor, the pt was continued on Vancomycin only to cover for possible soft tissue MRSA infection. Infectious disease was consulted for assistance in the pts workup. MRI of the pts sternum was ordered and revealed soft tissue enhancement in the anterior chest wall. ID was consulted and recommended 4 more weeks of vancomycin. The pt had already received 10 days of Vanc at the time of discharge. Radiology confirmed that the pts soft tissue infection was draining through his fistula. Although the pts wound cx was growing pseudomonas (pansensitive), this was felt to be a colonizer (according to ID) given pt has been afebrile on Vancomycin. The pt remained afebrile from HD#2 on. . # Diarrhea: The patient developed soft brown stool post chemotherapy with transient resolution on [**6-26**]. Diarrhea returned on [**6-27**]. Etoposide is known to cause diarrhea, however given several days post chemotherapy, concern was raised for possible hospital aquired infectious colitis. Pt WBC was also elevated, though likely [**3-16**] to filgastrim(GCSF. His stool was sent for C dificile antigen and the results are pending at the time of discharge. These results need to be followed up on. If diarrhea continues, would recommend resending the C dificile antigen test. #Mental Status Changes: Per pts wife, pt becomes confused with incontinence whenever he has a fever. He was admitted in [**3-20**] with fever and confusion as well. Sources included infection as discussed above. There was no evidence of intracranial hemorrhage or mass effect on CT of the head on admission. Remote infarcts in the right frontal and left caudate lobes were noted. His mental status drastically improved the day after admission when his fever had dissipated. The pt remained a and ox3 from HD#2 on. . #Tachycardia: This was likely related to infection. The pts tachycardia resolved on HD#2 . #HTN: Given the pts initial presentation, his lopressor 25 mg po bid, cozaar 100 mg po qd were initially held. These were restarted sequentially on HD2 and 3 as his blood pressure tolerated. . #DMII: On admission the pts metformin 1000 [**Hospital1 **] was held given his recent contrast given on [**6-16**] for CT. He was covered with HSSI, qid FS. His glyburide was also held given the pt was confused and not eating. These medications were restarted HD #3. . #CAD: The pt was continued on [**Last Name (LF) 17339**], [**First Name3 (LF) **]. On admission his lopressor/cozaar were held in the setting of possible impending sepsis. . #Small cell cancer in R lung: The pt received carboplatin/etoposide during this admission from [**Date range (1) 66873**] without any side effects. Pt has been on carboplatin/etoposide in the past. His CT shows resolution of the 2 R lung masses, although there is a new RML nodule which denotes a mixed response. The pt is to be on neupogen for 10 days following [**Date range (1) 3454**] (started [**6-24**]). . #COPD: Pt has history of 86% of predicted FEV1/FVC on PFT's in past. Also has decr TLC for unknown reasons. The pt was continued on advair diskus and ipratropium . #Anemia: Pt has baseline anemia with hct 25-30. Received 2 units PRBC on [**6-13**] at his rehab. He was continued on his epogen and iron supplements. The pts hct slowly dropped back down to 26 so he received 1 unit of PRBC on [**6-24**] with his hct rising up to 29. . #FEN: diabetic/cardiac diet. . #Contact: Wife, [**Name (NI) **], cell [**Telephone/Fax (1) 97060**], home [**Telephone/Fax (1) 97061**] . #CODE STATUS: DNR/DNI Medications on Admission: Toprol XL 50', Metformin 1000'', Colace 100", Zetia 10', [**Telephone/Fax (1) **] 10', Atrovent prn, Spiriva 10', Cozaar 100', [**Telephone/Fax (1) **] 81', Advair 250/50' Discharge Medications: 1. Atorvastatin 10 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO BID (2 times a day): please hold if diarrhea. 3. Ferrous Sulfate 325 (65) mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a day). 4. Epoetin Alfa 10,000 unit/mL Solution [**Telephone/Fax (1) **]: One (1) injection Injection QMOWEFR (Monday -Wednesday-Friday): 10,000 unit injection. 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Telephone/Fax (1) **]: One (1) inhalation Inhalation [**Hospital1 **] (2 times a day). 6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]: One (1) Cap Inhalation DAILY (Daily). 7. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 8. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 9. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: One (1) unit Injection ASDIR (AS DIRECTED): For Fingerstick of: 150-200 give 2 units; 201-250 give 4 units; 251-300 give 6 units; 301-350 give 8 units; 351-400 give 10 units. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 12. Metformin 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a day). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 14. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet [**Telephone/Fax (3) **]: One (1) Packet PO BID (2 times a day). 15. Glyburide 5 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO DAILY (Daily). 16. Losartan 50 mg Tablet [**Telephone/Fax (3) **]: Two (2) Tablet PO DAILY (Daily). 17. Vancomycin 500 mg Recon Soln [**Telephone/Fax (3) **]: Seven [**Age over 90 1230**]y (750) mg Intravenous Q 12H (Every 12 Hours). 18. Heparin Flush (10 units/ml) 3 ml IV PRN catheter care 10 ml NS followed by 3 ml of 10 Units/ml heparin (20 units heparin) each lumen Daily and PRN. Inspect site every shift. 19. Filgrastim 480 mcg/1.6 mL Solution [**Age over 90 **]: Four [**Age over 90 11578**]y (480) mcg Injection Q24H (every 24 hours) for 7 days: [**Date range (1) 66820**]. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Small Cell Lung Cancer Chronic anterior chest wall fistulas with underlying soft tissue infection Discharge Condition: stable, afebrile Discharge Instructions: Please take all medications as prescribed. Call your doctor or return to the ER for fever, worsening chest pain associated with your wounds, confusion, or any other concerning symptoms. Followup Instructions: 1) Please call Dr.[**Name (NI) 3279**] office on Monday [**7-3**] at [**Telephone/Fax (1) 97062**] to set up appointment for next chemotherapy which would be in approximately 2 weeks from discharge if all goes well. 2)Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 8495**] TAN Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2169-7-21**] 11:00 AM. Please call for directions. 3) Please present for a repeat Chest CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2169-7-19**] 1:00 PM; [**Location (un) **] [**Hospital Ward Name 23**] Building, [**Hospital Ward Name 5074**] [**Hospital3 **] [**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]

[ "428.0", "162.8", "250.80", "E849.8", "530.81", "496", "730.18", "998.6", "731.8", "414.00", "E878.8", "553.21", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "99.25", "38.93", "97.49", "99.04" ]

icd9pcs

[ [ [] ] ]

19405, 19477

11056, 16740

308, 346

19619, 19638

5224, 11033

19873, 20588

4348, 4377

16963, 19382

19498, 19598

16766, 16940

19662, 19850

4392, 5205

238, 270

374, 2208

2230, 4173

4189, 4332

8,071

183,878

22652

Discharge summary

report

Admission Date: [**2117-7-20**] Discharge Date: [**2117-7-27**] Date of Birth: [**2092-7-28**] Sex: F Service: OTOLARYNGOLOGY Allergies: Percocet Attending:[**First Name3 (LF) 8480**] Chief Complaint: subglottic and tracheal stenosis Major Surgical or Invasive Procedure: Tracheal reconstruction with left rib harvest / chest tube and t tube placement and revision. History of Present Illness: 24 yr old female s/p MVA w/ prolonged intubation from which she developed tracheal stenosis. Presented to [**Hospital1 18**] for laryngo-tracheal reconstruction w/ costal cartilage graft. Past Medical History: General: In NAD. HEENT: trach in place. COR: RRR S1, S2 Lungs: CTA bilat Abd: obses, soft, round, NT, +BS Extrem: no C/C/E Social History: 24 yr old female living in [**State 622**]. quit smoking 12 months ago, Occas ETOH, NO ilicit drug use. Family History: non contributary Physical Exam: General: In NAD. HEENT: trach in place. COR: RRR S1, S2 Lungs: CTA bilat Abd: obses, soft, round, NT, +BS Extrem: no C/C/E Pertinent Results: CT CHEST W/O CONTRAST [**2117-7-23**] 4:44 AM IMPRESSION: Essentially complete collapse of the left lung and a small left pneumothorax with resultant shift of the mediastinum towards the left. There appears to be soft-tissue density within the left main stem bronchus which probably represents mucous plug. Unchanged appearance of tracheal wall thickening in the superior mediastinum at the level of the aortic arch. The differential is the same as given on the prior examination, and may also include sarcoidosis and tuberculosis. Brief Hospital Course: pt was admitted for larygno-tracheal reconstruction on [**2117-7-19**]. Or course was uneventful. Post op course was notable for left lung collapse, right main-stem intubation, status post tracheotomy and T tube placement. T tube ended up being in the right main stem. For this reason, the patient was urgently broughtto the operating room to have this T tube changed to a shorter tube that had to be cut shorter thus allowing aeration of both lungs. Pt [**Last Name (un) 1815**] procdure well and was d/c'd to home on POD#6 once her left lung had reinflated and been cleared of secretions. Medications on Admission: nexium Discharge Medications: 1. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 5 days. Disp:*20 Capsule(s)* Refills:*0* 2. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every 3 to 4 Hours) as needed for pain. Disp:*80 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Tracheal reconstruction with left rib harvest / chest tube and t tube placement and revision. Discharge Condition: good Discharge Instructions: Call Dr.[**Name (NI) 1816**] ( [**Telephone/Fax (1) 170**]) or Dr.[**Name (NI) 18353**] ([**Telephone/Fax (1) 58707**]-6800) office if you have any questions. Followup Instructions: You have a follow up appointment with Dr. [**First Name (STitle) **] tomorrow at 8am. Call Dr.[**Name (NI) 1816**] office [**Telephone/Fax (1) 170**] for a follow up appointment when you see Dr. [**First Name (STitle) **] in 2 months Completed by:[**2117-7-27**]

[ "997.3", "E878.8", "519.1", "518.0" ]

icd9cm

[ [ [] ] ]

[ "31.74", "31.75", "77.89", "33.21" ]

icd9pcs

[ [ [] ] ]

2563, 2569

1639, 2232

308, 404

2707, 2713

1080, 1616

2920, 3186

904, 922

2289, 2540

2590, 2686

2258, 2266

2737, 2897

937, 1061

236, 270

432, 621

643, 767

783, 888

9,079

191,634

14532

Discharge summary

report

Admission Date: [**2168-8-1**] Discharge Date: [**2168-8-6**] Date of Birth: [**2109-3-8**] Sex: M Service: Medicine, [**Location (un) **] Firm HISTORY OF PRESENT ILLNESS: This is a 59-year-old male with a past medical history significant for hepatitis C, hepatocellular carcinoma (stage III, non-small cell lung cancer) sent to the Medical Intensive Care Unit for upper gastrointestinal bleed. The patient presented to the Emergency Department on [**2168-8-1**] for abdominal pain, decreased appetite, watery diarrhea, and an early satiety times five days. During preparation for nasogastric lavage in the Emergency Department, the patient had an episode of hematemesis of approximately 500 cc of frank blood. He denied any bright red blood per rectum, melena, or hematemesis previous to this episode. However, he did complain of some lightheadedness and dizziness prior to admission. Of note, the patient had been taking ibuprofen 200 mg p.o. b.i.d. times two weeks for shoulder pain. He was noted to have a drop in hematocrit from 38 earlier in the month to 31 while in the Emergency Department. He was then transferred to the Medical Intensive Care Unit and electively intubated for preparation for an esophagogastroduodenoscopy. On initial esophagogastroduodenoscopy, grade II varices were seen with no active bleeding, portal gastropathy, and a clot in the fundus of the stomach. He was given 2 units of fresh frozen plasma and 1 unit of packed red blood cells. During the administration of the packed red blood cells, the patient developed fever and tremors, and the transfusion was discontinued. He was stabilized overnight, and a repeat esophagogastroduodenoscopy was performed the following morning. On the second esophagogastroduodenoscopy it was assumed that the source of bleeding was from esophageal varices and these were banded. He was extubated a few hours the procedure, and maintained a stable hematocrit around 30 throughout his Intensive Care Unit stay. PAST MEDICAL HISTORY: 1. Hepatitis C diagnosed in [**2154**]. 2. Hepatocellular carcinoma diagnosed in [**2166**] with increasing acid-fast bacillus (2714 to 62,605 over the last two months). 3. Cirrhosis. 4. Stage III non-small cell lung carcinoma. 5. Portal hypertension. PAST SURGICAL HISTORY: 1. Right upper lobe lung resection secondary to non-small cell lung cancer; status post chemotherapy. 2. Radiofrequency ablation of two liver masses in [**2168-7-21**]. SOCIAL HISTORY: Quit tobacco 10 years ago. A remote history of heavy vodka use; denies current alcohol use. History of intravenous drug use in the past including intravenous heroin; none within the last 20 years. FAMILY HISTORY: Family medical history was noncontributory. ALLERGIES: INTRAVENOUS CONTRAST causes swelling. MEDICATIONS ON ADMISSION: Outpatient medications included spironolactone 150 mg p.o. q.d. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed temperature was 101.4, blood pressure was 124/51, heart rate was 105, respiratory rate was 26, oxygen saturation was 99% on 2 liters nasal cannula. In general, the patient was in no apparent distress. He was resting comfortably in bed. His oropharynx was clear. Mucous membranes were moist. Jugular venous pressure was not appreciably elevated. His neck was supple. His sclerae were mildly icteric. He had mild oral icterus. No thyromegaly. His chest was clear to auscultation bilaterally except for decreased breath sounds at the right base. He had an intact well-healed surgical scar at the right posterior thorax. His heart had a regular rate. He had a normal first heart sound and second heart sound. There were no murmurs, rubs or gallops appreciated. His abdomen was soft and distended. He had normal active bowel sounds. He had a positive fluid wave as well as shifting dullness. His liver were percussed to 2-cm below the costal margin. His skin was mildly jaundiced. He had palmar erythema and spider angiomas were present on his chest. He had no cyanosis, clubbing or edema. His dorsalis pedis and posterior tibialis pulses were 2+ bilaterally. His skin was warm and dry. On neurologic examination, he was alert and oriented times three, and there were no gross motor or sensory deficits. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory values on admission revealed white blood cell count was 6.3, hemoglobin was 11.4, hematocrit was 31.9, platelet count was 92. Urinalysis was negative except for occasional bacteria. Chemistry panel revealed sodium was 135, potassium was 4.4, chloride was 100, bicarbonate was 26, blood urea nitrogen was 23, creatinine was 0.8, blood glucose was 122. ALT was 110, AST was 164, alkaline phosphatase was 162, total bilirubin was 0.5, amylase was 53, lipase was 24, albumin was 2.9. Calcium was 8, phosphate was 2.9, magnesium was 1.7. Ammonia level was 33. PT was 14.3, PTT was 30.7, INR was 1.4. RADIOLOGY/IMAGING: A chest x-ray on [**2168-8-1**] revealed no acute cardiopulmonary disease. No free air under the diaphragm. A chest x-ray on [**2168-8-3**] revealed bilateral pleural effusions, loculated right effusion, bilateral basilar atelectasis. IMPRESSION: This is a 59-year-old male with hepatitis C, hepatocellular carcinoma, cirrhosis, presenting with upper gastrointestinal bleed from esophageal varices; status post non-small cell lung carcinoma resection of the right upper lobe. HOSPITAL COURSE: 1. GASTROINTESTINAL BLEED: The patient was seen in the Emergency Department and initially presented for abdominal pain with decreased appetite and early satiety. While in the Emergency Department, the patient had hematemesis of approximately 500 cc. He has no history of prior gastrointestinal bleeds. The patient had previously been diagnosed with portal hypertension (per abdominal imaging) but had no esophagogastroduodenoscopy performed prior to this admission. While in the Medical Intensive Care Unit, the patient underwent esophagogastroduodenoscopy times two with esophageal varices banding. No active bleeding was seen; however, there was a clot in the fundus of the stomach which was unable to be manipulated to examine for sources of bleeding within the stomach. Serial hematocrits were followed, and the patient was hemodynamically stable with hematocrit falling as low as 26. The patient had bloody/melanotic stools for two days after banding, but no blood or melena was noted the two days prior to discharge. The patient was maintained on an octreotide drip for 72 hours. He was started on Protonix 40 mg p.o. b.i.d. as well as nadolol 20 mg for portal hypertension. He was also continued on his outpatient dose of spironolactone. 2. HEMATOLOGY: After hematemesis of 500 cc of frank blood while in the Emergency Department, the patient had 2 units of fresh frozen plasma transfused without any difficulties. When transfusing 1 unit of packed red blood cells, the patient developed fever and tremors, and the transfusion was stopped. Investigation of this transfusion reaction indicated a nonhemolytic transfusion reaction, and no contraindications exist to subsequent blood product transfusions. The patient's baseline hematocrit at the beginning of this month was 38; which fell to approximately 30 on admission, and dropped as low as 26. Hematocrit trended up for the remainder of his hospital course, and on discharge had rebounded back to 30 without any additional blood products given. The patient's mean cell volume was also elevated, and given his history of alcohol use, he was given thiamine and folate q.d. secondary to possible megablastic anemia. Thrombocytopenia was also thought secondary to liver disease and was stable throughout his hospital course. 3. ASCITES: Per clinic note at the beginning of the month, the patient was without appreciable ascites. However, on presentation to the Emergency Department, the patient had an extremely distended abdomen with shifting dullness and a positive fluid wave. He was started on ciprofloxacin for spontaneous bacterial peritonitis prophylaxis. On [**2168-8-3**], a diagnostic/therapeutic paracentesis was performed at bedside which revealed a polymorphonuclear neutrophil count of approximately 500; however, no organisms were seen on Gram stain or grew out in cultures. It was thought that the patient had subacute bacterial peritonitis; however, pretreatment with ciprofloxacin may have influenced the Gram stain/culture results. He was treated with cefotaxime as well as ciprofloxacin for spontaneous bacterial peritonitis. After initial paracentesis fluid reaccumulated the following day, and he was sent for ultrasound-guided paracentesis. Approximately 1.5 liters was removed at that time. However, the fluid reaccumulated. Due to acute presentation of ascites over the period of this month, the patient underwent Duplex Doppler of the abdomen and pelvis to rule out portal vein thrombosis. On examination, no portal vein thrombosis was seen. Of note, the gallbladder had a few stones and an edematous wall; however, no other signs of acute cholecystitis. Diffuse hypodense lesions were also seen in the liver, consistent with hepatocellular carcinoma. 4. HEPATOCELLULAR CARCINOMA: The patient was diagnosed with hepatitis C in [**2154**] and hepatocellular carcinoma within the last year. The patient has had a dramatic increase in AFP over the last two months, increasing from 2714 to 62,605. He is status post radiofrequency ablation in [**2168-5-21**], but he declined any chemotherapy or embolization. He was to be started on thalidomide the week prior to admission; however, he was not able to fill his prescription yet. Thalidomide is to be started at a later date, per Oncology. 5. INFECTIOUS DISEASE: The patient had a low-grade fever of approximately 100 to 101 over the first few days of his hospital course. It defervesced with the start of ciprofloxacin. Numerous etiologies of low-grade fever existed including possible spontaneous bacterial peritonitis, atelectasis, tumor fever, or unknown infectious source. He was pan-cultured; of which all cultures were negative. He never mounted an elevated white blood cell count. Therefore, he was treated empirically for spontaneous bacterial peritonitis with a combination of ciprofloxacin and cefotaxime. 6. PULMONARY: The patient was electively intubated prior to esophagogastroduodenoscopy on [**2168-8-1**] and was extubated after the second esophagogastroduodenoscopy was performed on [**2168-8-2**]. The patient had a minimal oxygen requirement following extubation which improved with incentive spirometry use. Bilateral effusions were seen on chest x-ray; dated [**2168-8-3**]. A right lateral decubitus film was performed on the following day. There was no layering of fluid. However, a loculated effusion was seen in the right apex as well as fluid in the major fissure. It was deemed that there was not enough fluid present for a thoracentesis, and no further action was taken during this hospitalization. CONDITION AT DISCHARGE: Condition on discharge was stable and improved. DISCHARGE DIAGNOSES: 1. Hepatitis C. 2. Cirrhosis. 3. Hepatocellular carcinoma. 4. Upper gastrointestinal bleed. 5. Portal hypertension. 6. Esophageal varices; status post banding. 7. Spontaneous bacterial peritonitis. 8. Loculated right-sided pleural effusion, status post partial pneumonectomy. MEDICATIONS ON DISCHARGE: 1. Aldactone 150 mg p.o. q.d. 2. Nadolol 20 mg p.o. q.d. 3. Ciprofloxacin 500 mg p.o. q.12h. (times two days). 4. Docusate 100 mg p.o. b.i.d. 5. Protonix 40 mg p.o. b.i.d. 6. Multivitamin. 7. Folate. 8. Thiamine. 9. Lasix 40 mg p.o. q.d. DISCHARGE FOLLOWUP: 1. Esophagogastroduodenoscopy scheduled for [**2168-8-18**] at 1 p.m. with Dr. [**Last Name (STitle) 42908**] for possible repeat banding. 2. Dr. [**Last Name (STitle) **] (of Gastroenterology) on [**2168-8-30**] at 2 p.m. 3. Dr. [**First Name (STitle) **] (of Oncology) in three to four weeks; to be scheduled by the patient. 4. Dr. [**Last Name (STitle) **] (primary care physician) in three to four weeks; to be scheduled by the patient. 5. The patient was instructed to contact Dr.[**Name (NI) 24634**] office next week for electrolyte panel due to initiation of Lasix. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**] Dictated By:[**Last Name (NamePattern1) 6240**] MEDQUIST36 D: [**2168-8-7**] 02:15 T: [**2168-8-13**] 09:10 JOB#: [**Job Number 42909**]

[ "571.5", "456.20", "285.1", "287.5", "789.5", "070.54", "155.0", "572.3", "V10.11" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "42.33", "54.91" ]

icd9pcs

[ [ [] ] ]

2716, 2812

11168, 11453

11479, 11727

2839, 5445

5463, 11083

2309, 2481

11098, 11147

11747, 12569

189, 2006

2028, 2286

2498, 2698

31,712

197,809

31724

Discharge summary

report

Admission Date: [**2135-8-11**] Discharge Date: [**2135-9-6**] Date of Birth: [**2069-9-8**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4748**] Chief Complaint: Pain and ischemia bilateral lower extremities Major Surgical or Invasive Procedure: Left axillary-bifemoral bypass left fem-[**Doctor Last Name **] bypass History of Present Illness: 65 yo M significant PMH refered by Dr. [**Last Name (STitle) 74514**] with ischemic lower extremities bilaterally form [**Last Name (un) 11560**] Gen. Hospital. Pt states pain and coolness for several months, progressive in bilateral lower extremities, right more than left. Past Medical History: PMH: HTN, ESRD on hemodialysis, h/o congestive heart failure, COPD, anemia secondary to ESRD, CAD h/o MI, h/o angioplasty 30 yrs ago, hyperlipidemia, severe PVD . PSH: Left BKA [**2123**] secondary to trauma/osteo, ?bladder surgery, appendectomy, rotator cuff surgery, right forearm fistula failed Social History: see previous d/c summeries Family History: unknown Physical Exam: PE: VS: 98.9 96 124/52 18 99% 2L NC Gen: NAD Chest: decreased breath sounds bilaterally, o/w clear CV: RRR, no murmurs Abd: S/ND/NT, +BS Ext: cool stump on left, ischemic [**Year (4 digits) **] Pulses: Fem [**Doctor Last Name **] DP PT [**Name (NI) **] NP NP [**Name8 (MD) 74515**] NP palp Pertinent Results: [**2135-8-11**] 07:10PM GLUCOSE-141* UREA N-21* CREAT-5.3* SODIUM-141 POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-26 ANION GAP-18 [**2135-8-11**] 07:10PM estGFR-Using this [**2135-8-11**] 07:10PM ALT(SGPT)-4 AST(SGOT)-23 LD(LDH)-153 ALK PHOS-83 AMYLASE-94 TOT BILI-0.2 [**2135-8-11**] 07:10PM LIPASE-19 [**2135-8-11**] 07:10PM CALCIUM-9.9 PHOSPHATE-4.6* MAGNESIUM-1.6 [**2135-8-11**] 07:10PM WBC-12.5* RBC-4.05* HGB-11.2* HCT-33.6* MCV-83 MCH-27.8 MCHC-33.5 RDW-18.5* [**2135-8-11**] 07:10PM PLT COUNT-272 [**2135-8-11**] 07:10PM PT-17.4* PTT-35.5* INR(PT)-1.6* Brief Hospital Course: [**2135-8-11**] admitted to Vascular service. Vanco/cipro and flagyl began. Home meds continued.Transplant /hemodialysis acces team consulted for failed AVf secondary to stenosis.Renal dialysis team followed patient for his hemodialysis needs. [**2135-8-16**] thrombectomy RUE fistula, revision of fisutla with AVRUE graft. [**2135-8-16**] left ax-bifemoral bpg [**2135-8-17**] left cavicular hematoma, Iv heparin d/c'd,wound evacuation of hematoma. transfered to ICU requiring neo gtt for b/p support.Chronic pain consulted. PCA diludied effective. in addition to percocet tabs [**11-23**] q4h prn.Neurotin added to regment after discussion with renal. [**2135-8-18**] extubated. Pain meds adjusted for optium relief. [**2135-8-19**] Code "purple" for extreme agitatioon and hallucinations . Required haldol 5mgm IV with schedualed 2.5mgm tid and 5mgm IV prn for his agitation.Episode probable secondary to increased opate regment. [**2135-8-20**] delerium slowly improving. AF controlled with beta blockade.hypotension requiring vasopressor support.Right fem-bkpop with NRSVG for ischemic rt. foot. [**2135-8-21**] cardology for persistant af managment.Required amidarone gtt to convert. periop Mi, small. [**2135-8-22**] postop delerium controlled with haldol. wean to extubate began. tube feed began. 10/02/07Extubated.CVVHD. [**2135-8-24**] Neo gtt weaning. coumadin began. [**2135-8-25**] right leg sutured for bleeding @ incisiional site.Transfered to VICU. [**2135-8-26**] patient evaluated by physical thearphy-will require rehab. [**Date range (1) 74516**] persistant leukocytosis. stool for cdiff sent. AF with HD converted with 10mg lopressor Iv. [**8-31**] /07 pain meds adjusted Over the next week medications were reduced and PT was involved. The foot was warm and good doppler signals. He required HD per the renal service. His coumadin was titrated for a goal of [**12-25**]. He was screened for rehab with plans to return to clinic for evaluation of his toes and possible amputation. He will be continued on his antibiotic till follow-up Of note on [**2135-9-6**] his coumadin was held for an INR of 4.5. He was discharged to rehab on [**2135-9-6**] Medications on Admission: Albuterol, Aspirin, Atenolol, BusPIRone, Carvedilol, Calcium Acetate, Docusate Sodium, Ipratropium Bromide MDI, Isosorbide Mononitrate (Extended Release), Lisinopril, Mesalamine, Nephrocaps, Nicotine Patch, Nitroglycerin SL, Oxycodone-Acetaminophen, Pantoprazole, seroquel, Sevelamer, Senna, Simvastatin Discharge Medications: 1. Mesalamine 250 mg Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO BID (2 times a day). Disp:*240 Capsule, Sustained Release(s)* Refills:*2* 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*60 Cap(s)* Refills:*2* 3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). Disp:*60 Tablet, Sublingual(s)* Refills:*2* 4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 5. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*60 Capsule(s)* Refills:*2* 6. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed. Disp:*60 neb* Refills:*3* 7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*2* 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours) as needed. Disp:*60 neb* Refills:*0* 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). Disp:*60 * Refills:*2* 12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*60 Adhesive Patch, Medicated(s)* Refills:*2* 14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* 15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*60 Tablet(s)* Refills:*0* 16. Methadone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 17. Warfarin 1 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*60 Tablet(s)* Refills:*2* 18. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous QHD. Disp:*60 * Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: right lower extremity ischemia Discharge Condition: Stable to rehab Discharge Instructions: Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Continue on antibiotics for ... days. * Continue to amubulate several times per day. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 1391**]. Please call to make an appointment: [**Telephone/Fax (1) 1393**]

[ "729.72", "585.6", "453.8", "424.0", "E935.2", "996.73", "338.18", "410.71", "458.29", "427.31", "V58.61", "518.0", "414.01", "403.91", "428.0", "496", "285.21", "305.1", "707.03", "292.81", "V45.82", "780.52", "440.24", "998.12", "V49.75" ]

icd9cm

[ [ [] ] ]

[ "38.93", "39.49", "39.29", "86.04", "39.95", "38.22", "83.14", "96.6", "88.48", "39.42", "99.04" ]

icd9pcs

[ [ [] ] ]

6740, 6810

2075, 4244

358, 431

6885, 6903

1480, 2052

8056, 8182

1119, 1128

4598, 6717

6831, 6864

4270, 4575

6952, 8033

1143, 1461

273, 320

459, 737

759, 1059

1075, 1103

14,131

149,684

10744

Discharge summary

report

Admission Date: [**2118-4-17**] Discharge Date: [**2118-4-25**] Date of Birth: [**2058-4-29**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 425**] Chief Complaint: weight gain, dyspnea Major Surgical or Invasive Procedure: Endotracheal Intubation History of Present Illness: Ms. [**Known lastname **] is a 59 yoF with DMT1, atrial pacemaker, ischemic CM, CKD and several admission over the last several months for CHF, delirium and aspiration pneumonia. She has been at [**Hospital 100**] Rehab since her discharge on [**2118-4-4**]. She is on spironlactone but has had her lasix held in the setting of worsening renal function over the last few weeks; her renal function has started to improve though is very sensitive to lasix boluses received at HR. Over the last few weeks, she has had increasing weight [**Last Name (un) **] and her husband reports that she is nearly 50 pounds above her baseline weight. Problems included [**Name2 (NI) 4171**] renal dysfunction and low albumin as contributing to inability to diurese, and she has actually accumulated an additional 10 pounds of fluid, even after initiation of aldactone. She is a direct admission to the floor from HR. On ROS, she endorses dyspnea and SOB even at rest but especially with rolling; she has had limited mobility due to the anasarca and DOE; has a non-productive cough, PND; denies fever, sputum, myalgias, HA, and anorexia. In terms of her recent admissions, from [**2-22**] to [**2118-3-11**] she was admitted with CHF exacerbation and delirium thought ot be secondary to med effect (after being at an OSH for several weeks prior to that). She has been off and on [**Month/Day/Year **], and she is currently taking [**Month/Day/Year **] 2.5 mg QHS, which her husband feels she absolutely needs. That admission was complicated by torsades requiring shocks. She was delirious and combative for several weeks before it was ultimately decided to make her CMO. However, she was transferred here and treated by taking her off several medications, and her mental status improved, requiring only [**Month/Day/Year 7130**]. She was discharged to home ~40 pounds above her dry weight, with a plan to manage her as an outpatient. She has profound diastolic dysfunction and not much in the way of systolic dysfunction (likely combination of ischemia, scar, diabetes). For her delirium, she was also doing very well, and her [**Month/Day/Year 7130**] was discontinued, and her mental status has apparently also decompensated. On the admission from [**2118-3-28**] to [**2118-4-4**], she was treated for pnuemonia. Past Medical History: Cardiac Risk Factors: Diabetes, CKD Cardiac History: - CAD s/p anterior MI, multiple PCIs and history of left main thrombosis during last cath in [**3-/2112**]; with thrombotic event developed 10 minute asystolic arrest. Since then she has had positive stress test, not deemed to be intervened upon due to high risk. - Ischemic CHF with most recent known EF 20-25% in [**Month (only) 1096**] [**2117**]. - VT s/p ICD (hx torsades) placed [**2-13**] - PVD s/p fem-[**Doctor Last Name **] bypass. . Other Past History: - DM type I - CKD - baseline creatinine 2.5-3 - Legally blind due to diabetic retinopathy - Anoxic brain injury resulting from PEA arrest in cath as above. - Memory and word finding difficulties of unclear etiology; has been evaluated by neurology and cognitive neurology. - Diabetic neuropathy - Hypothyroidism - Anxiety - Depression - s/p carpal tunnel surgery - ?severe pulmonary hypertension Social History: She has one son. She finished a bachelor's degree in college, is married, and lives with her husband who is very involved in her care. She is a nonsmoker and does not drink any alcohol. At baseline uses a walker as a result of her diabetic neuropathy and can get around the house on her own. Family History: Her mother died at 50 of heart-related illness Physical Exam: (Per Admitting Resident) VS on the floor: 97.7, 150/69, 75,20, 100% 2L Admission weight: 210 lb (husband said baseline is more like 150-160) Gen: middle aged female, wearing NC, comfortable in bed when not moving but easily winded with rolling to side; rests with eyes closed (husband explained new baseline behavior), but does talk and give history HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: obese neck, hard to appreciate JVD CV: soft heart sounds, rate regular, no murmurs appreciated Chest: crackles anteriorly, end inspiratory squeak, no accessory muscel use Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext/Skin: full body anasarca, right heel ulcer with garnulation tissue and some surrounding erythema though limited and with no discharge/exudate; right arm PICC NT/not erythematous Pertinent Results: Admission Labs [**2118-4-17**] 10:02PM BLOOD WBC-5.9 RBC-2.83* Hgb-8.7* Hct-28.5* MCV-101* MCH-30.7 MCHC-30.5* RDW-19.2* Plt Ct-198 [**2118-4-17**] 10:02PM BLOOD Glucose-212* UreaN-68* Creat-2.0* Na-146* K-5.1 Cl-117* HCO3-22 AnGap-12 [**2118-4-17**] 10:02PM BLOOD Albumin-3.1* Calcium-8.7 Phos-4.5 Mg-2.7* Most Recent Labs [**2118-4-25**] 05:02AM BLOOD WBC-13.1* RBC-2.66* Hgb-8.0* Hct-26.8* MCV-101* MCH-30.1 MCHC-29.8* RDW-17.7* Plt Ct-250 [**2118-4-25**] 05:02AM BLOOD PT-16.1* PTT-35.4* INR(PT)-1.4* [**2118-4-25**] 05:02AM BLOOD Glucose-149* UreaN-97* Creat-3.4* Na-144 K-4.1 Cl-112* HCO3-21* AnGap-15 [**2118-4-25**] 05:02AM BLOOD Calcium-8.1* Phos-5.7* Mg-2.2 [**2118-4-25**] 12:29PM BLOOD Type-ART Temp-35.9 Rates-22/ Tidal V-400 PEEP-10 FiO2-50 pO2-136* pCO2-34* pH-7.35 calTCO2-20* Base XS--5 Intubat-INTUBATED Other Labs [**2118-4-19**] 05:30AM BLOOD ESR-50* [**2118-4-23**] 05:24PM BLOOD [**Doctor First Name **]-NEGATIVE [**2118-4-23**] 04:18PM BLOOD RheuFac-39* [**2118-4-19**] 05:30AM BLOOD PEP-ABNORMAL B IgG-1347 IgA-97 IgM-124 IFE-MONOCLONAL Cardiac Enzymes [**2118-4-21**] 10:34PM CK(CPK)-68 cTropnT-0.10* proBNP-GREATER TH [**2118-4-22**] 04:34AM CK(CPK)-81CK-MB-NotDone cTropnT-0.12* [**2118-4-22**] 02:00PM CK(CPK)-98CK-MB-NotDone cTropnT-0.13* [**2118-4-22**] 06:30PM CK(CPK)-91CK-MB-NotDone cTropnT-0.11* Urine Studies [**2118-4-21**] 11:51PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008 [**2118-4-21**] 11:51PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [**2118-4-21**] 11:51PM URINE RBC-[**4-8**]* WBC-[**4-8**] Bacteri-FEW Yeast-NONE Epi-0-2 [**2118-4-18**] 12:50PM URINE Hours-RANDOM TotProt-9 [**2118-4-23**] 01:02AM URINE Osmolal-359 [**2118-4-18**] 12:50PM URINE U-PEP-NEGATIVE F Pleural Fluid Studies: [**2118-4-22**] 12:30PM PLEURAL WBC-226* RBC-106* Polys-59* Lymphs-0 Monos-0 Meso-3* Macro-30* Other-8* [**2118-4-22**] 12:30PM PLEURAL TotProt-1.8 Glucose-178 LD(LDH)-306 Microbiology: CDiff NEGATIVE Blood Cx NEGATIVE x 3 Urine Cx - Klebsiella Pneumonia Pleural Fluid Cx - NEGATIVE ============================== IMAGING: CXR ([**2118-4-21**]) - IMPRESSION: Worsened pulmonary edema with left lower lobe opacity may represent pneumonia. CXR ([**2118-4-25**]) - FINDINGS: Widespread bilateral airspace opacities have slightly progressed since the recent radiograph. Appearance of the chest is otherwise similar to the recent study except for repositioning of a Swan-Ganz catheter, now terminating in the right ventricular outflow tract. Other indwelling support and monitoring devices are in standard position. Echo ([**2118-4-22**]) - The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular cavity is dilated with borderline normal free wall function. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] 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. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The tricuspid valve leaflets fail to fully coapt. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2118-2-28**], the tricuspid regurgitation is increased. Echo ([**2118-4-25**]) - No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast at rest. RUQ U/S - IMPRESSION: 1. Cholelithiasis without gallbladder distention. Mild and symmetric thickening of the gallbladder wall likely represents third spacing. 2. Pulsatility in the portal vein, a finding that can be seen in right heart failure. 3. Small right pleural effusion. Brief Hospital Course: In summary, this is a 59 yo female with PMHx DM, torsades s/p ICD, h/o left main thrombosis with cardiac arrest during cardiac cath complicated by anoxic brain injury, systolic and diastolic HF, CKD and several admissions over the last several months for acute heart failure, delirium and aspiration pneumonia. She was admitted on [**2118-4-17**] after failed outpatient diuresis at [**Hospital 100**] Rehab with furosemide and spironolactone, which was limited by acute renal failure. On admission, she was 50 pounds above dry weight, with dyspnea and slightly worsening delirium from her baseline. On the floor, she was being diuresed with a furosemide gtt, maintaining a UOP of ~100 ml/hr. Throughout the admission, the patient had frequently complained of dyspnea. However, at 4pm on [**2118-4-21**], she noted worsening dyspnea (no chest pain) and was found to have SpO2 of 82% on 2L NC with labored respirations and RR in the upper 30s. At that time, SBP 140s with HR 90s. She was given nebs with little improvement in oxygenation. She was then placed on NRB with improvement to SpO2 90-93%. She was also given SL nitro x1 in case of flash pulmonary edema. EKG was unchanged from prior. There was no clear evidence of aspiration prior to the event. She was transferred to the CCU for further management. On arrival to the CCU, patient still endorsed dyspnea, although improved with NRB. However, her respiratory status deteriorated, and she was placed on BiPAP. PA catheter was placed and showed a lower-than-expected PCWP. While in the CCU, the patient was also noted to spike a temperature, for which she was started on broad spectrum antibiotics. The patient was noted to have a pleural effusion, for which she underwent a thoracentesis that was complicated by a pneumothorax. She subsequently underwent chest tube placement with reexpansion of her right lung. She was also started on milrinone in the hopes that it would help with her urine output. Despite this, the patient still had poor urine output. Renal did not think that the patient was a good candidate for CVVH. The patient was also briefly tried on steroids to see if it would help mobilize fluid and prevent capillary leak (it had in the past); however, this was unsuccessful. Because of her worsened respiratory status and fluid overload, the patient was briefly intubated. Ultimately, however, after multiple discussions about the patient's poor prognosis with her family, she was made CMO and expired. Medications on Admission: Olanzapine 2.5 mg PO HS Acetaminophen PRN Alprazolam 0.5 mg PO/NG QHS:PRN -- patient doesn't take often traZODONE 25 mg PO/NG HS Thiamine 100 mg PO/NG DAILY Spironolactone 25 mg PO/NG DAILY Simvastatin 80 mg PO/NG DAILY Polyethylene Glycol 17 g PRN Gabapentin 300 mg PO/NG Q24H Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **] Fluoxetine 60 mg PO/NG DAILY Ferrous Sulfate 325 mg PO/NG [**Hospital1 **] Cyanocobalamin 250 mcg PO/NG DAILY Clopidogrel 75 mg PO/NG DAILY Aspirin 81 mg QD Albuterol 0.083% Neb Q8H standing -- confirmed with patient Losartan Potassium 100 mg PO/NG -- held on [**4-17**] Metoprolol Tartrate 50 mg PO/NG [**Hospital1 **] Levothyroxine Sodium 88 mcg PO/NG DAILY Ipratropium Bromide Neb 1 NEB IH Q8H Lantus 6/12 units QAM/QPM Colace SQH Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

[ "414.01", "403.90", "585.9", "V45.01", "293.0", "250.51", "V45.82", "995.92", "443.9", "369.4", "250.61", "038.9", "785.52", "357.2", "428.0", "300.4", "276.0", "512.1", "428.43", "244.9", "799.02", "518.81", "362.01", "414.8" ]

icd9cm

[ [ [] ] ]

[ "89.68", "89.64", "34.09", "96.71", "38.93", "96.04", "34.91" ]

icd9pcs

[ [ [] ] ]

12445, 12454

9114, 11594

315, 340

12505, 12514

4949, 9091

12570, 12580

3932, 3980

12413, 12422

12475, 12484

11620, 12390

12538, 12547

3995, 4930

255, 277

368, 2670

2692, 3607

3623, 3916

16,163

167,646

12385

Discharge summary

report

Admission Date: [**2151-2-17**] Discharge Date: [**2151-2-23**] Date of Birth: [**2085-9-23**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 66 year old woman with a history of hypertension, who had had on and off chest pain times one month and presented to an outside hospital. The patient underwent a cardiac catheterization after ruling in for myocardial infarction and the catheterization showed three-vessel disease. The patient was scheduled for coronary artery bypass graft times three on [**2151-2-18**]. PAST MEDICAL HISTORY: 1. Hypertension. 2. Dyslipidemia. 3. Anemia. 4. Degenerative joint disease. MEDICATIONS ON TRANSFER: From outside hospital: 1. Zocor 40 mg p.o. q. day. 2. Aspirin 81 mg p.o. q. day. 3. Lopressor 25 mg intravenously q. six. 4. Zestril 2.5 mg p.o. q. day. 5. Plavix 75 mg p.o. q. day. 6. Intravenous Nitroglycerin at 53 micrograms. SOCIAL HISTORY: Tobacco, 40 pack years. Lives with husband. PHYSICAL EXAMINATION: Temperature 98.2 F.; blood pressure 118/70; heart rate 62; respiratory rate 18; 96% on room air. In general, she is a pleasant female in no acute distress. HEENT shows moist mucous membranes with no carotid bruits. Heart: Regular rate and rhythm, S1 and S2 normal. Lungs are clear to auscultation bilaterally. Abdomen is soft, nontender, obese. Extremities with no clubbing, edema or cyanosis. Two plus dorsalis pedis pulses bilaterally. LABORATORY AT THE OUTSIDE HOSPITAL: White blood cell count of 8.5, hematocrit of 31 and platelets 223. Chem-7 is 137, 2.7, 102, 24, 14, 0.4 and 104. Calcium of 8.3. HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2151-2-17**], and on [**2151-2-18**], underwent a three-vessel coronary artery bypass graft with left internal mammary artery to the left anterior descending, and saphenous vein graft to obtuse marginal 1 and then obtuse marginal 2. The patient did well postoperatively and was transferred to the Intensive Care Unit. On postoperative day number one, the patient's Swan-Ganz catheter was removed. On the evening of postoperative day number one, the patient was transferred to the Floor. On postoperative day number one, the patient was seen by Physical Therapy who thought that she would probably be good to go home after several sessions with Physical Therapy. On postoperative day number two, the patient continued to do well and on postoperative day number three, the patient's chest tubes, wires and Foley catheter were removed. The post-removal chest x-ray showed no pneumothorax. On postoperative day number four, the patient continued to do well and worked with Physical Therapy and on postoperative day five the patient was transferred to home in good condition. The patient was discharged on the following medications. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. twice a day times seven days. 2. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. twice a day times seven days. 3. Percocet one to two tablets p.o. q. four to six hours p.r.n. 4. Colace 100 mg p.o. twice a day. 5. Aspirin 325 mg p.o. q. day. 6. Zantac 150 mg p.o. twice a day. 7. Metoprolol 12.5 mg p.o. twice a day. 8. Zocor 40 mg p.o. q. day. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft times three. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 6067**] MEDQUIST36 D: [**2151-2-22**] 09:27 T: [**2151-2-22**] 10:00 JOB#: [**Job Number 38559**]

[ "272.0", "429.9", "401.9", "414.01", "410.11", "285.9", "715.90", "305.1" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

3280, 3619

2849, 3259

1634, 2826

1003, 1616

160, 552

681, 917

574, 655

934, 980

31,879

115,752

10831+56172

Discharge summary

report+addendum

Admission Date: [**2130-11-6**] Discharge Date: [**2130-11-13**] Date of Birth: [**2077-1-15**] Sex: M Service: SURGERY Allergies: Ganciclovir / Acyclovir Attending:[**First Name3 (LF) 695**] Chief Complaint: The patient was admitted on [**2130-11-6**] for a liver transplant. Major Surgical or Invasive Procedure: Liver transplant [**2130-11-7**] History of Present Illness: Mr. [**Known lastname **] is a 53M w/ Hx Hep C cirrhosis and HCC. He presented [**11-6**] for a liver transplant. He has not had any fevers, and chills. No diarrhea, nausea or vomiting. No urinary symptoms. No cough. No shortness of breath. He has night sweats at baseline but this has not increased and has actually improved. He ate at 1830. Past Medical History: HCV, HCC, HTN, Osteoporosis PSH: lap CCY, cervical laminectomy with fusion, tib/fib fx s/p fixation with steel rod. Social History: former smoker who has quit in [**2130-2-16**]. He smoked 2 packs per day for 40 years. He denies any alcohol or drug use. Family History: unremarkable Physical Exam: VS: T 97.4 HR 91 BP 135/73 RR 20 O2Sat 98% RA NAD, AAOx3, He is w/o asterixis. HEENT: NC/AT,and anicteric. Neck is supple w/o lymphadenopathy. CV: Regular Rate and Rhythm Pulm: CTA B/L Abd:Soft/Nontender/Distended/+BS. No splenomegaly. There is no guarding or rebound tenderness. Ext: no peripheral edema Pertinent Results: [**2130-11-13**] 05:05AM BLOOD WBC-8.5 RBC-2.86* Hgb-8.9* Hct-26.2* MCV-92 MCH-31.0 MCHC-33.8 RDW-15.9* Plt Ct-164 [**2130-11-13**] 05:05AM BLOOD Plt Ct-164 [**2130-11-13**] 05:05AM BLOOD PT-11.9 PTT-20.3* INR(PT)-1.0 [**2130-11-10**] 04:45AM BLOOD Fibrino-251 [**2130-11-13**] 05:05AM BLOOD Glucose-76 UreaN-29* Creat-1.0 Na-140 K-4.6 Cl-103 HCO3-31 AnGap-11 [**2130-11-13**] 05:05AM BLOOD ALT-941* AST-108* AlkPhos-83 TotBili-0.7 [**2130-11-10**] 04:45AM BLOOD Lipase-19 [**2130-11-13**] 05:05AM BLOOD Albumin-3.3* Calcium-8.6 Phos-3.8 Mg-2.4 [**2130-11-13**] 05:05AM BLOOD FK506-7.2 [**2130-11-9**] 01:34PM ASCITES TotBili-1.4 DUPLEX DOP ABD/PEL LIMITED [**2130-11-7**] 2:33 PM DUPLEX DOP ABD/PEL LIMITED Reason: FLOW/ FLUID COLLECTION. S/P LIVER TX [**Hospital 93**] MEDICAL CONDITION: 53 year old man with liver transplant REASON FOR THIS EXAMINATION: flow/fluid collcetion .INDICATION: 53-year-old man with liver transplant today, evaluate for fluid collection and flow in vessels. FINDINGS: The liver shows no focal abnormalities. There is a tiny trace of fluid in Morison's pouch but no other fluid collections are identified. There is no biliary dilatation seen. DOPPLER EXAMINATION: Hepatopetal flow is identified in the main portal vein, the right portal vein, and the left portal vein. Velocity of flow within the main portal vein is 52 cm/sec. Appropriate flow is identified in the hepatic veins. Arterial waveforms in the main hepatic artery, right hepatic artery, and left hepatic artery are appropriate with good upstrokes. Flow is identified within the IVC; however, this vessel is not well imaged on this exam. IMPRESSION: Tiny trace of fluid in Morison's pouch. Appropriate flow is identified in all of the hepatic vessels. DUPLEX DOPP ABD/PEL [**2130-11-9**] 11:58 AM LIVER OR GALLBLADDER US (SINGL; DUPLEX DOPP ABD/PEL Reason: Need to look at arterial and venous flow of transplanted liv [**Hospital 93**] MEDICAL CONDITION: 53 year old man s/p liver transplant REASON FOR THIS EXAMINATION: Need to look at arterial and venous flow of transplanted liver. look for any fluid collections INDICATION: 53-year-old man status post liver transplant. [**Doctor Last Name **]-SCALE AND DOPPLER ULTRASOUND OF THE LIVER: Comparison was made with the prior ultrasound dated [**2130-11-7**]. Again note is made of a small amount of fluid in [**Location (un) 6813**] pouch, as seen on the prior study. Otherwise, the appearance of the liver is unchanged on [**Doctor Last Name 352**]-scale images. Hepatopetal flow is identified in the main and right and left portal veins. The velocity of flow within the main portal vein is 56 cm/sec. Hepatic veins are patent with appropriate waveforms. Main and right and left hepatic arteries show appropriate arterial waveform with good stroke as noted previously. The proximal right hepatic artery is visualized with normal waveforrms, but peripherally assessment is somewhat limited. IMPRESSION: Small free fluid in Morison's pouch as noted previously. Patent vessels with appropriate waveforms as described above. Note that distal right hepatic artery is not fully visualized on this study--correlate clinically with lab values, and followup if indicated. CT ABD W&W/O C [**2130-11-12**] 1:33 PM CT ABD W&W/O C Reason: CTA of the liver. smaller cuts around the liver to evaluate Field of view: 39 [**Hospital 93**] MEDICAL CONDITION: 53 year old man s/p liver transplant. REASON FOR THIS EXAMINATION: CTA of the liver. smaller cuts around the liver to evaluate hepatic artery. Need to evaluation for hematoma and bleeding. only need IV contrast CONTRAINDICATIONS for IV CONTRAST: None. CT LIVER (MULTIPHASE) INDICATION: Status post liver transplant. TECHNIQUE: Non-contrast, arterial phase and portal venous phase CT liver performed. FINDINGS: The portal vein is patent. The donor hepatic artery has been surgically anastomosed to the recipient replaced hepatic artery which arises from the patient's celiac artery. The left and right hepatic arteries and the proper hepatic artery are patent. There is mild dilatation of the donor hepatic artery at the anastamosis. There is a focal wedge- shaped area of patchy hypoattenuation on portal venous and arterial phase in segment VII of the liver possibly representing a focal area of contusion related to recent surgery. There is some periportal edema in segment II and also in segment IVb. Remainder of the liver enhancement is normal on arterial and portal venous phases. The hepatic veins are patent. The spleen is enlarged measuring 14.6 cm in diameter. The pancreas, kidneys, and adrenal glands are normal. There is a small amount of intraperitoneal air. There is perihepatic fluid and some hematoma, consistent with recent surgery. There is mild right basilar collapse consolidation and a small right pleural effusion. IMPRESSION: 1. Patent hepatic vasculature. 2. Right basal collapse/consolidation. Brief Hospital Course: The patient was admitted on [**2130-11-6**] for a liver transplant. On admission, he was made NPO, and pre-op blood work, EKG and CXR were obtained. The patient tolerated the procedure well and was admitted to the ICU intubated following surgery for close monitoring. On [**11-7**] sedation was weaned, the patient was extubated. Ultrasound showed: Hepatopetal flow is identified in the main portal vein, the right portal vein, and the left portal vein. Velocity of flow within the main portal vein is 52 cm/sec. Appropriate flow is identified in the hepatic veins. Arterial waveforms in the main hepatic artery, right hepatic artery, and left hepatic artery are appropriate with good upstrokes. Flow is identified within the IVC; however, this vessel is not well imaged on this exam. On [**11-9**] the patient was transferred to [**Hospital Ward Name 121**] 10 for continued monitoring. He was encouraged to ambulate, started on a regular diet and his fluids were stopped. [**11-10**] - the patient's home medications were started and his foley catheter was removed. The patient continued to do well, a CT abdomen was performed on [**11-12**] showing patent hepatic vasculature. He is to be discharged home on [**11-13**]. Medications on Admission: [**Last Name (un) 1724**]: Actigall 300 mg q.i.d., Diovan 160 mg daily, Omeprazole 20 mg daily, Calcium with vitamin D twice a day, Multi-vit, B complex vitamin, Boniva 3 grams every 3 months, started on an antihistimine for itching. Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). Disp:*60 Tablet(s)* Refills:*2* 3. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 10. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 12. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a day. Disp:*180 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Liver transplant Discharge Condition: Good Discharge Instructions: Please return to the nearest emergency department or call the transplant coordinator ([**Telephone/Fax (1) 673**]) should you have a temperature greater than 101.5, abdominal pain, nausea, vomiting, shortness of breath, chest pain, excessive drainage or redness surrounding surgical incision. You will need labs (CBC, Chem 10, LFTs, Coags, FK levels) drawn on either Tuesday ([**11-14**]) or Wednesday ([**11-15**]). These results must be faxed to the transplant coordinator [**Telephone/Fax (1) 697**]. You have been prescribed a study drug - you have received an educational session by the transplant team. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2130-11-22**] 3:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2130-11-29**] 2:20 Provider: [**Name10 (NameIs) 1248**],CHAIR ONE [**Name10 (NameIs) 1248**] ROOMS Date/Time:[**2130-12-5**] 8:15 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 6243**] Admission Date: [**2130-11-6**] Discharge Date: [**2130-11-13**] Date of Birth: [**2077-1-15**] Sex: M Service: SURGERY Allergies: Ganciclovir / Acyclovir Attending:[**First Name3 (LF) 48**] Addendum: The patient will start a study drug instead of valcyte. Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). Disp:*60 Tablet(s)* Refills:*2* 3. Study drug 4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 10. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 12. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a day. Disp:*180 Capsule(s)* Refills:*2* Discharge Disposition: Home [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**] MD, [**MD Number(3) 52**] Completed by:[**2130-11-13**]

[ "070.54", "789.59", "571.5", "733.00", "155.0", "401.9" ]

icd9cm

[ [ [] ] ]

[ "93.59", "50.59", "00.93", "99.04" ]

icd9pcs

[ [ [] ] ]

12284, 12445

6387, 7621

351, 386

9333, 9340

1429, 2188

10000, 10989

1062, 1076

11012, 12261

4835, 4873

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1091, 1410

244, 313

4902, 6364

414, 765

787, 906

922, 1046

47,045

106,960

7669+55860

Discharge summary

report+addendum

Admission Date: [**2117-3-18**] Discharge Date: [**2117-3-24**] Date of Birth: [**2050-2-11**] Sex: M Service: ADMISSION DIAGNOSIS: Abnormal stress exam with abnormal coronary artery catheterization. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft x2 vessel redo on [**2117-3-19**]. 2. Severe chronic history of coronary artery disease. CONSULT: Physical therapy HISTORY AND PHYSICAL EXAM: Mr. [**Known firstname **] [**Known lastname **] is a 67-year-old man who speaks mostly Portugese with a history of multiple prior interventions to the left circumflex artery and history of coronary artery bypass graft in [**2109**], as well as percutaneous transluminal coronary angioplasty and RCA in [**2114**] with a history of progressive rest angina, orthopnea and paroxysmal nocturnal dyspnea in the setting of a positive MIBI. In [**2097**], he noted the initial onset of his angina he was evaluated with coronary catheterization in [**2098-12-10**] as well as [**2106-12-11**], [**2109-7-11**], [**2114-7-11**] and finally [**2117-3-4**] he had a MIBI during which he was able to exercise for six minutes to a peak heart rate of 128 and blood pressure of 184/80. At this time, he experienced chest tightness, but an electrocardiogram was uninterpretable because of digoxin baseline abnormalities. MIBI revealed an ejection fraction of 37% in the inferior wall defecting reversibility. He was begun on Imdur one week prior to admission and he had a slight decrease in frequency of his symptoms as a result. Currently, he has been having very poor exercise tolerance with shortness of breath, chest tightness with walking in the house. The patient denies edema and lightheadedness, but reports two-pillow orthopnea and occasional paroxysmal nocturnal dyspnea. He has a long history of bilateral claudication and he gets symptoms after walking five minutes at a slow pace. Coronary artery disease risks are cholesterol, diabetes and family history. He has not had a history of hypertension, nor a history of smoking. PAST MEDICAL HISTORY: 1. Elevated lipids. 2. Myocardial infarction. 3. Bilateral claudication. 4. In [**February 2098**] a percutaneous transluminal coronary angioplasty to the LAD and LCX, in 12/90 percutaneous transluminal coronary angioplasty to the LCX and OM, in 2/93 percutaneous transluminal coronary angioplasty to LCX and OM, [**7-/2114**] percutaneous transluminal coronary angioplasty to the RCA. PAST SURGICAL HISTORY: 1. [**7-/2109**] coronary artery bypass graft with vein graft to the obtuse marginal 2. 2. Abdominal aortic aneurysm repair in [**2110**]. 3. Femoral popliteal bypass. ALLERGIES: He has no known drug allergies, no shellfish and no dye allergies. MEDICATIONS: 1. Humulin 45 NPH units subcutaneous q a.m. and 4 units subcutaneous q p.m. 2. Regular insulin 4 units [**Hospital1 **]. 3. Lasix 120 mg [**Hospital1 **]. 4. Zestril 20 mg qid. 5. Trental 400 mg tid. 6. Procardia XL 30 mg qd. 7. Pravachol 20 mg qd. 8. Aspirin 325 mg po qd. REVIEW OF SYSTEMS: Negative for cerebrovascular accident, transient ischemic attack and melena. SOCIAL HISTORY: He is married and lives with his wife who works for the school system in the dietary department. LABS: His white blood cell count was 10.7. His hematocrit was 37.2. His PTT was 12.6. His platelet count was 190. Sodium 142, potassium 4.6, chloride 103, bicarbonate 26, BUN 24, creatinine 1.4. PHYSICAL EXAM: GENERAL: He is a moderately obese male with no apparent distress, however he was obviously anxious. HEAD, EARS, EYES, NOSE AND THROAT: Within normal limits. LUNGS: Clear. He had a healed sternal scar. HEART: Regular rate and rhythm. ABDOMEN: Soft with an aortobifemoral scar. He had right saphenectomy vein harvest scar and a right femoral popliteal scar. EXTREMITIES: Left lower extremity had no major varicosities. SKIN: Okay. There was no edema. His pulses were 2+ carotids bilaterally without bruits. Radials were 2+ bilaterally and there was no palpable DP pulse on either the right or the left. NEUROLOGIC: Nonfocal. IMAGING: His electrocardiogram demonstrated a regular rate with a bundle branch block. There were global T-wave changes. The patient was admitted therefore to undergo a coronary artery bypass grafting. This was a redo procedure. He had a left internal mammary artery to left anterior descending and saphenous vein graft to the distal LAD performed. This was done by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and the patient was transported in the atrial paced mode from the Operating Room to the Cardiothoracic Intensive Care Unit on Neo-Synephrine drip with a mean arterial pressure of 58, CVP of 13, PAD of 15, [**Doctor First Name 1052**] of 20. The patient was weaned to extubation on postoperative day #1. The site was advanced. On postoperative day #2 he was pan cultured for a fever of 101.5??????. He was improved later on that day. His chest tubes were removed. He was diuresed. Follow up of his cultures revealed no growth in the blood or urine cultures. There was only oropharyngeal flora in the sputum. His chest x-ray demonstrated small bilateral pleural effusions. Swan was in place. There was no pneumothorax seen on either side. [**Female First Name (un) 3408**] saw the patient and recommended changes in his insulin. On postoperative day #3, the patient was found to be very upset. This was reported by the patient later on and his daughter to be reaction to Percocet and has been seen in the past. The patient was therefore taken off of all pure narcotic agents and placed on strictly Tylenol for pain control. He was supplemented with Nubain, a narcotic agonist-antagonist medication. His exercise capacity was good and he was seen ambulating in the [**Doctor Last Name **] multiple times during the day. The patient was seen by physical therapy and found to have a slight increase in his systolic blood pressure over his resting systolic blood pressure while he was exercising. He has a sliding scale provided by the [**Hospital 3408**] [**Hospital 982**] Clinic. On postoperative day #5, he had been ambulating sufficiently in the [**Doctor Last Name **] and was seen by physical therapy. They noted an increase in his systolic blood pressure during ambulation over his resting systolic blood pressure and plans were made to increase his Lopressor dose to 50 mg po bid from 25 mg po bid. Plans were therefore made to discharge the patient. DISPOSITION: Discharge to home. DISCHARGE CONDITION: Good DISCHARGE MEDICATIONS: 1. Lasix 120 mg po bid. 2. Zestril 20 mg po qd. 3. Procardia XL 30 mg po qd. 4. Pravachol 20 mg po qd. 5. ASA 81 mg po qd. 6. Lopressor 50 mg po bid. 7. Tylenol 1 gm po q8h prn pain. 8. NPH insulin 40 units subcutaneous q a.m., 50 units subcutaneous q hs. 9. Sliding scale of regular insulin. 0 to 100 give nothing, 100 to 150 2 units, 151 to 200 3 units, 201 to 250 4 units, 251 to 300 5 units, 301 to 350 6 units, 351 to 400 7 units and greater than 400 10 units and call the primary M.D. FOLLOW UP INSTRUCTIONS: The patient is to follow up with wound check at the Far Six Nursing Area in approximately one week. He should follow up with his primary care physician in one to two weeks and he should make arrangements to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for a postoperative wound check with the attending surgeon in approximately four weeks. [**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 13391**] MEDQUIST36 D: [**2117-3-24**] 13:01 T: [**2117-3-24**] 13:19 JOB#: [**Job Number 27894**] Name: [**Known lastname **], [**Known firstname **] P Unit No: [**Numeric Identifier 4839**] Admission Date: [**2117-3-19**] Discharge Date: [**2117-3-25**] Date of Birth: [**2050-2-11**] Sex: M Service: ADMITTING DIAGNOSIS: Ischemic chest pain. DISCHARGE DIAGNOSIS: Coronary artery bypass graft times two vessels. PROCEDURE: Review of procedure on [**2117-3-19**]. HOSPITAL COURSE: The morning of postoperative day six, the patient reported having experienced a decrease in visual acuity in the left eye which he described as a darkness over the left eye. He was still able to see objects; however, claims that everything appeared much darker and dimmer than previously. This had persisted for the last 24 hours. The patient had no extraocular movement defects and no visual field defects. He had no evidence of nystagmus. He reported a history of a left eye cataract which has gone unrepaired and a history of a right eye cataract which had been previously repaired, as well as a history of right retinal hemorrhages. Given his diabetes history and recent coronary artery bypass graft history, his neck was examined and this revealed a carotid bruit. Therefore the patient was sent for a Doppler ultrasound of his carotid bruit, although the suspicion for a transient ischemic attack causing this event was low. The left carotids were found to have 70% to 80% stenosis and the right carotid was found to have less than 40% stenosis. The patient was evaluated by Ophthalmology, who felt that the patient had suffered an anterior ischemic event to the eye, causing an optic neuropathy. The patient was recommended to be seen later on in the afternoon as an outpatient in the [**Hospital Ward Name **] Center by Dr. [**First Name (STitle) 2557**] for follow up with a specialist in this field. The patient returned to the floor and the results of the carotid ultrasound were reported to the attending. The consensus of opinion was that this was not an ischemic event at this time. Therefore the patient was to undergo further evaluation by the Ophthalmology specialist. Plans were set to discharge this patient home. Other elements of this discharge summary are the same as in the initial summary. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**], M.D. [**MD Number(1) 359**] Dictated By:[**Last Name (NamePattern1) 4840**] MEDQUIST36 D: [**2117-3-25**] 13:47 T: [**2117-3-25**] 14:01 JOB#: [**Job Number 4841**]

[ "414.02", "414.01", "433.30", "444.81", "429.9", "250.00", "272.0", "440.21", "413.9" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.11", "88.53", "36.15", "37.22", "88.56" ]

icd9pcs

[ [ [] ] ]

6587, 6593

243, 419

6616, 8047

8111, 8213

8231, 10335

2502, 3050

3478, 6565

153, 222

3070, 3148

8068, 8090

2088, 2479

3165, 3463

69,484

117,970

41850

Discharge summary

report

Admission Date: [**2111-11-10**] Discharge Date: [**2111-11-11**] Date of Birth: [**2031-12-30**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2712**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 90888**] is a 79[**Hospital **] transfer from OSH with a nonverbal/noncommunicative baseline due to mental retardation and schizophrenia who presented in respiratory distress. . At the OSH, he had a desaturation to 55% on RA. He has an active DNR/DNI, and was placed on noninvasives. He received vancomycin and solumedrol for pneumonia versus COPD exacerbation. Per EMS en route, his oxygenation improved with application of the BiPAP mask. ABG there revealed 7.39/40/24 on BIPAP 20/10. Received solumedrol prior to transfer. . On arrival to [**Hospital1 18**] ED, his initial vitals were pulse 92 BP108/76 RR24, sat 95%RA. He was found to be nonverbal with an examination revealing diffuse rhonchi throughout both lung fields. He was tachypneic but satting 95% on RA. He had a lactate of 3.4, leukopenia to 1.1. A CXR revealed possible left perihilar infiltrate raising concern for HCAP. Levofloxacin and metronidazole were added to his regimen and he was admitted to the MICU for further management. . On arrival to the unit, his initial VS were: T94.5 axillary, P76, BP93/58, Sat 95% 50% face tent. He could not provide further history. BiPAP was removed on admission with maintenance of his sats in the mid 90s on face tent. Thick secretions were noted. . Past Medical History: - schizophrenia - mental retardation - COPD - CKD (unknown baseline) - tardive dyskinesia - hypothyroidism - GERD Social History: lives in [**Hospital 2251**] nursing home Family History: Unknown Physical Exam: On admission: Vitals: T94.5 axillary, P76, BP93/58, Sat 95% 50% face tent General: grunting, grumbling, swearing HEENT: Sclera anicteric, MM dry NECK: supple, cannot assess JVD due to positioning LUNGS: auscultation procluded by vocalizations, but no wheezing. Wet cough. 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 Pertinent Results: TTE: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular function is not well visualized due to suboptimal views. Left ventricular systolic function appears grossly preserved with possible regional wall motion abnormality (EF ?50?). There may be apical hypokinesis but regional wall motion is not well seen. 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 stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . LENIs; IMPRESSION: 1. No deep vein thrombosis is seen bilaterally from the common femoral to the popliteal veins. Note is made that the patient did not tolerate evaluation of calf veins. 2. Small left popliteal [**Hospital Ward Name 4675**] cyst. . CXR: Evaluation is limited due to patient positioning. The lung volumes are low. There are left perihilar and right infrahilar opacities consistent with aspiration pneumonia. There is no pneumothorax amd no large pleural effusions. Brief Hospital Course: Mr. [**Known lastname 90888**] is a 79yoM with a history of MR, schizophrenia, transferred from OSH for respiratory distress, admitted to the MICU for monitoring 1. HEALTHCARE ASSOCIATED PNEUMONIA: He presented with desaturations at the OSH and arrived on BiPAP, which was rapidly weaned to face tent upon admission to the MICU, where he maintained his saturations in the mid to upper 90s. A CXR showed evidence of a left lingular pneumonia, and so he was broadly covered empirically with vancomycin, cefepime, and levofloxacin pending cultures. Levofloxacin was stopped on [**2111-11-11**] to avoid further QTC prolonging meds, and vancomycin was dced on discharged given no growth x48h. The pt will be continued on Cefepime 2g IV q12h to complete an 8day course (last day [**11-18**]). On discharge his O2 sats were stable on RA. 2. SEPSIS: He presented with borderline low blood pressures with MAPS in the 50s, leukopenia, tachycardia, and tachypnea, elevated lactate. With suspected pneumonic and urinary infectious source, sepsis was likely. He was fluid resuscitated, and broadly covered with antibiotics as above. He received stress dose hydrocortisone since he is on prednisone 5mg daily at baseline for COPD. His blood pressure remained stably low. His lactate downtrended. On day of discharge he received hydrocortisone 50mg IV q8h, and will be discharged on his home dose of prednisone 5mg daily. 3. ELEVATED TROPONIN: His trop was elevated to 0.16 on admission with a BNP>[**Numeric Identifier 2686**]. CK and MB fractions were negative. EKG showed lateral TWI which were seen on previous EKGs. A demand ischemia seems possible from sustained tachycardia. Trops were downtrending on serial assays. 4. ELEVATED BNP: BNP was >[**Numeric Identifier 2686**] on admission without a history of CHF. Clinically, he appeared hypovolemic on admission exam, so acute CHF was not suspected. A limited echo revealed a likely EF of 50% though no wall motion abnormality could be seen or excluded. 5. HYPERNATREMIA: He presented with a Na to 150 which downtrended with fluid resuscitation. 6. ACUTE KIDNEY INJURY: He has CKD with unclear baseline Cr, though presented with [**Last Name (un) **] to cr 2.0. Urine lytes showed sodium avidity with FeNa 0.08%. Creatinine improved with fluids. 7. SCHIZOPHRENIA: He has been institutionalized since age 18, and was continued on his outpatient anti-psychotic regimen including risperidone, risperdal consta, olanzapine, and valproic acid. Restraints necessary for attempted violent behavior. He appeared at his mental status baseline per niece's report. He often refused meals and oral medications. 8. HYPOTHYROIDISM: continued levothyroxine ---- Transitional Issues: - The patient should be continued on Cefepime 2g IV q12h until [**11-18**] to complete an 8 day course. - PICC line was placed for administration of IV abx. This should be discontinued on completion of antibiotic course. Medications on Admission: - levothyroxine 112mcg daily - divalproex 875mg daily 6am, noon, 1000mg every 6pm - risperidone 1 mg TID - omeprazole 20mg daily - risperdal consta 25mg IM every 2 weeks (due on [**11-11**]) - multivitamin with mineral - prednisone 5mg daily - zyprexa 15mg [**Hospital1 **] - sodium bicarb 650mg [**Hospital1 **] - scopolamine patch behind ear every 72 hrs - vitamin d 800units QHS - acetaminophen 650mg q4hrs prn - procrit 40K units prn HCT<30 (has not received in months) - dulcolax 10mg suppository qd prn - fleet enema prn - milk of mag 30mg daily prn - risperdal 0.5mg q4-6 hr prn agitation Discharge Medications: 1. risperidone 0.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 5. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for agitation. 6. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. olanzapine 15 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. risperidone microspheres 25 mg/2 mL Syringe Sig: One (1) Syringe Intramuscular Q2W (WE): Last dose [**11-11**]. 9. divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: Seven (7) Tablet, Delayed Release (E.C.) PO q6am, qnoon. 10. divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: Eight (8) Tablet, Delayed Release (E.C.) PO q6pm. 11. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO once a day. 12. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day. 14. Procrit 40,000 unit/mL Solution Sig: One (1) dose Injection PRN as needed for HCT <30. 15. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [**2-8**] Tablet, Delayed Release (E.C.)s PO once a day as needed for constipation. 16. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal PRN as needed for constipation. 17. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mg PO once a day as needed for heartburn. 18. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q12H (every 12 hours) for 13 doses. Disp:*13 Recon Soln(s)* Refills:*0* 19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [**Location (un) 2251**] Nursing and Rehabilitation - [**Location (un) 2251**] Discharge Diagnosis: Healthcare Associated Pneumonia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname 90888**], It was a pleasure participating in your care. You were admitted for difficulty breathing, decreased oxygen saturation and low blood pressure. You were found to have pneumonia, likely due to aspiration. You were started on broad spectrum antibiotics, given IV fluids, and we temporarily increased the dosage of your steroids. You have now improved and are ready to return to your nursing facility. You will continue on Cefepime 2g IV q12h through [**11-18**]. . Please START the following medications: - Cefepime 2g IV q12h through [**11-18**] Followup Instructions: Please follow up with your primary care doctor within 1 wk.

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

9282, 9387

3736, 6455

327, 333

9463, 9463

2455, 3713

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51034

Discharge summary

report

Admission Date: [**2133-9-21**] Discharge Date: [**2133-9-23**] Date of Birth: [**2073-8-19**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3705**] Chief Complaint: Hyperkalemia Major Surgical or Invasive Procedure: None History of Present Illness: This is a 60-year old woman with a history of CKD, fairly refractory HTN, untreated chronic hepatitis C, acute on chronic renal failure, mechanical AVR/MVR on Coumadin and depression who presents after being sent to the ED by her PCP for hyperkalemia with a K+ of 6.7. She was recently admitted for weakness in her legs and discharged on [**9-15**]. Today during routine follow up she was found to have hyperkalemia. She states that other than the ongoing weakness in her legs she is asymptomatic. . On arrival to the ED initial VS were 99.0 75 [**Telephone/Fax (2) 106016**]0% RA. Initial labs were significant for K of 6.7, Cr of 2.6, and H/H of 8.3/26.9 (stable), and INR of 3.4. She had no specific complaints. She received 1 gram of calcium gluconate, insulin, D50, and kayexelate. EKG showed slightly hyperacute T waves which were felt not significantly different from baseline. She received 1L NS. No evidence of end organ ischemia. Given IV metoprolol after missing her PM dose. . On arrival to the MICU she appeared comfortable and in no acute distress, breathing comfortably on room air. She had no active complaints and specifically denied headache or chest pain. Past Medical History: DEPRESSION [**2127-7-17**] ANEMIA ACUTE RENAL FAILURE [**8-/2125**] ALCOHOL ABUSE ATROPHIC VAGINITIS CARDIAC VALVE REPLACEMENT (MECHANICAL) [**2123**] AVR (19mm Regent) and MVR (27mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]) on [**2123-11-15**] (Dr [**Last Name (Prefixes) 16706**]) DIARRHEA [**2125**]: thickening of transverse colon on CT [**8-5**] ? significance HEPATITIS C: received hep A & B vaccines; genotype 1, viral load [**2-10**] was 1,160K - not currently being treated HERPES SIMPLEX HYPERTENSION [**2124**] LOW BACK PAIN MIGRAINE HEADACHES S/P HYSTERECTOMY TOBACCO ABUSE WEIGHT LOSS History of positive RPR at 1:2 ([**2132-7-17**] and [**2132-9-10**]), but never completed treatment (only received 2 of 3 Benzathine PCN G injections - [**2132-7-31**] and [**2132-8-11**]). Social History: Patient lives home alone in [**Location (un) 577**] up four flights of stairs. Smokes [**2-2**] pack per day. Denies EtOH (sober since [**2131-5-3**]) or drug use at this time (previous MJ, Percocet, cocaine, crack use per [**Year (4 digits) **]). Has not been sexually active in 5 years. Family History: Mom had breast cancer in her 50s. No h/o abdominal/GI diseases. Family h/o DM (brother, uncle, grandmother). Physical Exam: ADMISSION PE: Vitals: hr 74 bp 204/93 rr 12 O2 sat 98/ra 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, S1 and S2 loud clicks, 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, 1+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 1+ reflexes bilaterally, gait deferred Discharge PE: VS - 98.4 79 137/86 11 98% ra GEN Alert, oriented, no acute distress HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple, no JVD, no LAD PULM Good aeration, CTAB no wheezes, rales, ronchi CV RRR normal S1/S2, loud clicks, no mrg ABD soft NT ND normoactive bowel sounds, no r/g EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, motor function grossly normal SKIN no ulcers or lesions Pertinent Results: ADMISSION LABS: [**2133-9-21**] 07:47PM BLOOD WBC-10.7 RBC-3.08* Hgb-8.3* Hct-26.9* MCV-87 MCH-27.0 MCHC-31.0 RDW-15.5 Plt Ct-435# [**2133-9-21**] 01:34PM BLOOD PT-34.7* INR(PT)-3.4* [**2133-9-21**] 01:34PM BLOOD UreaN-53* Creat-2.6* Na-137 K-6.7* Cl-106 HCO3-20* AnGap-18 [**2133-9-21**] 07:47PM BLOOD ALT-48* AST-53* AlkPhos-121* TotBili-0.1 [**2133-9-21**] 07:47PM BLOOD Calcium-8.7 Phos-5.8* Mg-1.9 [**2133-9-21**] 07:56PM BLOOD K-6.6* Relevant Labs: CPK ISOENZYMES CK-MB cTropnT [**2133-9-22**] 12:28 2 <0.011 [**2133-9-22**] 01:27 2 <0.011 [**2133-9-22**] 01:27 BUN Cr Na K Cl Bicarb Gap 55* 2.5* 138 5.9* 109* 19* 16 Discharge Labs: [**2133-9-23**] 06:00 BUN Cr Na K Cl Bicarb Gap 52* 2.1* 137 5.0 107 24 11 COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2133-9-23**] 06:00 8.3 2.84* 7.9* 24.9* 88 28.0 31.9 15.6* 365 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2133-9-23**] 06:00 365 [**2133-9-23**] 06:00 28.2* 2.7* Pertinent Micro/Path: None Pertinent Imaging: [**Known lastname **]-[**Last Name (LF) **],[**Known firstname **] [**Medical Record Number 106017**] F 60 [**2073-8-19**] Cardiovascular Report ECG Study Date of [**2133-9-22**] 1:40:52 AM Sinus rhythm. Since the previous tracing of [**2133-9-21**] no significant change in previously noted findings. TRACING #2 Brief Hospital Course: Ms. [**Known lastname 106013**] is a 60-year-old female with HTN, CKD, untreated chronic Hepatitis C and active depression with related acute on chronic renal failure (baseline Cr 1.1), and mechanical AVR/MVR on Coumadin who is presenting with hyperkalemia and hypertensive urgency. . #1. Hyperkalemia: Most likely due to dietary indiscretion (she eats half a grapefruit/day) atop worsening renal function. EKG with peaked T waves. Received calcium gluconate, insulin, D50 and kayexelate in the ED. She received kayexelate x 2 and 20 mg IV Lasix in the MICU. K+ decreased to 5.0 by discharge. We added weekly kayexelate and HCTZ 50 mg po daily to her regimen to attempt to eliminate more potassium renally and through stool. #2. Hypertensive Urgency: SBPs 210s-230s with headache on arrival to ED; she had missed her evening medications, including metoprolol. She is a patient with a long history of labile blood pressures, hypertension as well as hypotension. Currently SBPs 150s-160s, which is around her baseline of SBPs in 150s per [**Known lastname **]. No signs of end organ damage, including no focal neurologic deficits, chest pain, elevated cardiac enzymes. We added HCTZ 50 mg po daily to her home regimen of amlodipine, metoprolol and guanfacine. We temporarily held her Adderall, and restarted it on [**9-23**] am, once her BPs were back in her typical range. . #3. Acute on chronic renal injury: Creatinine 2.5-2.7 on admission, and down to 2.1 on discharge, which are near her recent baseline since [**Month (only) 116**] of 1.9-3.4. Prior to [**2133-6-2**], her baseline creatinine was ~1.1. Followed by Dr. [**Last Name (STitle) 7473**]. Thought likely [**3-5**] hepatitis C related cryoglobulinemia vs hypertensive nephropathy. Dr.[**Name (NI) 12913**] renal consult team followed her while here, and he will see her in [**Name (NI) **] next week. Chronic Diagnosis: #4. Hepatitis C: No prior treatment. Per review of notes in [**Name (NI) **] she was most recently ([**2133-9-10**]) being considered for participation in a study. If she could not join this study she was interested in starting standard triple therapy. Her worsening renal function is felt likely [**3-5**] cryoglobinemia due to her hepatitis C. #5. History of Alcoholism: Sober now 1.5 years, on Antabuse. . #6. AVR/MVR: On coumadin. INR 3.4 on admission and 2.7 on discharge. Goal 2.5-3.5. . #7. Anemia: Normocytic, chronic, likely due to anemia of chronic disease vs CKD. Less likely mechanical shearing from valves. . #8. Ambulatory difficulty: As previously documented she has a recent history of difficulty ambulating which she feels is due to bilateral weakness in her legs. I do not appreciate any significant weakness on my exam. This could have been due to fluctuating levels of potassium; neurological, toxic-metabolic, systemic causes investigated and all negative during last admission. This has been stable over the last few weeks and can be further worked up as an outpatient. . #. Depression: Denies current or recent SI/HI. Continued on home regimen. To follow up with outpatient providers. TRANSITIONAL ISSUES: - Follow up urine electrolytes. - Re-check BPs, K within the next week and adjust medications as appropriate. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Amlodipine 5 mg PO DAILY hold for SBP < 100 2. Metoprolol Tartrate 100 mg PO BID hold for SBP < 100 or HR < 60 3. Mirtazapine 45 mg PO HS 4. Warfarin 6.5 mg PO DAYS ([**Doctor First Name **],MO,TU,WE,TH,FR,SA) 5. Adderall *NF* (amphetamine-dextroamphetamine) 10 mg Oral daily 6. BuPROPion 75 mg PO DAILY 7. Disulfiram 250 mg PO DAILY 8. guanFACINE *NF* 2 mg Oral qhs 9. hydrocortisone-pramoxine *NF* 2.5-1 % Rectal prn up to twice a day 10. urea *NF* 40 % Topical daily apply to feet for scaling 11. Multivitamins 1 TAB PO DAILY 12. Thiamine 100 mg PO DAILY Discharge Medications: 1. Adderall *NF* (amphetamine-dextroamphetamine) 10 mg Oral daily 2. Amlodipine 5 mg PO DAILY hold for SBP < 100 3. Metoprolol Tartrate 100 mg PO BID hold for SBP < 100 or HR < 60 4. Mirtazapine 45 mg PO HS 5. Multivitamins 1 TAB PO DAILY 6. Thiamine 100 mg PO DAILY 7. urea *NF* 40 % Topical daily apply to feet for scaling 8. Warfarin 6.5 mg PO DAYS ([**Doctor First Name **],MO,TU,WE,TH,FR,SA) 9. Disulfiram 250 mg PO DAILY 10. guanFACINE *NF* 2 mg Oral qhs 11. hydrocortisone-pramoxine *NF* 2.5-1 % Rectal prn up to twice a day 12. BuPROPion 75 mg PO DAILY 13. Sodium Polystyrene Sulfonate 30 gm PO QTUES RX *sodium polystyrene sulfonate 15 gram/60 mL 120 ml(s) by mouth every tuesday Disp #*1000 Milliliter Refills:*0 14. Hydrochlorothiazide 50 mg PO DAILY hold for sbp<100 RX *hydrochlorothiazide 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Hyperkalemia Hypertensive urgency Chronic kidney disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Hello Ms. [**Known lastname 106013**], You were admitted to the [**Hospital1 18**] because you were found to have a very elevated potassium value (at 6.7) at your appointment with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **]. He sent you to the ED to get this addressed. You were treated with medication to bring your potassium value down. We think this was partly from your diet and partly from your kidney disease (since your kidneys are not able to completely eliminate all the potassium you had been having). You received education about foods low in potassium for you to eat from here on out. We have added one medicine for you to take weekly to help you eliminate extra potassium through your stool: - We ADDED Kayexelate once a week. You were also found to have a very elevated blood pressure (about 230 systolic; normal is 120). We made some changes to your blood pressure regimen to allow for better control of your blood pressures from now on, which are as follows: - We ADDED hydrochlorothiazide 50 daily. Hopefully, with these changes (diet, Kayexelate, hydrochlorothiazide), your blood pressures and potassium values will be in better control. It was a pleasure taking care of you. We made the following changes to your medications: STARTED Hydrochlorothiazide STARTED Kayexalate Followup Instructions: Department: [**Hospital3 249**] When: THURSDAY [**2133-9-24**] at 11:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: THURSDAY [**2133-9-24**] at 5:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 36070**], [**Last Name (NamePattern1) 1046**] [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: WEST [**Hospital 2002**] [**Hospital **] When: MONDAY [**2133-9-28**] at 12:30 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 Department: [**Hospital3 249**] When: THURSDAY [**2133-10-1**] at 5:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 36070**], [**Last Name (NamePattern1) 1046**] [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10227, 10233

5391, 8488

317, 323

10334, 10334

3893, 3893

11852, 13264

2687, 2798

9337, 10204

10254, 10313

8647, 9314

10485, 11752

4586, 5368

2813, 3448

8509, 8621

11781, 11829

3462, 3874

265, 279

351, 1528

3910, 4570

10349, 10461

1550, 2364

2380, 2671

27,312

190,068

8829+55978

Discharge summary

report+addendum

Admission Date: [**2101-12-2**] Discharge Date: [**2101-12-17**] Date of Birth: [**2035-9-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2160**] Chief Complaint: Hypothermia Major Surgical or Invasive Procedure: Lumbar Puncture Endotracheal Intubation Central Venous Line History of Present Illness: 66 y/o male brought in by EMS for hypothermia. By EMS report, patient found standing in the [**Street Address(1) 30797**] St. in [**Location (un) **] after indeterminate amount of time outside. FS 91. BP 96/57 with pulse of 50, RR 16, sat 99% RA. Patient reports going out for the paper today, then forgeting where he was. He claims he was only outside for several minutes. His only symptome was dizziness, but he did not fall or loose consciousness. He has not been eating well, and has been having diarrhea described as loose stools without melena or blood for the last 3 months. Also reports leg weakness over the last several months. Records indicate he was complaining of left foot pain to the parametics. He denies fever, chills, headache, chest pain, dyspnea, dysuria. . In ED, oral temp 90.6 HR 60 BP 95/53. He received 5 L NS and 750 mg Levofloxacin. Past Medical History: Depression/Anxiety BPH s/p TURP Crohn's Disease Recurrant Leg infections Social History: Lives at senior housing in [**Location (un) **]. Graduated high school. HCP is his cousin, [**Name (NI) 565**] [**Name (NI) 10743**] at ([**Telephone/Fax (1) 30798**]. Family History: Mental illness on fathers side. Physical Exam: GENERAL: Male in no distress. VITALS: T 96.3 rectal HR 66 BP 90/57 RR 18 Sat 97%RA SKIN: no lesions HEENT: Anicteric, PERRL, Mild right lateral eye deviation, mouth dry NECK: No stiffness, No masses, No LAD, Palpable carotid pulses, no bruits, no tracheal deviation, no JVP elevation CHEST: no supraclavicular or axillary LAD, Lungs Clear to Asculation, No Wheezes/Rhonchi/Crackles HEART: Normal PMI, RRR, No Murmurs/Gallops/Rubs ABDOMEN: Flat, No scars, NABS, Soft, No organomegaly, No masses, No guarding, No rebound. EXT: No clubbing/cyanosis/edema. Good Pulses. NEURO: MS oriented to person, year/month/day. CN II-XII intact Muscle Strength 5/5 with some effort difficulty Pertinent Results: Admission Labs: ----------------- [**2101-12-2**] 12:35PM WBC-6.4 RBC-4.12* HGB-12.1* HCT-35.6* MCV-86 MCH-29.4# MCHC-34.1 RDW-14.3 [**2101-12-2**] 12:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2101-12-2**] 12:35PM NEUTS-68 BANDS-0 LYMPHS-26 MONOS-3 EOS-2 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [**2101-12-2**] 12:35PM PLT SMR-LOW PLT COUNT-126* [**2101-12-2**] 12:35PM FREE T4-1.2 [**2101-12-2**] 12:35PM TSH-1.1 [**2101-12-2**] 12:35PM CK-MB-NotDone [**2101-12-2**] 12:35PM ALT(SGPT)-59* AST(SGOT)-34 LD(LDH)-169 CK(CPK)-77 ALK PHOS-50 AMYLASE-51 TOT BILI-0.3 [**2101-12-2**] 12:35PM GLUCOSE-102 UREA N-26* CREAT-0.8 SODIUM-149* POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-32 ANION GAP-10 [**2101-12-2**] 01:10PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG . Other Labs: ------------- [**2101-12-12**] 04:34AM BLOOD WBC-8.4 RBC-3.26* Hgb-9.5* Hct-28.8* MCV-89 MCH-29.1 MCHC-32.9 RDW-15.1 Plt Ct-160 [**2101-12-12**] 04:34AM BLOOD Glucose-87 UreaN-19 Creat-2.0* Na-140 K-4.3 Cl-107 HCO3-22 AnGap-15 [**2101-12-12**] 02:00PM BLOOD Glucose-114* UreaN-17 Creat-1.8* Na-138 K-4.1 Cl-107 HCO3-25 AnGap-10 [**2101-12-13**] 03:43AM BLOOD Glucose-101 UreaN-15 Creat-1.7* Na-144 K-4.1 Cl-107 HCO3-29 AnGap-12 [**2101-12-14**] 07:20AM BLOOD Glucose-94 UreaN-14 Creat-1.4* Na-141 K-4.1 Cl-105 HCO3-30 AnGap-10 [**2101-12-9**] 07:15AM BLOOD ALT-125* AST-83* LD(LDH)-252* AlkPhos-66 TotBili-0.5 [**2101-12-9**] 07:51PM BLOOD ALT-112* AST-71* LD(LDH)-198 CK(CPK)-169 AlkPhos-62 TotBili-0.4 [**2101-12-12**] 04:34AM BLOOD ALT-58* AST-36 LD(LDH)-253* AlkPhos-55 TotBili-0.3 [**2101-12-13**] 03:43AM BLOOD ALT-61* AST-37 LD(LDH)-226 AlkPhos-57 TotBili-0.3 [**2101-12-14**] 07:20AM BLOOD ALT-53* AST-34 LD(LDH)-249 AlkPhos-61 TotBili-0.3 [**2101-12-3**] 04:00AM BLOOD Cortsol-25.6* [**2101-12-3**] 04:40AM BLOOD Cortsol-42.3* [**2101-12-3**] 05:10AM BLOOD Cortsol-44.8* [**2101-12-2**] 12:35PM BLOOD TSH-1.1 [**2101-12-2**] 12:35PM BLOOD Free T4-1.2 [**2101-12-10**] 02:30AM BLOOD Ammonia-22 [**2101-12-10**] 02:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2101-12-2**] 12:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2101-12-9**] 06:37PM BLOOD Type-ART Temp-36.7 FiO2-21 pO2-118* pCO2-49* pH-7.43 calTCO2-34* Base XS-7 Intubat-NOT INTUBA Vent-SPONTANEOU [**2101-12-9**] 08:14PM BLOOD Type-ART pO2-247* pCO2-54* pH-7.39 calTCO2-34* Base XS-6 [**2101-12-9**] 11:45PM BLOOD Type-ART Temp-36.2 Rates-12/ Tidal V-500 PEEP-5 FiO2-60 pO2-313* pCO2-46* pH-7.43 calTCO2-32* Base XS-5 Intubat-INTUBATED [**2101-12-10**] 05:32PM BLOOD Type-ART Temp-35.9 Rates-/14 Tidal V-280 PEEP-5 FiO2-40 pO2-94 pCO2-46* pH-7.41 calTCO2-30 Base XS-3 Intubat-INTUBATED [**2101-12-12**] 09:57AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007 [**2101-12-12**] 09:57AM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2101-12-12**] 09:57AM URINE Hours-RANDOM UreaN-172 Creat-41 Na-106 K-11 Cl-104 [**2101-12-9**] 11:46PM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [**2101-12-2**] 01:10PM URINE bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [**2101-12-9**] 11:21PM CEREBROSPINAL FLUID (CSF) WBC-20 RBC-2870* Polys-56 Lymphs-32 Monos-4 Eos-8 [**2101-12-9**] 11:21PM CEREBROSPINAL FLUID (CSF) WBC-15 RBC-3505* Polys-68 Lymphs-32 Monos-0 [**2101-12-9**] 11:21PM CEREBROSPINAL FLUID (CSF) TotProt-53* Glucose-65 LD(LDH)-14 [**2101-12-9**] 11:21 pm CSF;SPINAL FLUID Source: LP. QUANTITY NOT SUFFICIENT FOR ACID FAST SMEAR (MAW). GRAM STAIN (Final [**2101-12-10**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2101-12-15**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST CULTURE (Preliminary): The sensitivity of an AFB smear on CSF is very low.. If present, AFB may take 3-8 weeks to grow.. VIRAL CULTURE (Preliminary): No Virus isolated so far. . [**2101-12-9**] 11:21 pm CSF;SPINAL FLUID Source: LP. **FINAL REPORT [**2101-12-10**]** CRYPTOCOCCAL ANTIGEN (Final [**2101-12-10**]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. Performed by latex agglutination. (Reference Range-Negative). Results should be evaluated in light of culture results and clinical presentation. . HSV PCR ([**12-10**]) - negative . Discharge Labs: ---------------- WBC-10.7, Hct-38, Plt-294 Na-139, K-4.3, Cl-101, HCO3-28, BUN-13, Cr-1.1, Gluc-84, Ca-9.7, Mg-2.2, Phos-3.4 . Studies: --------- ECG ([**12-13**]): Sinus rhythm. Left anterior fascicular block. Since the previous tracing of [**2101-12-9**] sinus bradycardia is absent. Otherwise, baseline artifact on previous tracing makes comparison difficult. . RENAL U.S. [**2101-12-12**] 9:30 AM RENAL ULTRASOUND: The right kidney measures 10 cm and left kidney measures 11 cm, with no hydronephrosis, masses or stones. The cortices of both kidneys are mildly thinned. No echogenic calculi are identified. A 1.4 x 1 x 1.2 cm simple cyst with increased through transmission is seen within the lower pole of the left kidney. Foley catheter is seen within a decompressed bladder. IMPRESSION: 1. No evidence of echogenic renal calculi or hydronephrosis. 2. Mild thinning of the renal cortices which likely represents medical renal disease . CHEST (PORTABLE AP) [**2101-12-11**] 4:54 AM The tip of the ET tube is in satisfactory position approximately 4.7 cm above the carina. An NG tube is present, tip beneath diaphragm overlying stomach. There are low inspiratory volumes. Doubt CHF. There is continued opacity at the right base medially, consistent with collapse and/or consolidation. The extreme right costophrenic angle is excluded from the film. No gross effusion is identified. No pneumothorax detected. Compared with [**2101-12-10**] and allowing for differences in technique, there has probably been some re-expansion of atelectasis in the right lung. Otherwise, I doubt significant interval change. . MR HEAD W & W/O CONTRAST [**2101-12-11**] 2:15 PM FINDINGS: There is no evidence of hemorrhage, edema, masses, mass effect or infarction. The ventricles and sulci are normal in caliber and configuration. No diffusion abnormalities are identified. Bilateral T2 and FLAIR hyperintensities are grossly stable since [**2094-4-12**] and likely represent chronic small vessel ischemia. There are no areas of abnormal enhancement. MRA: The intracranial vertebral and internal carotid arteries and their major branches are unremarkable without evidence of stenosis, occlusion, or aneurysm formation. Incidentally noted is a small right A1, likely a congenital variant. IMPRESSION: Grossly unchanged since [**2094-4-12**] without evidence of acute intracranial process. . EEG ([**12-11**]): FINDINGS: ABNORMALITY #1: In the most awake-appearing portions of this tracing, a moderately well-organized 7-7.5 Hz theta frequency background was seen. BACKGROUND: As above. HYPERVENTILATION: Was contraindicated. INTERMITTENT PHOTIC STIMULATION: Could not be performed as the test was requested as a portable study. SLEEP: No transitions from sleep to wakefulness were seen. CARDIAC MONITOR: Revealed a generally regular rhythm with average rate of 66 bpm. IMPRESSION: This EEG demonstrates a slow background rhythm consistent with a mild encephalopathy or similar findings may be seen in patients with extensive subcortical white matter disease located bilaterally or in deep, midline locations. No evidence of ongoing seizures is seen. . Head CT ([**12-10**]): CT HEAD W/O CONTRAST [**2101-12-9**] 9:56 PM NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage. Again seen are scattered subcortical white matter hypodensities suggesting chronic small vessel ischemic disease. The more focal area of hypoattenuation within the right frontal lobe anteriorly is unchanged compared to one day prior. Visualized paranasal sinuses and mastoid air cells are clear. The osseous structures are unremarkable. IMPRESSION: No acute intracranial hemorrhage. Chronic microvascular ischemic disease. Again, MRI with DWI is more sensitive for acute ischemia. . CT HEAD W/O CONTRAST [**2101-12-8**] 6:36 PM FINDINGS: The study is motion degraded. There is no evidence of hemorrhage, edema, mass, or mass effect. There are scattered periventricular and subcortical white matter hypodensities, suggestive of chronic small vessel ischemic disease. More focal hypodensity in the right frontal white matter may reflect a small lacunar infarct. The ventricles and sulci are normal in caliber and configuration. There is no fracture. IMPRESSION: Mild small vessel ischemic changes. No intracranial hemorrhage. Please note that MRI with diffusion-weighted imaging is more sensitive for the detection of acute infarction. Brief Hospital Course: 66 y/o male with hypothermia. . 1. Hypothermia: Improved with warming. Was initially treated for sepsis and empirically on Levaquin for posssible sepsis, however no evidence of sepsis. Patient had a normal temp during the remainder of the hospitalization. . 2. Delirium: Acute delerius episode on [**12-9**] early AM. Psychiatry was consulted, as he was on so many baseline psychotropic medications. Seratonin syndrome was suspected in the setting of an elevated fluoxetine dose interacting with other medications, and all serotonergic medications were discontinued, including fluoxetine, buspirone, asacol and hysocamine. This required ICU transfer and patient was intubated for airway protection. He was successfully extubated 3 days later. CT head showed no acute changes. He also received an initial dose of cyproheptadine, which did not impressively change his mental status. He had an MRI with no acute change (results as above). An LP was done with results as above. Significant number of red cells seen (likely traumatic), but patient empirically placed on Acyclovir for possible HSV meningoencephalitis. Once HSV PCR returned on the day prior to discharge, this was discontinued. Prior to discharge, patient was oriented x 3 and appeared to back to baseline mental status. He was ultimately restarted on diazepam and risperdal. . 3. Acute renal falure - this was in setting of acyclovir. Cr elevated to as high as 2. This improved with hydration and was back to baseline level on discharge. . 4. GI Bleed - patient had an episode of coffee ground emesis while in the ICU. Hct was as low as 28, however patient received significant IV fluid for decreased bp. His hct was 38 on discharge. Hematocrit recheck is recommended in 10 days to ensure stability. . 5. Depression/Anxiety/Mild mental retardation: See above regarding medication changes. He should follow up with his primary psychiatrist. . 6. Crohn's: home medications were held. No episodes of abdominal discomfort. These medications can be restarted as an outpatient. . 7. Hyperlipidemia - LFTs were elevated so lipitor was held. LFTs should be monitored as an outpatient and lipitor can be restarted if LFT remain normal. . 8. Htn - bp decreased while patient in the ICU. Metoprolol was held. BP should be monitored as an outpatient, and consideration should be given to restarting this as an outpatient. . Of note, during the course during the course of this hospitalization, the patient's cousin, [**Name (NI) 565**] [**Name (NI) 10743**] who is his HCP, allegedly threatened to kill one of the physicians due to the patient's acute delirium which likely resulted from unusually high doses of SSRIs. Mr. [**Name13 (STitle) 10743**] was subsequently barred from entering the hospital. The patient was discharged to [**Location (un) **] Health on [**2101-12-17**]. He was originally set to be discharged on [**2101-12-16**] but due to bed unavailability this was postponed. On the day of discharge, health care proxy was called and was informed that the patient will be leaving to go to rehab. This was done at the patient's request. It was noted in the chart that in the ICU, patient's proxy had brought up that patient be DNR/DNI. This was brought up on phone with the proxy on discharge day. Mr [**First Name8 (NamePattern2) 565**] [**Last Name (NamePattern1) 10743**] stated that in event of a cardiac and respiratory arrest - he did want manual chest compressions but no shocks, mechanical ventilation, intubation or other artificial means of resuscitation. It was discussed with him at length that manual compressions alone would rarely be effective without the other aspects of CPR eg shocks, mechanical ventilation etc. He understood this and still wanted patient to only have manual compressions on chest. Dr [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 14936**] was contact[**Name (NI) **] as well. Per her, the patient has mental retardation and will need further detailed neuropsych assessment to determine if the patient has capacity to make his medical decisions. Upon my discussion with patient today, he had minimal recollection of the events during the hospitalization and could not tell me details about his hospital stay except that he had "hypothermia". This was discussed at length with legal ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**]). The patient will need formal capacity testing to determine if he can understand and make his own decisions about medical care and code status. Since there were concerns during this hospital stay about the health care proxy's descisions and that the patient stated at times that the cousin wanted to shoot him, it would be best if patient had a formal capacity evaluation and further determination of the decision maker be deferred to that time. It is recommended that social work and legal services should be involved at the rehab to pursue this further. Extensive discussion was held with legal services - [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**] prior to discharge. Medications on Admission: Asacol 800 mg TID Buspirone 20 mg [**Hospital1 **] Diazepam 2 mg [**Hospital1 **] Fluoxetine 60 mg [**Hospital1 **] Hyoscyamine 0.125 TID Lamictal 12.5 mg daily Lipitor 10 mg QHS Metoprolol xl 100 mg QHS MVA Risperdal 2 mg QHS Vit B12 100 mcg daily Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 4. Risperidone 2 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for agitation. 5. Diazepam 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for anxiety. 6. Vitamin B-12 100 mcg Tablet Sig: One (1) Tablet PO once a day. 7. Multiple Vitamins Tablet Sig: One (1) Tablet PO once a day. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital **] health care center Discharge Diagnosis: Primary: Altered mental status - likely secondary to serotonin syndrome Hypothermia - resolved Secondary: Acute renal failure - in setting of Acyclovir, resolved GI bleed Depression/Anxiety Dyslipidemia Crohn's Disease BPH s/p TURP Mental Retardation Discharge Condition: Afebrile, vital signs stable Discharge Instructions: You were admitted due to hypothermia. You subsequently had a change in your mental status, likely from an interaction of your medications (serotonin syndrome). This resulted in intubation. You subsequently were placed on a medication, Acyclovir that resulted in worsening of your kidney function. This has improved. Since your spinal fluid test for HSV was negative, this medication was stopped. Due to the reaction you had that caused the change in your mental status, many of your psychiatric medications (Fluoxetine, buspar, and lamictal) were held and your Crohn's disease medications (hycosamine and mesalamine) were stopped as well. Your Lipitor was held because there was an elevation in your liver enzymes. Your Metoprolol was held due to low blood pressures. These can be restarted if your primary doctor rechecks your liver tests and finds them to be back to your baseline and your blood pressure is elevated. You should follow up with your primary doctor and your psychiatrist about restarting the appropriate medications. . Please call your doctor or return to the emergency room if you were to develop worsening headache, change in your vision, high fever, or increased confusion. Followup Instructions: 1) Primary Care - Dr. [**First Name (STitle) **] [**Name (STitle) 5404**]. ([**Telephone/Fax (1) 30799**]. Please call to arrange a follow up appointment within the next 1-2 weeks. 2) Psychiatry - Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**Telephone/Fax (1) 5260**]. Message left to set up appointment. You should call as well to schedule an appointment in the next 1-2 weeks regarding your psych meds. Name: [**Known lastname 5375**],[**Known firstname 4049**] R Unit No: [**Numeric Identifier 5376**] Admission Date: [**2101-12-2**] Discharge Date: [**2101-12-17**] Date of Birth: [**2035-9-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1455**] Addendum: The patient was taking fluoxetine 60 mg at bedtime (not [**Hospital1 **]) on admission to hospital. This was confirmed with the Hospitalist Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Discharge Disposition: Extended Care Facility: [**Hospital 5377**] health care center [**Name6 (MD) **] [**Last Name (NamePattern4) 1456**] MD [**MD Number(2) 1457**] Completed by:[**2101-12-19**]

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Discharge summary

report

Admission Date: [**2153-2-11**] Discharge Date: [**2153-2-14**] Date of Birth: [**2074-6-3**] Sex: M Service: MEDICINE Allergies: Namenda Attending:[**First Name3 (LF) 2108**] Chief Complaint: fever, nausea, vomiting Major Surgical or Invasive Procedure: ERCP on [**2153-2-12**] History of Present Illness: Transfer from [**Hospital Ward Name 332**] ICU after admission for bradycardia and e coli sepsis 78 year old male with functional dementia, hypertension and type 2 diabetes mellitus who was admitted to [**Hospital3 20284**] Center on [**2153-2-8**] from home due to three day history of altered mental status, nausea and vomiting. At [**Hospital3 20284**] Center, he was noted to have fever of 104, blood cultures positive for pansensitive E. Coli bacteremia thought to be due to cholangitis based on RUQ showing intra and extrahepatic biliary ductal dilatation and elevated liver enzymes. He underwent ERCP in the OR which was unsucessful on [**2153-2-9**] due to inability to cannulate common bile duct. CT abdomen on [**2153-2-11**] showed a 3.1 x 3.5 cm encasing common hepatic artery and 50% of SMV concerning for malignancy along with resultant extra and intrahepatic bile duct and pancreatic dilation. Post-ERCP, he was noted to have significant pause while having a bowel movement but it was not recorded as the leads had fallen off. Later that day, he was noted to have another significant pause, only a single complex over 22 seconds during which he was unresponsive requiring transvenous pacer wire placement by cardiology. He was subsequently transferred to [**Hospital1 18**] for another ERCP to treat his cholangitis and evaluate for the pancreatic head mass. On the floor, he does not report fever, chills, abdominal pain, nausea, vomiting, chest pain, shortness of breath, cough, dysuria or itchiness. On further review of system, he has had weight loss of [**10-31**] lbs for the past six weeks along with progressive weakness/fatigue and imbalance which has led to two falls with loss of consciousness or head trauma. In the ICU the patient underwent an ERCP with brushings and stent placement and a 2cm long distal CBD stricture was stented. He clinically improved. He had a transvenous pacer placed at [**Hospital3 20284**] center which was pulled as EP consult felt his episodes of sinus arrest were vagally mediated and he did not use his transvenous pacer. Past Medical History: 1. Type 2 diabetes mellitus 2. Alzheimer's dementia 3. Hypertension 4. Hyperlipidemia 5. Depression 6. s/p cochlear implant Social History: No tobacco or illicit drug use. Occassional alcohol and cigar intake. He retired as a college professor two years ago. Able to perform activities of daily living independently including driving. Family History: No family history of colon or pancreatic cancer. Physical Exam: VS: T 98 HR 75 BP 122/65 RR 12 O2 SAT 94% on RA. GEN: AOX3, mild forgetfullness HEENT: MM dry, JVP 7cm CARD: RRR, no m/r/g PULM: CTAB ABD: soft, NT, ND, no masses or organomegaly EXT: WWP, no c/c/e NEURO: AOx3, able to move all extremities, with assistance able to stand, able to walk a couple of steps with some imbalance and just stabilization Pertinent Results: CBC ([**2153-2-11**]): WBC of 3.9 with 10% bands; HCT: 35.0; Plt:138 Liver enyzmes ([**2153-2-8**]) --> ([**2153-2-9**]) --> ([**2153-2-11**]) T. Bili 1.9-->1.4--> 2.0; Direct bili: 1.2--> 1.0--> 0.8; AST: 232-->81 -->80 ; ALT:370-->225--> 154, ALP: 316-->280--> 348 Lipase ([**2153-2-8**]) --> ([**2153-2-11**]): 447 --> 525 [**2153-2-14**] 08:00AM BLOOD WBC-4.3 RBC-3.70* Hgb-11.5* Hct-34.5* MCV-94 MCH-31.1 MCHC-33.2 RDW-14.1 Plt Ct-190 [**2153-2-13**] 04:02AM BLOOD PT-14.8* PTT-25.0 INR(PT)-1.3* [**2153-2-14**] 08:00AM BLOOD Glucose-170* UreaN-9 Creat-0.8 Na-141 K-4.0 Cl-106 HCO3-30 AnGap-9 [**2153-2-13**] 04:02AM BLOOD Lipase-391* [**2153-2-14**] 08:00AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.0 CA19-9 495 (HIGH) Microbiology Blood culture ([**2153-2-8**]): Pansensitive E. coli. Imaging Abdominal Ultrasound ([**2153-2-8**]) Intra and extrahepatic biliary ductal dilatation with gallbladder sludge and tiny stones and a trace pericholecystic fluid. The cause of obstruction is not visible with the pancreas is entirely obscured by bowel gas. Evaluation of the abdominal aorta is limited. Minimally enlarged spleen incidentally noted. CXR ([**2153-2-11**]) Pacemaker wire tip is seen in stable position with its tip projecting over the right atrium. No evidence of acute cardiopulmonary process. CT Abdomen ([**2153-2-11**]) Pancreatic head mass (3.5 x 3.1 cm) encasing the common hepatic artery and 50% of SMV with resultant moderate intra and extrahepatic biliary ductal dilation. The pancreatic duct is severely dilated and there is atrophy of the pancreatic body and tailed. Enlarged gallbaldder is also noted. Labs: EKG (OSH): NSR @ rate of 62. Left axis deviation vs possible left anterior fascicular block with QRS borderline at 96. Normal P wave morphology. Tele (OSH): Pause less than 3 seconds. Unable to tell if there is shortening of PR prior to the pause. [**2153-2-13**] CTA OF THE PANCREAS: TECHNIQUE: MDCT images were acquired through the abdomen with and without IV contrast in multiple phases. Multiplanar reformations, maximum intensity projections, volume-rendered images and minimum intensity projections were obtained and reviewed. The partially imaged lungs show left greater than right pleural effusions with associated compressive atelectasis. No nodules or consolidations are noted. The partially imaged heart is unremarkable. CT OF THE ABDOMEN WITH IV CONTRAST: A common bile duct stent is in appropriate position. There is dilation of the pancreatic duct up to 1 cm terminating in a possible lesion in the head of the pancreas which is not definitely visualized. Mild soft tissue is noted around the hepatic artery as well as a replaced left hepatic artery (4:35 and 4:45). The liver shows small hypodensities that are too small to accurately characterize (4:24). Pneumobilia in the left lobe is expected and unchanged. There is vicarious secretion of contrast into a distended gallbladder. The spleen, both adrenals, both kidneys are unremarkable. The visible small and large bowel loops are unremarkable. No abdominal free fluid or free air is present. The visible osseous structures show anterior osteophyte formation in the lower thoracic and mid lumbar spine. No fractures, suspicious lytic or blastic lesions are noted. Pancreatic Tumor Table: I: Pancreatic tumor present: Yes. a) Location: Probably in the head of the pancreas. b) Size: 25 x 34 mm. c) Enhancement relative to pancreas: Iso. d) Confined to pancreas with clear fat planes (duodenum and IVC do not apply): No. e) Remaining pancreas: Atrophic with pancreatic ductal dilatation. II. Adenopathy present: Yes. a) Size and location of largest lymph node: Portal venous and 16 mm. b) Necrosis in lymph nodes: No. c) Size of gastroduodenal artery node, "node of importance": No definitely seen. III. Metastatic disease, definitely present: Yes. IV: Ascites/peripancreatic fluid: No. Pancreatic Vascular Table: I: Vascular Tumor Involvement: Yes. a) Celiac involvement: Yes. b) SMA involvement: No. c) SMV involvement and percent encasement: Yes and 100%. d) Less than 1 cm SMV between tumor and first major SMV branch: Yes. e) Portal vein involvement: Yes, it is mildly attenuated with no thrombus noted. g) Splenic vein involvement: No. h) Splenic artery involvement and distance from tumor to celiac artery bifurcation: No. i) Vascular Involvement, Other: No. II: Thrombosis, any vessel: No. III: Aberrant Anatomy: Yes. a) Replaced right hepatic artery: No. IMPRESSION: 25 x 34 mm pancreatic head tumor as described above with soft tissue along the hepatic artery and left aberrant hepatic artery as well as encasement of the superior mesenteric vein and narrowing of the portal vein. Brief Hospital Course: CHOLANGITIS / LIKELY NEW DIAGNOSIS OF PANCREATIC CANCER / E COLI SEPTICEMIA / BILE DUCT OBSTRUCTION: e coli is pansensitive, the patient was initially on broad spectrum antibiotics, narrowed to oral cipro for a 14 day course. (day # 1 of treatment was [**2153-2-8**], last day of treatment should be 14 days from adequate drainage which was [**2153-2-12**] so last day of treatment is [**2153-2-25**]). S/p stenting of bile duct obstruction. pancreatic surgery consulted and based on the CTA of the pancreas with significant vascular involvement including 100% encasement of the SMV the patient is not a surgical candidate. CA19-9 very elevated. Cytology pending at the time of discharge. The patient was set up to see Dr. [**Last Name (STitle) **] from oncology as an outpatient. His PCP was notified of the diagnosis. The patient and family were informed of the incurable nature of the diagnosis. BRADYCARDIA/PAUSE: currently with a normal HR, per EP pauses were vagally mediated. maintain good hydration. COMMUNICATION: WIFE IS HCP: [**Telephone/Fax (1) 90139**] Medications on Admission: Home Medications 1. Celexa 10 mg po qdaily 2. Exelon patch 3. Lisinopril 2.5 mg po qdaily 4. Metformin 500 mg po BID Discharge Medications: 1. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 11 days. Disp:*22 Tablet(s)* Refills:*0* 2. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Exelon Transdermal 4. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day: restart on Monday [**2153-2-19**]. 5. ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**1-21**] Tablet, Rapid Dissolves PO three times a day as needed for nausea. Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*1* 6. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO four times a day as needed for pain: this medication can be sedating. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Primary Diagnosis: Pancreatic mass bile duct obstruction Discharge Condition: Activity Status: Ambulatory - requires assistance or aid (walker or cane). Level of Consciousness: Alert and interactive. Mental Status: Confused - sometimes. Discharge Instructions: You were admitted to the hospital with fevers and found to have an infection in your bile ducts as well as a new diagnosis of pancreatic cancer. You will see an oncologist to help with the management of this. Please take your medications as prescribed and make your follow up appointments. MEDICATION CHANGES: START taking CIPROFLOXACIN (ANTIBIOTIC) for the next 11 days STOP taking LISIONPRIL HOLD OFF on restarting your METFORMIN until monday [**2153-2-19**] Followup Instructions: PCP [**Name Initial (PRE) **]: Thursday, [**2-22**] at 11:30am With: [**First Name8 (NamePattern2) 3049**] [**Last Name (NamePattern1) **],[**First Name3 (LF) **] Address: [**Doctor Last Name 90140**], [**Hospital1 **],[**Numeric Identifier 26407**] Phone: [**Telephone/Fax (1) 54992**] **Please discuss the pathoghy results from the biopsy you had done with your pancreas during your hospitalization with your PCP. Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2153-2-22**] at 11:00 AM With: [**Last Name (LF) 3150**],[**Name8 (MD) **] MD [**Telephone/Fax (1) 11133**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "45.14", "51.87" ]

icd9pcs

[ [ [] ] ]

9866, 9941

7992, 9068

292, 318

10042, 10164

3256, 7969

10716, 11437

2819, 2870

9236, 9843

9962, 9962

9094, 9213

10227, 10520

2885, 3237

10540, 10693

228, 253

346, 2439

9981, 10021

10179, 10203

2461, 2587

2603, 2803

32,194

152,167

7729

Discharge summary

report

Admission Date: [**2158-5-30**] Discharge Date: [**2158-6-2**] Date of Birth: [**2121-8-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 36 yo M with h/o EtOH abuse and recurrent pancreatitis thought [**1-21**] to EtOH now re presents with abdominal pain. He reports acute onset of epigastric abdominal pain at 2am on the day of admission; [**9-29**] without radiation. He notes pain is similar to prior episodes of pancreatitis. Reports last meal at 6pm day PTA. He endorses nausea and vomiting (no blood) x several episodes early this am through early afternoon. He denies fevers. Does endorse sweating and chills. No diarrhea, BRBPR/dark, tarry stools. He reports he has been drinking heavily since losing his job in [**3-/2158**] (more heavily than previously); however he has "cut back" to his normal 1 pint to 1 liter southern comfort daily since mid [**Month (only) 116**]; last drink 8pm night PTA. He reports h/o "the shakes" in the setting of EtOH, but denies DTs/seizures. Currently he reports feeling shaky however denies anxiety; he denies hallucinations and "creepy crawlies." Of note, he was recently admitted to the medical service [**2158-4-27**] to [**2158-4-29**] for abdominal pain at which time clinical diagnosis of pancreatitis was made. He was initially kept NPO with pain control with IV dilaudid. His pain quickly improved and he was discharged to home when tolerating POs. In the ED, initial vitals were T: 97.8 BP: 170/104 HR: 76 RR: 16 O2 sat: 100%RA. Labs were notable for lipase of 498. Calcium and LFTs were unremarkable. CT abd/pelvis was performed which revealed acute pancreatitis with evidence of rupture of previously seen pseudocyst. CT did not show e/o necrosis. He is known to general surgery and they were consulted in the ED: they recommended admission to medicine for IVFs and pain control. Blood pressures remained consistently 170s-200/100s. He received a banana bag and then 3.6L IV NS. He received 1mg dilaudid x3, 4mg zofran IV x1, valium 5mg IV x4, metoprolol 5mg IV x1, labetalol 20mg IV x1, atenolol 50mg PO x1. Despite multiple BP meds, pain meds, and valium, his BP remained markedly elevated and, thus, he is being transferred to the ICU for BP management and EtOH withdrawal. ROS: No HA/changes in vision. No LH/dizziness. No cough/SOB. No CP/palpitations. No orthopnea/PND. No LE edema. No dysuria/hematuria. No rashes, no joint pain. No numbness, tingling, weakness. Past Medical History: -HTN -Pancreatitis: from etoh. mx prior episodes. followed by Dr. [**Last Name (STitle) **]. hx of being on TPN. -Etoh abuse: 1Q-1L/d of Southern Comfort x >5yrs; c/b withdrawal, but no h/o DTs/seizures -s/p appy [**2150**] -C. diff s/p 14d abx -Anxiety/depression -GERD Social History: Lives with wife and 2 kids. +tobacco [**12-21**] ppd x 25yrs. +EtOH with 1Q to 1L southern comfort daily. Denies IVDU and intranasal drugs ever. Sexually active with wife only. [**Name2 (NI) 4084**] STDs. HIV tested (after tattoo) yrs ago and was neg. Family History: Mother w DM, many members with etoh abuse. Physical Exam: VS: 98.9 188/117 86 26 96%RA GEN: Appears very uncomfortable, mildly diaphoretic and markedly tremulous in b/l upper extremities. Mild voice tremor as well. HEENT: NC, PERRL, EOMI, no conjuctival injection, anicteric, OP clear, MMM, Neck supple, no LAD, no carotid bruits CV: RRR, nl s1, s2, no m/r/g PULM: CTAB, no w/r/r with good air movement throughout ABD: soft, TTP epigastrium and RUQ, no rebound/guarding, + hypo-normoactive BS. EXT: warm, dry, +2 distal pulses B/L NEURO: alert & oriented, CN II-XII grossly intact, strength and soft touch intact grossly. No asterixis. +tremor b/l upper extremities. PSYCH: flat affect. Pertinent Results: CXR: FINDINGS: Portable bedside chest radiograph is compared to [**5-30**], [**2157**]. The lung volumes are lower than the prior which explains a vague opacity in left retrocardiac region. The pulmonary vasculature are sharp. The cardiopulmonary contours are normal. CXR: FINDINGS: Portable AP upright chest radiograph is obtained. The lungs are clear bilaterally, demonstrating no evidence of pneumonia or CHF. No pleural effusion or pneumothorax is seen. Cardiomediastinal silhouette is normal. The osseous structures appear intact. No free air is seen below the diaphragm. CT ABDOMEN WITH IV CONTRAST: There is a large amount of peripancreatic fluid. At the level of the gastrohepatic ligament, a previously identified pancreatic pseudocyst is no longer identified. In its place is a large amount of peripancreatic fluid (2:23 - 28), with fluid tracking inferiorly along the anterior pararenal space (2:33). These findings are consistent with pancreatic pseudocyst rupture. There is pancreatic edema without evidence of pancreatic necrosis. Acute pancreatitis is likely present. There is no splenic or portal vein thrombosis. No arteriovenous fistula, bowel stricture, or abscess is identified. Several peripancreatic enhancing nodes are identified, likely reactive (2:23, 2:32). The liver, spleen, gallbladder, and adrenal glands are unremarkable. There is no change in multiple bilateral renal cysts. The abdominal aorta and common iliac arteries demonstrate multiple calcifications. There is no nodule, opacity, or pleural effusion demonstrated at the lung bases. CT PELVIS WITH IV CONTRAST: The prostate, rectum, sigmoid colon, and bladder are unremarkable. There is no pelvic or inguinal lymphadenopathy. Osseous structures are unremarkable. [**2158-6-2**] 07:00AM BLOOD WBC-8.4 RBC-3.75* Hgb-11.6* Hct-32.7* MCV-87 MCH-31.0 MCHC-35.6* RDW-14.9 Plt Ct-153 [**2158-5-30**] 09:25AM BLOOD WBC-10.7# RBC-5.90# Hgb-17.7# Hct-49.3# MCV-84 MCH-30.1 MCHC-36.0* RDW-15.5 Plt Ct-285# [**2158-6-2**] 07:00AM BLOOD Neuts-87.1* Lymphs-9.8* Monos-2.7 Eos-0.1 Baso-0.2 [**2158-5-30**] 09:25AM BLOOD Neuts-77.9* Lymphs-18.7 Monos-3.1 Eos-0.1 Baso-0.1 [**2158-6-2**] 07:00AM BLOOD Glucose-114* UreaN-6 Creat-0.6 Na-136 K-3.7 Cl-101 HCO3-24 AnGap-15 [**2158-5-30**] 09:25AM BLOOD Glucose-176* UreaN-16 Creat-0.7 Na-140 K-4.1 Cl-100 HCO3-23 AnGap-21 [**2158-6-1**] 12:16PM BLOOD ALT-8 AST-21 LD(LDH)-304* AlkPhos-69 Amylase-121* TotBili-1.1 [**2158-5-30**] 09:25AM BLOOD ALT-19 AST-17 AlkPhos-89 TotBili-0.4 [**2158-6-1**] 12:16PM BLOOD Lipase-182* [**2158-6-2**] 07:00AM BLOOD Calcium-8.1* Phos-1.4* Mg-2.0 [**2158-5-30**] 08:31PM BLOOD %HbA1c-5.7 Brief Hospital Course: 36 year old male with h/o EtOH abuse and recurrent pancreatitis presented with abdominal pain secondary to pancreatitis initially admitted to ICU for BP control and management of EtOH withdrawal. . # Pancreatitis: The patient initially had epigastric pain, with elevated lipase and CT evidence of pancreatitis without evidence of necrosis. The previously visualized pseudocyst has ruptured in the interim (last CT [**2-25**]), likely in the setting of acute pancreatitis. Presentation [**Last Name (un) **] score was zero. His calcium normal on presentation with slight drop with IVFs, however stable. The most likely etiology EtOH given heavy drinking history. His LFTs were normal and without e/o ductal dilatation on CT to suggest obstructive pathology. His TG have been elevated to nearly 500 in past, but ? as to whether this was in the setting of TPN; 289 on this admission. Lipase continued to trend down. On transfer to the floor, the patient had a completely benign exam. He did spike one fever, which resolved. His pain was initially controlled with IV dilaudid, which the patient no longer required while on the floor. The patient eloped from the hospital the morning after being called out to the floor. # Hyponatremia: The patient had a mild hyponatremia at 132 which was resolved on his labs on the morning of discharge. # Hypertension: The patient carries a diagnosis of hypertension however was only on 1 [**Doctor Last Name 360**] as outpatient. On presentation to the ICU, his BP was markedly elevated on likely secondary to a combination of both pain and EtOH withdrawal. His admission EKG was without ischemic changes. His blood pressure was within normal limits while on the floor. # EtOH abuse: The patient has had heavy EtOH for many years, currently drinking 1 quart to 1 liter of southern comfort daily. He denied any history of DTs or seizures, but endorsed tremor/shakiness in setting of no EtOH. His CIWA was 17 on arrival to the ICU, with improvement on the floor. He was maintained on a CIWA scale with Valium until his elopement from the floor. He was also started on MVI/thiamine and folate. # Hyperglycemia: In review of labs, has had elevated BS on nearly all checks in our system this past year. His labs, however, correlate with his admissions for pancreatitis and are likely [**1-21**] to this given normal hgba1c. # Anemia/thrombocytopenia: Although his baseline Hct fluctuates, previously appears mainly within low-high 30s range; normocytic with climbing although still normal RDW. Hct normal upon presentation and was suspected to be hemoconcentrated as all cell lines were increased when compared to last admission at which time he was pancytopenic (presumably from direct effect of EtOH on bone marrow). His platelets were below already low BL and he had been exposed to SC heparin on multiple previous admissions. PF4 antibody was sent and was negative. Cell lines up within normal range this admission and suspect still hemoconcentrated although improved. His hematocrit on the morning of elopement had dropped, however the patient left prior to the ordered redraw. # GERD: The patient was continued on his outpatient omeprazole. # Anxiety/Depression: Pt. has not been taking escitalopram as an outpatient as he has been reluctant and would like to d/w his therapist. The patient eloped from the floor. Security was notified by nursing. The patient was contact[**Name (NI) **] by the resident, who impressed the importance of returning to the hospital to the patient, who refused. Medications on Admission: Atenolol 50mg PO daily Omeprazole 40mg PO daily Escitalopram 20mg PO daily Discharge Medications: 1. Atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary - Alcohol withdrawal/Alcohol abuse Acute pancreatitis Secondary - Hypertension Anxiety/depression GERD Discharge Condition: Currently afebrile, with controlled blood pressure Discharge Instructions: Patient eloped. Security notified by nursing. Attending notified. Resident attempted to contact patient without success. He was then able to reach the patient who declined to return to the hospital. Followup Instructions: N/A [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

[ "577.2", "285.9", "276.1", "530.81", "303.91", "287.5", "305.1", "296.20", "291.81", "401.9", "577.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10680, 10686

6612, 10159

328, 335

10842, 10895

3945, 6589

11146, 11247

3236, 3280

10285, 10657

10707, 10821

10185, 10262

10919, 11123

3295, 3926

274, 290

363, 2656

2678, 2951

2967, 3220

29,355

171,454

913+55243

Discharge summary

report+addendum

Admission Date: [**2154-7-2**] Discharge Date: [**2154-7-10**] Date of Birth: [**2096-7-25**] Sex: F Service: CARDIOTHORACIC Allergies: Vicodin / Lisinopril Attending:[**First Name3 (LF) 1505**] Chief Complaint: Exertional chest pain Major Surgical or Invasive Procedure: s/p Aortic Valve Replacement ([**First Name8 (NamePattern2) 6158**] [**Male First Name (un) 923**] Regent Mechanical) [**2154-7-2**] History of Present Illness: 57 year old female with history of aortic stenosis followed by serial echocardiogram and now symptomatic with increased exertional chest burning Past Medical History: Aortic Stenosis Hypertension Elevated cholesterol Palpitations Gastric Esophageal reflux disease Duodenal ulcer Depression Attention deficit disorder H pylori Social History: Semi retired architect/professor Married, lives with spouse [**Name (NI) 1139**] - 20 pack year history, quit 2 years ago Etoh denies Family History: Father with PVD, deceased MI age 57 Physical Exam: General HR 52, RR 16, 146/61 Skin and HEENT: unremarkable Neck supple, full ROM Chest CTA bilat Heart RRR Abd soft, ND, NT, +BS Ext warm +edema pulses palpable Neuro grossly intact Pertinent Results: [**2154-7-4**] 05:30AM BLOOD WBC-10.1 RBC-2.88* Hgb-8.7* Hct-25.1* MCV-87 MCH-30.3 MCHC-34.8 RDW-14.3 Plt Ct-141* [**2154-7-4**] 05:30AM BLOOD PT-13.3 INR(PT)-1.1 [**2154-7-4**] 05:30AM BLOOD Plt Ct-141* [**2154-7-4**] 05:30AM BLOOD Glucose-141* UreaN-13 Creat-0.7 Na-139 K-4.1 Cl-103 HCO3-29 AnGap-11 Conclusions Prebypass 1.No atrial septal defect is seen by 2D or color Doppler. 2.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3.Right ventricular chamber size and free wall motion are normal. 4.There are simple atheroma in the descending thoracic aorta. 5.There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (area <0.8cm2). Trace aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 7. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2154-7-2**] at 830 am. Post bypass 1. Biventricular systolic function is unchanged 2. Patient is a - paced and receiving an infusion of phenylephrine. 3. Mechanical valve seen in the aortic position. Leaflets move well and the valve appears well seated. Peak gradient across the valve is 22 mm Hg. 4. 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) **] [**2154-7-2**] 13:27 ?????? [**2149**] Brief Hospital Course: Admitted same day for surgery, went to operating room for aortic valve replacement on [**7-2**]. See operative report for further details. Transferred to the intensive care unit for hemodynamic management. In the first twenty four hours she was weaned from sedation, awoke neurologically intact, and was extubated without complications. She continued to progress and was transferred to the floor post operative day one. Coumadin and heparin were started for her mechanical valve, betablockers for rate control, and lasix for gentle diuresis. She awaited therapeutic INR and was ready for discharge home on POD #6. Medications on Admission: ASA 81 mg daily Clonidine 0.1 mg daily Dextroamphetamine 5mg daily HCTZ 25mg daily Lipitor 40mg daily Nadolol 20 mg daily Omeprazole 20mg daily Zoloft 100 mg daily Fiber supplements Vitamin B Calcium and vitamin D Estroven daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 6. Outpatient [**Name (NI) **] Work PT/INR for coumadin dosing - goal INR 2.5-3.5 for mechanical aortic valve - results to [**Company 191**] coumadin clinic phone # [**Telephone/Fax (1) 2173**] fax # [**Telephone/Fax (1) 3534**] 7. Dextroamphetamine 5 mg Tablet Sig: One (1) Tablet PO once a day. 8. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 11. Valsartan 80 mg Tablet Sig: One (1) Tablet PO once a day. 12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed. Disp:*50 Tablet(s)* Refills:*0* 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*0* 15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA of Greater [**Location (un) 5871**]/[**Location (un) 6159**] Discharge Diagnosis: Aortic Stenosis s/p AVR PMH: hypertension, Elevated lipids, GERD, Palpitations, Duodenal Ulcer, Depression, ADD, H Pylori 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**] PT/INR for coumadin dosing - goal INR 2.5-3.5 for mechanical aortic valve - results to [**Company 191**] coumadin clinic phone # [**Telephone/Fax (1) 2173**] fax # [**Telephone/Fax (1) 3534**] Followup Instructions: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 250**]) in 1 week Dr [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] in [**2-10**] weeks Dr [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) in 4 weeks Wound check [**Hospital Ward Name **] 6 - please schedule with RN [**Telephone/Fax (1) 3071**] PT/INR for coumadin dosing - goal INR 2.5-3.5 for mechanical aortic valve - results to [**Company 191**] coumadin clinic phone # [**Telephone/Fax (1) 2173**] fax # [**Telephone/Fax (1) 3534**] Completed by:[**2154-7-10**] Name: [**Known lastname 738**],[**Known firstname 739**] S. Unit No: [**Numeric Identifier 740**] Admission Date: [**2154-7-2**] Discharge Date: [**2154-7-10**] Date of Birth: [**2096-7-25**] Sex: F Service: CARDIOTHORACIC Allergies: Vicodin / Lisinopril / Nystatin Attending:[**First Name3 (LF) 741**] Addendum: Post-operatively, Ms. [**Known lastname 742**] hematocrit dropped reflecting acute blood loss anemia, which resolved with transfusions. Major Surgical or Invasive Procedure: s/p Aortic Valve Replacement ([**First Name8 (NamePattern2) 743**] [**Male First Name (un) 744**] Regent Mechanical) [**2154-7-2**] Discharge Disposition: Home With Service Facility: VNA of Greater [**Location (un) 745**]/[**Location (un) 746**] Discharge Diagnosis: Aortic Stenosis s/p AVR PMH: hypertension, Elevated lipids, GERD, Palpitations, Duodenal Ulcer, Depression, ADD, H Pylori Discharge Condition: Good [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2154-8-7**]

[ "785.1", "272.4", "311", "314.01", "401.9", "530.81", "424.1", "532.90", "285.1" ]

icd9cm

[ [ [] ] ]

[ "88.72", "39.64", "35.22", "39.61" ]

icd9pcs

[ [ [] ] ]

7950, 8043

2925, 3546

7793, 7927

8209, 8338

1222, 2902

6664, 7755

968, 1005

3826, 5669

8064, 8188

3572, 3803

5984, 6641

1020, 1203

247, 270

471, 617

639, 800

816, 952

76,644

147,332

37412

Discharge summary

report

Admission Date: [**2176-1-25**] Discharge Date: [**2176-2-3**] Date of Birth: [**2113-6-29**] Sex: M Service: NEUROLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 618**] Chief Complaint: found "down" with a left hemiparesis Major Surgical or Invasive Procedure: * intubated at OSH History of Present Illness: PER ADMITTING RESIDENT: 62 year old man with unkown PMH last seen well 1 week ago; found down today on his apartment; left lateral recumbent; with an ulcer on left leg; found on CT head to have R MCA territory stroke with hemorrhagic transformation. He was taken to OSH where BP 194/119; HR 120 RR 24 Sat 98%; he was intubated; received vecuronium; he received labetolol 20mg IV and he was loaded with phosphenytoin 1g and transferred here. BP 117/61 HR 75 RR 16 Sat 100%, intubated; CT head and unchanged and CTA neck shows obstruction R ICA. On further discussion with family patient has history of large ?brainstem stroke at 37 leaving him with severe ataxia and needing a wheelchair to ambulate. He also has HTN, HLD. He lives alone and has a housekeeper see him once a week. Past Medical History: - HTN - stroke at age 37 brainstem, residual of severe ataxia, cerebllar speech, needs wheelchair for ambulation - HLD - ? Asthma Social History: - Lives alone, has housekeepr once a week. - Able to cook and do most of his ADLs, uses a wheelchair at baseline. - Has wife and child but they have been separated for many years. . HABITS . - Tobacco: remote use, 10-20yrs x 1 PPD, but quit after 37, - ETOH: none since stroke at 37 either - Recreational Drugs: none Family History: - positive for CAD, stroke in various family members Physical Exam: ON ADMISSION: Exam: T-97.6 BP-117/61 HR-75 RR-16 100O2Sat Gen: Lying in bed,intubated Neck: on collar CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema; ulcer on left leg Neurologic examination: Mental status: intubated; on sedation; non-responsive Cranial Nerves: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Corneal present. L facial weakness; tongue midline Motor: No spontaneous movement. Retracts R arm and leg to noxious stimuli but not the left. Increased tonus on left leg. Sensation: Retracts R arm and leg to noxious stimuli but not the left Reflexes: B T Br Pa Pl Right 1 1 1 1 0 Left 2 2 2 2 0 Upgoing toes BL Coordination: unable to examine Gait: unable to examine Pertinent Results: Admission Labs: . WBC-22.0* RBC-5.29 Hgb-15.3 Hct-46.9 MCV-89 Plt Ct-338 Neuts-92* Bands-2 Lymphs-3* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 BLOOD PT-14.2* PTT-23.9 INR(PT)-1.2* Glucose-141* UreaN-47* Creat-0.8 Na-148* K-3.6 Cl-109* HCO3-28 AnGap-15 ALT-51* AST-76* LD(LDH)-389* CK(CPK)-1645* AlkPhos-70 TotBili-1.7* CK-MB-10 MB Indx-0.8 cTropnT-<0.01 Calcium-8.5 Phos-4.0 Mg-2.7* . URINE RBC-10* WBC-9* Bacteri-FEW Yeast-NONE Epi-0 . Discharge Labs: . Imaging: . CT/A Head and Neck([**2176-1-25**]): IMPRESSION: 1. Large right MCA distribution infarct involving just over 50% of the territory with associated deep hemorrhagic conversion and moderate local mass effect without herniation. 2. Critical stenosis at the origin of the right internal carotid artery with no evidence of flow above the skull base, with no flow within the right M1 segment. This may all be secondary to soft plaque at the ICA origin with embolization though dissection cannot be excluded. 3. Marked segmental narrowing and/or occlusion of the vertebral arteries bilaterally, left greater than right, with what may represent old post-embolic encephalomalacia within the pons. 4. Moderate brainstem and cerebellar atrophy out of proportion to the supratentorial volume loss. . CT Head without Contrast ([**2176-1-26**]): IMPRESSION: 1. Unchanged size and appearance of large right MCA territory infarct with stable edema and internal hemorrhage. No new focus of hemorrhage or additional infarction is present. 2. Disproportionate cerebellar atrophy; clinical correlation is recommended . CT Head without Contrast ([**2176-1-29**]): IMPRESSION: 1. Expected evolution of large right middle cerebral artery territorial infarction as above. The region cytotoxic edema has increased over the past 48 hours, but there is signficant shift of midline structures or herniation. 2. Hemorrhagic transformation involving small regions of the infarcted corona radiata and deep [**Doctor Last Name 352**] matter structures, stable, with no new focus of hemorrhage. 3. Global cerebellar atrophy. . CT C-Spine ([**2176-1-25**]): IMPRESSION: 1. No acute fracture or malalignment. 2. Degenerative change as above, most significant at C5 through C7. . CXR ([**2176-1-25**]): 1. ET tube in appropriate position. 2. NG tube with last side hole at the GE junction. Recommend repositioning. 3. No focal consolidation within limits described above. . Brief Hospital Course: Mr. [**Known lastname **] is a 62 year old man with a past medical history including previous posterior circulation stroke (age 37) with residual ataxia requiring a wheelchair for mobility, hypertension, and hyperlipidemia who was "found down" by his house keeper on [**2176-1-25**] (last seen normal [**2176-1-17**]). He was transported to an outside institution where he was intubated. As his blood pressure was 194/119, he received labetolol and was loaded with phosphenytonin 1g. A head CT head showed a right superior MCA territory stroke with hemorrhagic transformation. The patient was transferred to [**Hospital1 18**] for further evaluation and care. He was admitted to the stroke service from [**2176-1-25**] to [**2176-2-3**]. . NEURO Upon his arrival to the [**Hospital1 18**], the patient had a CTA in the emergency room which showed a R ICA occlusion. The patient was not a candidate for any intervention.He was noted by the next day to be alert and awake and able to follow commands on his right side. A head CT was repeated to evaluate for evolution of the infarct which did reveal hemorrhagic transformation. He was eventually restarted on aspirin 325 mg daily. . No anti-epileptic drugs were restarted as there did not seem to be a clear nidus of seizure. . ID At the time of admission, the patient was found to have a large pressure ulcer on his left hip. The Surgery Team was contact[**Name (NI) **] to debride the wound. As there was cellulitis surrounding the wound, treatment with clindamycin was initiated. . In the course of the admission, a stool culture was discovered to be positive for c. difficile colitis ([**2176-1-26**]). Accordingly, a course of flagyl was initiated. Blood, urine, and MRSA cultures were found to be negative. . Given the patient's current condition and extremely poor prognosis, a family meeting was held. It was decided that continuing aggressive care would not be consistent with the patient's wishes and therefore he was transitioned to comfort-measures only. He will be transferred to hospice care for further care. . Medications on Admission: Propranolol 60mg [**Hospital1 **] Artane 4mg [**Hospital1 **] Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 2. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for agitation. 3. Morphine Concentrate 20 mg/mL Solution Sig: 0.25-0.5 mL PO Q1H (every hour) as needed for pain or air hunger. 4. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal DAILY (Daily) as needed for secretions. Discharge Disposition: Extended Care Facility: Hospice of the [**Location (un) 1121**] Discharge Diagnosis: R MCA stroke Discharge Condition: Awake, occasionally follows basic commands. Hypophonic voice. 0/5 strength in LUE, LLE. Discharge Instructions: You were admitted after being found down. You were found to have a large stroke on the right side of your brain. After discussion with your family, you were transitioned to comfort care as it was thought this would be consistent with your wishes. Followup Instructions: Please follow up as needed with your primary care physician [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

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Discharge summary

report

Admission Date: [**2186-10-10**] Discharge Date: [**2186-10-28**] Date of Birth: [**2114-9-4**] Sex: M Service: MEDICINE Allergies: Mobic Attending:[**First Name3 (LF) 1436**] Chief Complaint: Elective left hip replacement Major Surgical or Invasive Procedure: S/p left total hip replacement Endotracheal Intubation Aspiration fluid surrounding L hip Direct cardiac cardioversion for atrial fibrillation - [**2186-10-27**] History of Present Illness: 72 year old male with CAD, CHF EF 20%, s/p pacemaker/ICD, DM admitted to Orthopedics service on [**2186-10-10**] for elective total left hip replacement for OA. Past Medical History: * Coronary artery disease s/p anteroapical MI '[**62**] with aneurysm formation (per OMR note from Dr. [**Last Name (STitle) 73**]; pt reports having cardiac cath (thinks they were done here, but no reports in OMR; Dr. [**Last Name (STitle) 73**] thinks pt may have had one done at OSH.) * Congestive heart failure w/ EF 20% * H/o sustained VT, poorly tolerated with hypotension & near-syncope-->VVI pacer/ICD in [**2178**] [**Company 1543**] GEM Settings: VVI 40 VF> 188 35jx6 FVT (VIA VF) 188-261 VT 150-188 35jx 6 * Diabetes Mellitus * Hypertension * Hypercholesterolemia * Atrial fibrillation on coumadin * Osteoarthritis left hip * TIA * Glaucoma * H/o GI bleeding Social History: Married, lives with wife. [**Name (NI) **] grown daughters. Retired bar-tender; still works part-time as cab/limo driver (despite being informed he should not drive by his cardiologist). Smoker for 55 yrs - unclear current tobacco history; occassional drinker Family History: NC Physical Exam: V: 98.0F HR 84 BP 125/62 RR 16 97% on PS 60%/[**5-6**] Gen: awake, alert, intubated, nodding yes/no appropriately HEENT: EOMI, OP with ET tube otherwise MMM Neck: supple, obese CV: RRR Pulm: CTA-ant Abd: Normoactive BS, soft, obese, nontender to palpation Ext: WWP, no edema, left hip with dsg C/D/I Neuro: awake, responsive, moving all extremities. Pertinent Results: Admission labs: [**2186-10-10**] 03:37PM WBC-25.9*# RBC-4.21* HGB-13.4* HCT-39.7* MCV-94 MCH-31.7 MCHC-33.7 RDW-14.4 [**2186-10-10**] 10:40PM PT-13.5* INR(PT)-1.2* [**2186-10-10**] 10:40PM PLT COUNT-308 [**2186-10-10**] 10:40PM WBC-20.6* RBC-4.12* HGB-13.0* HCT-38.8* MCV-94 MCH-31.6 MCHC-33.5 RDW-14.3 [**2186-10-10**] 10:40PM GLUCOSE-184* UREA N-34* CREAT-1.5* SODIUM-135 POTASSIUM-6.0* CHLORIDE-103 TOTAL CO2-23 ANION GAP-15 . Discharge labs: [**2186-10-28**] 07:35AM WBC 17.8* Hgb 9.8* Hct 30.6* Plt 664* [**2186-10-28**] 07:35AM PT 23.3* PTT 125.5*1 INR 2.3* [**2186-10-28**] 07:35AM Glucose 92 BUN 24* CRT 1.4* Na 138 K 4.0 Cl 98 HCO3 34* Imaging: [**2186-10-11**] Hip 1 view There has been placement of a left total hip prosthesis with noncemented acetabular component fixed with two screws and a noncemented femoral stem. Gas is seen in the soft tissues. No immediate hardware-related complication is seen. Please refer to operative report for full details EKG [**10-11**] Sinus rhythm. Intraventricular conduction delay. Left axis deviation. Low QRS voltage in the precordial leads. Compared to prior tracing of [**2186-10-4**] there is now low QRS voltage in the precordial leads and the rate has increased. Portable CXR [**2186-10-12**] There has been interval extubation. ICD remains in standard position. Heart is enlarged, but there is no evidence of pulmonary edema. Lungs are clear. [**2186-10-17**] TTE: Conclusions - The left atrium is elongated. The estimated right atrial pressure is 11-15mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. A left ventricular mass/thrombus cannot be excluded. Overall left ventricular systolic function is severely depressed (LVEF= 20 %) with akinesis of mid to apical segments and hypokinesis of the basal segments. Transmitral Doppler imaging is consistent with Grade III/IV (severe) LV diastolic dysfunction. 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. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. Compared with the report of the prior study (images unavailable for review) of [**2184-8-17**], the left ventricule is more dilated with increased mitral regurgitation severity and severe systolic and diastolic dysfunction. [**2186-10-22**] CT Chest/ABD/Pelvis - FINDINGS: Exophytic right thyroid nodule, posteroinferiorly, approximately 1cm. AICD is seen in the left chest wall with subcutaneous tissues, with continuous lead to the heart. There is curvilinear calcification seen along the left vintricular apex, compatible with previous infarct and possible ventricular aneurysm. The heart is enlarged, no pericardial effusion. Small pleural effusions and dependent atelectasis is seen. There is a single 7-mm nodule in the right upper lobe, series 2, image 18, as well as a smaller RML granuloma. No focal consolidative airspace disease or pneumonia identified. No significant mediastinal or hilar lymphadenopathy. There are dense coronary artery calcifications. Bilateral gynecomastia. Small calcification/loose body within right gleno-humeral joint. ABDOMEN: Liver and spleen are within normal limits. There is a large amount of peripancreatic edema and stranding throughout the mesentery of the lesser sac extending to the retroperitoneum and left paracolic gutter, along which the fluid tracks to the iliac fossa and anterior left hemipelvis. The pancreas remains well perfused without definite necrotic areas. There is attenuation of the splenic vein, which is markedly narrowed through the midline, but does remain patent. No pancreatic ductal dilatation. Gallbladder is present with a single large stone seen near the gallbladder neck, measuring 1.5 cm. No intrahepatic biliary dilatation is seen. The adrenal glands are prominent with a more focal 1.5 cm nodular density along the lateral limb of the left adrenal gland, which likely represents a benign adenoma; however, this is indeterminate on a single phase examination. PELVIS: The kidneys enhance and excrete contrast symmetrically. Subcentimeter renal hypodensities likely represent cysts, but are too small to thoroughly characterize. There is atherosclerotic calcification within a normally sized aorta. The right iliac artery is slightly ectatic. Small bowel loops are unremarkable. Within the deep pelvis, there is a segment of focal bowel wall thickening involving the sigmoid as it crosses the midline, measuring approximately 12 cm, with some mild surrounding stranding. This focal colitis is likely infectious or inflammatory in etiology or possibly ischemic, or it may be a sequela of the aforementioned pancreatitis, as the fluid from the lesser sac does track into the pelvis and terminate in the region of this focally inflamed segment of bowel. There is no evidence for obstruction. No definite mass lesion is identified. There is inflammation in the subcutaneous tissues surrounding the left hip, in keeping with recent total left hip replacement. Hardware is intact without evidence for complication. No periacetabular fluid collection is seen. Review of bone windows demonstrates no suspicious abnormalities. Degenerative changes of the lower lumbar spine, and facet joints. IMPRESSION: 1. Extensive pancreatitis, with peripancreatic and retroperitoneal edema and stranding as well as attenuation of the splenic vein, but no necrosis or pseudocyst. 2. Short segment of focal sigmoid colitis; infectious, ischemic or inflammatory in etiology. Although unlikely neoplastic in etiology, a followup colonoscopy upon resolution of symptoms is advised to rule out an underlying malignancy. 3. Incidental 1.5 cm left adrenal nodule, likely adenoma. Non-contrast CT evaluation advised on a nonemergent basis is recommended to verify benignity. 4. Small bibasilar pleural effusions and atelectasis. Single 7 mm right upper lobe nodule; a twelve-month followup CT of the chest also advised to document stability, in the absence of known malignancy, in which case a follow-up in [**3-7**] months is advised. 5. Cholelithiasis without biliary dilatation. Right thyroid nodule, which could be better evaluated with ultrasound. 6. Calcified left ventricular apical aneurysm. Brief Hospital Course: Mr. [**Known lastname 1557**] is a 72 year old male with h/o diabetes, CAD, severe systolic CHF (EF 20%), afib, ventricular tachycardia s/p AICD who initially presented for elective left hip replacement, and had a complicated post-operative course complicated by Vtach arrest, requiring re-intubation, followed by CHF exacerbation, UTI, sigmoid colitis, pancreatitis, and atrial fibrillation with rapid ventricular response. See below for a problem based summary of [**Hospital **] hospital course. -Left total hip replacement: Pt underwent hip surgery on [**2186-10-10**] with Dr. [**Last Name (STitle) **]. As above, the patient had a complicated post-op course. However, from an orthopedic perspective, the patient has been doing well, and his hip & wound appear to be healing nicely. An evaluation for infection during his hospital stay included an IR procedure on [**2186-10-17**] to sample fluid from his wound. Only 5cc of nonpurulent fluid was removed. Culture of the fluid was negative. The patient was not thought to have an infection involving his hip. The patient had no complaints of hip pain/discomfort. His activity was gradually increased as tolerated. At the time of discharge, he was getting OOB with assist and walking short distances (steps). Dr. [**Last Name (STitle) **] set no limitations on the patient's activity from a hip perspective. -Ventricular Tachycardia: Pt has a history of prior episodes of Vtach. In [**2178**], he had an ICD placed for multiple poorly tolerated episodes of VTach. In [**2184**], pt had multiple shocks from ACID & b/c of this underwent VT ablation. During this hospital stay, the patient had an episode of Vtach day #1 post-op. He lost consciousness, required reintubation (he was extubated the following day). His AICD fired appropriately for the Vtach event. A few days later pt had a syncopal event after another episode of Vtach, during which his AICD, again, fired appropriately. The patient was followed by the electrophysiology service. He was loaded with amiodarone and then treated with 200mg twice daily (400mg total daily dose). He had no further VTach episodes & was treated with amio & b-[**Year (4 digits) 7005**] therapy. Regarding the patient's amiodarone dosing, Dr. [**Last Name (STitle) 73**], the patient's long-time cardiologist, recommends that the patient complete three additional weeks of 400mg total daily dosing, which will make approximately 4weeks at this dose. Thereafter, the patient should take 300mg total daily dose of amiodarone(which can be given in divided dose of 200mg in AM and 100mg in PM). During his evaluation by EP service, the pt's AICD generator was noted to be low on energy. The device is working as it should, but will need a generator change (non-emergently) within a few weeks. The patient is scheduled for this procedure on [**2186-11-15**] at [**Hospital1 18**]. If there are questions regarding the scheduling/plan for this procedure, please contact [**Name (NI) **] [**Name (NI) **] at [**Telephone/Fax (1) 28976**]. Additionally, at the time of generator change, an atrial lead will likely be placed. There has been discussion of upgrading to a [**Hospital1 **]-ventricular pacer at the time of generator change as well; however, it is not clear that the pt would be a good candidate for this. Dr. [**Last Name (STitle) 73**] will follow him for this issue. -Congestive Heart Failure: Mr. [**Known lastname 1557**] has a long history of severe systolic & diastolic dysfunction. However, prior to admission his heart failure had been well controlled on low dose lasix, spironolactone, b-[**Known lastname 7005**] & ace-i. Following hip replacement, the patient developed acute, systolic failure with significant volume overload. This was thought to be precipitated by the stress of the surgery & volume of fluid he received peri-operatively. Additionally, his lasix was held for a period in the setting of hypotensive episodes. Transthoracic ECHO from [**10-17**] confirmed EF = 20% with both diastolic and systolic dysfunction. LV noted to be more dilated with increased mitral regurgitation. Pt had an episode of acute pulmonary edema, requiring transfer to the ICU; however, he did not require re-intubation. (The patient required only a few days in the ICU before being transferred to the wards for further diuresis.) The pt was treated with lasix gtt and had a length of stay fluid balance > 7L negative. He was gradually transitioned to PO lasix. He continued treatment with a low-dose b-[**Last Name (LF) 7005**], [**First Name3 (LF) **] ace-inhibitor, and spironolactone. He received a 2gram daily salt diet and have 1.5L fluid restriction, which he should continue on discharge. He will be discharged on higher dose of PO lasix than what he took at the time of admission. Depending on his symptoms/exam, this dose may need to be adjusted. At time of discharge, he has ~1+ LE edema & some mild [**Hospital1 **]-basilar crackles on lung exam. However, he reports no symptoms of dyspnea, orthopnea of PND. He should have electrolytes/renal function checked every few days, particularly while adjusting to new lasix dosing. - Hypotension: pt has low baseline BP with systolic BP in 90-110s. This is thought to be due to his poor systolic fuction & valvular disease. During this hospital stay, the patient maintained a slightly lower blood pressure than prior to admission--likely b/c of overall worsening of cardiac function from volume overload & afib. During his hospital stay, the patient tolerated SBP from 80's to 100s without symptoms. This may be his new baseline. - Atrial fibrillation: pt was admitted in sinus rhythm. He went into atrial fibrillation during the hospital stay, occasionally with rapid ventricular response. It was thought that the afib was contributing to his worsening cardiac function, leading to lower than baseline blood pressure. Because of this, the patient underwent cardioversion on [**2186-10-27**]. He had a therapeutic levels of anti-coagulation throughout his hospital stay (except for a brief period when he was in sinus rhythm); thus, he did not undergo TEE prior to cardioversion. The patient tolerated the cardioversion. He is in sinus rhythm w/ HR 50-70s at time of transfer/discharge. INR on day of discharge is 2.3, thus, his heparin gtt is being stopped. His goal INR is [**2-4**]. - Leukocytosis: pt post-operative leukocytosis with WBC was ~20. This continued to trend up as high as 30. Despite leukocytosis, pt remained afebrile. Work-up included blood, urine, sputum cultures, aspiration of fluid from left hip wound, and imaging w/ chest/abd/pelvis CT, and lower extremity dopplers (for DVT). The workup was significant for UTI, pancreatitis, and sigmoid colitis (see discussion of each issue). His WBC was still elevated at time of discharge, though slowly trending down. - Pancreatitis: pt was found to have a rising leukocytosis, WBC as high as 30 w/ bandemia, during his hospital stay. Exhaustive infectious workup was unrevealing for significant infection. (He was found to have UTI which was treated with 7 days of anti-biotics--initially cipro, then ceftriaxone.) He went for chest/abd/pelvis CT which was notable for marked pancreatic inflammation and edema. Pt did have elevated pancreatic enzymes post-op; they have since trended down no normal. Pt never had abd pain, or characteristic features of pancreatitis. He was treated conservatively. Cause of pancreatitis thought to be from possible medication given in operative setting--possibly anesthesia. There was no evidence of stones, no significant h/o ETOH. - Urinary tract infection: UA notable for UTI. Urine culture grew pan-sensitive KLEBSIELLA OXYTOCA. No signs of urosepsis. He was treated with 7 days of anti-biotics--initially cipro, then ceftriaxone. Abx course completed on [**2186-10-25**]. Foley was changed, then removed. - Sigmoid Colitis: Incidental finding seen on CT. Infectious vs. inflammatory vs. malignancy. Cause not clear. No h/o colitis. Pt had been constipated/impacted with stool for some time, then received aggresive bowel regimen, after which he developed diarrhea. Stool was neative for cdiff x3. Despite this, ID recommended treating empirically with 14days of flagyl given CT findings--14 day course started [**2186-10-25**]. He should have a colonoscopy performed within 6 months/once he is stable for further eval. - Guaiac (+) stool: may be related to colitis, though pt has other potential sources for GIB. (Has had them in past). Colonoscopy from [**2184**] showed angioectasia in the cecum, diverticulosis of the sigmoid colon, and grade 1 internal hemorrhoids. Pt's hct was stable b/t 28-32. He was not transfused (except in the post-op setting). He should have his hct rechecked one week after discharge to assure stability. He should have a colonoscopy performed within 6 months/once he is stable for further eval. - Coronary Artery Disease: Pt has history of anteroapical MI in [**2162**]. Pt reports having prior cath though no records here of it at [**Hospital1 18**]. Pt did have elevated troponins (peaked at 0.41) in setting of acute pulmonary edema; however CKs not signifcantly elevated. No CP. No concerning EKG changes. NSTEMI vs. demand ischemia in setting of CHF exacerbation. Pt was continued on outpatient regimen of asa, bblocker & statin - Diabetes: Blood sugars relatively well controlled. Gave sliding scale insulin. - Acute renal failure: Pt had a bout of pre-renal failure post-operatively. Crt peaked at 2.4, trended down to 1. Crt trending up slightly at time of discharge--crt 1.4. It is thought to be from pre-renal cause w/ diuresis. This should be rechecked within a few days of discharge and, if necessary, lasix can be adjusted. However, the pt needs to be on lasix, even low dose given the severity of his heart failure. - Pulmonary nodule: single 7-mm nodule in the right upper lobe, as well as a smaller RML granuloma. No focal consolidative airspace disease or pneumonia identified. No significant mediastinal or hilar lymphadenopathy. Per radiology a follow-up CT of the chest is advised to document stability; this should be done in 6 months. - Adrenal nodule: Incidental 1.5 cm left adrenal nodule, likely adenoma seen on [**2186-10-21**] CT. Non-contrast CT evaluation advised on a nonemergent basis is recommended to verify benignity. - Right thyroid nodule: incidentally identified on CT which could be better evaluated with ultrasound. Prior TSH have been WNL, though was not checked during this hospital stay. - Constipation: pt requires regular bowel regimen. Please monitor for constipation. - FEN: 1.5L fluid restriction; low salt cardiac diet - Advanced Directive: FULL CODE -- confirmed with patient Medications on Admission: 1. Amiodarone 200mg daily 2. Coumadin 3. Lasix 20mg daily 4. Atorvastatin 5. Quinapril 5mg daily 6. Spironolactone 50mg daily 7. Toprol XL 50mg daily 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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Ferrous Sulfate 325 (65) 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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 11 days: For 14 days starting [**2186-10-25**] . 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 10. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for INSOMNIA. 11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 weeks: After 3 more weeks on 200mg [**Hospital1 **], decrease dose to 200mg in AM and 100mg in PM. 12. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day: hold for SBP<85. 15. Insulin Regular Human 100 unit/mL Solution Sig: Per sliding scale Injection ASDIR (AS DIRECTED). 16. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day: hold for SBP<90. 17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for SBP<75 . 18. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold SBP >75 . Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: Left hip replacement Systolic and diastolic heart failure Ventricular tachycardia Atrial fibrillation Acute renal failure Diabetes Pancreatitis Sigmoid colitis Guaiac positive stools Constipation Pulmonary nodule Thyroid nodule Adrenal Adenoma . Secondary: - TIA - Glaucoma Discharge Condition: Good, able to ambulate a few steps with assistance, tolerating room air; systolic blood pressure ranging from 80 to 100, HR in 50-70s. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5-2L daily . The patient will need to have pacemaker/AICD procedure in a few weeks; tentatively scheduled at [**Hospital1 18**] for [**2186-11-15**]. Please contact [**Name (NI) **] [**Name (NI) **] at [**Telephone/Fax (1) 28976**] with questions/further scheduling. . There are a number of follow-up imaging/diagnostic tests that the patient will need within the next 6months: 1. Colonoscopy: should be done w/in 6 or so months to further eval guaiac positive stool. If hct dropping, this should be done earlier. 2. Chest CT: in about 6 months to follow up 7-mm pulmonary nodule in incidentally found on CT scan. 3. Non-contrast Abdominal CT: Incidental 1.5 cm left adrenal nodule, likely adenoma seen on [**2186-10-21**] CT. Radiologist recommends nonemergent evaluation to verify benignity. 4. Thyroid ultrasound: incidentally identified on CT which could be better evaluated with ultrasound--non-emergent. . Followup Instructions: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2186-11-8**] 10:30 . Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2186-11-8**] 11:00 Please see your primary care doctor within one month for follow-up (see issues below). The patient will need to have pacemaker/AICD procedure in a few weeks; tentatively scheduled at [**Hospital1 18**] for [**2186-11-15**]. Please contact [**Name (NI) **] [**Name (NI) **] at [**Telephone/Fax (1) 28976**] with questions/further scheduling. . There are a number of follow-up imaging/diagnostic tests that the patient will need within the next 6months: 1. Colonoscopy: should be done w/in 6 or so months to further eval guaiac positive stool. If hct dropping, this should be done earlier. 2. Chest CT: in about 6 months to follow up 7-mm pulmonary nodule in incidentally found on CT scan. 3. Non-contrast Abdominal CT: Incidental 1.5 cm left adrenal nodule, likely adenoma seen on [**2186-10-21**] CT. Radiologist recommends nonemergent evaluation to verify benignity. 4. Thyroid ultrasound: incidentally identified on CT which could be better evaluated with ultrasound--non-emergent.

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icd9cm

[ [ [] ] ]

[ "99.04", "81.51", "96.04", "99.62", "99.61", "96.71", "81.91" ]

icd9pcs

[ [ [] ] ]

21407, 21479

8632, 19466

297, 461

21806, 21943

2029, 2029

23031, 24266

1639, 1643

19666, 21384

21500, 21785

19492, 19643

21967, 23008

2485, 8609

1658, 2010

228, 259

489, 652

2045, 2469

674, 1345

1361, 1623

72,924

191,884

28776

Discharge summary

report

Admission Date: [**2112-2-29**] Discharge Date: [**2112-3-5**] Date of Birth: [**2030-7-22**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2777**] Chief Complaint: Left leg swelling Major Surgical or Invasive Procedure: Left internal iliac artery coiling with left common iliac artery and external iliac artery stents. History of Present Illness: 81 year old man with history of sp endovascular repair in [**2107**] presents to outside hospital with some left leg swelling. A CT abdomen/pelvis was performed without contrast given Cr 3.0. This showed a abdominal aortic aneurysm leak with retroperitoneal/psoas hematoma. He was transferred emergently to [**Hospital1 18**] for further management. He was taken directly for a CTA which showed an endoleak involving the repaired infrarenal abdominal aortic aneurysm with enlargement of the aneurysmal sac. There was aneurysmal change of the bilateral common iliac arteries adjacent to the distal tips of the endovascular repair in the iliac arteries and a left hemipelvis retroperitoneal hematoma. From there, he [**Hospital1 20354**] directly to the operating room for repair. Past Medical History: Left inguinal hernia repair Umbilical hernia repair Arthritis/gout Prostatectomy AAA sp endovascular repair [**2107**] Hypothyroidism CVA Dementia Hypercholesterolemia Chronic Kidney Disease Social History: past history of tobacco and EtOH usage. none currently. Family History: non contributory Physical Exam: On Discharge: Vitals: T 97.2, HR 61, BP 145/67, RR 14, 95% RA Gen: NAD, A&Ox1 CV: RRR Pulm: CTAB Abd: S/NT/ND Wound: C/D/I Ext: mild edema to bilateral lower extremities L>R Pulses: palpable DP/PT bilaterally Pertinent Results: [**2112-3-1**] 12:15AM BLOOD WBC-8.4 RBC-2.14*# Hgb-6.6*# Hct-19.5*# MCV-92 MCH-30.9 MCHC-33.6 RDW-14.8 Plt Ct-111* [**2112-3-1**] 07:43AM BLOOD WBC-6.8 RBC-2.37* Hgb-7.2* Hct-21.0* MCV-89 MCH-30.5 MCHC-34.3 RDW-14.9 Plt Ct-102* [**2112-3-1**] 09:47PM BLOOD WBC-9.6 RBC-3.31*# Hgb-10.2*# Hct-28.7* MCV-87 MCH-30.9 MCHC-35.7* RDW-15.2 Plt Ct-113* [**2112-3-3**] 04:07AM BLOOD WBC-7.2 RBC-2.97* Hgb-9.4* Hct-26.7* MCV-90 MCH-31.5 MCHC-35.1* RDW-14.9 Plt Ct-116* [**2112-3-4**] 07:00AM BLOOD WBC-6.3 RBC-3.39* Hgb-10.5* Hct-30.2* MCV-89 MCH-31.0 MCHC-34.9 RDW-14.5 Plt Ct-130* [**2112-3-1**] 12:15AM BLOOD Glucose-134* UreaN-65* Creat-3.2*# Na-143 K-5.2* Cl-110* HCO3-19* AnGap-19 [**2112-3-2**] 02:06AM BLOOD Glucose-125* UreaN-58* Creat-2.9* Na-141 K-4.6 Cl-111* HCO3-21* AnGap-14 [**2112-3-4**] 07:00AM BLOOD Glucose-99 UreaN-56* Creat-2.4* Na-145 K-3.6 Cl-110* HCO3-25 AnGap-14 [**2112-3-1**] ECHO: The left atrium is elongated. The left ventricular cavity size is normal. Overall left ventricular systolic function is probably mildly depressed but was not fully assessed. (LVEF= ?45 %). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is a very small pericardial effusion. [**2112-3-1**]: Endoleak involving the repaired infrarenal abdominal aortic aneurysm with enlargement of the aneurysmal sac. There is aneurysmal change of the bilateral common iliac arteries adjacent to the distal tips of the endovascular repair in the iliac arteries. Left hemipelvis retroperitoneal hematoma. Although no foci of active arterial extravasation is visualized, given the proximity of the hemorrhage to the aneurysmal left common iliac artery and the lack of a fat plane separating the two, aneurysm leak/rupture is a possible etiology. However, particularly if the patient is chronically anticoagulated or has had recent intervention in this region (such as angiography with left femoral stick), muscular or retroperitoneal bleeding along the vessels may also have this appearance. Evidence of a new atherosclerotic ulcer superior to the level of the infrarenal abdominal aortic aneurysm. Continued followup is recommended. Assymetric enlargement of the left external iliac vein which may be due to the mass effect as described above. Evidence for new bladder hernia through the musculature of the anterior pelvic wall. [**2112-3-4**] LE Doppler: No evidence of DVT. Slow flow in the left common femoral vein likely relates to upstream compression by the aneurysmal and stented left common iliac artery. Brief Hospital Course: Mr [**Known lastname 36427**] [**Last Name (Titles) 20354**] directly to the operating [**2112-3-1**] after a CTA showed an endoleak involving the repaired infrarenal abdominal aortic aneurysm with enlargement of the aneurysmal sac. There were aneurysmal change of the bilateral common iliac arteries adjacent to the distal tips of the endovascular repair in the iliac arteries and a left hemipelvis retroperitoneal hematoma. His admission hematocrit was 19.7. Intra-operatively, he was closely monitored and remained hemodynamically stable. He tolerated the procedure well without any difficulty or complications. Post-operatively, he was transferred to the ICU for further stabilization and monitoring. He received a total of 7 units prbcs. Mr. [**Known lastname 69533**] hematocrit has remained stable since the date of his operation. On POD #1, he was transferred to the VICU for further recovery. While in the VICU, received monitored care. When stable was delined. His blood pressures were closely monitored, and his medications were adjusted as needed to maintain a SBP of 100-140. Throughout his hospitalization, Mr. [**Known lastname 36427**] remained hemodynamically stable. His diet was advanced as tolerated without issue. On POD#3 he was noted to have mild swelling of his left upper thigh and scrotum. A doppler US was obtained and was negative for DVT, but did demonstrate slow venous flow likely secondary to his known left retroperitoneal hematoma. He was treated with leg elevation and diuretics to good effect. He was evaluated by physical therapy who felt that he would need a stay in short term rehab prior to safety returning to home secondary to weakness and deconditioning. He was discharged on [**2112-3-5**] to a rehab facility in stable condition. Medications on Admission: Iron 325mg daily, Avodart 0.5mg daily, Plavix 75mg daily, Lopressor 12.5mg daily, levothyroxine 175mcg daily, simvastatin 20mg daily, KCl 10 meq daily, lysine 500mg daily, namenda 10mg twice daily, donepezil 10mg daily, lasix 20mg daily. Discharge Medications: 1. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. memantine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 13. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 14. potassium chloride 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. 15. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - Wedgemere - [**Location (un) 2498**] Discharge Diagnosis: Left common iliac artery rupture 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 where transferred to the [**Hospital1 18**] from an outside hospital for treatment of possible ruptured AAA with internal bleeding. You were taken directly for a CT scan which showed a leak near your previously repaired aneurysm that we were able to repair. Division of [**Hospital1 **] and Endovascular Surgery Lower Extremity Angioplasty/Stent Discharge Instructions Medications: ?????? Take Aspirin (enteric coated) once daily ?????? If instructed, take Plavix (Clopidogrel) 75mg once daily ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**3-11**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated ?????? It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [**4-10**] weeks for post procedure check and ultrasound What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call [**Date Range 1106**] office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2112-4-6**] 10:45 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**] Date/Time:[**2112-4-6**] 11:00 Completed by:[**2112-3-5**]

[ "716.96", "568.81", "244.9", "294.20", "796.2", "285.9", "442.2", "585.9", "584.9", "V12.54", "272.0" ]

icd9cm

[ [ [] ] ]

[ "88.49", "39.79", "88.42" ]

icd9pcs

[ [ [] ] ]

8132, 8226

4763, 6551

320, 420

8303, 8303

1801, 4740

11361, 11646

1538, 1556

6843, 8109

8247, 8282

6577, 6820

8481, 10750

10776, 11338

1571, 1571

1585, 1782

263, 282

448, 1234

8318, 8457

1256, 1449

1465, 1522

19,549

175,765

53309

Discharge summary

report

Admission Date: [**2101-6-30**] Discharge Date: [**2101-7-10**] Date of Birth: [**2037-6-24**] Sex: M Service: ACOVE CHIEF COMPLAINT: Epigastric pain times two days. HISTORY OF THE PRESENT ILLNESS: This is a 64-year-old male with history of acute pancreatitis attributed to hypertriglyceridemia in [**2100-1-28**]. The patient complained of severe epigastric pain, which radiated to his back. He had also experienced right upper quadrant pain over the last two days. The patient experienced nausea and vomited times one. There was no blood or bile in the vomit. The patient denied alcohol use. The patient also reports polydipsia, polyuria, and polyphagia over the preceding eight weeks. The patient denies PO intake since the onset of pain. REVIEW OF SYSTEMS: System review was negative for chest pain, shortness of breath, melena, hematochezia, dysuria, hematuria, dizziness, or headache. PAST MEDICAL HISTORY: 1. Acute pancreatitis [**2100-1-28**], attributed to hypertriglyceridemia. 2. Hypertriglyceridemia. 3. Hypertension. The patient is not currently on medication. 4. Adenomatous colon polyp removed in [**2099-1-28**]. 5. Peyronie disease. 6. Fatty liver. 7. Left adrenal adenoma. 8. Gout. ALLERGIES: The patient is allergic to CHYMORAL, WHICH GIVES THE PATIENT A RASH. MEDICATIONS: 1. Lipitor 10 mg PO q.d. 2. Colchicine 0.6 mg PO b.i.d. 3. Multivitamin ginseng, gingko biloba, saw [**Location (un) 6485**], vitamin E, vitamin C, vitamin B complex, coenzyme Q, marine fish oil, glucosamine, and chondroitin sulfate. SOCIAL HISTORY: The patient is an osteopathic physician and practices manipulative medicine in [**Location (un) 583**]. He resides in [**Location (un) **] with his wife. [**Name (NI) **] denies tobacco and alcohol use, as well as intravenous drug use. PHYSICAL EXAMINATION: Examination revealed the following: Vital signs: Temperature 96, blood pressure 163/86, pulse 93, respirations 20, oxygen saturation 93% on room air. GENERAL: The patient appeared to be resting comfortably when examined. This was likely secondary to morphine received in the emergency room. HEENT: Sclerae are nonicteric, conjunctiva without pallor, oropharynx clear and mucous membranes moist. NECK: Supple, no lymphadenopathy, no thyromegaly, no jugulovenous distention. NEUROLOGICAL: The patient was alert and oriented times three. There was no sensory or motor deficit. Coordination was intact. Cranial nerves II through XII intact. CARDIOVASCULAR: Regular rate and rhythm, no rubs, or murmurs. Third heart sound was ausculted, unable to discern whether it was a gallop or a split S2. PULMONARY: Lungs were clear to auscultation bilaterally. ABDOMEN: Soft, nondistended, extremely tender to palpation in the egigastric area, positive bowel sounds, no organomegaly, no rebound, no rigidity, no guarding. EXTREMITIES: No edema, no calf tenderness, negative [**Last Name (un) 4709**] retractor. HOSPITAL COURSE: (by problem) #1. Acute pancreatitis: Upon admission, the patient's white blood cell ranged from 6.7 to 12.7. Amylase was 1,374, lipase 6,500, LDH 192. LFTs were all normal. Triglycerides were 5,170, and cholesterol was 648. The patient was hydrated with 0.9 normal saline at 200 cc per hour and pain controlled with morphine. The patient was kept NPO and called out to the floor on hospital day #2. He was then placed on a morphine PCA, kept NPO and IV hydration continued. Attempt was made to advance the patient to clear liquids on hospital day #3, but this resulted in recurrent epigastric pain so the patient was once again made NPO. Right upper quadrant ultrasound revealed perihepatic ascites, but no biliary obstruction, dilatation, or gallstones. On hospital day #5 the patient was started on PPN. Because of the need for total parenteral nutrition, an attempt was made to place a PIC line, but it was unsuccessful. The patient's epigastric pain gradually began to abate and the patient was started on clear fluids on hospital day #9. He was quickly advanced to full liquid and finally to a normal [**Doctor First Name **] diet on hospital day #10. At the time of discharge, amylase and lipase were normal and triglycerides were 230. The patient was discharged on Tricor. #2. Diabetes mellitus: Admission labs were as follows: Urinalysis revealed ketones of 40, glucose of greater than 1000 and protein of greater than 300. Blood glucose was 403, bicarbonate 15, and the anion gap was 23. Hemoglobin Alc was 11.6. The patient was treated with an insulin drip at two units per hour and the patient was hydrated with 0.9 normal saline at 200 cc per hour. Anion gap closed within 48 hours and the patient was transferred to the floor. The [**Last Name (un) **] staff was following the patient. NPH insulin and regular insulin sliding scale were used and adjusted as the patient went from NPO to a full PO diet with good glycemic control achieved throughout the hospitalization. The patient received inhouse diabetes education. The patient was discharged to followup with the [**Hospital 109687**] [**Hospital 982**] Clinic. #3. Left lower lobe pneumonia with parapneumonic effusion: On hospital day #3, rales were ausculted in the base of the left lung. At this time, chest x-ray was read as left lower lobe atelectasis with small left pleural effusion. Also, at this time, the patient's oxygen saturations were within normal limits The white blood cell count was 9.4, He was afebrile and without cough. On hospital day #4, the patient's white blood cell count rose to 12. On hospital day #5, the white blood cell count rose to 15.5. At this time, blood cultures were drawn from the patient, although he was still afebrile and without localizing symptoms. On hospital day #6, the patient's white blood cell count was 12.4. He spiked a temperature to 101. Repeat chest x-ray revealed a left lower lobe infiltrate larger from the one seen on previous chest x-ray and it was consistent with left lower lobe pneumonia with effusion. The patient was still asymptomatic at this time. Levofloxacin 500 mg IV q.d. was started. A left lateral decubitus film revealed a significant (greater than 1.0 cm) freely layering left pleural effusion. On hospital day #9, the patient underwent thoracentesis. Analysis of the pleural fluid revealed a pleural protein level of 2.3 and pleural LDH of 153, compared to serum protein level of 5.5 and serum LDH of 314. Blood cultures and pleural cultures demonstrated no growth. The pH of the pleural fluid was 7.68. The patient was discharge on Levofloxacin to complete a 10-day course. DISCHARGE STATUS: The patient is stable for discharge home. DISCHARGE DIAGNOSES: 1. Acute pancreatitis secondary to hypertriglyceridemia. 2. Diabetes mellitus. 3. Left lower lobe pneumonia with parapneumonic effusion. 4. Hypertriglyceridemia. 5. Hypertension. 6. History of adenomatous colonic polyp removed in [**2099-1-28**]. 7. Peyronie disease. 8. Fatty liver. 9. Left adrenal adenoma. 10. Gout. DISCHARGE MEDICATIONS: 1. Fenofibrate 67 mg PO q.d. with PM meal. 2. Levofloxacin 500 mg PO q.d. with lunch through [**2101-7-14**]. 3. Protonix 40 mg PO q.d. in a.m. 4. Insulin regimen: 18 units NPH plus 6 units regular insulin before breakfast; 12 units NPH plus four units of regular insulin before PM meal plus a regular insulin sliding scale. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**] Dictated By:[**Last Name (NamePattern4) 109688**] MEDQUIST36 D: [**2101-7-10**] 13:57 T: [**2101-7-10**] 14:02 JOB#: [**Job Number 109689**]

[ "577.0", "607.89", "272.9", "274.9", "227.0", "486", "571.8", "250.11", "276.5" ]

icd9cm

[ [ [] ] ]

[ "34.91" ]

icd9pcs

[ [ [] ] ]

6740, 7069

7092, 7706

2991, 6719

1856, 2973

794, 925

156, 774

947, 1577

1594, 1833

31,977

137,879

47423

Discharge summary

report

Admission Date: [**2180-3-1**] Discharge Date: [**2180-3-13**] Date of Birth: [**2128-8-29**] Sex: F Service: CARDIOTHORACIC Allergies: Latex / Lasix Attending:[**First Name3 (LF) 922**] Chief Complaint: fevers Major Surgical or Invasive Procedure: [**3-6**] Sternal plating with 4 sternal plates, three 8- hole and one 12-hole plate, and then bilateral pectoralis major muscle advancement flaps. History of Present Illness: 51 yo F s/p CABG [**1-26**], d/c home [**1-30**]. readmission for sternal wound infection [**2-8**] and subsequent d/c home with VAC and iv vancomycin. Presented to office on [**3-1**] after c/o fever, exam concerning for worsening/new sternal wound infection. Past Medical History: CABG, DM, HTN, COPD, osteoporosis, ^lipids, hypothyroid, gastric ulcer w/UGIB 20y ago, PVD, chronic R breast inflamation, s/p C section, umbilical hernia repair, s/p bladder suspension, s/p chole, s/p R breast surgery ;prior MRSA Social History: Pt is a nurse at a nursing home. Smokes [**12-15**] ppd x 24 years. No EtOH. No drugs. Married with 6 children Family History: PGM: died at 50 of MI, DM2. M: HTN, DM2. B: HTN. . Physical Exam: HR 88 RR 16 BP UTA T 98.8 NAD but tired, upset Lungs decreased at both bases Cor RRR no rub/murmur Abdomen obese, benign Extrem 2+ edema EVH incision clean Pertinent Results: CHEST (PA & LAT) [**2180-3-12**] 9:20 AM CHEST (PA & LAT) Reason: eval for pleural effusions [**Hospital 93**] MEDICAL CONDITION: 51 year old woman s/p CABG and plating REASON FOR THIS EXAMINATION: eval for pleural effusions CHEST TWO VIEWS ON [**3-12**] HISTORY: Status post CABG and plating. REFERENCE EXAM: [**3-8**] The sternotomy fixation devices are unchanged. The cardiac and mediastinal silhouettes are unchanged. There continues to be some patchy areas of volume loss that have increased in the right lower lung and left mid lung. There is a small right and small left pleural effusions that have also slightly increased. There is a left PICC line with tip in the SVC. There is a second catheter overlying the right upper abdomen and right chest, it is unclear exactly where this catheter drain is located. PICC LINE PLACEMENT INDICATION: IV access needed for antibiotics. The procedure was explained to the patient. A timeout was performed. RADIOLOGIST: Drs. [**Last Name (STitle) 9441**] and [**Name5 (PTitle) 3175**] performed the procedure. Dr. [**First Name (STitle) 3175**], the Attending Radiologist, was present and supervised the entire procedure. TECHNIQUE: Using sterile technique and local anesthesia, the left brachial vein was punctured under direct ultrasound guidance using a micropuncture set. Hard copies of ultrasound images were obtained before and immediately after establishing intravenous access. A peel-away sheath was then placed over a guidewire and a single lumen PICC line measuring 46 cm in length was then placed through the peel-away sheath with its tip positioned in the SVC under fluoroscopic guidance. Position of the catheter was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and guidewire were then removed. The catheter was secured to the skin, flushed, and a sterile dressing applied. The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided single lumen PICC line placement via the left brachial venous approach. Final internal length is 46 cm, with the tip positioned in SVC. The line is ready to use. [**2180-3-13**] 06:04AM BLOOD WBC-11.8* RBC-3.31* Hgb-8.4* Hct-27.3* MCV-83 MCH-25.2* MCHC-30.6* RDW-14.4 Plt Ct-496* [**2180-3-13**] 06:04AM BLOOD Plt Ct-496* [**2180-3-8**] 02:49AM BLOOD PT-14.4* PTT-27.6 INR(PT)-1.3* [**2180-3-13**] 06:04AM BLOOD Glucose-87 UreaN-15 Creat-0.6 Na-137 K-4.3 Cl-101 HCO3-29 AnGap-11 Brief Hospital Course: She was admitted to cardiac surgery. She was seen by plastic surgery. CT scan showed deep sternal wound infection. She was taken to the operating room on [**3-2**] where she underwent a sternal debridement with placement of VAC dressing. She was transferred to the ICU and remained sedated and paralyzed while her chest was open. She continued on vancomycin, as well as zosyn for broad empiric coverage. She was taken back to the operating room on [**3-6**] where she underwent sternal plating and bilateral pectoralis flap advancement. She was extubated on POD #2, and she was transferred to the floor. She progressed well, 1 JP drain was dc'd and she was ready for discharge home on POD #[**10-20**]. Medications on Admission: lantus, humalog ss, synthroid 50, toprol 25', zantac 150'', vanco 1500'' from [**2-14**] through [**3-27**], asa Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*0* 4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day) as needed for thrush. Disp:*qs 1 week* Refills:*0* 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 9. Insulin Glargine 100 unit/mL Solution Sig: Fifty (50) units Subcutaneous at bedtime. Disp:*qs 1 month* Refills:*0* 10. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous four times a day. Disp:*qs 1 month* Refills:*0* 11. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q12H (every 12 hours): through [**4-27**]. Disp:*qs 8 weeks* Refills:*0* 12. PICC care per protocol 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 Saline 5-10 cc SASH and PRN 13. Edecrin 25 mg Tablet Sig: One (1) Tablet PO twice a day as needed for edema for 7 days. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home with Service Facility: TBA Discharge Diagnosis: Sternal wound infection s/p debridement, sternal plating and blateral pectoralis flaps PMH:CABG [**1-21**], DM, tobacco abuse, morbid obesity, HTN, COPD, osteoporosis, ^lipids, hypothyroid, gastric ulcer w/UGIB 20y ago, PVD, chronic R breast inflamation, s/p C section, umbilical hernia repair, s/p bladder suspension, s/p chole, s/p R breast surgery Discharge Condition: Stable. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: [**Hospital **] clinic [**4-10**] at 9am Dr. [**Last Name (STitle) 914**] 4 weeks Dr. [**First Name (STitle) **] 1 week Completed by:[**2180-3-13**]

[ "272.4", "733.00", "041.11", "611.0", "998.59", "278.01", "427.89", "285.9", "998.32", "V45.89", "V58.67", "244.9", "401.9", "496", "305.1", "V45.81", "458.29", "414.00", "250.00", "410.72", "780.09", "715.89", "E878.2", "433.10", "433.30" ]

icd9cm

[ [ [] ] ]

[ "77.61", "96.72", "96.6", "86.74", "86.22", "38.93", "78.51" ]

icd9pcs

[ [ [] ] ]

6464, 6498

3892, 4596

285, 435

6893, 6903

1368, 1465

7216, 7367

1123, 1176

4759, 6441

1502, 1541

6519, 6872

4622, 4736

6927, 7193

1191, 1349

239, 247

1570, 3869

463, 725

747, 978

994, 1107

57,806

158,598

49040

Discharge summary

report

Admission Date: [**2125-3-3**] Discharge Date: [**2125-3-4**] Date of Birth: [**2060-6-21**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2901**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Cardiac catheterization Intra arterial balloon pump placement History of Present Illness: See hospital course Past Medical History: 1. Obesity 2. Hypertension 3. Diabetes, poorly controlled, HbA1c 11, est. av. glucose 280. On oral agents at admission. 4. Chronic renal insufficiency (likely diabetic) 5. Hyperlipidemia, not clear that this was being treated. 6. History of smoking - remote, 20 pack years 7. Coronary artery disease s/p catheterization (at [**Hospital 2586**]). He had had a positive stress test and elective cath. in [**2117**]: Anatomy: LAD 50-60% stenosis distally. RCA mid 100% stenosis. LCx and LM without lesions. Excellent left to right collaterals. No stents placed. Last echo revealed LVEF of 55%, per [**Hospital3 **] Cath. report. No evidence of CABG (although in ED note - no evidence of incision and no sternotomy wires). 8. Obstructive sleep apnea 9. Hemorrhoids 10. Anxiety 11. Gridiron incision c/w past appendectomy. 12. Gout - fifth finger of right hand affected. Social History: Unknown Family History: Unknown Physical Exam: Expired Pertinent Results: [**2125-3-3**] 11:11PM BLOOD WBC-13.6* RBC-5.36 Hgb-11.7* Hct-40.1 MCV-75* MCH-21.9* MCHC-29.3* RDW-17.7* Plt Ct-237 [**2125-3-3**] 11:11PM BLOOD Neuts-77* Bands-3 Lymphs-12* Monos-5 Eos-1 Baso-0 Atyps-2* Metas-0 Myelos-0 [**2125-3-3**] 11:11PM BLOOD Glucose-327* UreaN-39* Creat-2.2* Na-138 K-4.7 Cl-107 HCO3-19* AnGap-17 [**2125-3-3**] 11:11PM BLOOD cTropnT-0.23* [**2125-3-3**] 11:11PM BLOOD Calcium-7.2* Phos-5.1* Mg-2.0 [**2125-3-4**] 12:37AM BLOOD Type-ART PEEP-5 pO2-58* pCO2-37 pH-7.30* calTCO2-19* Base XS--7 Intubat-INTUBATED [**2125-3-3**] 11:14PM BLOOD Type-ART pO2-69* pCO2-46* pH-7.29* calTCO2-23 Base XS--4 Intubat-INTUBATED [**3-3**] CXR Severe pulmonary edema Brief Hospital Course: ?????? ?????? The patient was a 64 year-old man with a history of obesity, coronary artery disease, hypertension, dyslipidemia, poorly-controlled diabetes, chronic kidney disease, obstructive sleep apnea, anxiety and gout. He had a positive stress test and elective catheterization in [**2117**], which showed an ejection fraction of 55%, 50-60% stenosis of the left anterior descending artery and 100% stenosis of the right coronary artery; no stents were previously placed. ??????In [**2122**], he experienced a prior episode of bradycardic arrest with development of complete heart block, for which he was admitted to [**Hospital1 1170**]. ??????Sinus rhythm was restored after control of his hyperglycemia. ?????? ?????? On the evening of [**2125-3-3**], the patient was reportedly dining when he experienced a witnessed sudden cardiac arrest. Immediate cardiopulmonary resuscitation was administered and he was taken to the emergency department at [**Hospital1 102921**]. He regained a rhythm and awakened at the outside emergency department before subsequently experiencing two brief successive arrests for which he was quickly resuscitated with epinephrine and cardiopulmonary resuscitation. He was noted to have gross pulmonary edema and was intubated. Workup for pulmonary embolism was negative and his cardiac enzymes were documented as CK 444, MB 7.70, MBI 1.7, and troponin-T 0.062. He was subsequently transferred to [**Hospital1 18**] for advanced cardiac care. ?????? ?????? At [**Hospital1 18**], he remained somewhat hypotensive and extremely hypoxic. Electrocardiography showed right bundle branch block, diffuse repolarization changes, and no ST segment elevation myocardial infarction. A repeat electrocardiogram showed rhythm with negative deflections in leads one and aVL; a chest radiograph showed pulmonary edema, and ventilation was difficult. His caretaker/friend noted that he was on insulin for control of diabetes and azithromycin for a ??????few days?????? due to a respiratory infection. Labs on admission showed leukocytosis and microcytic anemia; troponin T was elevated at 0.23; glucose, BUN, creatinine and phosphate were elevated; calcium and bicarbonate were low. ?????? ?????? The patient was taken to the catheterization lab with a systolic blood pressure of 100. He subsequently developed hypotension and bradycardia. Intravenous inotropes and bolus epinephrine were administered. ??????Fluoroscopy and echocardiography confirmed absence of pneumothorax. ??????Echocardiography performed in the catheterization laboratory demonstrated severe pump dysfunction, no pericardial effusion, and no evidence of mitral regurgitation or aortic insufficiency. An intaaortic balloon pump was placed for blood pressure support. Despite resuscitative efforts for pulseless electrical activity including placement of a pacemaker, further epinephrine and vasopressors, there was no improvement in blood pressure, and the patient continued to deteriorate and expired at 1:00 A.M. on the morning of [**2125-3-4**]. Both the patient??????s aunt and friend consented to a full autopsy, given the absence of living spouse, parents, or children. Medications on Admission: Unknown Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Cardiac arrest Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

[ "414.01", "585.9", "300.00", "426.4", "327.23", "403.90", "278.00", "518.82", "414.2", "427.5", "250.40", "V58.67", "443.9", "272.4", "274.9", "V15.82", "V49.87", "785.51" ]

icd9cm

[ [ [] ] ]

[ "37.21", "88.56", "37.78", "37.61", "96.71", "99.60" ]

icd9pcs

[ [ [] ] ]

5362, 5371

2110, 5276

314, 377

5429, 5439

1408, 2087

5491, 5626

1356, 1365

5334, 5339

5392, 5408

5302, 5311

5463, 5468

1380, 1389

263, 276

405, 426

448, 1315

1331, 1340

59,318

179,448

2880

Discharge summary

report

Admission Date: [**2119-12-14**] Discharge Date: [**2119-12-22**] Date of Birth: [**2052-7-16**] Sex: M Service: GOLD SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 67 year-old man who had undergone a pylorus sparing Whipple procedure on [**2117-12-11**] for intraductal papillary mucinous tumor of the pancrease. The patient presented to the Emergency Department on [**2119-12-14**] complaining of three weeks of intermittent nausea and vomiting and abdominal pain. The patient reports that the abdominal pain and nausea and vomiting became most severe the night prior to admission with three episodes of vomiting including some bilious fluid. The patient reports that his pain is located in the right upper quadrant and is described as being severe without any radiation and it is described in quality as being colicky and intermittent in nature. The pain was so severe that the patient could not sleep. The patient denies having fevers at home, however, he reported having chills while having his episodes of pain. The patient also reports that his bowel movements have become pale colored, but denies having any changes in frequency. He did not report changes in flatus or urinary symptoms, but did report that his urine had become dark recently. The patient also reports having pruritus and has recently started taking Atarax. PAST MEDICAL HISTORY: 1. Intraductal papillary mucinous tumor of the pancrease and chronic pancreatitis. 2. History of diabetes. PAST SURGICAL HISTORY: 1. Pylorus sparing Whipple procedure in [**2117-12-11**]. 2. Incisional hernia repair status post Whipple procedure [**2119-1-24**]. ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: 1. Atarax. 2. Pancrease enzymes. 3. Insulin regimen including NPH doses at breakfast, dinner and bedtime and a regular insulin sliding scale. 4. Reglan. 5. Percocet. 6. Colace. 7. Pletal. 8. Aciphex. PHYSICAL EXAMINATION ON ADMISSION: The patient was afebrile temperature of 96.9. Heart rate 80. Blood pressure 121/64. Respiratory rate 18. Sating 95% on room air. The patient was alert and oriented times three, jaundice in appearance. The patient had icteric sclera. The neck was supple. There was no JVD. Cardiovascular examination was regular rate and rhythm. S1 and S2. No murmurs were heard. Respirations clear to auscultation bilaterally. Abdominal examination showed a well healed incision from the Whipple procedure with bowel sounds soft, nondistended, but mildly tender in the right upper quadrant. Extremities were warm and without any edema. LABORATORIES ON ADMISSION: White blood cell count 17.1 with neutrophil of 77%, lymphocytes of 18%, hematocrit 41.9 and platelets 469. PT 12. PTT 23.8 with an INR of 1.0. Chemistries sodium 141, potassium 3.9, chloride 103, CO2 27, BUN 11 and creatinine 0.7 and glucose of 167. AST 49, ALT 48, alkaline phosphatase 338 with a total bilirubin of 6.7, amylase 19, lipase 7. The patient had a recent CAT scan dated [**2119-12-11**], which did not show any recurrence of the IPMT. HOSPITAL COURSE: Given the patient's significant past medical history and his surgical history of having gone a Whipple procedure and the patient's current state of biliary obstruction and symptoms of chills the patient was suspected of having obstructive jaundice and cholangitis. The patient was made NPO and was put on intravenous fluids and was started on Amp, Levo and Flagyl empirically. The patient was sent for an ERCP urgently, however, the patient's biliary anastomosis could not be reached by the endoscope therefore endoscopic retrograde cholangiopancreatography could not be performed. Because the patient's bilary obstruction could not be relieved the patient was sent to the interventional radiology for percutaneous transhepatic biliary drainage and the patient underwent procedures successfully without any complications. Upon admission the patient was found to have occasional fever spikes to 101 on hospital day one and two. The patient was pan cultured. Blood cultures ultimately did not grow out any bacteria, however, the bile cultures drawn from the PTC2s grew out pan sensitive E-coli and pan sensitive Enterococcus and the bowel cultures specimens sent on hospital day two also grew out pan sensitive E-Coli and pan sensitive Klebsiella oxytoca. The patient was still having a fever on hospital day two and because his total bilirubin level had increased from 6.7 to 7.8 the patient was resent to the interventional radiology for check of the catheter. This was done without any complications. Although the patient still had a continuous structure of the common bile duct at the biliary anastomosis contrast flowed freely into the small bowel without any difficulty, therefore the catheter was working properly and the patient was continued on intravenous antibiotics and Ampicillin, Levaquin and Flagyl. The patient's total bilirubin and his liver function tests were followed daily and the patient's total bilirubin peaked at a level of 9.3 on hospital day three and four with temperature spikes to temperature max of 103.7 on hospital day four. The patient was carefully observed and continued on his intravenous antibiotics. The patient's total bilirubin gradually decreased with the PTC2 draining dark bilious drainage and the patient subsequently was doing well on intravenous antibiotics. On discharge the patient had been afebrile for 48 hours with total bilirubin trending down to a level of 6.0 from a peak of 9.3. The patient's liver function tests levels were within normal limits. The patient was tolerating a regular diet without any difficulty and without nausea and vomiting. The patient's abdominal pain decreased significantly after the PTC and drainage with only mild tenderness at the incision site of the PTC2. This pain was initially treated with po Percocet, but because the patient became somnolent the patient was switched over to Tylenol #3 with good effect. On hospital day eight the patient was switched over to po Levaquin after confirming the sensitivities on the E-Coli enterococcus and the Klebsiella that grew out from the bile culture on admission the patient was discharged home on [**2119-12-22**] on hospital day nine to finish his po antibiotics course at home. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Discharged to home. DISCHARGE DIAGNOSES: 1. History of pancreatic intraductal papillary mucinous tumor status post Whipple procedure on [**2118-1-6**] found to have cholangitis due to anastomotic stricture with E-Coli, Klebsiella oxytoca and Enterococcus. 2. Diabetes mellitus. DISCHARGE MEDICATIONS: The patient is to continue all of his preoperative medications as listed above. The patient is also to complete a fourteen day course of Levaquin 500 mg po q.d. for twelve more days. The patient is also prescribed Tylenol with codeine 300/30 mg one to two tables po q 4 hours prn pain and Colace 100 mg po b.i.d. prn constipation. FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) 468**] in his office on [**2120-1-1**] and is to undergo a 2 cholangiogram on the morning of the 22nd to check for presence of biliary obstruction. [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**] Dictated By:[**Last Name (NamePattern1) 10201**] MEDQUIST36 D: [**2119-12-24**] 08:53 T: [**2119-12-25**] 06:21 JOB#: [**Job Number 13961**]

[ "576.1", "997.4", "428.0", "250.00", "V10.09", "576.2" ]

icd9cm

[ [ [] ] ]

[ "45.13", "51.98", "46.85" ]

icd9pcs

[ [ [] ] ]

6344, 6393

6414, 6654

6678, 7012

3096, 6322

1719, 1949

1524, 1698

7024, 7499

176, 1369

2624, 3078

1391, 1501

23,152

189,270

24580

Discharge summary

report

Admission Date: [**2119-5-19**] Discharge Date: [**2119-6-2**] Date of Birth: [**2094-3-26**] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3190**] Chief Complaint: Back pain s/p trauma Major Surgical or Invasive Procedure: Anterior vertebrectomy L1/ fusion T12-L2 Posterior fusion T8-L3 History of Present Illness: S/p Fall at work with severe L1 burst fracture and initial paraparesis which resolved with IV steroids. Past Medical History: Non-contributory Social History: Works doing construction Family History: Non-contributory Physical Exam: This white male with severe back pain. Strength intact in both lower extremeties but L1 dysesthesias present Pertinent Results: [**2119-5-19**] 10:04PM GLUCOSE-105 LACTATE-1.2 NA+-142 K+-4.5 CL--103 TCO2-25 [**2119-5-19**] 10:04PM GLUCOSE-105 LACTATE-1.2 NA+-142 K+-4.5 CL--103 TCO2-25 [**2119-5-19**] 09:50PM WBC-16.8* RBC-4.87 HGB-14.2 HCT-42.1 MCV-86 MCH-29.2 MCHC-33.8 RDW-12.3 Brief Hospital Course: Patient was admitted to hospital on [**2119-5-19**]. He was brought to OR on [**2119-5-24**] for anterior procedure. This was tolerated well. He was brought back to OR on [**2119-5-28**] for posterior spinal fusion with instrumentation. He had acute blood loss anemia requiring transfusion of 2 units prbc's. He was begun with ambulation with a TLSO. On [**2119-6-1**] he was ambulating independently without assistance. Medications on Admission: None Discharge Medications: Oxycontin 20mg po TID/ Oxycodone 5mg po q4 hours Discharge Disposition: Home Discharge Diagnosis: L1 Burst Fracture Discharge Condition: stable Discharge Instructions: Keep incisions clean dry and inatct. Use TLSO when OOB. Followup Instructions: Follow-up in Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office in 2 weeks.

[ "805.2", "805.4", "E884.9", "285.1", "493.90" ]

icd9cm

[ [ [] ] ]

[ "99.04", "84.51", "77.89", "81.63", "80.51", "81.05", "99.05", "81.04", "99.07", "77.79" ]

icd9pcs

[ [ [] ] ]

1631, 1637

1081, 1503

339, 404

1698, 1706

797, 1058

1810, 1914

635, 653

1558, 1608

1658, 1677

1529, 1535

1730, 1787

668, 778

279, 301

432, 537

559, 577

593, 619

23,492

125,577

24489+57398

Discharge summary

report+addendum

Admission Date: [**2146-7-4**] Discharge Date: [**2146-7-21**] Date of Birth: [**2077-2-13**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 17683**] Chief Complaint: Peripheral Vascular Disease Acute Cholecystitis Major Surgical or Invasive Procedure: Left below the knee popliteal to posterior tibial artery bypass Laparoscopic converted to open cholecystectomy for a gangrenous, necrotic gall bladder. History of Present Illness: Patient is 69 year old male who was admitted [**7-4**] to the vascular surgery service. He had been discharged a week prior (admitted for debridement of left foot ulcer) on antibiotics, and returned on [**7-4**] for LLE bypass surgery. Past Medical History: CAD, s/p CABG ([**2137**]) Aortic valve dz s/p AVR ([**2144**]) Gout DM2-insulin dependant Prostate CA s/p XRT Hx thrombophlebitis of lower extremity hx rosacea Hypercholesterolemia s/p right breast lumpectomy Physical Exam: (Day of Gerneral Surgery Consult:) Exam unremarkable except for abdomen with RUQ tenderness to palpation, positive [**Doctor Last Name 515**] sign, palpable gall bladder. Pertinent Results: [**2146-7-16**] 03:07AM BLOOD WBC-9.2 RBC-3.91* Hgb-10.0* Hct-32.8* MCV-84 MCH-25.7* MCHC-30.7* RDW-16.5* Plt Ct-338 Brief Hospital Course: Patient underwent left below the knee popliteal to posterior tibial artery bypass for a non-healing LLE ulcer on [**2146-7-6**]. His post-operative course was uncomplicated until [**7-10**], on which day he began to have RUQ pain, nausea and vomiting. General surgery was consulted on [**7-12**], at which point an ultrasound revealed a picture consistent with acute cholecystitis. The patient was taken to the operating room on [**7-12**] where a gangrenous, necrotic gallbladder necessitated a conversion from laparoscopic to open choecystectomy. He was taken to the PACU intubated, where his recovery was slow, complicated by poor urine output and borderline ABGs. He was admitted to the ICU on [**7-13**] for above reasons. He recovered steadily in the ICU, where his fluid status was carefully managed, and he was slowly weaned from IV sedation. On [**7-14**] he was successfully extubated, sips were started on [**7-15**], and on [**7-16**] he was stable enough to be transferred to the floor. He continued to successfully recover on the floor, was advanced slowly to a full diet, and on [**7-19**] he was in good condition, stable and ready for discharge to rehabilitation facility. Medications on Admission: allopurinol, prilosec, glyburide, metformin, lipitor, lasix, metroget, vit c, lantus, multivitamin Discharge Medications: Allopurinol 300 mg PO DAILY Morphine Sulfate 2-4 mg IV Q2H:PRN Insulin SC (per Insulin Flowsheet)Sliding Scale & Fixed Dose Miconazole Powder 2% 1 Appl TP TID to scrotal and groin areas View Aspirin 325 mg PO DAILY Heparin 5000 UNIT SC TID Metformin 1000 mg PO BID [**7-16**] @ 1618 View Glyburide 10 mg PO BID Atorvastatin 10 mg PO DAILY Furosemide 40 mg PO DAILY Lisinopril 30 mg PO DAILY Metoprolol 100 mg PO BID Oxycodone-Acetaminophen [**1-9**] TAB PO Q4-6H:PRN Pantoprazole 40 mg PO Q24H Acetaminophen 325-650 mg PO Q4-6H:PRN [**7-19**] @ 0933 View Levofloxacin 500 mg PO Q24H for a total of 10 days (ends [**7-27**]) Lantus *NF* 18 UNIT SC DINNER Tamsulosin HCl 0.4 mg PO HS Discharge Disposition: Extended Care Facility: [**State **] veterans home Discharge Diagnosis: Peripheral Vascular Disease Acute Cholecystitis Discharge Condition: Good Discharge Instructions: Call immediately if you have chills, or fevers greater than 100.5, or the operative incisions become more red, swollen, or begin draining pus. Please take all medications as predcribed and in particular continue the oral antibiotics until [**7-27**] (for a total of 10 days). Avoid lifting heavy objects for 6-8 weeks, and follow-up with both Dr. [**Last Name (STitle) **] and your vascular surgeon as recommended below. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 2867**], your vascular surgeon by calling the number above to make an appointment within 2 weeks. Please also make a separate appointment with Dr. [**Last Name (STitle) **], your gall bladder surgeon in two weeks by calling ([**Telephone/Fax (1) 33502**]. [**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**] Completed by:[**2146-7-19**] Name: [**Known lastname **],[**Known firstname 8687**] Unit No: [**Numeric Identifier 11155**] Admission Date: [**2146-7-4**] Discharge Date: [**2146-7-21**] Date of Birth: [**2077-2-13**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3673**] Addendum: Please followup with Dr. [**Last Name (STitle) **] in 1 week. Please call for a followup appointment. Brief Hosp Course: [**Date range (1) 11156**]. Pt remained stable, afebrile, vitals stable, good urine output, no abdomenal pain, with JP's drainage ranging minimal-moderate. It will be pulled today. Pt is discharged in good condition. Chief Complaint: Admitted for fem-tib w/ cephalic vein bypass, abdomenal pain Major Surgical or Invasive Procedure: Left below the knee popliteal to posterior tibial artery bypass Laparoscopic converted to open cholecystectomy for a gangrenous, necrotic gall bladder. History of Present Illness: 69 year old male with CAD, s/p CABG [**2137**] originally admitted for femoral-tibial w. cephalic vein bypass Past Medical History: CAD, s/p CABG ([**2137**]) Aortic valve dz s/p AVR ([**2144**]) Gout DM2-insulin dependant Prostate CA s/p XRT Hx thrombophlebitis of lower extremity hx rosacea Hypercholesterolemia s/p right breast lumpectomy Social History: 10 yrs tob 1ppd Family History: [**Name (NI) 11157**], Dad-MI at 65 y/o Physical Exam: NAD heart reg, systolic murmur aortic area lungs crackles left lower lung abdomen: obese, non-tender non-distended, normal bowel sounds Neuro: alert and oriented Pertinent Results: [**2146-7-17**] 05:51AM BLOOD Hct-33.1* [**2146-7-16**] 03:07AM BLOOD WBC-9.2 RBC-3.91* Hgb-10.0* Hct-32.8* MCV-84 MCH-25.7* MCHC-30.7* RDW-16.5* Plt Ct-338 [**2146-7-15**] 02:20AM BLOOD WBC-9.4 RBC-3.74* Hgb-9.6* Hct-31.0* MCV-83 MCH-25.6* MCHC-30.9* RDW-16.4* Plt Ct-300 [**2146-7-14**] 02:18AM BLOOD WBC-10.2 RBC-3.59* Hgb-9.6* Hct-28.6* MCV-80* MCH-26.7* MCHC-33.4 RDW-16.4* Plt Ct-260 [**2146-7-13**] 04:35AM BLOOD WBC-12.2* RBC-3.82* Hgb-9.9* Hct-30.8* MCV-81* MCH-25.8* MCHC-31.9 RDW-16.5* Plt Ct-256 [**2146-7-12**] 10:10AM BLOOD WBC-21.1* RBC-4.05* Hgb-10.2* Hct-32.9* MCV-81* MCH-25.2* MCHC-31.1 RDW-17.1* Plt Ct-281 [**2146-7-12**] 06:00AM BLOOD WBC-23.6*# RBC-4.00* Hgb-10.4* Hct-32.3* MCV-81* MCH-26.1* MCHC-32.3 RDW-16.9* Plt Ct-329# [**2146-7-10**] 05:00AM BLOOD WBC-7.2 RBC-3.63* Hgb-9.2* Hct-29.0* MCV-80* MCH-25.4* MCHC-31.7 RDW-16.7* Plt Ct-156 [**2146-7-8**] 03:36AM BLOOD WBC-7.5 RBC-3.70* Hgb-9.7* Hct-29.4* MCV-79* MCH-26.1* MCHC-32.8 RDW-16.5* Plt Ct-148* [**2146-7-7**] 03:46AM BLOOD WBC-7.0 RBC-3.62* Hgb-9.1* Hct-28.6* MCV-79* MCH-25.2* MCHC-32.0 RDW-16.4* Plt Ct-167 [**2146-7-5**] 05:20AM BLOOD WBC-6.5 RBC-4.43* Hgb-11.3* Hct-35.3* MCV-80* MCH-25.4* MCHC-31.9 RDW-16.4* Plt Ct-191 [**2146-7-16**] 03:07AM BLOOD Glucose-187* UreaN-19 Creat-0.8 Na-142 K-3.7 Cl-110* HCO3-26 AnGap-10 [**2146-7-14**] 02:18AM BLOOD Glucose-113* UreaN-35* Creat-1.5* Na-132* K-3.6 Cl-102 HCO3-23 AnGap-11 [**2146-7-13**] 11:43AM BLOOD Glucose-56* UreaN-39* Creat-2.0* Na-133 K-3.8 Cl-100 HCO3-25 AnGap-12 [**2146-7-13**] 04:35AM BLOOD Glucose-114* UreaN-38* Creat-1.9* Na-136 K-3.5 Cl-99 HCO3-26 AnGap-15 [**2146-7-12**] 09:14PM BLOOD Glucose-196* UreaN-34* Creat-1.9* Na-134 K-4.0 Cl-97 HCO3-24 AnGap-17 [**2146-7-12**] 06:00AM BLOOD Glucose-224* UreaN-24* Creat-1.6* Na-134 K-4.4 Cl-94* HCO3-24 AnGap-20 [**2146-7-10**] 05:00AM BLOOD Glucose-126* UreaN-18 Creat-1.0 Na-134 K-4.1 Cl-100 HCO3-26 AnGap-12 [**2146-7-7**] 03:46AM BLOOD Glucose-166* UreaN-19 Creat-1.0 Na-137 K-5.0 Cl-105 HCO3-25 AnGap-12 [**2146-7-6**] 04:44PM BLOOD Glucose-114* UreaN-25* Creat-1.0 Na-140 K-4.7 Cl-108 HCO3-24 AnGap-13 [**2146-7-6**] 05:27AM BLOOD Glucose-165* UreaN-30* Creat-1.2 Na-138 K-5.0 Cl-104 HCO3-25 AnGap-14 [**2146-7-12**] 10:10AM BLOOD ALT-27 AST-35 LD(LDH)-277* AlkPhos-266* Amylase-31 TotBili-1.1 [**2146-7-13**] 04:35AM BLOOD Lipase-91* [**2146-7-16**] 03:07AM BLOOD Calcium-7.8* Phos-2.1* Mg-1.3* [**2146-7-14**] 04:54PM BLOOD Calcium-8.0* Phos-3.5 Mg-1.7 [**2146-7-14**] 02:18AM BLOOD Calcium-7.8* Phos-3.7 Mg-1.8 [**2146-7-13**] 04:35AM BLOOD Calcium-8.7 Phos-4.7* Mg-2.3 [**2146-7-12**] 09:14PM BLOOD Calcium-9.0 Phos-4.9* Mg-1.3* [**2146-7-10**] 05:00AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.5* [**2146-7-15**] 03:23AM BLOOD Type-ART pO2-126* pCO2-45 pH-7.36 calHCO3-26 Base XS-0 [**2146-7-14**] 05:16PM BLOOD Type-ART pO2-142* pCO2-42 pH-7.39 calHCO3-26 Base XS-0 [**2146-7-14**] 03:12AM BLOOD Type-ART Temp-38.2 PEEP-5 pO2-146* pCO2-44 pH-7.38 calHCO3-27 Base XS-0 Intubat-INTUBATED [**2146-7-13**] 05:23AM BLOOD Type-ART pO2-143* pCO2-45 pH-7.39 calHCO3-28 Base XS-2 [**2146-7-13**] 01:11AM BLOOD Type-ART pO2-60* pCO2-42 pH-7.40 calHCO3-27 Base XS-0 [**2146-7-14**] 03:12AM BLOOD Glucose-110* Lactate-1.0 [**2146-7-13**] 04:17PM BLOOD Glucose-61* Lactate-0.9 [**2146-7-12**] 07:06PM BLOOD Glucose-209* Lactate-4.1* Na-130* K-4.0 Cl-97* calHCO3-25 [**2146-7-6**] 02:51PM BLOOD Glucose-118* Lactate-2.3* [**2146-7-6**] 01:41PM BLOOD Glucose-139* Lactate-2.4* K-4.7 [**2146-7-6**] 12:34PM BLOOD Glucose-151* Lactate-2.5* Na-137 K-4.7 [**2146-7-6**] 11:17AM BLOOD Glucose-218* Lactate-2.4* Na-134* K-5.3 Cl-104 [**2146-7-12**] 07:06PM BLOOD Hgb-9.3* calcHCT-28 [**2146-7-6**] 12:34PM BLOOD Hgb-10.9* calcHCT-33 Brief Hospital Course: Pt was originally admitted for femoral-tibial w. cephalic vein bypass. He started to develop abd pain. U?S revealed enlarged gallbladder. He was taken to the Or of a laparoscopic cholecystectomy due to gangrenous gallbladder, which latter became an open cholecystectomy. Pt was admitted to the ICU, and subsequently to the surgical floor. [**Hospital **] hospital stay was complicated by high blood glucose, which was later controlled. Pt has been tolerating regular diabetic food, getting physical therapy, and will be discharge to a rehabilitation center in [**State 4488**]. Discharge Medications: 1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Disp:*100 ml* Refills:*2* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*100 Tablet(s)* Refills:*2* 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). Disp:*100 Appl* Refills:*2* 5. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18) units Subcutaneous DINNER (Dinner). Disp:*1000 units* Refills:*2* 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. Disp:*10 Tablet(s)* Refills:*0* 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*60 Capsule, Sust. Release 24HR(s)* Refills:*2* 11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 12. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*100 Tablet(s)* Refills:*2* 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*100 Tablet(s)* Refills:*2* 14. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 15. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 16. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**State **] veterans home Discharge Diagnosis: Peripheral Vascular Disease Acute Cholecystitis Discharge Condition: Good Discharge Instructions: Call immediately if you have chills, or fevers greater than 100.5, or the operative incisions become more red, swollen, or begin draining pus. Please take all medications as predcribed and in particular continue the oral antibiotics until [**7-27**] (for a total of 10 days). Avoid lifting heavy objects for 6-8 weeks, and follow-up with both Dr. [**Last Name (STitle) **] and your vascular surgeon as recommended below. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 11158**], your vascular surgeon by calling the number above to make an appointment within 2 weeks. Please also make a separate appointment with Dr. [**Last Name (STitle) **], your gall bladder surgeon in two weeks by calling ([**Telephone/Fax (1) 11159**]. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 3676**] Completed by:[**2146-7-21**]

[ "V10.46", "730.07", "440.23", "250.60", "574.31", "274.9", "401.9", "V45.81", "V64.41", "V43.3", "730.17" ]

icd9cm

[ [ [] ] ]

[ "99.04", "77.88", "86.22", "77.89", "51.22", "39.29", "38.93", "93.59" ]

icd9pcs

[ [ [] ] ]

12421, 12474

9885, 10468

5329, 5484

12566, 12572

6145, 9862

13043, 13497

5906, 5947

10491, 12398

12495, 12545

2580, 2680

12596, 13020

5962, 6126

5229, 5291

5512, 5623

5645, 5857

5873, 5890

23,238

135,795

44747

Discharge summary

report

Admission Date: [**2117-11-18**] Discharge Date: [**2117-11-24**] Service: MEDICINE Allergies: Ciprofloxacin / Amiodarone Attending:[**Doctor First Name 1402**] Chief Complaint: transfer from [**Hospital 7168**] hospital for ventricular tachycardia and potential EP study and ablation procedure Major Surgical or Invasive Procedure: [**2117-11-19**] EP study for VT ablation [**2117-11-19**] Pericardiacentesis with drain [**2117-11-20**] Drain removed History of Present Illness: Mr [**Known lastname 32729**] is an 82 yo with h/o CAD s/p large anterior MI at age 36 with EF 25%; 2 vessel CAGB in [**2104**] (LIMA to LAD; SVG to OM); s/p SNTEMI [**10/2114**] with stent to native L circ. He had a pacemaker/defibrillator placed in [**2114**] for primary prevention; he had an episode of VTach in [**2115**] causing syncope and was begun on amiodarone (d/c'd) and then procainamide since 4/[**2116**]. This was recently decreased from 1000mg po tid to 500mg tid. . He presented to [**Hospital **] hospital on [**11-17**] after 1 day of intermittent palpitations that kept him awake most of the night of [**2037-11-14**]. Later that day he reported associated light headedness/diaphoresis which prompted him to go to the ED. He denied any chest pain or shortness of breath, LOC associated with these episodes. At [**Location (un) 14078**] he was found to have 150 episodes of VT. Overnight he evidently had 10 episodes ventricular tachycardia (asymptomatic) and is transferred to [**Hospital1 18**] for EP study and possible ablation. . Otherwise Mr. [**Known lastname 32729**] is feeling well. He denies any CP, SOB, or current lightheadedness. At baseline he can walk the length of a long corridor without significant SOB. His walking is limited by orthopedic problems rather than dyspnea. He has been compliant with all of his medications. Past Medical History: # CAD s/p large anterior MI at age 36; # 2 vessel CABG [**2101**] LIMA to LAD; SVG to OM # NSTEMI [**10/2114**] s/p stent to native L circ. # CHF with LV EF of 25% # Ventricular Tachycardia: had pacemaker placed in [**2114**] for primary prevention (MADIT criteria); had [**Hospital1 18**] hospitalization [**3-26**] (started on amio; d/c'd due to "balance disorder/falls"), started on procainamide [**12/2116**]; decreased from 1000mg tid to 500mg tid with level 7.2 on [**10-15**]. # s/p [**Company **] [**Last Name (un) **] pacer/defibrillator [**2116-12-31**] (Madit II criteria) # atrial flutter: recenty hospitalized at [**Hospital1 18**] # CRI with baseline Cr in low 2 range # ???L arm emolism; on coumadin since [**7-/2116**] # B achilles tendon rupture [**12-24**] ciprofloxacin # Prostate CA: s/p brachytherapy # osteoarthritis (currently taking prednisone) . Social History: retired; works as volunteer at local hospital. Remote smoking history, no EtOH Family History: Father died with CAD; healthy son; daughter with [**Name2 (NI) 95740**] Physical Exam: HR 63 (atrially paced); BP 104/76; T 98.1; RR 13 98% RA Gen: well-appearing elderly male in NAD HEENT: NCAT, MMM CV: RRR grade 2-3/6 mid-peaking systolic murmur heard best at RUSB and LUSB; No radiation to carotids or axilla. No JVD Pulm: Clear B Abd: s/nd/nt Extremities: warm, well-perfused; 2+ DP pulses B; good groin pulses, no bruits Pertinent Results: [**2117-11-18**] 01:56PM PT-22.8* PTT-33.2 INR(PT)-2.3* [**2117-11-18**] 01:56PM PLT COUNT-195 [**2117-11-18**] 01:56PM WBC-6.5 RBC-4.19* HGB-12.9* HCT-38.2* MCV-91 MCH-30.8 MCHC-33.8 RDW-13.9 [**2117-11-18**] 01:56PM ALBUMIN-4.0 CALCIUM-9.4 PHOSPHATE-2.5* MAGNESIUM-2.1 [**2117-11-18**] 01:56PM GLUCOSE-114* UREA N-36* CREAT-2.2* SODIUM-137 POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-27 ANION GAP-12 . Proc: 8.9, NAPA: 11.4 . Tx reaction w/u: negative . Cx: all no growth . [**11-19**] eccho: The left ventricular cavity is moderately dilated. LV systolic function appears depressed. The right ventricular cavity is unusually small. There is a moderate sized pericardial effusion. There is severe right ventricular compression, consistent with impaired fillling/tamponade physiology. [**11-24**] eccho: Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe regional left ventricular systolic dysfunction. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are thickened. The mitral valve leaflets are mildly thickened. There is a small to moderate sized pericardial effusion measuring ~1.2cm anterior to the right ventricle and right atrium, and <1cm posterior to the left ventricle and left atrium. Transmitral Doppler does not suggest hemodynamic compromise. Compared with the prior study (images reviewed) of [**2117-11-23**], the size of the posterior effusion is slightly smaller. Brief Hospital Course: A/P 82 yo with CAD s/p old IMI, 2 vessel CABG in [**2101**], NSTEMI in [**2113**] with stent to native L circ, CHF with EF 25-30%, VT s/p ICD placement presenting with recurrent VT. Briefly, Mr [**Known lastname 32729**] was admitted w/o evidence of sustained VT on telemetry. He had successful ablation of LV scar but this procedure was complicated by pericardial effusion/tamponade. . # Cardiac: -- Rhythm: Patient had recurrent VT likely [**12-24**] old IMI with scar. His procainamide dose was increased to 750mg po tid (goal proc level 8) with similar metoprolol dose at 50mg toprol XL daily. He had a successful VT ablation with mapping complicated by bloody pericardial effusion/tamponade and groin bleed (see below). His pacemaker was reset to 80 bpm; there has been an advisory on his specific pacemaker and he was instructed to place a magnet to it daily to ensure that it is working correctly. Mr [**Known lastname 95741**] ablation was complicated by hemorrhagic effusion causing tamponade requiring pericardial drain (140cc off). The drain was pulled and repeat eccho initially showed some small reaccumulation which was subsuquently stable with no evidence tamponade. -- CAD: s/p IMI at age 36, CABG [**2103**] with SVG to OM and LIMA to LAD, NSTEMI [**2113**] with PTCA to L circ; He was kept on metoprolol, losartan, aspirin, and statin -- Pump: baseline of EF 25-30%; symptomatically NYHA class II. During hospitalization had several episodes of hypotension, one resolving with draining of pericardial fluid, one with a NS bolus of 500cc and dopamine. Thought to be in setting of tamponade phsyiology and hypovolemia. This resolved quickly and he has been normotense on home antihypertensive regimen (metoprolol XL 50, losartan 25) for several days prior to discharge. . # Groin Bleed/Hematoma: Patient had groin bleed/hematoma in setting of elevtaed INR (coumadin outpt) and instrumentation in fem art for EP study. Direct pressure and pressure dressing applied with good effect. Anticoagulation was reversed with FFP, a small amount of vit K and protamine. He did not require any pRBC transfusion. His anticoagulation was discontinued (as below). . # Rigors/Fever: Patient had rigors during groin bleed Differential includes transfusion reaction from FFP or bacteremia (transient or otherwise) from lines/lungs. All cx NGTD; the patient otherwise remained AF the rest of his hospital course. he was briefly covered with vancomycin. . # CRI: Baseline Cr of 2.1-2.3. Not an acute issue . # L arm thrombosis: Discontinued anticoagulation as he has been anticoagulated for over 6 mos and likely no further indication. . # Arthritis: continued prednisone as per outpatient PCP (although this is not likely an appropriate regimen). he was adrenally sufficient. . # Prostate CA: outpt managmement, continued home medications of flomax and detrol. . # FEN/GI: Euvolemic on admission; low-salt cardiac diet. Put back on outpt lasix dose on discharge. . # Mr [**Known lastname 32729**] is discharged with f/u in 2 days with Dr. [**Last Name (STitle) **]. Medications on Admission: ASA 81 # digoxin 0.0625 dialy # coumadin 3 # losartan 25mg daily # metoprolol 25 [**Hospital1 **] # procanamide 500mg po tid # lasix 20 mg po daily # zetia 10mg po daily # folate 1mg po daily # omeprazole 25mg po daily # Detrol 5mg po daily # flomax 0.5mg daily # prednisone 5mg daily (for ?arthritis?) Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 8. Detrol LA 4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO once a day. 9. Procainamide 250 mg Capsule Sig: Three (3) Capsule PO three times a day. Disp:*270 Capsule(s)* Refills:*2* 10. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 5 days. Disp:*10 Capsule(s)* Refills:*0* 11. Losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 12. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 932**] VNA Discharge Diagnosis: Primary diagnosis: Ventricular tachycardia cardiac tamponade systolic left ventricular dysfunction congestive heart failure chronic renal insufficiency CAD . Secondary diagnosis: arthritis prostate CA GERD Discharge Condition: ambulating, tolerating oral intake, vital signs stable. Discharge Instructions: You were admitted because you had an arrythmia. You had a procedure to ablate your ventricular tachycardia and had the complication of some fluid around your heart called "cardaic tamponade". You then had a drain placed into your heart sac which was removed. If this fluid reaccumulates you could have symptoms such as light headedness, severe fatigue, low blood pressure, lower extremity swelling, or difficulty breathing. If you have any of these symtpoms you should go to the emergency room or seek prompt medical attention. You should also seek medical attention if you have chest pain, worsening shortness of breath, palpitations, fevers, or for any other concerns. . You are being treated with antibiotics, Keflex or cephalexin, and should continue a total 7 day course. . You should continue the medications we have prescribed for you. We have increased your procainamide dose and made changes to the doses of other medications as well. You will need to go see Dr. [**Last Name (STitle) **] on Friday (see below). . YOu should continue with a low sodium diet (2grams per day) and weigh yourself daiy; if you gain >2lbs or if you have trouble breathing you should contact your doctor. You should also limit your fluid intake to 1.5L per day. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 40075**] in [**5-31**] days at [**Telephone/Fax (1) 40076**]. You will need to have your procainamide level checked and potassium and BUN, Creatinine checked. We tried to make you the follow up appointment but could not get through. . Follow up appointment with Dr. [**Last Name (STitle) **] in cardiology on Friday [**2117-11-26**] at 12:30pm. [**Hospital Ward Name 516**] [**Hospital1 18**] in the [**Hospital Ward Name 23**] Building on the [**Location (un) 436**]. [**Telephone/Fax (1) 2934**]

[ "414.00", "715.90", "530.81", "427.1", "V45.81", "453.8", "585.9", "185", "V45.02", "998.12", "428.0", "458.29", "423.0", "412" ]

icd9cm

[ [ [] ] ]

[ "89.59", "37.34", "37.27", "37.0", "93.90", "37.26", "96.04" ]

icd9pcs

[ [ [] ] ]

9536, 9594

4868, 7943

354, 476

9844, 9902

3323, 4845

11204, 11756

2874, 2947

8298, 9513

9615, 9615

7970, 8275

9926, 11181

2963, 3304

198, 316

504, 1867

9794, 9823

9634, 9773

1889, 2762

2778, 2858

16,683

178,516

20371

Discharge summary

report

Admission Date: [**2129-5-25**] Discharge Date: [**2129-6-1**] Date of Birth: [**2069-2-22**] Sex: M Service: [**Last Name (un) 7081**] Patient is a 60-year-old gentleman with a history of asthma, who was previously hospitalized for severe respiratory distress requiring intubation. [**Hospital **] hospital course was prolonged complicated by congestive heart failure and MRSA pneumonia. Patient had a prolonged wean from the ventilator at the time requiring a tracheostomy. Patient was eventually decannulated and was discharged to home when he represented in [**2129-2-20**] with respiratory distress again requiring intubation. On bronchoscopy at that time he was found to have significant subglottic stenosis and a trach tube was placed. Again, his hospital course was complicated by MRSA respiratory infection as well as GI bleeding and non-ST- elevation myocardial infarction. At that time he underwent cardiac catheterization revealing nonsignificant coronary artery disease and no lesions requiring intervention. He was subsequently transferred to [**Hospital1 188**] and evaluated by Dr. [**Last Name (STitle) **] for the subglottic stenosis. He is found to have a near complete obstruction of his upper airway at the level of first and second tracheal ring with some degree of involvement of the anterior coracoid on rigid bronchoscopy. On flexible bronchoscopy, he was found to have no disease at the stomal site or distally. At that time, Dr. [**Last Name (STitle) 952**] was consulted and patient was advised to undergo a surgical resection of the stenosis and reconstruction. Patient after understanding fully the risks and benefits involved to the undergo the elective surgery and presents to the operating room on [**5-24**]. PAST MEDICAL HISTORY: 1. Coronary artery disease status post non-ST-elevation myocardial infarction. 2. Hypertension. 3. Anemia. 4. Peptic ulcer disease. 5. GI bleeding. 6. Asthma. 7. Hypercholesterolemia. 8. Type 2 diabetes. 9. CHF. MEDICATIONS AT HOME: 1. Clonidine 0.2 mg b.i.d. 2. Hydralazine 10 mg p.o. b.i.d. 3. Lipitor 20 mg p.o. q.d. 4. Zestril 20 mg q.d. 5. Paxil 20 mg q.d. 6. Norvasc 10 mg q.d. 7. Protonix 40 mg p.o. q.d. 8. Lopressor 50 mg p.o. b.i.d. 9. Hydrochlorothiazide 25 mg p.o. q.d. 10. Glyburide 5 mg b.i.d. 11. Glucophage 500 mg b.i.d. ALLERGIES: Patient reports no known drug allergies. SOCIAL HISTORY: Patient has immigrated from [**Country **] and is a bus driver in [**State 350**]. He smoked one pack a day of cigarettes for 16 years and has quit in [**2106**]. He does not drink a significant amount of alcohol. PHYSICAL EXAMINATION: Patient has stable vital signs. Thin male, who appears quite healthy and not in no apparent distress at the time of examination with trach mask collar with humidified air. He is unable to speak. HEENT exam is within normal limits. Cervical examination reveals no supraclavicular or cervical adenopathy. The ostomy site is well healed around the indwelling trach tube. Lungs are clear to auscultation bilaterally. Heart was regular, rate, and rhythm. S1, S2 without murmurs. Thorax is symmetrical without lesions or masses. Abdomen is soft, nontender, and nondistended. Extremities shows no clubbing or edema. Neurologically the patient is grossly intact. CT scan from [**2129-4-21**] shows a subglottic stenosis at the level of the anterior coracoid down to approximately [**2-22**] tracheal rings. Otherwise, the rest of the airway tracheal rings were within normal limits. There was also noted a small ________ nodule, which appears to be benign. LABORATORY STUDIES: Patient's last hematocrit was 30 with a white count of 5, platelets was 165. PT was 13.9, PTT 36, BUN was 20, creatinine 1.2. Patient presented to the OR on [**2129-5-25**] for elective resection of his subglottic stenosis and reconstruction of airway. Patient underwent this procedure without significant difficulty. Left the OR intubated and was transferred directly to the Surgical ICU. Patient did well there. Patient was weaned to extubate and was extubated on postoperative day two. At the time, patient was also covered with Vancomycin, Kefzol, and Flagyl prophylactically. Postoperatively, patient's hematocrit was down to 22.5. Patient received 2 units of packed red cells with good response. After successful extubation, patient's neck remained flushed. Patient was transferred to the floor, and his course on the floor was uncomplicated. Patient's Vancomycin was D/C'd and patient continued on Kefzol and Flagyl for seven day course. On postoperative day seven, patient underwent a bronchoscopy for evaluation of his surgical site. Patient was found to have a normal anastomosis with granulation tissue, secretions were noted, which were suctioned. Patient's neck was D/C'd from the flexed position. Patient's previously placed PICC was D/C'd, and patient was discharged home without any complications on [**2129-6-1**]. Patient's hypertension was controlled with his usual regimen while taken at home, and did require a slight adjustment with increase in Lopressor to 50 mg p.o. t.i.d. and hydralazine 20 mg p.o. q.8h. DISCHARGE STATUS: Discharged with home VNA services. DISCHARGE CONDITION: Good. DISCHARGE DIAGNOSES: 1. Subglottic tracheal stenosis. 2. T tube prolonged intubation and tracheostomy. 3. Status post resection of the stenosis and airway reconstruction. 4. Hypertension. 5. Coronary artery disease. 6. Diabetes type 2. 7. Asthma. DISCHARGE MEDICATIONS: 1. Clonidine 0.2 mg p.o. b.i.d. 2. Lipitor 20 mg p.o. q.d. 3. Zestril 20 mg p.o. q.d. 4. Lopressor 50 mg p.o. t.i.d. This is increased from his usual home dose. 5. Hydralazine 20 mg p.o. q.8. This is increased from patient's usual home dose. 6. Norvasc 10 mg p.o. q.d. 7. Hydrochlorothiazide 25 mg p.o. q.d. 8. Glyburide 5 mg p.o. b.i.d. 9. Percocet 5/325 mg 1-2 tablets p.o. q.4-6h. 10. Colace 100 mg p.o. b.i.d. while taking Percocet. 11. Protonix 40 mg p.o. q.d. 12. Glucophage 500 mg p.o. b.i.d. FOLLOW UP: Patient is to followup with Dr. [**Last Name (STitle) 952**] within one week, and is to see his primary care physician regarding his blood pressure control. [**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], MD [**MD Number(1) 3352**] Dictated By:[**Last Name (NamePattern1) 12164**] MEDQUIST36 D: [**2129-6-1**] 21:48:52 T: [**2129-6-2**] 05:18:57 Job#: [**Job Number **]

[ "428.0", "250.00", "401.9", "519.02", "412", "414.01", "E878.3", "285.9", "493.90" ]

icd9cm

[ [ [] ] ]

[ "99.04", "31.5", "33.21", "33.22", "96.05", "31.79" ]

icd9pcs

[ [ [] ] ]

5269, 5276

5297, 5527

5550, 6070

2035, 2403

6082, 6509

2660, 5247

1797, 2014

2420, 2637

61,085

193,593

40785

Discharge summary

report

Admission Date: [**2193-7-7**] Discharge Date: [**2193-7-22**] Date of Birth: [**2131-5-21**] Sex: M Service: MEDICINE Allergies: Ativan Attending:[**First Name3 (LF) 4891**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: Intubation History of Present Illness: Mr. [**Known lastname **] is a 62 year old male with a h/o bipolar disorder, and recent need for a hip replacement who initially presented to his PCP for [**Name9 (PRE) **] evaluation and altered mental status. Per his wife one week prior to admission he was falling/syncopizing at home and was also experiencing a fine tremor. Per his wife when he had these episodes she saw him just fall with no prodrome, and hit his head on one occasion with a brief loss of consciousness. His family also noted that he was having difficulty with confusion over the past 2-3 months, with worsening short term memory. His wife also noted a shuffling gait, resting tremor and recently was found pouring milk into soup on the stove and kept pouring until the milk overflowed. With these symptoms his wife brought him to his PCP for evaluation, at that appointment he was noted to be confused, hypotensive to the 70's, not oriented to the day and then had a syncopal episode so his PCP referred him to the ER for evaluation of his altered mental status and for further work up prior to his hip replacement. In the ER at the OSH his vital signs had stabilized, his he said that he remembered falling but otherwise felt well. Denied any chest pain, palpitations, shortness of breath, orthopnea, PND, abdominal pain, vomiting or diarrhea. He was then admitted to [**Hospital3 417**] for a syncope work up. . During his hospital stay he was seen by neurology and cardiology for further evaluation of his syncope and mental status changes. He was seen by psychiatry, neurology and cardiology in consultation. Given the report of hs shuffling gait, and cognitive decline there was concern about early Parkinson's though he had no cogwheeling or rigidity on exam. For further evaluation it was felt that he should undergo an MRI/MRA of his head, prior to these studies he received ativan for sedation. The ativan caused a paradoxical reaction and he became extremely agitated. At that time he was given large amounts of haldol, a total of 17mg and required 4 point leather restraints and an eventual transfer to the ICU. In the ICU after receiving the large amounts of sedating medications he became apneic and was intubated. He had an EEG which showed diffuse slowing, there was also concern for a possible neuroleptic malignant syndrome vs. serotonin syndrome given his rigidity so he was given 1 dose of dantrolene, there was also concern about OSA and the need for CPAP, however they had difficulty weaning sedation. On the day of transfer he became febrile, in the setting of his AMS there was concern about possible meningitis vs. encephalitis so an LP was done. The LP showed 1WBC (100%lymphs), 1RBC, glucose of 76, protein of 99, Gram stain and culture pending at the time of transfer. With his multiple problems and difficulty weaning sedation he was transferred to [**Hospital1 18**] for further management. . On the floor, his initial VS were: 101.6, 72, 147/63, 20, 97% on CMV 500x14, PEEP of 5, 40% FiO2. Past Medical History: Hypertension Hyperlipidemia Bipolar Disorder SVT Osteoarthritis Social History: Lives with his wife, have a 30 y/o special needs daughter at home. He used to work as a firefighter. - Tobacco: denies - Alcohol: drinks one drink per day - Illicits: denies Family History: Father with dementia at age [**Age over 90 **] Mother with dementia at age [**Age over 90 **] Physical Exam: Admission: Gen: intubated, sedated, opens eyes to voice, follows commands HEENT: PERRLA 2mm->1mm CV: nl S1/S2, no m/r/g, RRR Chest: anterior vent sounds with rhonchi Abd: soft, NT/ND, BS+, no grimace to deep palpation Ext: 1+ upper ext edema L>R, no leg edema Skin: erythematous macular rash on back diffusely, small petechhiae appearing lesions on legs Neuro: PERRLA, moves all extremities spontaneously, withdraws to deep pain, no increased tone or cogwheel rigidity Discharge: AF, VSS GA: pleasant, well appearing male in NAD, AAOx3, coherent, speaking in full sentences, logical, asking appropriate questions. HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. Cards: RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: CTAB no crackles or wheezes Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign. Extremities: wwp, no edema. DPs, PTs 2+. Skin: large black lesion with irregular border in upper mid back Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT. gait WNL. Pertinent Results: ADMISSION LABS: ================ [**2193-7-7**] 09:34PM BLOOD WBC-10.2 RBC-3.21* Hgb-10.3* Hct-30.6* MCV-95 MCH-32.0 MCHC-33.6 RDW-13.9 Plt Ct-198 [**2193-7-7**] 09:34PM BLOOD Neuts-87.8* Lymphs-7.1* Monos-3.8 Eos-1.0 Baso-0.3 [**2193-7-7**] 09:34PM BLOOD PT-15.0* PTT-32.1 INR(PT)-1.3* [**2193-7-7**] 09:34PM BLOOD Glucose-109* UreaN-24* Creat-1.0 Na-151* K-4.2 Cl-117* HCO3-26 AnGap-12 [**2193-7-8**] 03:27AM BLOOD ALT-22 AST-19 CK(CPK)-449* AlkPhos-63 TotBili-0.6 [**2193-7-7**] 09:34PM BLOOD Calcium-8.6 Phos-3.1 Mg-2.2 [**2193-7-8**] 05:03PM BLOOD Type-ART pO2-86 pCO2-40 pH-7.46* calTCO2-29 Base XS-4 . DISCHARGE LABS: =============== [**2193-7-21**] 04:56AM BLOOD WBC-5.8 RBC-3.40* Hgb-10.7* Hct-31.2* MCV-92 MCH-31.5 MCHC-34.4 RDW-14.5 Plt Ct-655* [**2193-7-22**] 06:05AM BLOOD Glucose-101* UreaN-10 Creat-0.9 Na-144 K-4.4 Cl-108 HCO3-25 AnGap-15 [**2193-7-18**] 09:49PM BLOOD ALT-27 AST-30 CK(CPK)-184 AlkPhos-88 TotBili-0.5 [**2193-7-22**] 06:05AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.0 . . . MICROBIOLOGY: ============= OSH CSF: WBC-1, 100% lymphs, negative gram stain and culture, negative HSV PCR and VDRL . [**2193-7-7**] 9:40 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2193-7-12**]** GRAM STAIN (Final [**2193-7-8**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2193-7-12**]): MODERATE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. STAPH AUREUS COAG +. MODERATE GROWTH. SECOND MORPHOLOGY. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | STAPH AUREUS COAG + | | CLINDAMYCIN-----------<=0.25 S <=0.25 S ERYTHROMYCIN----------<=0.25 S <=0.25 S GENTAMICIN------------ <=0.5 S <=0.5 S LEVOFLOXACIN---------- 0.25 S 0.25 S OXACILLIN------------- 0.5 S 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S . . IMAGING: ======== TTE [**7-8**]: Poor image quality. The left atrium is mildly dilated. 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>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. There is no aortic valve stenosis. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . MRI [**7-8**]: FINDINGS: There is no evidence of acute intracranial hemorrhage, mass, mass effect or shifting of the normally midline structures. Few scattered foci of high signal intensity are demonstrated on T2 and FLAIR, distributed in the subcortical and periventricular white matter, more significant on the right side, which are nonspecific and may reflect chronic microvascular ischemic disease. There is no evidence of abnormal enhancement. No diffusion abnormalities are detected. Normal flow void signal is maintained at the major arterial vascular structures. The orbits are unremarkable, bilateral mucosal thickening is identified at the maxillary, ethmoidal, frontal and sphenoid sinus, new since the prior examination, likely indicating an ongoing inflammatory process, there is also bilateral patchy mucosal thickening at the mastoid air cells. IMPRESSION: There is no evidence of acute intracranial pathology or significant intracranial changese since the prior MRI study dated [**2193-7-5**]. Few scattered foci of high signal intensity are demonstrated in the subcortical white matter, more significant on the right side, which are nonspecific and may reflect chronic microvascular ischemic disease. No diffusion abnormalities are detected, there is no evidence of abnormal enhancement. Pansinusitis and also bilateral mastoid mucosal thickening, new since the prior examination. . [**7-11**] UE U/S: No evidence of deep vein thrombosis in the left arm. CXR [**2193-7-20**]: FINDINGS: In comparison with the study of [**7-18**], there is no longer any evidence of pulmonary vascular congestion. No pneumonia, pleural effusion, or other abnormality. Brief Hospital Course: Mr. [**Known lastname **] is a 62 year old gentleman with a h/o bipolar d/o, HTN, HL and osteoarthritis, who was admitted to an OSH with AMS, intubated for apnea post large doses of haldol/ativan, now transferred with fever and difficulty weaning the ventilator. He recovered from his VAP and is mental status improved by the time of discharge. #) Altered Mental Status: initial cause is unclear, however given wife's report and documentation from the OSH there was concern for early onset Parkinson's and possible [**Last Name (un) 309**] Body Dementia, additionally his paradoxical reaction to ativan is concerning for an underlying dementia. CSF was negative for signs of infection. MRI was also negative for any acute intracranial process. Neurology was consulted and felt that his mental status changes were secondary to receiving benzodiazapines in the substrate of [**Last Name (un) 309**] Body Dementia. He was sedated on propofol while intubated, and switched to presedex around the time of extubation. Also while intubated, required several doses of seroquel for agitation. Once extubated, patient was oriented to only person, and after speaking with family, seemed to be at baseline. His confusioin became severe 24 hours later, with difficult to control agitation. Recevied quetiapine, olanzapine, risperidone, haldol, trazodone with no improvement of agitation. Required placement back on Precedex gtt for sedation. Sent to floors with readmission to ICU for acute agitation. Required Precedex gtt again for control of acute agitation. Removed all antipsychotics. Weaned off Precedex. Return to nonagitated, pleasant state within 36 hours of ICU admission. Had EEG that was non-suggestive of seizure. He will need full neurpsych and cognitive testing once his acute delerium resolves. Continued on lamotrigine, which may need uptitration. Seroquel for agitation has been suggested although not required for last 24 hours of admission. #) Respiratory Failure: Patient initially intubated at OSH for altered mental status in the setting of recieving large amounts of haldol. Failed extubation attempt on [**7-8**] and was reintubated. CXR showed both pneumonia/aspiration pneumonitis and pulmonary edema. Patient was emperically started on vancomycin and zosyn. Sputum cultures grew MSSA, and patient was initially started on nafcillin, then swtiched to cefazolin after he developed drug rash. Total course will be 7 days, Day 1 = [**7-12**]. He was eventually extubated on [**7-14**] once his mental status improved, pneumonia improved on CXR, and diuresis with IV Lasix. He tolerated the extubation well. #. SVT: On [**7-17**], patient flipped into SVT at 180, which resolved with carotid massage. Likely AVRT or AVNRT. Upon readmission to ICU, had sinus tachycardia and hypertension thought to be from agitation. Started metoprolol 25 mg [**Hospital1 **] with good control. #. Urinary Retention: Patient on terzosin at home. He was switched to flomax secondary to hypotension and required intermittent straight caths while in the unit. #) Hypertension: Patient on lisinopril and metoprolol at home. While intubated, these medications were held. SBPs > 200 when patient was agitated. He was started on a labetolol drip and BPs improved. Once patient's sedation was changed to presedex, labetolol gtt was weaned off. After extubation, his home BP medications were restarted, and on transfer to the floor, he was on metoprolol and lisinopril. #) Bipolar Disorder: While patient was intubated, he was unable to take his home lamotrigine, cymbalta and wellbutrin as currently unable to get an NG or OG tube. Lamotrigine was restarted as above. #Sleep Apnea: found to have episodes of apnea with desaturations into the mid to low 80's. Will need a sleep evaluation. TRANSITION OF CARE: - Recommend outpatient dermatology follow-up for dark lesion on mid-upper back. - Recommend sleep study for episodes of sleep apnea. Medications on Admission: Home Medications: Toprol XL 50mg daily Terazosin 5mg daily Klor-Con 20meq daily Zocor 40mg QHS Wellbutrin 450mg daily Cymbalta 60mg daily Lamictal 100mg [**Hospital1 **] Percocet prn . Medications on Transfer: Acyclovir 400mg IV Q8H Fentanyl gtt Midazolam gtt Propofol gtt Lamotrigine 100mg [**Hospital1 **] Lisinopril 5mg daily Cyanocobalamin 1000mcg daily Folic Acid 1mg daily Heparin SQ 5000units TID Metoprolol Tartrate 5mg IV Q6h Pantoprazole 40mg IV daily Acetaminophen 650mg Q4h prn Maalox 30ml q4h prn Docusate 100mg [**Hospital1 **] prn Magnesium Hydroxide 10ml QHS prn Diphenhydramine 25mg IM q4h prn Fentanyl 25mcg Q2h prn Discharge Medications: 1. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. lamotrigine 25 mg Tablet Sig: see below Tablet PO 1 tab in the morning; 2 tabs at night . Disp:*90 Tablet(s)* Refills:*0* 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 5. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for severe agitation. Disp:*30 Tablet(s)* Refills:*0* 6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO at bedtime. Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary: Altered Mental Status Secondary: Bipolar disorder Hypertension Supraventricular Tachycardia 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 brought to the hospital because of behavior changes at home. You became very agitated at the outside hospital and you required multiple medications for sedation and eventually needed to be intubated. Your intubation was complicated by a pneumonia and you were transferred to [**Hospital1 18**] for further management of your pneumonia and your mental status changes. You were treated with a 7 day course of antibiotics for your pneumonia and you improved. You were seen by psychiatry and neurology. You again became very agitated and required IV sedation to control your agitation. You then improved without additional medications. The following changes were made to your medications: - STOPPED Wellbutrin, Cymbalta, tamsulosin, Klor-Con, Percocet - DECREASED Lamictal from 100 mg twice a day to 25 mg in the morning, 50 mg in the evening - STARTED Seroquel 25 mg by mouth twice a day as needed for severe agitation - STARTED Tamsulosin 0.4 mg by mouth at night (used for urinary retention) Followup Instructions: Please keep the following appointments: Name: [**Last Name (LF) **], [**First Name3 (LF) **] Location: [**Hospital3 15290**] Counseling Address: [**Street Address(2) **] [**Location (un) 38**], [**Numeric Identifier 89129**] Phone: [**Telephone/Fax (1) 89130**] Appointment: Tuesday [**7-30**] at 4PM Name: [**Last Name (LF) **],[**First Name3 (LF) **] M. Location: [**Hospital1 **] HEALTHCARE - [**Hospital1 **] Address: ONE PEARL ST, [**Apartment Address(1) 12836**], [**Hospital1 **],[**Numeric Identifier 9647**] Phone: [**Telephone/Fax (1) 17919**] Appointment: Wednesday [**7-31**] at 3:15PM Department: ORTHOPEDICS When: FRIDAY [**2193-8-30**] at 1:55 PM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: FRIDAY [**2193-8-30**] at 2:15 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: COGNITIVE NEUROLOGY UNIT When: THURSDAY [**2193-9-5**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD [**Telephone/Fax (1) 1690**] Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage

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icd9cm

[ [ [] ] ]

[ "96.72", "96.04", "38.91", "96.6", "96.71", "33.29" ]

icd9pcs

[ [ [] ] ]

15480, 15531

10104, 10461

289, 301

15677, 15677

4842, 4842

16887, 18425

3641, 3737

14755, 15457

15552, 15656

14096, 14096

15828, 16864

5467, 10081

3752, 4823

14114, 14281

227, 251

329, 3341

4858, 5451

15692, 15804

14306, 14732

3363, 3429

3445, 3625

31,366

110,223

44836

Discharge summary

report

Admission Date: [**2178-10-9**] Discharge Date: [**2178-10-14**] Date of Birth: [**2141-10-11**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6743**] Chief Complaint: CC:[**CC Contact Info 95926**] Major Surgical or Invasive Procedure: Total Abdominal Hysterectomy Bilateral salpingo-oophorectomy Appendectomy Cystoscopy Lysis of Adhesions History of Present Illness: HPI: Ms. [**Known lastname 1661**] is a 36 y/o F with PMH of recent ongoing abdominal pain and prior endometriomas who presents to the [**Hospital Unit Name 153**] following surgical exploration with 1750 cc of blood loss. Per prior OMR notes, the patient has multiple recent primary care and ED visits/admissions due to ongoing abdominal pain which began in mid-[**2178-9-2**]. At that time, the patient presented to the emergency room and was found to have bilateral multiloculated cysts in the adnexae. At that time, she also had a leukocytosis and left-shift; she was discharged home to follow up with her gynecologist. She was subsequently admitted to the medical service from [**2093-9-20**] for abdominal pain and transient transaminitis which was attributed to a passed gallstone. She was treated during this admission for presumed PID with one dose of ceftriaxone and a course of doxycycline; GC/Chlamydia cultures were negative at that time. She was admitted a second time from [**2102-9-26**] for abdominal pain; she was treated with IV antibiotics for a short time for presumed PO antibiotic failure. Infectious workup (including TTE) was negative at that time. She was not discharged home on any antibiotics. . Apparently, her abdominal pain persisted throughout this time and she presented again to the emergency room on [**10-8**]. Repeat CT scanning demonstrated stable appearance of the multiloculated cystic mass with new fat stranding and fluid in the R paracolic gutter. She was admitted to the Gynecology team, and given her known intraabdominal pathology with fever and leukocytosis, the patient was taken to the OR for exploration earlier this evening. She underwent supracervical hysterectomy, bilateral salpingoopherectomy, appendectomy, lysis of adhesions, and cystoscopy. Her surgery was complicated by estimated blood loss of 1750 cc; she was transfused 2 U PRBCs intraoperatively, and her immediate post-transfusion Hct was 32 (from ABG). . On arrival to the [**Hospital Unit Name 153**], the patient is drowsy following her procedure. Per anesthesia notes, the patient received 250 mcg fentanyl, 17 mg morphine, 2 mg midazolam, and 200 mg propofol in the OR. At this time, the patient is pointing to her abdomen and indicating that she is having pain. She denies difficulty breathing or pain elsewhere. . Past Medical History: PMH: Endometriosis History of past chlamydia infection History of polycystic ovaries Social History: . SH (per prior notes): Lives with 2 sons (16, 14). Sexually active with 2 male partners, does not consistently use barrier protection. Has [**2-3**] alcoholic beverages per month. Denies illicits, tobacco. Family History: . Family History (per prior notes): Patient has limited knowledge. Mother with hypertension, asthma. Father died at 56 of "natural causes". Older brother with diabetes. Physical Exam: PE: T: 98.1 BP: 133/70 HR: 83 RR: O2 100% on face mask (half on) Gen: drowsy middle-aged female who appears in pain HEENT: MMM, OP clear NECK: Supple, JVD < 10 cm. No thyromegaly. CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**] appreciated. LUNGS: clear to auscultation anteriorly, no wheeze or crackles ABD: no bowel sounds auscultated, midline abdominal incision with covering bandage, minimal serosanguinous drainage at inferior aspect, abdomen tender to minimal palpation diffusely EXT: warm and well perfused, DP pulses 2+ bilaterally, SCDs in place SKIN: No rashes/lesions, ecchymoses. NEURO: face symmetric, moving upper extremities without difficulty, Gait assessment deferred PSYCH: Nodding appropriately to answer questions. Brief Hospital Course: A/P: This is a 36 y/o F s/p supracervical hysterectomy, BSO, LOA, appendectomy, and cystoscopy for tubo-ovarian abscess, now in ICU for monitoring given severe pelvic infection and intraoperative blood loss. . Tubo-ovarian abscess. The patient was taken to the OR on [**2178-10-10**] and found to have a large tubo-ovarian abscess and significant adhesions. She underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, appendectomy, cystoscopy and lysis of adhesions. Given the extent of the abscess, the patient was monitored in the ICU on POD 0. She was transferred to the floor in stable condition on ampicillin/gentamicin and metronidazole IV. She remained afebrile until [**10-11**] when she had a fever. An ID consult was obtained which recommended that the patient's antibiotics be switched to Vancomysin and Zosyn. An intraoperative culture returned pan-sensitive E.coli. No anaerobes were isolated. Due to the nature of polymicrobial abscesses, the patient's antibiotics were kept broad but narrowed slightly to Levofloxacin/Flagyl. THe patient remained afebrile from [**10-11**] until discharge home. She was sent home with 2 week course of PO Levofloxacin and Flagyl. Blood cultures were negative from the Emergency department and ICU. Most recent blood cultures pending from this admission. No growth to date. Urine culture negative. . Pain: Controlled with Dilaudid PCA. The patient was transitioned to PO Dilaudid when tolerating adequate oral intake. Ileus: The patient had an NG tube placed that was discontinued on post-operative day 1. The patient developed an ileus on post-operative day [**3-7**]. She was kept NPO and her diet was advanced when she had return of bowel function. The patient was tolerating regular diet at time of discharge home. Drains: The patient's JP drain was discontinued on POD 5. Prophylaxis: Protonix, Pneumoboots, Heparin sc 5000 mg TID, ambulation TID . Discharge: The patient was discharged in stable condition on POD 5 ([**2178-10-14**]) tolerating regular diet Medications on Admission: MEDS 1. Ibuprofen 600mg 2. Senna 1 tab [**Hospital1 **] 3. Biotin 4. Docusate 1 tablet [**Hospital1 **] 5. Simethicone 6. Doxycycline 100mg PO bid 7. Tylenol prn 8. Cod liver oil and biotin prn 9. OCP unspecified . Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*14 Tablet(s)* Refills:*0* 3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 weeks. Disp:*42 Tablet(s)* Refills:*0* 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO BID (2 times a day) for 1 days. Disp:*20 ML(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Tubal Ovarian Abscess Post operative Ileus Thrush Discharge Condition: Stable Discharge Instructions: Please call if fever > 100.5, chills, severe abdominal pain not relieved by pain medicine, redness around incision, chest pain or shortness of breath or other worrisome signs. No heavy lifting for 6 weeks. Do not lift anything more than 10 pounds. You may walk and go upstairs. No heavy exercising. No intercourse for 6 weeks. For thrush you may use Nystatin "Swish and Swallow" one teaspoon twice a day. Continue to take your antibiotics, Levofloxacin and Flagyl, for 2 weeks as prescribed. For pain: You may take Dilaudid 1-2 tablets every 4 hours. Please take Colace (stool softener) while on Dilaudid. No driving while on Dilaudid. You may also take Motrin 600 mg every 6 hours Followup Instructions: 9:15am [**10-19**] Monday Follow up for Staple removal with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2028**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 858**] Provider: [**First Name8 (NamePattern2) 95925**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2178-10-30**] [**Location (un) **] [**Hospital Ward Name 23**] Center 9:00 am [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**]

[ "617.1", "285.1", "E878.6", "997.4", "614.6", "041.4", "540.9", "614.0", "560.1", "112.0", "276.1" ]

icd9cm

[ [ [] ] ]

[ "57.32", "54.59", "47.09", "99.04", "68.39", "65.61" ]

icd9pcs

[ [ [] ] ]

7030, 7036

4144, 6187

360, 466

7130, 7139

7875, 8415

3181, 3352

6452, 7007

7057, 7109

6213, 6429

7163, 7852

3367, 4121

291, 322

494, 2831

2853, 2939

2955, 3165

66,629

173,017

9481

Discharge summary

report

Admission Date: [**2162-8-1**] Discharge Date: [**2162-8-9**] Date of Birth: [**2078-4-14**] Sex: F Service: MEDICINE Allergies: Meperidine / Fosamax / Aspirin / Calcitonin Attending:[**First Name3 (LF) 800**] Chief Complaint: femur fracture, hypotension Major Surgical or Invasive Procedure: ORIF right femur Red blood cell transfusion x5 History of Present Illness: 84 yo female with history of CAD, CVA, HTN, HLD who presented to [**Hospital1 18**] after a fall and was found to have a femur fracture. Patient is status post ORIF today, EBL 400cc. Post-op her Hct was 28. She was given 2 units of PRBC with repeat Hct 28. She was not given any further units of PRBRC. Her BP had been stable with SBP in 130/80. She was given PM BP medications including atenolol 50mg, valsartan 320mg and amlodipine 10 mg daily. She was also on dilaudid PCA. At midnight on routine VS check her BP was 64/palp. Her lowest BP was 55/palp. Her surgical dressing was noted to be soaked with blood. [**Hospital1 1957**] replaced the dressing. Her repeat Hct was 25. She was given 1.5 L of NS. She was also transfused 1 u PRBC as she was transfered to the MICU. . On arrival to MICU T 96.9 BP 128/65 HR 76 96% on 2LNC. Patient was sleepy but easily arousable. She denied any pain or difficulty breathing. She is unable to give any more history. Past Medical History: 1. CAD (80% cx) 2. CVA x2 3. HTN 4. Hyperlipidemia 5. Osteoporosis c/b spine compression fractures (T5,7,9,11,12, L1-5) 7. Depression 8. Stress/Urge Incontinence s/p surgery 9. Admission [**12-4**] for LGIB [**12-28**] colonic polyp 10. Chronic pain syndrome 11. Chronic normocytic anemia - Fe 31 and percent sat of 11 ([**12-4**]) 12. History of rib fractures 13. Status post right hip replacement 8-9 years ago, ?revision, appy, TAH 14. Chronic diastolic heart failure 15. GERD 16. Colonic adenoma s/p removal Social History: Lives in [**Hospital3 **] without help at night. Wheelchair bound. No tobacco for "yrs," h/o [**11-27**] ppd for 20yrs. EtOH h/o 1 glass wine/day, none currently. No drug use hx. Family History: No h/o colon CA, GI diseases. Mother had MI at 70, father had MI at 56, brother had MI at 37. Physical Exam: Vitals: On arrival to MICU T 96.9 BP 128/65 HR 76 96% on 2LNC. General: Sleepy but easily arousable with verbal stimuli, oriented x 1, in NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Heart: Regular rate and rhythm, normal S1 + S2 Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, right hip dressing in place. Spont moves all four ext. Pertinent Results: Admission Labs: [**2162-8-1**] 04:00PM BLOOD WBC-16.8*# RBC-4.29 Hgb-10.3* Hct-33.1* MCV-77* MCH-24.0*# MCHC-31.0 RDW-16.7* Plt Ct-291 [**2162-8-1**] 04:00PM BLOOD Glucose-170* UreaN-17 Creat-0.7 Na-142 K-2.9* Cl-103 HCO3-25 AnGap-17 [**2162-8-2**] 06:10AM BLOOD Albumin-3.7 Calcium-8.3* Phos-2.0* Mg-1.4* [**2162-8-1**] 09:25PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011 [**2162-8-1**] 09:25PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM [**2162-8-1**] 09:25PM URINE RBC-21-50* WBC-[**10-15**]* Bacteri-FEW Yeast-NONE Epi-0-2 Interval Labs: [**2162-8-2**] 06:10AM BLOOD WBC-12.7* RBC-3.56* Hgb-8.6* Hct-27.9* MCV-78* MCH-24.0* MCHC-30.7* RDW-16.9* Plt Ct-278 [**2162-8-4**] 02:05AM BLOOD Hct-25.4* [**2162-8-4**] 05:38AM BLOOD WBC-11.8* RBC-3.94* Hgb-10.8*# Hct-32.3*# MCV-82 MCH-27.4# MCHC-33.5 RDW-15.7* Plt Ct-182 [**2162-8-6**] 06:35AM BLOOD WBC-13.1* RBC-4.66 Hgb-13.0 Hct-39.2 MCV-84 MCH-27.8 MCHC-33.1 RDW-16.7* Plt Ct-195 [**2162-8-3**] 07:00AM BLOOD ALT-12 AST-18 AlkPhos-50 TotBili-0.5 [**2162-8-4**] 05:38AM BLOOD CK(CPK)-323* [**2162-8-4**] 05:38AM BLOOD CK-MB-6 cTropnT-0.01 [**2162-8-5**] 04:50AM BLOOD proBNP-4305* [**2162-8-5**] 04:50AM BLOOD Calcium-8.2* Phos-1.6* Mg-1.8 [**2162-8-2**] 01:55PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2162-8-2**] 01:55PM URINE Blood-MOD Nitrite-NEG Protein-NEG Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM [**2162-8-2**] URINE CULTURE: NO GROWTH. [**2162-8-2**] BLOOD CULTURE: NO GROWTH TO DATE x2. [**2162-8-4**] BLOOD CULTURE: NO GROWTH TO DATE x2. Discharge Labs: [**2162-8-9**] 06:10AM BLOOD WBC-10.3 RBC-4.18* Hgb-11.7* Hct-36.4 MCV-87 MCH-27.9 MCHC-32.1 RDW-17.5* Plt Ct-270 [**2162-8-9**] 06:10AM BLOOD Glucose-98 UreaN-17 Creat-0.5 Na-142 K-4.2 Cl-107 HCO3-25 AnGap-14 [**2162-8-9**] 06:10AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.6 CT C-spine [**8-1**]: No acute fracture or malalignment of the cervical spine. Diffuse osteopenia. Right hip/femur/tib-fib films [**8-1**]: Oblique comminuted fracture of the distal femur. No clear intra-articular extension noted. Suboptimal visualization of the tibial plateau as above. Severe profound osteopenia. Right femur intra-op [**8-3**]: 35 fluoroscopic images of the right femur are submitted for dictation. The total intraservice time of 181 seconds. These demonstrate interval placement of a large lateral fracture plate with multiple associated cortical screws. This is fixating an obliquely oriented fracture through the right distal femoral metaphysis. There are no signs for hardware-related complication. Inferior portion of the femoral prosthetic stem is visualized. Please refer to the procedure note for additional details. CXR [**8-2**]: There is a small left pleural effusion. Calcification of the mitral annulus. The right hilum is prominent and it is unclear if this is projectional or due to vascular engorgement. A hilar mass cannot be totally excluded. Recommend followup. There is pulmonary vascular re-distribution suggesting an element of fluid overload. Compared to the prior study the right hilar prominence and fluid overload are increased. CXR [**8-4**]: Slight improvement of left pleural effusion; hypoinflation but no discrete consolidation. Video swallow [**8-5**]: 1. Retention of solids/thick liquids in valleculae. 2. Aspiration of thin liquids. Brief Hospital Course: 1. Right Distal Femoral Fracture: Patient underwent open reduction and internal fixation. Her right leg was placed in a brace. Pain was initially controlled with a hydromorphone PCA, although there was concern for patient's ability to comply with PCA. She was changed to around-the-clock tylenol with morphine IR PO as needed for breakthrough pain. She was discharged on lovenox 40 mg SC daily for two weeks per orthopedics recommendations. 2. Hypotension: Occurred post-op in the setting of hypovolemia from blood loss while receiving antihypertensive medications and hydromorphone for pain. She received 5 units packed red blood cells total, 1 unit fresh frozen plasma. Although her hematocrit was initially not responding to transfusion, it stabilized and then continued to trend up. Once stable, she was restarted on enoxaparin SC, clopidogrel, and all her outpatient BP meds except clonidine patch. Her BP was controlled, although clonidine can be restarted as an outpatient if necessary. 3. Fever/Leukocytosis: Felt most likely due to systemic response to her leg trauma. She was initially started on vancomycin and cefepime empirically, although these were later stopped as she remained stable. Her fevers and leukocytosis gradually defervesced. 4. Hypoxia: Patient was maintained on O2 via NC initially. She did not appear to be volume overloaded on exam, CXR showed no discrete consolidation. Her oxygen was weaned without difficulty. Possible explanation is atelectasis / shallow breathing in perioperative period. 6. Dispo: All of the patient's other chronic medical issues were treated per her outpatient regimen with exceptions as noted above. Patient had her code status changed from DNR/I to full code for her ORIF. Afterward, code status was addressed with the patient and her [**Last Name (LF) 802**], [**Name (NI) **] [**Name (NI) 3707**]. It was agreed to resume DNR/I code status. Based on aspiration risk and video swallow results, she was started on ground solids/nectar thick liquids with crushed medications. Medications on Admission: (per prior lists, pt unable to remember her meds) ~Oxycodone 5 mg Tab Oral 1 Tablet(s) Twice Daily plus q4 hrs prn ~Zolpidem 5 mg Tab Oral [**11-27**] Tablet(s) Once Daily, at bedtime prn ~Prochlorperazine Maleate 5 mg Tab Oral 1 Tablet(s)TID prn ~Ciprofloxacin 250 mg Tab Oral 1 Tablet(s) Once Daily ~Plavix 75 mg Tab Oral 1 Tablet(s) Once Daily One Daily Multivitamin Tab Oral 1 Tablet(s) Once Daily ~Ferrex 150 150 mg Cap Oral 1 Capsule(s) Twice Daily ~Senna 8.6 mg Cap Oral 1 Capsule(s) Once Daily, as needed ~Catapres-TTS-2 0.2 mg/24 hr Transderm Patch Transdermal 1 Patch Weekly ~Calcium 500 mg Tab Oral 1 tablet(s) Three times daily ~Atenolol 100 mg Tab Oral 1 Tablet(s) Once Daily ~Lipitor 40 mg Tab Oral 1 Tablet(s) Once Daily, at bedtime ~Amlodipine 10 mg Tab Oral 1 Tablet(s) Once Daily -->Fluoxetine 30 mg Tab Oral 1 Tablet(s) Once Daily ~Seroquel 50 mg Tab Oral 1 Tablet(s) Once Daily, at bedtime ~Isosorbide Mononitrate SR 60 mg 24 hr Tab Oral 1 Tablet SR Daily ~Diovan 320 mg Tab Oral 1 Tablet(s) Once Daily ~Folic Acid 1 mg Tab Oral 1 Tablet(s) Once Daily ~Pantoprazole 40 mg Tab, Delayed Release Oral 1 Tablet, Delayed Release (E.C.)(s) Once Daily ~Detrol LA 4 mg 24 hr Cap Oral 1 Capsule, Sust. Release 24 hr(s) daily Discharge Medications: 1. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain: Hold for sedation. 2. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomnia. 3. Prochlorperazine Maleate 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 4. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO twice a day. 8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime): Can hold if pt has BM. 9. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day: Hold if SBP < 100, HR < 60. 11. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day: Hold for SBP < 100 . 13. Fluoxetine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): total daily dose 30mg. 14. Fluoxetine 10 mg Tablet Sig: One (1) Tablet PO once a day: total daily dose 30mg. 15. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 17. Valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day: Hold for SBP < 100. 18. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 20. Tolterodine 4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 21. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. 22. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 23. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 24. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). 25. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO BID (2 times a day). 26. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen (17) g PO DAILY (Daily) as needed for constipation. 27. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg Subcutaneous DAILY (Daily) for 2 weeks. Discharge Disposition: Extended Care Facility: [**Hospital 745**] Health Care Center Discharge Diagnosis: Primary: Right distal femur fracture Acute blood loss anemia Secondary: Hypertension Chronic diastolic heart failure Coronary artery disease Discharge Condition: Stable Discharge Instructions: You were admitted to [**Hospital1 18**] for a right femur (thigh bone) fracture. You had this repaired by the orthopedic surgeons. You also required red blood cell transfusions and fluids for low blood counts and low blood pressure. These numbers improved and remained stable. Please take all medications as prescribed and go to all follow up appointments. We have made the following medication changes: - Changed oxycodone to oral morphine for pain control as the latter is more easily obtained. - Tylenol around the clock to help with pain control. - Started enoxaparin, a blood thinner to prevent clots after your surgery. This will be stopped by the orthopedic surgeons when you follow up in clinic. If you experience worsened leg pain, fevers, confusion, chest pain, trouble breathing, dizziness, or any other concerning symptoms, please seek medical attention or return to the ER immediately. Followup Instructions: Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2162-8-17**] 11:20 Provider: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2162-8-17**] 11:40 Please follow up with your PCP, [**First Name8 (NamePattern2) 46**] [**Last Name (NamePattern1) **], on Tuesday [**8-24**] at 1:30pm. Phone: [**Telephone/Fax (1) 1408**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**] Completed by:[**2162-8-9**]

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icd9cm

[ [ [] ] ]

[ "79.35" ]

icd9pcs

[ [ [] ] ]

12051, 12115

6221, 8281

329, 378

12301, 12310

2784, 2784

13259, 13874

2119, 2214

9569, 12028

12136, 12280

8307, 9546

12334, 12719

4436, 6198

2229, 2765

12739, 13236

262, 291

406, 1372

2800, 4420

1394, 1907

1923, 2103

30,836

131,582

48012

Discharge summary

report

Admission Date: [**2167-7-20**] Discharge Date: [**2167-7-28**] Date of Birth: [**2098-10-9**] Sex: F Service: Surgery HISTORY OF PRESENT ILLNESS: This is a 68-year-old female with a past medical history significant for hypertension and acute cholecystitis (for which she underwent an open cholecystectomy on [**2167-5-22**]). She presented to the Emergency Department with one week of nausea, abdominal pain, and diarrhea. She denies vomiting, fevers, or chills. Her symptoms are exacerbated by food by not any particular type. PAST MEDICAL HISTORY: (Her past medical history includes) 1. Hypertension. 2. History of a small-bowel obstruction. 3. Cholecystitis. PAST SURGICAL HISTORY: (Her past surgical history includes) 1. Lipoma excision. 2. Total abdominal hysterectomy and bilateral salpingo-oophorectomy. 3. Exploratory laparotomy for a small-bowel obstruction. 4. Open cholecystectomy (in [**2167-5-14**]). MEDICATIONS ON ADMISSION: (Her home medications included) 1. Hydrochlorothiazide 25 mg p.o. once per day. 2. Premarin. 3. Nasacort. ALLERGIES: PHYSICAL EXAMINATION ON PRESENTATION: Her physical examination on admission revealed vital signs with a temperature of 98 degrees Fahrenheit, heart rate was 86, blood pressure was 145/85, respiratory rate was 18, and oxygen saturation was 99% on room air. In general, she was alert and oriented times three and in no acute distress. Her sclerae were anicteric with no jaundice. Her neck was supple with no lymphadenopathy. Her heart was regular in rate and rhythm with no murmurs, rubs, or gallops. Her lungs were clear to auscultation bilaterally. Her abdomen was soft, nontender, and nondistended. No guarding and no rebound. Her abdomen was notable for a well-healed midline incisional scar. Her extremities were warm and well perfused with no clubbing, cyanosis, or edema. PERTINENT LABORATORY VALUES ON PRESENTATION: Her laboratories on admission included a white blood cell count of 6.4, hematocrit was 39.7, and platelets were 288,000. The differential on her white blood cell count included 55% neutrophils, no band neutrophils, and 37% lymphocytes. Her chemistries revealed sodium was 141, potassium was 4.1, chloride was 101, bicarbonate was 301, blood urea nitrogen was 19, creatinine was 0.8, and blood glucose was 117. Her liver function tests were as follows; ALT was 1325, AST was 1194, alkaline phosphatase was 345, total bilirubin was 1.9, amylase was 73, and lipase was 54. HOSPITAL COURSE: The patient was admitted to the Surgery Service with a diagnosis of a presumed retained stone and choledocholithiasis. It was recommended that she be seen by the Gastroenterology Service for a possible endoscopic retrograde cholangiopancreatography (ERCP). In addition, she had a magnetic resonance cholangiopancreatography (MRCP) which identified a stone in the common bile duct. Following this study, she had a endoscopic retrograde cholangiopancreatography on hospital day two. Please see the full report of endoscopic retrograde cholangiopancreatography for details of the procedure. The patient had a sphincterotomy as well as a retained stone from the common bile duct removed. On hospital day three, the following day after endoscopic retrograde cholangiopancreatography, the patient was afebrile with stable vital signs and complained only of slight nausea. Per recommendation of the ERCP staff, she was started on clear liquids. On hospital day four, the patient had an episode of a dark bowel movement as well as dark red emesis times one. In addition, she felt weak and dizzy when standing to go to the bathroom. At that time, her laboratories were as follows: Her hematocrit was 31.4. Her liver function tests revealed ALT was 926, AST was 261, alkaline phosphatase was 324, amylase was 104, and total bilirubin was 0.8. The patient was referred to the ERCP Service for a question of a gastrointestinal bleed status post endoscopic retrograde cholangiopancreatography. On hospital day four, the patient was taken back to the ERCP Suite for exploration and treatment of the bleeding source. Please see the full ERCP report for details of this procedure. The patient's repeat hematocrit on hospital day four was 21. The patient was transferred to the Surgical Intensive Care Unit following the conscious sedation for endoscopic retrograde cholangiopancreatography. She was transfused one unit of packed red blood cells followed by an additional two units of packed red blood cells. The patient's vital signs stabilized in the Intensive Care Unit, and her hematocrit resolved to 30 on hospital day five. On hospital day six, she was transferred back to the floor and remained afebrile with stable vital signs. She had no subsequent episodes of bright red blood per rectum or dark stool as well as no further episodes of emesis. On the following day, on hospital day eight, the patient continued to do well. Her hematocrit was 34.5, and she continued to be stable with no further evidence of bleeding. On [**7-28**], on hospital day nine, the patient was deemed in stable condition with stable vital signs and was discharged to home. Her liver function tests continued to resolve. CONDITION AT DISCHARGE: The patient's condition on discharge was good and stable. DISCHARGE STATUS: The patient's discharge status was to home with no services. DISCHARGE DIAGNOSES: 1. Choledocholithiasis. 2. Retained gallstone status post cholecystectomy. 3. Hypertension. 4. Blood loss anemia. MEDICATIONS ON DISCHARGE: (She was given no further discharge medications other than to resume her normal medication regimen) 1. Hydrochlorothiazide 25 mg p.o. once per day. 2. Premarin. 3. Nasacort. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in one to two weeks. The patient was given the telephone number for the office to contact in order to set up this appointment. 2. The patient was also informed to return to the Emergency Department or contact her physician if she developed any intractable nausea, vomiting, dark stools, bright red blood per rectum, or emesis of blood. [**First Name11 (Name Pattern1) 4952**] [**Last Name (NamePattern1) 4953**], M.D. [**MD Number(1) 4954**] Dictated By:[**Last Name (NamePattern1) 5657**] MEDQUIST36 D: [**2167-7-28**] 14:26 T: [**2167-8-4**] 08:10 JOB#: [**Job Number 101275**]

[ "998.11", "401.9", "285.9", "E849.7", "E878.8", "574.51" ]

icd9cm

[ [ [] ] ]

[ "51.10", "51.88", "51.85" ]

icd9pcs

[ [ [] ] ]

5422, 5541

5568, 5746

976, 2506

2525, 5246

5779, 6510

715, 949

5261, 5401

165, 551

574, 690

67,172

130,787

2612

Discharge summary

report

Admission Date: [**2167-7-5**] Discharge Date: [**2167-7-17**] Date of Birth: [**2098-1-23**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2291**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: intubation [**Date range (3) 13151**] History of Present Illness: Ms. [**Known lastname **] is a 64y/o lady with emphysema, HTN, DM, HLD, who presents with shortness of breath. Of note, she was recently admitted in [**2167-4-26**] for chest pain and SOB. She required a non-rebreather and was admitted to the MICU where CXR, CTA chest, EKG, and cardiac enzymes were all reassuring. She was given nebs, oxygen was weaned, and she was called out to the floor. Her hospital course was complicated by a mechanical fall in which she sustained an intertrochanteric left femoral fracture s/p ORIF. She was discharged to [**Hospital 100**] Rehab on Lovenox on [**2167-6-1**]. short of breath a week after arriving. Had some leg edema and weight gain. Some wheezing as well. Denied chest pain, nausea, vomiting, abdominal pain. Pulmonary consult was obtained. She was started on Lasix 40mg (in mid-[**Month (only) 116**]) and was continued on nebs for COPD. Patient became progressively dyspneic despite treatment and presented to the ED when she was noted to appear extremely uncomfortable in her breathing. In the ED patient triggered for respiratory distress with initial VS 97.5, 99, 154/60, 31, 88%RA. EKG showed sinus 95, no ischemic changes. Patient was given nebs, solumedrol, and started on BIPAP. Labs notable for nml WBC, nml lactate, neg trop, Na 148. ABG was 7.31/82/105/43. CXR showed right-sided atalectasis vs. infiltrate. CTA chest neg for PE. CT head neg for acute process. Patient was intubated for increasing obtundation. AC, TV 400, PEEP 5, FiO2 60, RR 18. ABG post-extubation was 7.39/64/83/40, so RR was increased. She received cefepime and levofloxacin for possible pneumonia. VS prior to transfer were 104/59, 73, 20, 99% on vent. On arrival to the MICU, patient is intubated and sedated. Current vent settings are AC, VT 400, PEEP 5, RR 20, FIO2 60%. Past Medical History: - IDDM - HTN - HLD - Hepatitis C - Multiple thoracic spine compression fractures - Vertigo - Left eye blindness - Emphysema Social History: -Lives with daughter [**Name (NI) **] and with her daughter's three children. Her other daughter [**Name (NI) 1453**] works in a medical office near [**Hospital1 18**] and is quite involved as well. -She is widowed. -She does not drink, smoke or use any illicit substances currently. -Prior cigarette use. -Former teacher, currently disabled. Family History: No early MI, malignancy. DM in mother. Physical Exam: ADMISSION EXAM: Vitals: 98.4, 81, 137/72, 16, 100% on vent General: Intubated, sedated. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, unable to assess JVP, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Decreased BS at bases L>R, no rales or wheezes. Abdomen: Obese, soft, non-tender, bowel sounds present, unable to assess HSM GU: + foley Ext: Cool feet but LE otherwise WWP, 2+ pulses, 1+ dependent edema behind legs and abdomen Neuro: Sedated, unable to assess DISCHARGE EXAM: VS: 97.5-98.2, 124-143/49-54, 65-78, 18-20, 93-94%RA FS: 142-212 I/O: incontinent, 4 loose BMs General: obese lady in NAD HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL, left cataract and slight ptosis (chronic per patient) Neck: Obese, unable to assess JVP, no LAD CV: Regular rate and rhythm, no murmurs Lungs: Decreased BS at bases, no rales or wheezes. mild exp wheezes Abdomen: Obese, soft, non-tender, bowel sounds present Ext: Cool feet but LE WWP, 2+ pulses, 1+ dep edema legs and abdomen Neuro: Alert, oriented x 3 Pertinent Results: ADMISSION LABS: [**2167-7-5**] 06:00PM BLOOD WBC-7.1 RBC-3.64* Hgb-11.8* Hct-38.9 MCV-107* MCH-32.5* MCHC-30.4* RDW-15.7* Plt Ct-286 [**2167-7-5**] 06:00PM BLOOD Neuts-80.9* Lymphs-14.6* Monos-3.9 Eos-0.2 Baso-0.4 [**2167-7-5**] 06:00PM BLOOD PT-12.0 PTT-37.2* INR(PT)-1.1 [**2167-7-5**] 06:00PM BLOOD Glucose-178* UreaN-27* Creat-0.5 Na-148* K-4.3 Cl-106 HCO3-40* AnGap-6* [**2167-7-5**] 06:00PM BLOOD cTropnT-<0.01 MOST RECENT LABS PRIOR TO DISCHARGE: [**2167-7-14**] 04:10AM BLOOD WBC-8.6 RBC-3.31* Hgb-10.2* Hct-34.3* MCV-104* MCH-31.0 MCHC-29.8* RDW-14.8 Plt Ct-279 [**2167-7-14**] 04:10AM BLOOD Glucose-90 UreaN-61* Creat-0.9 Na-145 K-4.1 Cl-102 HCO3-41* AnGap-6* [**2167-7-14**] 04:10AM BLOOD Calcium-8.5 Phos-2.7 Mg-3.3* OTHER PERTINENT LABS: [**2167-7-5**] 06:00PM BLOOD cTropnT-<0.01 [**2167-7-6**] 02:08AM BLOOD CK-MB-1 cTropnT-<0.01 [**2167-7-5**] 06:04PM BLOOD Lactate-1.1 [**2167-7-7**] 06:50AM BLOOD Glucose-79 Lactate-1.1 Na-143 K-3.9 Cl-98 MICRO DATA: [**2167-7-6**] 11:09AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018 [**2167-7-6**] 11:09AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM [**2167-7-6**] 11:09AM URINE RBC-0 WBC-11* Bacteri-FEW Yeast-MOD Epi-0 NonsqEp-<1 [**2167-7-6**] 11:09 am URINE Source: Catheter. **FINAL REPORT [**2167-7-7**]** URINE CULTURE (Final [**2167-7-7**]): YEAST. >100,000 ORGANISMS/ML.. --- [**2167-7-16**] 05:12AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012 [**2167-7-16**] 05:12AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG [**2167-7-16**] 05:12AM URINE RBC-3* WBC-32* Bacteri-FEW Yeast-FEW Epi-0 [**2167-7-16**] 5:12 am URINE Source: Catheter. **FINAL REPORT [**2167-7-17**]** URINE CULTURE (Final [**2167-7-17**]): YEAST. 10,000-100,000 ORGANISMS/ML.. --- [**2167-7-6**] 5:14 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2167-7-8**]** GRAM STAIN (Final [**2167-7-6**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [**2167-7-8**]): SPARSE GROWTH Commensal Respiratory Flora. YEAST. MODERATE GROWTH. --- [**2167-7-6**] 11:09 am URINE HEM # 0822D [**7-6**] 11:09AM. **FINAL REPORT [**2167-7-7**]** Legionella Urinary Antigen (Final [**2167-7-7**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. --- [**2167-7-5**] BLOOD CULTURES x2 - NEGATIVE --- [**2167-7-14**] 5:28 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2167-7-15**]** C. difficile DNA amplification assay (Final [**2167-7-15**]): Positive for toxigenic C. difficile by the Illumigene DNA amplification. (Reference Range-Negative). ECG [**2167-7-5**] 11:30:26 PM Sinus rhythm. Isolated ventricular premature contractions. No interval change compared to the previous tracing. CXR [**2167-7-5**] 1. Findings suggesting moderate pulmonary edema. 2. Consolidation suspected in the left lower lobe. 3. Patchy right lower lung opacification; an area of confluent edema could be considered versus an additional early developing focus of infection. CTA CHEST W&W/O C&RECONS [**2167-7-5**] 1. No pulmonary embolus to the proximal segmental levels. Mild cardiomegaly and atherosclerosis. 2. Multifocal atelectasis, with probable lower lobe consolidation suggesting pneumonia as the main etiology for pulmonary decompensation. Mild pulmonary edema and small bilateral effusions. 3. Endotracheal tube terminates 2.5 cm above the carina; retracting the tube slightly further is suggested. 4. Right adrenal adenoma. 5. Chronic T8 compression deformity. CT HEAD W/O CONTRAST [**2167-7-5**] No evidence of acute intracranial process. CHEST U.S. [**2167-7-13**] 3:59 PM Normal diaphragmatic movement on inspiration as described. No ultrasound features to suggest diaphragmatic paralysis. CHEST (PORTABLE AP) [**2167-7-14**] 3:42 AM Endotracheal tube and nasogastric tube have been removed. Right PICC terminates in the mid to distal SVC. Vascular congestion, bibasilar atelectasis and effusions are slightly improved. Mild Cardiac size remains moderately enlarged. HIP UNILAT MIN 2 VIEWS LEFT Study Date of [**2167-7-14**] 3:29 PM ORIF changes in the left hip through previously identified comminuted intertrochanteric fracture with mild increased bridging callus formation medially and inferiorly. No evidence of orthopedic hardware complication. Conclusions The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). 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 stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. TTE [**2167-7-16**] 11:11:42 AM IMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavity size and hyperdynamic left ventricular systolic function. No clinically significant valvular regurgitation or stenosis. Mild pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of [**2167-3-2**], the left ventricular global systolic function is now hyperdynamic (previously normal). Mild pulmonary artery systolic hypertension is now seen; previously indeterminate. Brief Hospital Course: Ms. [**Known lastname **] is a 64y/o lady with COPD, obesity hypoventilation, and suspected OSA who presented with an acute on chronic dyspnea and was intubated [**Date range (3) 13151**] for hypercarbic respiratory failure that was likely due to COPD exacerbation as well as diastolic heart failure. She was stabilized in the MICU with diuresis and COPD treatment, and then she was transferred to the medical floor on [**7-14**] in stable condition. Her stay was notable for yeast UTI as well as C. difficile colitis. She was evaluated by PT who recommended rehab so she was discharged to [**Hospital 100**] Rehab. ACTIVE ISSUES # Hypercarbic respiratory failure: resolved, now comfortable on room air. On initial presentation patient was in hypercarbic respiratory failure requiring intubation. She was started on broad spectrum antibiotics out of concern for infectious etiology. These were later discontinued due to low suspicion for pneumonia. She was ruled out for PE with a CTA. Bronchoscopy was uneventful (BAL grew only yeast which was felt to represent colonizer versus contaminant, not infection. Her respiratory failure was thought to be a combination of COPD, sleep apnea, obesity hypoventilation, and volume overload from diastolic heart failure. After treatment of these, she was successfully extubated on [**7-13**] and has been alert and breathing comfortably with O2sat 90-94% on room air. -For her CHF: She was diuresed with a lasix gtt initially and then transitioned to her prior dose of Lasix 40mg daily. Transthoracic echo revealed no wall motion abnormality, preserved EF, and LVH. She continues on Metoprolol, Lisinopril, and Lasix. She should have daily weights to assess whether she needs more diuresis. Weight on discharge is 200.4 lbs (by bed scale; she should be re-weighed soon after arriving at rehab). -For her COPD: She was given prednisone 40 mg x 5 days ([**Date range (1) 13152**]). She was noted to be alert and comfortable while on the medical floor. For her emphysema, she was started on Spiriva and will continue PRN Albuterol/Ipratropium nebs. She might benefit from outpatient PFTs. -For her likely OSA: She has obesity hypoventilation; she should have an outpatient sleep study as it is likely that she has OSA. # Agitation: mild delirium. Patient became delirious after extubation which is likely due to her underlying illnesses and recent ICU admission. Infections (yeast UTI and C.difficile) might be contributing as well. She became agitated and was started on Seroquel, which stabilized her mood very effectively. Daughter [**Name (NI) 1453**] felt that she was "better than her usual self" in terms of mood. At the time of discharge, she is slightly disoriented at times. # Diarrhea: C. difficile colitis. Developed watery stools during this hospitalization. C. diff DNA assay was positive and she was started on Metronidazole: 10 day course, from [**Date range (1) 13153**]. # Flank pain: yeast UTI. Urine culture x2 grew yeast. She is being treated with Fluconazole: 2 week course, from [**Date range (1) 13154**]. Pain control with Tylenol and she could receive Ibuprofen PRN as well. INACTIVE ISSUES # h/o Left hip fracture: s/p ORIF last hospitalization on [**2167-5-27**]. Orthopedics visited the patient during her stay. PA/lateral hip x-ray was obtained that appeared as expected with no complications. She was initially continued Lovenox, but as it had been more than 4 weeks since her procedure she was discharged on Heparin SC per Ortho recs. She is weight-bearing as tolerated. She will follow-up at [**Hospital 5498**] clinic on [**2167-8-13**]. # Hypertension: stable. She continues on Metoprolol and Lisinopril. # Diabetes: stable. Her Glargine (Lantus) dose was decreased due to borderline-low glucose and she was covered with sliding scale Humalog. Her fingerstick glucose was reasonably controlled. # Hyperlipidemia: not currently on a statin. Outpatient providers might consider statin therapy. # Hepatitis C: does not see Hepatology, is not treated. The patient does not appear to have previously seen hepatology for this or been treated. She will need outpatient f/u for this. TRANSITIONAL ISSUES #. Labs/studies pending at discharge: None #. Should have daily weght check, with consideration of increasing her Lasix dose. #. Should consider outpatient sleep study as well as pulmonary function tests. #. Should consider increasing Glargine +/- Humalog if QACHS fingersticks become poorly controlled. #. Outpatient Hepatology follow-up should be arranged for Hepatitis C. #. Outpatient providers might consider statin therapy for hyperlipidemia. #. Follow-up: with Ortho on [**2167-8-13**]. #. Code Status: Full Code #. Emergency Contact: daughters [**Name (NI) 1453**] and [**Name (NI) **] are very involved Medications on Admission: PER REHAB RECORDS: 1. acetaminophen 975mg Q8h 2. albuterol neb Q6h 3. aspirin 81mg daily 4. calcium carbonate 1250mg [**Hospital1 **] 5. cholecalciferol 1000 unit daily 6. docusate 100mg [**Hospital1 **] 7. enoxaparin 30mg Q12 8. furosemide 40mg daily 9. glargine 46units QAM 10. lispro sliding scale 11. lactulose 10gm [**Hospital1 **] 12. lisinopril 40mg daily 13. metoprolol tartrate 12.5mg [**Hospital1 **] 14. senna 8.6mg [**Hospital1 **] 15. albuterol neg Q4h prn 16. bisacodyl 10mg daily 17. maalox 30ml [**Hospital1 **] Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheezing 3. Aspirin 81 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Furosemide 40 mg PO DAILY 6. Glargine 30 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 7. Lisinopril 40 mg PO DAILY 8. Metoprolol Tartrate 12.5 mg PO BID Hold for SBP<100 or HR<60. 9. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB, wheezing 10. Quetiapine Fumarate 25 mg PO BID hold for sedation or rr<10 11. Calcium Carbonate 1250 mg PO BID 12. Vitamin D 1000 UNIT PO DAILY 13. Lactulose 30 mL PO DAILY:PRN constipation 14. Senna 1 TAB PO BID:PRN constipation 15. Bisacodyl 10 mg PO DAILY:PRN constipation 16. Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO BID:PRN heartburn 17. Tiotropium Bromide 1 CAP IH DAILY 18. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H 19. Heparin 5000 UNIT SC TID 20. Fluconazole 200 mg PO Q24H Duration: 2 Weeks 2 week course for yeast UTI ([**Date range (3) 13155**]) Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: PRIMARY: respiratory failure diastolic heart failure emphysema delirium Clostridium difficile colitis SECONDARY: hypertension diabetes mellitus obesity hypoventilation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to [**Hospital1 18**] because you were progressively short of breath at your rehab and presented here in respiratory failure, requiring intubation (a breathing tube). Your symptoms were likely due to a combination of emphysema (COPD) as well as fluid buildup in the lungs from heart failure (heart not pumping blood well). You were treated with steroids, antibiotics, and breathing treatments for the COPD as well as diuretics for heart failure. You were able to be extubated (have the breathing tube removed) and are now comfortable breathing room air. While you were here, you were evaluated by Physical Therapy who felt it would be safest to send you to rehab, especially considering your recent hip fracture repair on [**2167-5-27**]. While you were here, you had a repeat echocardiogram (ultrasound of the heart) which showed that currently the heart is pumping fine, but you should continue on oral diuretics daily. Please weight yourself daily, and seek help if your weight increases by 3lbs, as this might mean that your diuretics need to be increased. In addition, your PCP should consider pursuing outpatient polysomnography (sleep study) to see if you have sleep apnea, which could have contributed to your symptoms as well. Note that while you were here, We made the following changes to your medications: -CHANGED dose of Acetaminophen -DECREASE insulin Glargine dose -CHANGED Humalog sliding scale -START Spiriva (Tiotropium) for emphysema -START Ipratropium nebs as needed for shortness of breath/wheezing -START Seroquel for mood -STOP Lovenox injections and change to Heparin injections instead (you already completed the 4 week post-operative course of Lovenox) -START a course of Metronidazole (antibiotics) for C.difficile infection (10 day course, from [**Date range (1) 13153**]) -START a course of Fluconazole (antifungal) for yeast UTI (2 week course, from [**Date range (1) 13154**]) Followup Instructions: Department: ORTHOPEDICS When: THURSDAY [**2167-8-13**] at 9:00 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: THURSDAY [**2167-8-13**] at 9:20 AM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "96.04", "38.91", "96.6", "38.97", "33.22", "96.72" ]

icd9pcs

[ [ [] ] ]

16243, 16309

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323, 363

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45144+58790

Discharge summary

report+addendum

Admission Date: [**2186-4-2**] Discharge Date: [**2186-4-13**] Service: MEDICINE Allergies: Ipratropium Attending:[**First Name3 (LF) 5827**] Chief Complaint: lethargy Major Surgical or Invasive Procedure: R PICC placement History of Present Illness: [**Age over 90 **]M with h/o CRI, CAD, dementia, presented to the ED from [**Hospital3 2558**] with 1 day of lethargy. Labs showed BUN/Cr 67/2.3 and glucose 748. WBC was 21.5 [**4-1**], down to 13.3 on day of admission. CXR was read as negative, but he was given levofloxacin at the NH for empiric treatment of pneumonia. He was brought to the ED for further evaluation given his lab abnormalities and altered mental status. In the ED, VS were T 99 (rectal), HR 81, BP 105/63, RR 21, O2sat 95% 10L, FSBG critically high. CXR showed bibasilar infiltrates, UA dirty. CT head with only chronic microvascular changes. He was given Humalog 7U IV, then started on an insulin gtt. He was also given vancomycin 1g IV and Flagyl 500mg IV. He was transferred to the MICU for further management. Past Medical History: 1. CRI- baseline creatinine 1.2-1.4 2. CAD- h/o AMI [**2175**] s/p PCI to LAD 3. CHF- TTE [**2183**] with EF 25% including apical akinesis, 1+ MR, 2+ TR, moderate PA systolic HTN 4. HTN 5. Dementia Social History: Lives in nursing home, apparently has two caregivers who are very involved (listed in communication section). Heavy tobacco use in past, but quit ~20 years ago, no EtOH. Family History: non-contributory Physical Exam: VS 97.9 122/71 120/70 85 94%3L GENERAL: NAD, lying in bed HEENT: EOMI, OMMM NECK: Supple, no LAD CARDIOVASCULAR: S1, S2, reg, no MRG LUNGS: Soft occ rhonchi ABDOMEN: Soft, NT, ND, no rebound or guarding. EXTREMITIES: Warm, 2+ edema NEURO: Sleeping, but easily rousable. One word answers. Pertinent Results: Labs: [**2186-4-2**] 07:00PM BLOOD WBC-15.1* RBC-4.65 Hgb-14.6 Hct-45.5 MCV-98# MCH-31.5 MCHC-32.2 RDW-14.8 Plt Ct-175 [**2186-4-2**] 07:00PM BLOOD Neuts-84.1* Lymphs-11.0* Monos-1.4* Eos-2.2 Baso-1.2 [**2186-4-2**] 07:00PM BLOOD Glucose-705* UreaN-69* Creat-2.6*# Na-163* K-5.5* Cl-127* HCO3-24 AnGap-18 [**2186-4-12**] 05:39AM BLOOD Glucose-97 UreaN-15 Creat-1.2 Na-141 K-3.7 Cl-110* HCO3-25 AnGap-10 [**2186-4-2**] 07:00PM BLOOD ALT-36 AST-46* CK(CPK)-84 AlkPhos-102 Amylase-20 TotBili-0.6 [**2186-4-3**] 01:00AM BLOOD CK(CPK)-91 [**2186-4-4**] 05:41AM BLOOD CK(CPK)-71 [**2186-4-2**] 07:00PM BLOOD cTropnT-0.08* [**2186-4-3**] 01:00AM BLOOD CK-MB-NotDone cTropnT-0.08* [**2186-4-4**] 05:41AM BLOOD CK-MB-NotDone cTropnT-0.05* [**2186-4-2**] 09:36PM BLOOD %HbA1c-8.3*# . EKG: NSR 73, RBBB, LAFB, PRWP. . CT Head [**2186-4-2**] 7:16 PM: 1. No hemorrhage or mass effect. 2. Moderate-to-severe chronic periventricular white matter hypodensities consistent with chronic microvascular ischemia. 3. Chronic lacunar infarcts. 4. Air-fluid level in the right maxillary and left sphenoid sinuses consistent with acute sinusitis. MRI with diffusion-weighted images is more sensitive in the detection of acute infarction. . CXR [**2186-4-2**] 7:00 PM: Cardiomegaly. Probable COPD and pulmonary hypertension. Increased retrocardiac density - - question collapse and/or consolidation versus hiatal hernia. Patchy opacity right mid zone - - question scarring versus infiltrate. Compared with [**2184-5-19**], the right cardiophrenic opacity is new and therefore more likely to represent an infectious infiltrate or aspiration. The degree of retrocardiac opacity is also worse. At least, part of this may relate to a tortuous aorta. Imaging: CXR [**2186-4-4**] 2:52 PM: Persistent atelectasis and/or consolidation left lung base. Possible subtle parenchymal infiltrate in right lower lung. . Video Speech and Swallow Evaluation [**2186-4-7**]: Pt demonstrates a mild oropharyngeal dysphagia characterized by reduced bolus formation and control, prolonged mastication of all textures, mild swallow initiation delay, and reduced valve closure. Pt appreciated to aspirate cup sips, but straw sips of thin liquid were safe for PO intake. As such, I recommend the pt's PO diet include thin liquids, pureed solids, and PO meds crushed in puree. Pt will require 1:1 assistance with meals to maintain aspiration precautions as listed below. Please reconsult if pt's performance improves such that upgrade to regular solids might be reasonable and a repeat swallow evaluation can be completed at that time. RECOMMENDATIONS: 1. PO diet: thin liquids, pureed solids, PO meds crushed in puree. 2. 1:1 assistance with meals to maintain aspiration precautions including: a) Pt MUST use straws for thin liquids b) Pt should only take one sip at a time from straw 3. Please reconsult if pt's performance improves such that upgrade to regular solids might be reasonable and a repeat swallow evaluation can be completed at that time. Brief Hospital Course: He received 2L NS. He temporarily required NRB, but was quickly weaned down to 6LNC. His EKG was thought to have slight changes in the STE V1-V3 and troponin was slightly elevated at 0.08-- Cardiology reviewed his EKG and felt there was no significant change. On arrival to MICU required NRB, but titrated to 6LNC. In the MICU, treated w/ vanco/levo/flagyl, given insulin gtt and fluid resuscitated. Ultimately, sodium was brought to 140s over the course of five days, pt completed 5d of antibiotics (planned course of ten, vanco discontinued), converted to SC insulin regimen, and felt stable for transfer to floor. Per signout from MICU team, major new issue has been an issue of aspiration. Although pt apparently passed bedside swallow w/ nectar thickened, pt has continued to have evidence of aspiration while eating/drinking/meds. MICU team therefore recommended video swallow eval. ASSESSMENT/PLAN: [**Age over 90 **]M with h/o CRI, CAD, dementia, initially admitted to MICU for HONC (FSBS 700s), severe hypernatremia (174), UTI and PNA treated w/ vanco/levo/flagyl. Commpleting a 10 day course of levo/flagyl. Hypernatremia resolved, blood glucose in better control and transitioned to subq heparin. . # SEPSIS: The patient presented from NH with elevated WBC and dirty U/A and started on levoquin. He received 2L NS. He temporarily required NRB, but was quickly weaned down to 6LNC. He was continued on levofloxacin and started on vancomycin and flagyl. All of his cultures here have been negatiave, although he was started on antibiotics prior to his arrival. Vancomycin was discontinued after a 5 day course as urine and blood cultures were negative. Plan for levofloxacin and flagyl to be continued to complete a 10 day course. At the time of discharge, he is afebrile, hemodynamically stable and breathing without O2 supplementation. . # HYPERNATREMIA/ELECTROLYTES: Appeared to have nongap acidosis, probably initially related to dehydration and later attributed to NS given for fluid rescuscitation. Fluids were changed to slow fluids w/ LR instead. By the time of discharge, his sodium level was within normal limits. . # ASPIRATION: There was evidence of clinical aspiration. A video swallow examination was perfromed and showed that the patient is able to take thin liquids with a straw and pureed food with 1:1 meal assist. After discussion with the family and nutrition, will hold off on PEG placement and reevaluate in nursing home. Will continue 1:1 assist diet per nutrtion recs. . # CHF: Systolic CHF with EF 25% and grossly volume overloaded by exam plus O2 requirement likely [**3-10**] fluid administration for sepsis. He responded well to diuresis and by the end of his hosptial course, no longer had an O2 requirement. . # DM: The patient presented with elevated blood glucose in the 700s, he was initially started on an insulin drip and transitioned to insulin subq. He did not previously have a diagnosis of diabetes, but on review of CCC shows multiple hyperglycemic episodes while here, so probably undiagnosed DM. Hgb A1C at admission 8.3 He will be discharged on his inpatient insulin regimen and will need to follow up with his primary care for further management. . # CAD: - started on ASA and metoprolol . # DEMENTIA: As above, Aricept and namenda were initially held whil NPO, then restarted prior to discharge. . # FEN: Thin liquids and pureed diet with 1:1 assist. Will hold off on PEG for now and this can be readdressed as an outpatient. Family is in agreement with holding feeding tube for now. . # Code status: Full Medications on Admission: Actonel 35mg Q week ASA 325mg Colace MVI Namenda 10mg [**Hospital1 **] Metoprolol 12.5 [**Hospital1 **] Celexa 20mg Senna Aricept 10mg Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for constipation: Hold for loose stools. 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 4. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week: Sit for 30 minutes after taking this medication. 5. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day. 6. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Eight (8) units Subcutaneous qam and qhs: This dose may be adjusted by the primary care provider. 10. Insulin Lispro (Human) 100 unit/mL Solution Sig: As directed Subcutaneous As directed: Half dose if patient is NPO. If glucose is less than 60 or greater than 350, notify MD. 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary diagnosis: - Sepsis - Hypernatremia - Hyperosmolar hyperglycemic state . Secondary diagnosis: - Chronic renal insufficiency - Coronary artery disease - Congestive heart failure - Hypertension - Dementia Discharge Condition: Stable, breathing well on room air Discharge Instructions: You have been admitted to the hospital with sepsis, high blood glucose, and high sodium. You were treated with antibiotics, insulin and fluids. Please take all medications as directed. Please go to all follow up appointments. If you develop fever, chills, chest pain abdominal pain or any other symptom that concerns you, seek medical attention. Followup Instructions: Have your primary doctor follow up your glucose levels and help you adjust your insulin regimen. PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5351**] [**Telephone/Fax (1) 608**] Name: [**Known lastname **],[**Known firstname 785**] Unit No: [**Numeric Identifier 15330**] Admission Date: [**2186-4-2**] Discharge Date: [**2186-4-13**] Date of Birth: [**2090-7-25**] Sex: M Service: MEDICINE Allergies: Ipratropium Attending:[**First Name3 (LF) 2191**] Addendum: Heparin subq TID also a discharge medication. Discharge Disposition: Extended Care Facility: [**Hospital3 901**] - [**Location (un) 382**] [**First Name11 (Name Pattern1) 732**] [**Last Name (NamePattern4) 2192**] MD [**MD Number(2) 2193**] Completed by:[**2186-4-13**]

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icd9cm

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icd9pcs

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1487, 1505

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54876

Discharge summary

report

Admission Date: [**2174-7-2**] Discharge Date: [**2174-7-14**] Date of Birth: [**2118-1-11**] Sex: F Service: MEDICINE Allergies: morphine Attending:[**First Name3 (LF) 2712**] Chief Complaint: SOB/COPD Major Surgical or Invasive Procedure: Mechanical Intubation Central line placement right femoral and right IJ Arctic Sun s/p PEA arrest History of Present Illness: 56 yo F with PMH COPD and asthma who presented to OSH with increasing SOB x 3d. Per family, despite report of SOB, she was doing relatively fine until the day of admission, when she developed N/V/D. Daughter came over to help transport pt to ED and says at that time she was c/o feeling like she "couldn't breathe" and having sweats. Called paramedics who took patient to OSH. At OSH, pt was somnolent and minimally responsive. She was trialed on BiPAP and then intubated for resp distress and airway protection [**1-6**] AMS. After intubation her pressures dropped to 80s systolic and she was started on a levophed drip via EJ peripheral line and sedated with propofol. A CXR showed a LLL consolidation, so she was started on azithro/CTX and solumedrol and given 2L IVF. Labs significant for Na 141, K 3.8, bicarb 31, AG 9, Cr 1.3, lactate 2.2, LFTs WNL, INR 1.04, WBC 25.5, Hct 41.9, Plt 218She was transferred to [**Hospital1 18**]. At [**Hospital1 18**] she triggered on arrival for O2 sat 65%, though this was thought to be inaccurate pulse ox and first vital set in ED records noted to be 137, 68/55, 16, 99% ETT. Labs significant for WBC 18.8 (84% PMN), Hct 38.3, plats 203, Cr 1.6 (CHEM-7 otherwise unremarkable). U/A neg with 23 hyaline casts. Patient had no prior records and baselines unknown. CXR showed LLL PNA. She was broadened to vanc/cefepime and the propofol was weaned. A right IJ was placed and she was continued on levophed (at 4.5 upon transfer) with fentanyl/midaz for sedation. Pressures improved to 92/57 with pressors. She was tachy to 130s on arrival. On transfer, HR 115, 92/57, 96% on CMV. She was sent for CTA to r/o PE on way up to MICU floor. On arrival to MICU, VS 99.5, 111, 88/55, 16, 100% CMV. Shortly after arrival to MICU, pressures dropped and pt became pulseless. Pt noted to have high auto-PEEP of 23 prior to arrest. A code blue was called and chest compressions started immediately. Rhythm check was performed and pt noted to be in PEA arrest. Pt was coded for approx. 10 minutes after which time pulse was regained. During that time period she received 2 amps of epi, 2 amps of bicarb, and started on an epi drip. Labs prior to arrival in MICU revealed unremarkable electrolyte panel. Decreased BS noted on left both before and during code, likely [**1-6**] to LLL PNA. Pt was very difficult to ventilate and there was concern for large PTX, however, this was not seen on CXR. CTA was negative for PE. Echo performed at bedside during code did not show pericardial effusion. Repeat echo after code showed global hypokinesis. Etiology was never identified but most likely explanation for arrest was thought to be [**1-6**] worsened resp failure and subsequent acidosis. Immediately after code we were unable to assess mental status since pt was already heavily sedated. Arctic Sun protocol was initiated and pt was paralyzed with cisatrocurium. She was on three pressors after stabilization - levophed, epinephrine, and neosynephrine with pressure 102/59, HR 105, 100% on CMV. Review of systems: unable to obtain. Sick contacts - baby granddaughter with h/o MRSA with whom she has frequent contact Past Medical History: COPD (emphysema) - diagnosed 3 years ago, intubated at that time for 2 days, on 3L O2 at home asthma anxiety benign ovarian tumor s/p resection [**2174-5-6**] Social History: Lives at home with family. No pets. Former smoker, quit 3 years ago. Family History: NC Physical Exam: Admission Physical Vitals: T:99.0 BP: 130/75 P: 120 R: 17 18 O2: 95% 2L NC General: Alert, oriented X 3 male in no acute distress , speaking in full sentences. HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rhythm,tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: left insp. crackles, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley placed Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact . Discharge Physical Physical Examination General: Awake, alert, able to sit up with minimal assistance, pleasant, occasional cough HEENT/Neck: MMM, clear oropharynx, no scleral icterus Lungs: few scattered wheezes, no rhales, decreased air movement bilaterally Cardiac: Regular, no gallops, rubs Abdomen: Soft, non-distended, non-tender, bowel sounds present Extremities: No edema Neuro: Awake, alert, appropriate. Able to sit up with minimal assistance. Pertinent Results: Admission Labs [**2174-7-2**] 10:49PM TYPE-[**Last Name (un) **] PO2-53* PCO2-77* PH-7.10* TOTAL CO2-25 BASE XS--7 [**2174-7-2**] 10:49PM LACTATE-3.1* [**2174-7-2**] 10:44PM TYPE-ART PO2-162* PCO2-74* PH-7.14* TOTAL CO2-27 BASE XS--5 [**2174-7-2**] 10:19PM TYPE-ART PO2-365* PCO2-99* PH-7.02* TOTAL CO2-28 BASE XS--8 INTUBATED-INTUBATED [**2174-7-2**] 10:06PM TYPE-CENTRAL VE PO2-73* PCO2-129* PH-6.95* TOTAL CO2-31* BASE XS--8 [**2174-7-2**] 10:06PM LACTATE-4.4* [**2174-7-2**] 09:54PM GLUCOSE-211* UREA N-20 CREAT-1.5* SODIUM-142 POTASSIUM-4.8 CHLORIDE-108 TOTAL CO2-27 ANION GAP-12 [**2174-7-2**] 09:54PM CK(CPK)-124 [**2174-7-2**] 09:54PM CK-MB-4 cTropnT-<0.01 [**2174-7-2**] 09:54PM CALCIUM-6.8* PHOSPHATE-5.3* MAGNESIUM-1.9 [**2174-7-2**] 09:54PM WBC-23.8* RBC-3.17* HGB-10.0* HCT-31.1* MCV-98 MCH-31.4 MCHC-32.0 RDW-13.6 [**2174-7-2**] 09:54PM PLT COUNT-174 [**2174-7-2**] 09:54PM PT-17.1* PTT-65.0* INR(PT)-1.6* [**2174-7-2**] 08:05PM TEMP-36.7 RATES-/14 TIDAL VOL-400 PEEP-5 O2-50 PO2-94 PCO2-65* PH-7.17* TOTAL CO2-25 BASE XS--5 INTUBATED-INTUBATED VENT-SPONTANEOU [**2174-7-2**] 08:05PM O2 SAT-95 [**2174-7-2**] 06:24PM TYPE-ART RATES-14/0 TIDAL VOL-450 PEEP-5 O2-100 PO2-397* PCO2-61* PH-7.22* TOTAL CO2-26 BASE XS--3 AADO2-251 REQ O2-50 INTUBATED-INTUBATED VENT-CONTROLLED [**2174-7-2**] 06:15PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.014 [**2174-7-2**] 06:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2174-7-2**] 06:15PM URINE HYALINE-23* [**2174-7-2**] 06:15PM URINE MUCOUS-FEW [**2174-7-2**] 06:00PM GLUCOSE-98 UREA N-19 CREAT-1.6* SODIUM-145 POTASSIUM-3.8 CHLORIDE-109* TOTAL CO2-24 ANION GAP-16 [**2174-7-2**] 06:00PM estGFR-Using this [**2174-7-2**] 06:00PM CK(CPK)-143 [**2174-7-2**] 06:00PM CK-MB-4 cTropnT-0.01 [**2174-7-2**] 06:00PM WBC-18.8* RBC-4.00* HGB-12.3 HCT-38.3 MCV-96 MCH-30.8 MCHC-32.1 RDW-13.6 [**2174-7-2**] 06:00PM NEUTS-84* BANDS-11* LYMPHS-4* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2174-7-2**] 06:00PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL STIPPLED-OCCASIONAL [**2174-7-2**] 06:00PM PLT COUNT-203 [**2174-7-2**] 06:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2174-7-2**] 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2174-7-2**] 06:00PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE EPI-0 [**2174-7-2**] 06:00PM URINE GRANULAR-1* HYALINE-23* [**2174-7-2**] 06:00PM URINE MUCOUS-OCC . [**2174-7-12**] 07:25AM BLOOD WBC-21.2* RBC-3.28* Hgb-10.0* Hct-31.5* MCV-96 MCH-30.4 MCHC-31.7 RDW-13.8 Plt Ct-160 [**2174-7-10**] 03:52AM BLOOD WBC-25.0* RBC-3.41* Hgb-10.3* Hct-32.0* MCV-94 MCH-30.2 MCHC-32.2 RDW-14.0 Plt Ct-131* [**2174-7-8**] 03:46AM BLOOD WBC-14.5* RBC-3.00*# Hgb-9.3*# Hct-28.1* MCV-94 MCH-31.0 MCHC-33.1 RDW-14.0 Plt Ct-65* [**2174-7-6**] 03:21PM BLOOD WBC-12.9* RBC-2.54* Hgb-7.9* Hct-24.6* MCV-97 MCH-31.1 MCHC-32.1 RDW-13.8 Plt Ct-47* [**2174-7-6**] 03:10AM BLOOD WBC-14.3* RBC-2.65* Hgb-8.2* Hct-25.1* MCV-95 MCH-30.9 MCHC-32.7 RDW-13.6 Plt Ct-47* [**2174-7-4**] 04:15AM BLOOD WBC-18.6* RBC-3.60* Hgb-11.2* Hct-34.0* MCV-94 MCH-31.0 MCHC-32.8 RDW-14.0 Plt Ct-78* [**2174-7-3**] 09:51PM BLOOD WBC-17.0* RBC-3.48* Hgb-10.8* Hct-33.2* MCV-95 MCH-31.0 MCHC-32.5 RDW-14.0 Plt Ct-83* [**2174-7-10**] 03:52AM BLOOD Neuts-95.8* Lymphs-2.2* Monos-1.7* Eos-0 Baso-0.4 [**2174-7-9**] 03:14AM BLOOD Neuts-82* Bands-5 Lymphs-0 Monos-6 Eos-0 Baso-0 Atyps-2* Metas-4* Myelos-0 Promyel-1* [**2174-7-8**] 03:46AM BLOOD Neuts-83* Bands-1 Lymphs-3* Monos-11 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 NRBC-1* [**2174-7-6**] 03:10AM BLOOD Neuts-90* Bands-2 Lymphs-3* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 [**2174-7-12**] 07:25AM BLOOD Plt Ct-160 [**2174-7-10**] 03:52AM BLOOD PT-13.5* PTT-24.0* INR(PT)-1.3* [**2174-7-9**] 03:14AM BLOOD PT-12.7* PTT-22.5* INR(PT)-1.2* [**2174-7-8**] 03:46AM BLOOD Plt Ct-65* [**2174-7-8**] 03:46AM BLOOD PT-12.6* PTT-22.6* INR(PT)-1.2* [**2174-7-13**] 02:50AM BLOOD Glucose-155* UreaN-24* Creat-0.7 Na-140 K-5.0 Cl-98 HCO3-33* AnGap-14 [**2174-7-12**] 03:19PM BLOOD Glucose-233* UreaN-28* Creat-0.6 Na-141 K-4.4 Cl-96 HCO3-38* AnGap-11 [**2174-7-12**] 07:25AM BLOOD Glucose-101* UreaN-29* Creat-0.6 Na-146* K-4.3 Cl-101 HCO3-40* AnGap-9 [**2174-7-11**] 04:12AM BLOOD Glucose-210* UreaN-33* Creat-0.8 Na-145 K-4.2 Cl-98 HCO3-42* AnGap-9 [**2174-7-9**] 03:47PM BLOOD Glucose-149* UreaN-51* Creat-1.0 Na-146* K-3.0* Cl-98 HCO3-41* AnGap-10 [**2174-7-9**] 11:25PM BLOOD Glucose-319* UreaN-45* Creat-1.0 Na-145 K-5.4* Cl-98 HCO3-39* AnGap-13 [**2174-7-10**] 03:52AM BLOOD ALT-35 AST-25 LD(LDH)-514* AlkPhos-78 TotBili-0.9 [**2174-7-9**] 03:14AM BLOOD ALT-39 AST-38 LD(LDH)-577* AlkPhos-80 TotBili-0.5 [**2174-7-7**] 03:59AM BLOOD LD(LDH)-199 TotBili-0.1 [**2174-7-6**] 03:10AM BLOOD ALT-52* AST-17 LD(LDH)-187 CK(CPK)-134 AlkPhos-73 TotBili-0.2 [**2174-7-4**] 04:15AM BLOOD ALT-89* AST-59* LD(LDH)-252* AlkPhos-59 TotBili-0.6 [**2174-7-3**] 04:11AM BLOOD ALT-54* AST-56* AlkPhos-56 TotBili-0.7 [**2174-7-13**] 02:50AM BLOOD Calcium-9.3 Phos-3.0 Mg-2.2 [**2174-7-12**] 03:19PM BLOOD Calcium-9.0 Phos-3.4 Mg-2.2 [**2174-7-12**] 07:25AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.3 [**2174-7-11**] 04:12AM BLOOD Calcium-9.0 Phos-2.7 Mg-2.4 [**2174-7-7**] 03:59AM BLOOD Hapto-375* [**2174-7-3**] 11:06AM BLOOD %HbA1c-5.3 eAG-105 [**2174-7-8**] 09:15PM BLOOD Type-ART pO2-106* pCO2-53* pH-7.40 calTCO2-34* Base XS-5 [**2174-7-8**] 05:08PM BLOOD Type-ART pO2-102 pCO2-69* pH-7.29* calTCO2-35* Base XS-3 [**2174-7-8**] 02:53PM BLOOD Type-ART Temp-37.1 Rates-/21 Tidal V-400 PEEP-0 FiO2-40 pO2-138* pCO2-50* pH-7.43 calTCO2-34* Base XS-8 Intubat-INTUBATED Vent-SPONTANEOU [**2174-7-8**] 11:39AM BLOOD Type-ART Rates-/17 PEEP-8 FiO2-40 pO2-124* pCO2-46* pH-7.44 calTCO2-32* Base XS-6 Intubat-INTUBATED Vent-SPONTANEOU [**2174-7-7**] 09:35PM BLOOD Type-ART pO2-124* pCO2-44 pH-7.41 calTCO2-29 Base XS-3 [**2174-7-5**] 04:11PM BLOOD Glucose-164* [**2174-7-5**] 04:10AM BLOOD Lactate-1.6 [**2174-7-4**] 01:23AM BLOOD Lactate-3.4* [**2174-7-3**] 08:51PM BLOOD Lactate-3.6* [**2174-7-3**] 05:53PM BLOOD Lactate-3.8* [**2174-7-3**] 02:10AM BLOOD Lactate-2.5* [**2174-7-2**] 10:49PM BLOOD Lactate-3.1* [**2174-7-2**] 10:06PM BLOOD Lactate-4.4* TTE: IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with low normal global systolic function. Right ventricular cavity enlargement with mild free wall hypokinesis. Compared with the prior study (images reviewed) of [**2174-7-2**], global left ventricular systolic function is improved. The severity of mitral regurgitation and tricuspid regurgitation are now reduced. CTA Chest: 1. Dense consolidation in the left upper lobe, consistent with pneumonia. Small parapneumonic left effusion. Findings are superimposed on a background of emphysema. 2. No evidence of pulmonary embolism. 3. No acute findings within the abdomen or pelvis. Brief Hospital Course: 56 year old female with PMH COPD and asthma who transferred from OSH with LLL PNA who went into PEA arrest upon arrival to MICU s/p resuscitation on Arctic Sun cooling protocol now extubated, treated for strep pneumonia, and severe COPD exacerbation. # LLL PNA-Found to have a lingular/LLL consolidation on CXR. Grew Strep pneumomia from sputum cx. Treated with 8 days of Ceftriaxone and Levofloxacin. --> Will need Pneumovax on or after discharge from rehab facility #COPD exacerbation- Was intubated for resp failure and started on IV steroids during whole admission which was transitioned to oral prednisone 40 mg daily on [**7-13**]. Was also placed on standing albuterol Q4H and Ipratroipium Q6H during the admission and is stable on this regimen. Will need aggressive pulm rehab and outpatient pulmonology follow up. Has not been on BIPAP since [**7-10**] which she intermittently needed since extubation on [**7-8**]. Will benefit from formal sleep eval. Goal oxygen sat should be 90-94% given severe COPD. Placed on Bactrim prophylaxis, home pantoprazole and started calcium and vitamin D. --> Please slow taper prednisone but should not be discontinued until followed by pulmonology due to severity of her asthma and her history on always being on prednisone. #Constipation-Severe until [**7-10**] when it was resolved with aggressive bowel reg of lactulose, senna, Colace and bisacodyl. Now having florid bowel movements. # Leukocytosis: s/p treatment for PNA. [**Month (only) 116**] be secondary to left shift from steroids. CXR improved. No fevers. Lines pulled but WBC count stable at approx. 20 for days. # Thrombocytopenia: likely ceftriaxone induced, Hit ab negative, now resolved. # Anemia: Hemolysis labs negative. guaiac stools neg. Likely marrow suppression from medications vs acute illness, stable Hct at approx. 30. # hypernatremia: at times has been mildly hypernatremic to 148, resolved with oral water intake, with normal sodium level on [**7-13**] #Hyperglycemia- start 8 units of Lantus, and sliding scale. Likely due to IV steroids. Running low 100s. will adjust dosing as needed ,Please monitor sugar as steroids are weaned off as want to avoid hypoglycemia. --> Please monitor her sugars and decrease lantus as needed. She did not require insulin prior to her hospital stay on higher dose steroids. # Nutrition: Was receiving tube feeds through NG tube because of failed speech and swallow eval. On [**7-13**] passed a second speech and swallow eval and started oral intake. # Communication: HCP is Daughter [**Name (NI) **] # Code: Full code Medications on Admission: tiotropium 1 cap daily advair 500/50 one puff [**Hospital1 **] albuterol inhaler 2 puff q4h prn albuterol neb q4h prn prednisone 10mg po daily lorazepam 1mg q4h prn citalopram 20mg po daily oxygen 3L pantoprazole 40mg po daily Discharge Medications: 1. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 2. Pantoprazole 40 mg PO Q12H 3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H 4. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB/wheezing 5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **] 6. Ipratropium Bromide Neb 1 NEB IH Q6H 7. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety 8. Glargine 8 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 9. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 10. Docusate Sodium (Liquid) 100 mg PO BID 11. Senna 1 TAB PO BID:PRN Constipation 12. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes 13. Chloraseptic Throat Spray 1 SPRY PO Q6H:PRN odynophagia 14. Heparin 5000 UNIT SC TID 15. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 16. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 17. Diltiazem Extended-Release 360 mg PO DAILY hold for SBP<100 or HR<60 18. PredniSONE 40 mg PO DAILY 19. Citalopram 20 mg PO DAILY 20. Vitamin D 1200 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: COPD exacerbation Pneumonia strep PEA arrest Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure caring for you at the hospital. . You were admitted to the hospital after having difficulty breathing. You were intubated and put on a breathing machine for a period of time. You were found to have a pneumonia and a severe COPD exacerbation. Your admission was complicated by your heart stopping and you underwent CPR and a cooling protocol. You recovered and were taken off the breathing machine. You are now being transferred to a rehab facility for further care. . Please follow the attatched medication list which will be continued at rehab. . Please establish care with a pulmonologist once leaving rehab. . You should also receive pneumovax with your primary care physician after discharge Followup Instructions: Follow with the rehab facility

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icd9cm

[ [ [] ] ]

[ "96.6", "99.60", "33.23", "96.72" ]

icd9pcs

[ [ [] ] ]

15999, 16071

12157, 14745

278, 378

16160, 16160

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17050, 17084

3840, 3845

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3860, 5038

3449, 3553

229, 240

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27,049

143,280

25606

Discharge summary

report

Admission Date: [**2199-10-6**] Discharge Date: [**2199-10-14**] Date of Birth: [**2144-10-24**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 8487**] Chief Complaint: Respiratory Failure Requiring Intubation Major Surgical or Invasive Procedure: Intubation- enroute to hospital [**2199-10-6**] Self extubation and re-intubation [**2199-10-8**] Extubation [**2199-10-12**] PICC line placement [**2199-10-9**] s/p Thoracentesis [**2199-10-11**] History of Present Illness: 54-year-old woman with a history of ILD, COPD, diastolic CHF (EF 50% in [**2-/2199**]), DM2, PVD s/p R AKA, chronic pancreatitis, alcoholic cirrhosis who was transferred from OSH with pneumonia and was intubated enroute because of desaturation and agitation. . For the past few days the patient has experienced subjective fevers, chills, chest tightness, and orthopnea. She presented to [**Hospital3 **] today, was diagnosed with pneumonia and CHF exacerbation (BNP > 35,000). She was started on moxifloxacin and given furosemide 40 mg IV x 1 for presumed CHF exacerbation as well as IV steroids. Reportedly her respiratory status improved after the furosemide. There was some mentioning of her being started on a heparin gtt for presumed PE in the [**Location (un) **] chart but there was no documentation of her arriving to [**Hospital1 **] on heparin gtt. She was deemed too sick for [**Location (un) **] and was transferred to [**Hospital 18**] medical floor. During the ambulance ride, she desated to 80% on NRB, became agitated, and was intubated. . On arrival to [**Hospital1 18**] ED, T 99.1, HR 98, BP 128/66, RR 16, intubated. ABG was 7.41/50/105. Exam revealed bibasilar crackles. CXR was c/w RLL pna and also ?pulmonary edema. She received vanco, levo. Was admitted to [**Hospital Unit Name 153**] for further management. . ROS: not obtained as patient was intubated Past Medical History: * Diastolic CHF: EF 50% in [**2-/2199**] * COPD: on nebs and inhaled steroids; s/p temp trach in [**3-/2199**] after intubation for respiratory failure * DM2: insulin-dependent * respiratory bronchiolitis-ILD: on VATS biopsy, now on intermittent supplemental oxygen * PVD: s/p R AKA [**11/2198**], s/p rt. ileo-fem bpg [**12-10**] complicated by lymphocele s/p drainage [**2198-1-11**],rt. ililac/femoral thrombectomy [**4-10**],rt. ileo-fem graft thrombectomy with bovine patch angioplasty [**2196**],rt. ileofem bpg with PTFE [**2195**], * chronic pancreatitis s/p Puestow,J-tube,ccy1998,Expl lap [**2189**] * EtOH cirrhosis * L breast cyst s/p excision * GERD * PUD * esophagitis with stricture * small bowel obstruction * PV,SMV thrombosis; h/o DVT/PE * cervical ca s/p multiple d/c's * entero-colonic fistula * s/p cholecystectomy Social History: Currently at rehab. Married and lives at home generally with her husband, no children. Previously worked as a counselor in drug and alcohol programs. She quit smoking approximately [**12/2198**] with an over 80-pack year history of smoking. She quit drinking alcohol 23 years ago. She has no known exposure to tuberculosis. She was cleaning her husband's clothes during the time that he was working with asbestos for a three-month period. Family History: Noncontributory Physical Exam: On admission: Tmax: 37.3 ??????C (99.1 ??????F) Tcurrent: 37.3 ??????C (99.1 ??????F) HR: 96 (94 - 96) bpm BP: 122/58(73) {122/58(73) - 144/63(78)} mmHg RR: 21 (15 - 21) insp/min SpO2: 96% Heart rhythm: SR (Sinus Rhythm) GEN: Middle-aged woman, intubated, withdrawing to painful stimuli HEENT: PERRL, sclera anicteric, ET tube in place, MM dry, COR: RRR, no M/G/R, normal S1 S2, radial pulses +2, JVP flat PULM: coarse BS bilaterally ABD: Soft, ND, +BS, no HSM, no masses EXT: R AKA, L leg with chronic statis changes, weak PD pulse SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: Admission Labs: [**2199-10-6**] 08:20PM URINE RBC-21-50* WBC-[**2-6**] BACTERIA-RARE YEAST-NONE EPI-0-2 [**2199-10-6**] 08:20PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2199-10-6**] 08:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2199-10-6**] 08:20PM FIBRINOGE-487* D-DIMER-1641* [**2199-10-6**] 08:20PM PLT COUNT-303 [**2199-10-6**] 08:20PM PT-22.9* PTT-36.3* INR(PT)-2.2* [**2199-10-6**] 08:20PM WBC-6.3 RBC-2.50* HGB-7.6* HCT-24.4* MCV-97 MCH-30.5 MCHC-31.3 RDW-17.5* [**2199-10-6**] 08:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2199-10-6**] 08:20PM ASA-4 ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2199-10-6**] 08:20PM cTropnT-0.03* [**2199-10-6**] 08:20PM cTropnT-0.03* [**2199-10-6**] 08:20PM UREA N-61* CREAT-1.4* [**2199-10-6**] 08:36PM GLUCOSE-261* LACTATE-1.0 [**2199-10-6**] 08:36PM TYPE-ART PO2-105 PCO2-50* PH-7.41 TOTAL CO2-33* BASE XS-5 [**2199-10-6**] 08:42PM GLUCOSE-265* LACTATE-1.1 NA+-144 K+-4.8 CL--97* TCO2-30 . Pertinent Micro: RESPIRATORY CULTURE (Final [**2199-10-10**]): SPARSE GROWTH OROPHARYNGEAL FLORA. 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------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN G---------- =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S . CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2199-10-13**]): REPORTED BY PHONE TO [**First Name5 (NamePattern1) 1037**] [**Last Name (NamePattern1) 63910**] [**2199-10-13**] @1:40 PM. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). . CXR: [**2199-10-13**]: HISTORY: Thoracentesis. One portable view. Comparison with [**2199-10-11**]. Diffuse bilateral interstitial infiltrates and a small right pleural effusion persist. Loculated pleural fluid or pleural thickening is again noted on the left. Mediastinal structures are unchanged. The patient has been extubated. A PICC line remains in place. IMPRESSION: No significant change post extubation. . Discharge labs: [**2199-10-14**] 05:00AM BLOOD WBC-9.5 RBC-2.72* Hgb-8.3* Hct-25.7* MCV-95 MCH-30.6 MCHC-32.3 RDW-17.2* Plt Ct-212 [**2199-10-13**] 04:47AM BLOOD Neuts-90.2* Lymphs-4.9* Monos-3.3 Eos-1.6 Baso-0.1 [**2199-10-14**] 05:00AM BLOOD PT-19.7* PTT-55.1* INR(PT)-1.8* [**2199-10-14**] 05:00AM BLOOD Glucose-266* UreaN-36* Creat-1.0 Na-140 K-4.2 Cl-106 HCO3-28 AnGap-10 [**2199-10-13**] 10:42PM BLOOD CK(CPK)-54 [**2199-10-11**] 05:05AM BLOOD ALT-17 AST-17 LD(LDH)-299* AlkPhos-263* TotBili-0.2 [**2199-10-13**] 10:42PM BLOOD CK-MB-6 cTropnT-0.02* [**2199-10-9**] 04:00AM BLOOD proBNP-[**Numeric Identifier 63911**]* [**2199-10-14**] 05:00AM BLOOD Calcium-6.8* Phos-3.2 Mg-2.4 [**2199-10-7**] 06:40AM BLOOD calTIBC-260 Ferritn-885* TRF-200 [**2199-10-7**] 06:40AM BLOOD Triglyc-78 HDL-48 CHOL/HD-2.3 LDLcalc-45 [**2199-10-14**] 05:00AM BLOOD Vanco-28.9* Brief Hospital Course: Ms. [**Known lastname 7168**] is a 54 yo WF w PMHx of MSSA pna/bacteremia earlier in [**2198**], ILD, COPD, diastolic CHF who presents with hypoxic respiratory failure and is found to have MRSA pna and new cardiomyopathy. 1. Hypotension/hypothermia: noted on arrival from ICU to floor on [**2199-10-13**]. Pt asymptomatic and had recently recieved both Metoprolol and Lisinopril in quick succession. Pt was bolused 1L and SBP quickly went from 80's to 120's. BP remains stable at 130's/50's at discharge. 2. MRSA Pna - Has hx of MSSA pna earlier in [**2198**] which required multiple hospitalizations and intubations. Now presented with MRSA pna requiring intubation from [**10-6**] to [**10-12**]. Pt initially started on broad spectrum abx with Vanc (day 1= [**10-6**]) but then narrowed following MRSA in sputum. Pt to finish full 14 day course Vanco [**10-20**]. Vancomycin was dosed intermittently [**1-5**] fluctuation renal function causing fluctuating vanco levels. Vanco is currently being dosed 1000mg for daily vanco level <20 (this is approx QOD). Last dose was [**2199-10-13**]. PICC in place. Pt will follow up with pulmonary on [**10-30**]. 3. New cardiomyopathy - [**Month/Year (2) **] in [**2-9**] showed EF of 50-55% w mild-mod MR. [**Name14 (STitle) **] this admission shows EF of 30%, mod-severe MR and TR. Pt was ruled out for MI w serial CEs on admission. Has no diagnosed CAD but has high risk factors for CAD (Peripheral arterial disease and DM). Continue with ASA, metoprolol and lisinopril. Unclear why pt was not on statin at admission but given PAD lipitor was added [**10-13**]. AST/ALT [**2199-10-11**] was wnl. Pt was diuresed PRN with 100mg Lasix IV. She is not requiring standing lasix at discharge. 4. Hx of COPD/ILD - On home oxygen at 3Liters NC at baseline. At discharge, on 3L NC. Pt given solumedrol 125mg IV Q6 initially in ICU for COPD exacerbation, which was quickly tapered. At discharge, pt to recieve 20mg Predx 4 days then 10mg for 4 days then to finsih. Continued Advair, spiriva, albuterol. 5. T2DM - On lantus 14 units QHS and Humalog SS. 6. ARF - Cr 1.4 on admission, improved w fluids down to 0.8. IVFS stopped given CHF. At discharge, Cr 1.0 likely [**1-5**] diuresis. 7. Hx of multiple venous and arterial clots on chronic anticoagulation - In ICU, pt was put on heparin gtt which was stopped prior to discharge on [**10-14**]. Coumadin was restarted [**10-13**]. INR should be checked daily at rehab until therapeutic. 8. Cdiff colitis - [**10-12**] stool Cdiff +, started on flagyl [**10-13**], will need a 14 day course and re-eval. 9. Anemia - Hct 25 on discharge and stable. Iron panel consistent with anemia of chronic disease. Of note, pt has had an outpt EGD and Colonoscopy at [**Hospital1 **] end of [**Month (only) **] which only showed gastritis and benign polyps. 10. Hx of chronic pancreatitis - Continued viokase. 11. Abnormal CT scan finding - spiculated nodule noted on [**10-10**] chest CT in LLL. Repeat CT in 6 weeks is recommended. PCP [**Name Initial (PRE) **]/fax sent but husband tells me that the old PCP has retired. Appt is set up at [**Hospital1 18**] in [**Location (un) **] for [**10-23**]. Pt will start with new PCP in [**Hospital1 18**] on [**2200-1-3**]. 12. Hx of ETOH cirrhosis - LFTS nl here. Ascites noted on CT chest 11/6likely [**1-5**] hx of ETOH cirrhosis but pt not having abd pain, afebrile for several days prior to discharge. 13. Hx of gastritis/gerd - recent EGD w/o ulcers, only gastritis. Continued PPI. Medications on Admission: warfarin 6 mg qday senna prn vitamin D lactulose 30 mL qday artificial tears both eyes tid floranex [**Hospital1 **] viokase tid humibid 600 mg [**Hospital1 **] Advair 250/50 1 inh [**Hospital1 **] tums 500 mg [**Hospital1 **] phoslo 667 mg tid spiriva 18 mcg 1 inh qday omeprazole 40 mg qday alb nebs [**Hospital1 **] and prn lidoderm to AKA site qday pepto-bismol prn morphine 45 mg PO q6h prn MoM prn dulcolax prn mucomyst via nebs prn acetaminophen prn fleet enema prn glargine 15 u qhs mirtazapine 22.76 mg qhs trazodone 150 qam bumex 20 mg qday aldactone 12.5 mg qday Discharge Medications: 1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: [**12-5**] Caps Inhalation DAILY (Daily). 2. Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QDAY (). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily) as needed. 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) 10 ml PO BID (2 times a day): Hold for diarrhea. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. 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. 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 11. Vancomycin 1000 mg IV DAILY:PRN vanco level <20 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 15. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): 1 tab daily for 4 days then half tab daily for 4 days then stop. . 17. Morphine 10 mg/5 mL Solution Sig: Five (5) ml PO Q6H (every 6 hours) as needed. 18. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 19. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 20. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): 14 day course to finish [**2199-10-27**]. 21. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14) units Subcutaneous once a day. 22. Humalog 100 unit/mL Solution Sig: One (1) sliding scale Subcutaneous three times a day: see attached sliding scale. 23. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) inh Inhalation twice a day. Discharge Disposition: Extended Care Facility: [**Hospital1 4860**] - [**Location (un) 4310**] Discharge Diagnosis: Primary Diagnosis: PNA Secondary Diagnoses: C Diff colitis ILD COPD PVD s/p right AKA CHF DM type 2 Chronic Pancreatitis GERD Discharge Condition: Stable on home O2 requirement of 3L NC Discharge Instructions: You were admitted after you had difficulty breathing. You were intubated on your way here on [**2199-10-6**] because of this. Here, you briefly pulled out your intubation tube on [**10-8**] after which it was quickly replaced. On the 7th, you had fluid removed from your lung space which seemed to help you breathe better. On the 8th, you were extubated and have been doing well ever since on 3L oxygen by nasal canulla. On the 9th, you were transferred to the floor briefly but then brought back to the ICU with low blood pressure. You have been stable here since that time. We think the underlying causes of your difficulty breathing include your congestive heart failure, COPD and interstitial lung disease as well as a MRSA pneumonia and fluid accumulation in your lung space. . You are being discharged on the attached medications. Please take all your medications as directed. . Please keep all your follow up appointments as below. . If you have worstening shortness of breath, chest pain, fever, cough, pain with urination, vomitting or any other concerning symptoms, please call your doctor or return to the emergency room. Followup Instructions: Please follow up with Pulmonary Medicine with Dr. [**Last Name (STitle) 4507**] on Wed [**10-30**] at 9:40am. This is located in the [**Hospital Ward Name 23**] Building, [**Location (un) **] in the Medical Specialty Office. If you need to reschedule, please call([**Telephone/Fax (1) 63912**]. . Please follow up at your current primary care office, Dr. [**Last Name (STitle) **], at [**Hospital1 18**] in [**Location (un) **] on [**10-23**] at 12:00 noon. If you need to reschedule, please call [**Telephone/Fax (1) 9556**]. You will meet your new primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], at [**Hospital3 **] in the [**Location (un) 448**] of the [**Hospital Ward Name 23**] building at [**Hospital1 18**] on [**1-2**] at 9:40 am. If you cannot for any reason make this appointment, you must call [**Telephone/Fax (1) 1247**] to reschedule. Completed by:[**2199-10-14**]

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icd9cm

[ [ [] ] ]

[ "38.91", "34.91", "88.72", "96.72", "96.04", "38.93" ]

icd9pcs

[ [ [] ] ]

13956, 14030

7575, 11099

315, 514

14200, 14241

3910, 3910

15423, 16342

3258, 3275

11723, 13933

14051, 14051

11125, 11700

14265, 15400

6706, 7552

3290, 3290

14095, 14179

235, 277

543, 1925

3926, 6689

14070, 14074

3304, 3891

1947, 2786

2802, 3242

18,771

134,750

26506

Discharge summary

report

Admission Date: [**2191-2-5**] Discharge Date: [**2191-2-10**] Date of Birth: [**2113-1-15**] Sex: F Service: MEDICINE Allergies: Shellfish / Ativan / Fentanyl Attending:[**First Name3 (LF) 425**] Chief Complaint: Shortness of breath, flash pulmonary edema Major Surgical or Invasive Procedure: 1. Cardiac Catheterization- No intervention History of Present Illness: 70 year old with hypertension initially presenting with acute-onset SOB [**2-4**], tranferred from NWH and [**Location (un) 620**] for acute pulmonary edema in setting of ? new LBBB, ? CK elevation. In brief, patient had, at 10 AM, acute-onset SOB last night while laying flat attempting to sleep. Of note, over past few months, patient has had difficulty sleeping, but does not attribute this to shortness of breath or cough, no orthopnea, PND, or LE edema, though has gained > 30 lbs over ? months - ? years. In setting of SOB, no associated fevers, chills, cough, sputum, chest pain, palpitations, pleuritic chest pain, LE edema or calf tenderness. Never had this SOB in past; reports no exertional chest pain or dyspnea. Also, no recent dietary indiscretion or medication changes/non-compliance. Had echocardiogram in distant past, with "normal results," but admits to "heart murmur" since birth. No history of clotting abnormalities. At [**Hospital3 **], her O2 saturation was 95% NRB, RR 32, BP 165/79 HR 98, given lasix 60 mg IV (-100 cc), morphine 2 mg IV, baby ASA, [**Name2 (NI) 63084**] 1" for acute pulmonary edema, with O2 requirement down to 4 L 91%. Given ciprofloxacin 400 mg IV for UTI. Also ? CK elevation (? at 2 AM) prompting eventual transfer to [**Hospital1 18**]-[**Location (un) 620**], where afebrile, HR 106, BP 133/67; chest x-ray consistent with pulmonary edema, BNP 335, CK 71, Tn < 0.01 (unclear when these were drawn). Transferred to [**Hospital1 18**] for further management. Past Medical History: HTN Hyperthyroidism (s/p RAI ablation, on synthroid) Social History: No IVDU, smokes, or ETOH. Retired spinstress. [**University/College **]. Family History: Father with massive MI and SCD in 60s. Physical Exam: VS: 97.2 120-130/60 HR102 atrial fibrillation 20 93%-4L Gen: NAD, breathing comfortably, reclining HEENT: OP clear, MM dry, EOMI, anincteric Neck: Supple, full ROM. JVP < clavicle, no HJR Chest: Wet rales [**2-18**] way up bilaterally, + inspiratory wheeze on R Cor: Regular rate and rhythm, harsh III/VI systolic murmur at RUSB => carotids, no augmentation with Valsalva Abd: Soft, NT ND + BS Extr: No edema, 2+ DP Neuro: CN II-XII intact, motor/sensory grossly intact Pertinent Results: [**2191-2-5**] 10:38PM %HbA1c-6.0* [Hgb]-DONE [A1c]-DONE [**2191-2-5**] 09:17AM WBC-14.2* RBC-3.85* HGB-11.9* HCT-32.4* MCV-84 MCH-30.8 MCHC-36.6* RDW-14.0 [**2191-2-5**] 03:30PM ALT(SGPT)-14 AST(SGOT)-17 CK(CPK)-78 ALK PHOS-63 TOT BILI-0.8 [**2191-2-5**] 05:45PM PT-14.1* PTT-63.0* INR(PT)-1.3 [**2191-2-5**] 05:46PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2191-2-5**] 05:46PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2191-2-5**] 09:17AM GLUCOSE-103 UREA N-22* CREAT-1.1 SODIUM-140 POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-25 ANION GAP-17 [**2191-2-5**] 03:30PM TSH-2.9 [**2191-2-5**] 03:30PM TRIGLYCER-177* HDL CHOL-49 CHOL/HDL-2.9 LDL(CALC)-56 [**2191-2-5**] 03:30PM ALBUMIN-3.7 CHOLEST-140 Imaging EKG [**2-5**]: AF at 89, LBBB with 2' ST/T wave changes, none > 5 mm or concordant, no Q waves EKG [**2184**] (old): NSR at 96, nl axis, nl intervals, no ST/T wave changes, no evidence of LVH, +PAC +PVC, no Q waves CXR: pulmonary edema (OSH) CATH: 1. Normal coronary arteries 2. Severe aortic stenosis with [**Location (un) 109**] of 0.7cm2 3. Severely elevated left heart filling pressure. 4. Severe pulmonary arterial hypertension. COMMENTS: 1. Selective coronary angiography in this right dominant circulation demonstrated normal coronary arteries. The LMCA, LAD, LCx, and RCA were all patent without any angiographically apparent flow limiting disease. The vessels were also noted to be tortuous. 2. Resting hemodynamics from right and left heart catheterization demonstrated moderately elevated right and severely elevated left sided filling pressures (RVEDP 15mmHg, LVEDP 35mmHg). There was severe pulmonary arterial hypertension. There was no mitral stenosis appreciated. The calculated cardiac output by the Fick method was 4.2 L/min with a cardiac index of 2.2. 3. The mean transaortic pressure gradient was 26mmHg measured with a double lumen pigtail catheter. The aortic valve area calculated by the Gorlin formula was 0.7 cm2. Carotid non-invasive studies [**2191-2-9**] negative Brief Hospital Course: HOSPITAL COURSE BY SYSTEM: 1) CARDIOVASCULAR: Initially transferred for flash pulmonary edema, that was thought possibly secondary to tight aortic stenosis + mitral regurgitation. Echocardiogram demonstrated results as above: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**], LV moderately dilated, LV systolic function depressed, resting mid-distal anteroseptal hypokinesis. 1+ AR, 3+ MR, moderate AS, small effusion w/o tamponade. Cardiac catheterization as above. Lasix was continued as home PO lasix and [**Last Name (un) **]. Chest x-ray with cardiomegaly. ECG was NSR at 96 with normal axis, intervals, no ST/T wave changes, with multiple multifocal PACs. Telemetry with one episode to 120s, with pause x 6 seconds x 1 in setting of beta-blockade, which was decreased. ASA, statin was continued. She was seen by cardiac surgery, who recommended pre-op eval (Carotids non-invasive negative) for MVR, AVR, which will be scheduled for next week. She will follow with Dr. [**Last Name (STitle) 65483**] (of CT surgery). 2) Renal/FEN: Creatinine of baseline of 1.0 => 1.4, which remained at that level throughout. This will need to be followed as outpatient. Lasix and [**Last Name (un) **] were continued at home dose. 3) ID: She was diagnosed and treated with bactrim x 3 days for UTI. WBC was increased on discharge, but she was without symptoms of infection and remained afebrile and hemodynamically stable. 5) Endo: TSH 2.9, with continuation of synthroid and MVI. 6) Prophy: PPI, SQ heparin, colace FULL CODE Medications on Admission: Diovan HCTZ Fosamax Synthroid Advil Calcium MVI Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 7. Valsartan 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1. Severe Aortic Valve Stenosis 2. Severe Mitral Regurgitation 3. Flash Pulmonary Edema 4. Hypertension 5. ? New Left Bundle Branch Block Discharge Condition: Good Discharge Instructions: Please report chest pain, shortness of breath, fever or chills, palpitations, lightheadedness or dizziness to your primary physician. [**Name10 (NameIs) **] notify surgery of these symptoms since they could change your operation schedule. You may contact Dr. [**Name2 (NI) 65484**] office at [**Telephone/Fax (1) 170**]. Please take all medications as outlined below. Please follow-up as scheduled for your Surgery next week. Followup Instructions: Follow-up for surgery as scheduled. . Please follow-up with Dr. [**Last Name (STitle) 38170**] at [**Location (un) 583**]-Marine for post-hospital follow-up. . You may also follow-up with Dr. [**Last Name (STitle) 73**] if needed, please contact his office at [**Telephone/Fax (1) 62**] Completed by:[**2191-2-11**]

[ "244.9", "396.2", "272.4", "398.91", "599.0", "426.3", "E939.4", "416.8", "293.0" ]

icd9cm

[ [ [] ] ]

[ "37.23", "88.56" ]

icd9pcs

[ [ [] ] ]

7131, 7137

4780, 4780

331, 377

7319, 7326

2646, 4757

7803, 8121

2099, 2140

6415, 7108

7158, 7298

6343, 6392

7350, 7780

4808, 6317

2155, 2627

249, 293

405, 1915

1937, 1992

2008, 2083

20,334

177,602

6779

Discharge summary

report

Admission Date: [**2190-5-7**] Discharge Date: [**2190-5-16**] Date of Birth: [**2124-2-28**] Sex: M Service: Cardiac surgery HISTORY OF PRESENT ILLNESS: Patient is a 66 year-old gentleman who started having angina in [**2187-4-26**]. He underwent prior catheterization at the time and was found to have a mid LAD stenosis which was stented. He presented to he Emergency Room in [**2189-11-26**] and was found to have electrocardiogram changes. He again underwent cardiac catheterization and had stenting of his left main into the circumflex. Patient did well and was discharged on Plavix and Lopressor. He again underwent an elective cardiac catheterization as follow up on [**2190-5-7**]. He has had some progression of his symptoms of dyspnea. The cardiac catheterization revealed diffuse 50 percent restenosis of his LMCA. This extended into the ostial circumflex stent which showed restenosis up to 60 percent. The LAD had a 90 percent ostial stenosis. His ejection fraction preoperatively was 55 percent. Patient was referred to the cardiac surgery service. PAST MEDICAL HISTORY: Is significant for coronary artery disease. Status post percutaneous interventions as above, hypertension, pancreatitis, hypercholesterolemia, colon surgery times two for diverticulitis and hernia repair. MEDICATIONS: Aspirin 325 mg p.o. q.d., Lipitor 60 mg p.o. q.d., Plavix 75 mg p.o. q.d., Lopressor 50 mg p.o. b.i.d., multivitamin and vitamin E. Patient has a questionable allergy to morphine and Accupril. HOSPITAL COURSE: The patient was taken to the operating room on [**2190-5-8**] and underwent coronary artery bypass graft times two with LIMA to the LAD and saphenous vein graft to the obtuse marginal. Patient's operative course was complicated and he was transferred to the SCRU. He was extubated postoperatively and did well and was transferred to the floor on postoperative day number one. Patient was noted to have copious sputum production. Although he did remain afebrile with a normal white count his sputum was sent off for culture and was positive for hemophilus influenza. Patient was started on Levaquin. He was also started on Combivent and albuterol MDI for his wheezing. Patient continued to improve and was limited only by his respiratory status which improved with MDI and diuresis. Patient also complained of dyspepsia throughout his hospital course and was started on Protonix as well as well as Reglan at the recommendation of Dr. [**Last Name (STitle) 1940**], his gastroenterologist and primary care physician. [**Name10 (NameIs) **] is being discharged on postoperative day number six. He is doing well. On discharge he is afebrile. His heart is regular at a rate of 82. His blood pressure was 130/70 and he is breathing comfortably with O2 saturations of 91 o 94 percent on room air. On examination his heart is regular. His sternum is stable. His wounds are clean, dry and intact. His lungs are clear to auscultation bilaterally without wheezes, rales or rhonchi. His abdomen is soft, nontender, nondistended. His extremities are warm. He had a chest x-ray on [**5-13**] showed bibasilar atelectasis and small bilateral pleural effusions. On discharge his white count is 7.9 and his hematocrit is 30, his platelets are 210. His BUN and creatinine are 19 and 1.2. His medications on discharge include: 1) Lopressor 75 mg p.o. b.i.d., 2) Lasix 20 mg p.o. b.i.d. time 14 days, 3) KayCiel 20 mEq p.o. q.d. times 14 days, 4) Percocet 1 to 2 tablets p.o. q 4 to 6 hour p.r.n. eor pain, 5) Colace 100 mg p.o. b.i.d., 6) multivitamin 1 p.o. q.d., 7) Combivent 2 puffs q.i.d., 8) ECASA 326 mg p.o. q.d., 8) Levaquin 500 p.o. q.d. times 10 days, 9) Protonix 40 mg p.o. q.d., 10) Reglan 10 mg p.o. t.i.d. 1/.2 hour prior to meals, 11) Lipitor 60 mg p.o. q.h.s. and 12) Plavix 75 mg p.o. q.d. CONDITION ON DISCHARGE: Good. [**Last Name (STitle) 25726**] follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 1940**] within two weeks and he will follow up with Dr. [**Last Name (Prefixes) **] in six weeks. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 25727**] MEDQUIST36 D: [**2190-5-16**] 09:58 T: [**2190-5-16**] 10:35 JOB#: [**Job Number 25728**]

[ "427.81", "414.01", "427.41", "411.1", "577.0", "996.72", "487.1", "997.1", "401.9" ]

icd9cm

[ [ [] ] ]

[ "37.23", "39.61", "88.56", "36.11", "99.61", "36.15" ]

icd9pcs

[ [ [] ] ]

1554, 3866

176, 1098

1121, 1536

3891, 4368

22,192

142,604

49595

Discharge summary

report

Admission Date: [**2132-4-8**] Discharge Date: [**2132-4-13**] Service: MEDICINE Allergies: Penicillins / Macrodantin / Amiodarone Attending:[**First Name3 (LF) 338**] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **] yo F with h/o CAD, A fib, HTN, CHF s/p recent hospitalization [**Date range (1) 103736**] involving MICU stay for hypoxia attributed to underlying interstitial lung disease with overlying pulmonary edema now admitted for hypoxia. Pt currently at [**Hospital 100**] Rehab - reportedly received ativan 1mg and ambien for agitation and became more confused than at baseline and fell. . During previous admission [**Date range (1) 103736**] pt was diagnosed with allergic rash thought [**2-22**] requip as well as hypoxia thought [**2-22**] underlying interstitial lung disease with overlying pulm edema. She was aggressively diuresed in the MICU for O2 sats in the 70's on 5L NC with a lasix gtt and nitro gtt. CT scan chest showed diffuse interstitial changes c/w pneumonitis as well. Seen by pulmonary consult who rec swallow eval (no overt aspirations when eating slowly), ANCA (negative), diuresis, and attempt at slower prednisone taper. Patient was doing better at time of discharge needing only 1L NC. . In the ED CXR was c/w worsening pulm edema vs. infection. O2 sats were initially 70% on RA, 85% on NRB, and 95% on CPAP. She was treated with 40mg IV lasix and put out approx 300 cc urine. Was also given solumedrol 125mg IV, Ceftazidime 1gm IV, Vancomycin 1gm IV, and Morphine 1mg IV. Past Medical History: 1. CAD s/p PTCA [**Month/Day (2) **] to LCX, RCA, PDA (last cath [**8-20**]) 2. Afib with pacemaker 2 yrs ago for tachy-brady syndrome 3. HTN 4. CRI, baseline Cr 1.3 (as of [**2130**]) 5. Anemia 6. GERD 7. Bladder spasms 8. s/p appy 9. s/p TKR [**2128**] 10. Chronic low back pain from "ruptured disc" 30 yrs ago 11. Breast Ca, [**2126**], T1N0M0, LN neg, ER pos, Her2/Neu neg, on Arimidex 12. Hiatal hernia 13. RLS: s/p allergic reaction to Requip. 14. CHF: EF >55% in [**3-26**]. Social History: Pt used to live at home w/ health aide, worked in antique store, no tobacco/alcohol use, no IVDA, used to perform most ADLs independently at home. s/p last admission she has been at [**Hospital 100**] Rehab Family History: mother died of CVA Physical Exam: Vital signs: 95.8, 92, 158/89, 36, 94% on CPAP+PS 10/5, TV 537, FIO2 100. Gen: agitated, heavy abdominal breathing. HEENT: unable to examine due to CPAP mask. Neck: supple, no LAD. Chest: coarse breath sounds throughout with crackles bilaterally. CVS: irregularly irregular, no m/r/g Abd: soft, slightly protruberant, +tympanic, NABS, NT, ND, using muscles heavily with breathing. many ecchymoses from heparin injections. Extrem: no c/c/e. Neuro: moving all extremities well, not cooperating with exam. Pertinent Results: Head CT [**2132-4-8**]: Extremely limited study due to patient condition and motion. No gross hemorrhage or mass effect identified . CXR [**2132-4-8**]: Marked progression of the interstitial opacities and peripheral alveolar opacities in both lungs, worrisome for worsening of pulmonary edema. Diffuse infection is another possibility if the patient has fever. Worsening of the underlying interstitial lung disease such as AIP can also manifest this appearance, so as pulmonary hemorrhage if the patient has hemoptysis. Enlarged right hilar contour, which can represent hilar lymphadenopathy in addition to known enlarged pulmonary artery. . Echo [**2132-3-24**]: The left atrium is mildly dilated. The interatrial septum is mildly aneurysmal. The estimated right atrial pressure is 11-15mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace 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 moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . ECG [**2132-4-8**]: AFib at 95, RBBB (old), demand atrial pacing. no ST/T changes comp to prior. Brief Hospital Course: [**Age over 90 **] yo F with h/o interstitial lung disease, CHF admitted with severe hypoxia: . # Hypoxia: this presentation similar to previous admission which was felt to be a combination of underlying interstitial lung disease with overlying pulmonary edema. On admission had increase in WBC with left shift, slightly hypothermic, concerning for infection. BNP 15,525. Was initially on BiPAP for approx 8 hours and was diuresed aggressively with lasix gtt. She initially responded and was being weaned to lower amounts of oxygen for a few days. She was initially treated with IV solumedrol given poor clinical picture on presentation but then switched to PO steroids given unclear of utility. She was initially given cefepime and vanc for broad coverage given severe hypoxia but once diuresed she improved so drastically so changed coverage to levoflox. She seemed to improve for a few days, but then even despite negative I/O's each day (autodiuresis) she began to have more difficulty with oxygenation. She was put back on Bipap with transient improvements but then her mental status began to decline. Oxygenation and overall respiratory status continued to worsen and this was felt possibly secondary to her underlying interstitial lung disease (which was never very well understood). Her family and HCP were [**Name (NI) 653**] and confirmed the pt was DNR/DNI. She was made CMO and passed away several hours later. Medications on Admission: -lasix 20mg po daily -insulin sliding scale -isosorbide mononitrate 30mg daily -lactulose 30mg po bid -pantoprazole 40mg po daily -prednisone 20mg po daily (to be changed to 15mg on [**4-8**] - on taper (5 days on each dose). -anastrozole 1mg po daily -aspirin 325mg daily -clopidogrel 75mg daily -colace 100mg po bid -gabapentin 100mg daily -heparin 5000 units SC tid -senna 1 tab po bid -sertraline 75mg po qhs -simvastatin 20mg po qhs -sotalol 40mg po daily -tylenol prn -albuterol nebs prn -bisacodyl 10mg PR prn -ipratropium neb q6 prn -nystatin 5ml q6 prn Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: hypoxic respiratory failure likely secondary to interstitial lung disease of unknown etiology and CHF Discharge Condition: expired Discharge Instructions: pt expired Followup Instructions: pt expired

[ "403.90", "428.0", "530.81", "515", "V10.3", "V45.82", "414.01", "518.81", "427.31", "585.9", "285.21" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6512, 6521

4444, 5870

252, 258

6666, 6675

2906, 4421

6734, 6747

2346, 2367

6483, 6489

6542, 6645

5896, 6460

6699, 6711

2382, 2887

205, 214

286, 1600

1622, 2106

2122, 2330

5,879

152,417

9838+9839

Discharge summary

report+report

Admission Date: [**2175-5-19**] Discharge Date: [**2175-5-28**] Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: This is an 81 year old female with known coronary artery disease, status post myocardial infarction in [**2170**], hypertension, hyperlipidemia, who was transferred to [**Hospital1 69**] on [**2175-5-19**], for cardiac catheterization. By report, the patient suffered a myocardial infarction in [**2170**]. Subsequent follow-up stress test in [**2172-9-25**], demonstrated inferior ischemia; at that point, the patient was uninterested in surgical intervention and was therefore treated medically. The patient was in her usual state of health until approximately one month prior to admission when she noted gradual onset of left arm pain and chest tightness in association with activity. The patient was evaluated by her primary care physician and was subsequently scheduled for a stress test. While awaiting the stress test, the patient presented to an urgent care facility on [**2175-5-17**], with chief complaint of increasing shortness of breath, productive cough and chest pain. The patient reported cold symptoms and fever with associated cough times two to three days. The patient was treated with Albuterol for suspected bronchial infection; however, upon administration, the patient became dizzy, tachycardic, diaphoretic and was noted to be hypotensive. She was subsequently transferred to [**Hospital 1474**] Hospital, where an electrocardiogram showed diffuse inferior and anterior ST-T wave changes. Troponin levels at that point were noted to be positive at 10.0; the patient's CK was noted to be 125 and her MB was 9.0 with subsequent values of 104/7.8 and 113/7.5, respectively. Echocardiogram demonstrated an ejection fraction of 40 to 45% with an apical aneurysm. The patient was subsequently transferred to [**Hospital1 190**] on [**2175-5-19**], for cardiac catheterization. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post myocardial infarction in [**2170**]. 2. Hypertension. 3. Hyperlipidemia. 4. Colon cancer, status post resection in [**2170**]. 5. Status post appendectomy. 6. Status post partial hysterectomy. MEDICATIONS ON TRANSFER: 1. Aspirin. 2. Lasix. 3. Isordil. 4. Captopril. 5. Lopressor. 6. Zocor. 7. Magnesium Oxide. 8. Guaifenesin. ALLERGIES: Codeine, Penicillin, Sulfa, Biaxin, Lipitor. SOCIAL HISTORY: The patient lives alone in senior housing development in [**Location (un) **], [**State 350**]. The patient has one son. The patient works as an office assistant. The patient is independent in her activities of daily living. No notable smoking history. HOSPITAL COURSE: The patient was admitted to the C-Medicine service on [**2175-5-19**]. Cardiac catheterization conducted on [**2175-5-19**], demonstrated three vessel coronary artery disease with 90% stenosis in the mid left anterior descending, 90% proximal occlusion of the OM1, and total occlusion of the right coronary artery. Normal ventricular function was noted with a recorded ejection fraction of 51%. Following extensive discussion with the patient regarding the benefits and risks of surgery, the patient elected to undergo coronary artery bypass graft procedure which was scheduled for [**2175-5-22**]. On [**2175-5-22**], the patient underwent a four vessel coronary artery bypass graft procedure with anastomosis from the left internal mammary artery to the left anterior descending, saphenous vein graft to posterior descending, saphenous vein graft to the OM and saphenous vein graft to the diagonal. The patient's pericardium was left open; lines placed intraoperatively included arterial line, Swan-Ganz catheter and CVP/RA catheter, both ventricular and atrial pacing wires were placed; both mediastinal and left pleural tubes were placed. The patient was subsequently transferred from the operating room to the Cardiac Surgery Recovery Unit intubated, for further evaluation and management. Shortly following transfer, the patient failed initial attempt at extubation but was successfully weaned and extubated several hours later. The patient remained stable under observation in the CSRU through postoperative day number two, at which point her chest tube and pacing wires were removed without complication and the patient was subsequently cleared for transfer to the floor for further evaluation and management. The patient was subsequently admitted to the Cardiothoracic service under the direction of Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]. The patient's postoperative course was uneventful and she progressed well clinically. Physical therapy evaluation suggested that the patient would benefit from postdischarge home physical therapy which was subsequently arranged for her. On postoperative day number three, the patient's Foley catheter was successfully removed and the patient was at this point noted to be independently productive of adequate amounts of urine for the duration of her stay. Given persistent coarse breath sounds in the patient's lung examination, routine screening chest x-ray was obtained which demonstrated bilateral pleural effusions with bibasilar atelectasis. The patient was subsequently begun on a fourteen day course of Levofloxacin, on which she remains upon discharge. The patient was successfully advanced to a full regular diet and was noted to have adequate pain control provided via oral pain medications. On postoperative day number five, the patient was noted to have significant constipation secondary to opioid administration. Following aggressive administration of Colace and Dulcolax, the patient was noted to pass stool freely and was subsequently independently productive of adequate bowel movements through the duration of her stay. The patient was subsequently cleared for discharge to home with services on postoperative day number six, [**2175-5-28**]. DISCHARGE STATUS: The patient is to be discharged to home with services and with instructions for follow-up. CONDITION ON DISCHARGE: Stable. MEDICATIONS ON DISCHARGE: 1. Lasix 20 mg p.o. q12hours times ten days. 2. Potassium Chloride 20 meq p.o. q12hours times ten days. 3. Colace 100 mg p.o. twice a day. 4. Aspirin 325 mg p.o. once daily. 5. Dilaudid 2 mg one to two tablets p.o. q4-6hours p.r.n. pain. 6. Levofloxacin 500 mg p.o. once daily times seven days. 7. Captopril 6.25 mg p.o. three times a day. 8. Lopressor 50 mg p.o. twice a day. DISCHARGE INSTRUCTIONS: 1. The patient is to maintain her incisions clean and dry at all times. The patient may shower but should pat dry any incisions afterwards; no bathing or swimming until further notice. 2. The patient has been advised to limit physical activity; no heavy exertion. 3. The patient has been scheduled for home physical therapy for continued strength and endurance training, as well as with a home health aid for wound checks once daily. 4. No driving while taking pain medications. 5. Follow-up with primary care physician within one to two weeks following discharge. 6. Follow-up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] within four weeks following discharge; the patient is to call to schedule an appointment. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 1053**] MEDQUIST36 D: [**2175-5-28**] 11:01 T: [**2175-5-28**] 11:46 JOB#: [**Job Number 33080**] Admission Date: [**2175-5-19**] Discharge Date: [**2175-5-28**] Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: This is an 81 year old female with known coronary artery disease, status post myocardial infarction in [**2170**], hypertension, hyperlipidemia, who was transferred to [**Hospital1 69**] on [**2175-5-19**], for cardiac catheterization. By report, the patient suffered a myocardial infarction in [**2170**]. Subsequent follow-up stress test in [**2172-9-25**], demonstrated inferior ischemia; at that point, the patient was uninterested in surgical intervention and was therefore treated medically. The patient was in her usual state of health until approximately one month prior to admission when she noted gradual onset of left arm pain and chest tightness in association with activity. The patient was evaluated by her primary care physician and was subsequently scheduled for a stress test. While awaiting the stress test, the patient presented to an urgent care facility on [**2175-5-17**], with chief complaint of increasing shortness of breath, productive cough and chest pain. The patient reported cold symptoms and fever with associated cough times two to three days. The patient was treated with Albuterol for suspected bronchial infection; however, upon administration, the patient became dizzy, tachycardic, diaphoretic and was noted to be hypotensive. She was subsequently transferred to [**Hospital 1474**] Hospital, where an electrocardiogram showed diffuse inferior and anterior ST-T wave changes. Troponin levels at that point were noted to be positive at 10.0; the patient's CK was noted to be 125 and her MB was 9.0 with subsequent values of 104/7.8 and 113/7.5, respectively. Echocardiogram demonstrated an ejection fraction of 40 to 45% with an apical aneurysm. The patient was subsequently transferred to [**Hospital1 190**] on [**2175-5-19**], for cardiac catheterization. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post myocardial infarction in [**2170**]. 2. Hypertension. 3. Hyperlipidemia. 4. Colon cancer, status post resection in [**2170**]. 5. Status post appendectomy. 6. Status post partial hysterectomy. MEDICATIONS ON TRANSFER: 1. Aspirin. 2. Lasix. 3. Isordil. 4. Captopril. 5. Lopressor. 6. Zocor. 7. Magnesium Oxide. 8. Guaifenesin. ALLERGIES: Codeine, Penicillin, Sulfa, Biaxin, Lipitor. SOCIAL HISTORY: The patient lives alone in senior housing development in [**Location (un) **], [**State 350**]. The patient has one son. The patient works as an office assistant. The patient is independent in her activities of daily living. No notable smoking history. HOSPITAL COURSE: The patient was admitted to the C-Medicine service on [**2175-5-19**]. Cardiac catheterization conducted on [**2175-5-19**], demonstrated three vessel coronary artery disease with 90% stenosis in the mid left anterior descending, 90% proximal occlusion of the OM1, and total occlusion of the right coronary artery. Normal ventricular function was noted with a recorded ejection fraction of 51%. Following extensive discussion with the patient regarding the benefits and risks of surgery, the patient elected to undergo coronary artery bypass graft procedure which was scheduled for [**2175-5-22**]. On [**2175-5-22**], the patient underwent a four vessel coronary artery bypass graft procedure with anastomosis from the left internal mammary artery to the left anterior descending, saphenous vein graft to posterior descending, saphenous vein graft to the OM and saphenous vein graft to the diagonal. The patient's pericardium was left open; lines placed intraoperatively included arterial line, Swan-Ganz catheter and CVP/RA catheter, both ventricular and atrial pacing wires were placed; both mediastinal and left pleural tubes were placed. The patient was subsequently transferred from the operating room to the Cardiac Surgery Recovery Unit intubated, for further evaluation and management. Shortly following transfer, the patient failed initial attempt at extubation but was successfully weaned and extubated several hours later. The patient remained stable under observation in the CSRU through postoperative day number two, at which point her chest tube and pacing wires were removed without complication and the patient was subsequently cleared for transfer to the floor for further evaluation and management. The patient was subsequently admitted to the Cardiothoracic service under the direction of Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]. The patient's postoperative course was uneventful and she progressed well clinically. Physical therapy evaluation suggested that the patient would benefit from postdischarge home physical therapy which was subsequently arranged for her. On postoperative day number three, the patient's Foley catheter was successfully removed and the patient was at this point noted to be independently productive of adequate amounts of urine for the duration of her stay. Given persistent coarse breath sounds in the patient's lung examination, routine screening chest x-ray was obtained which demonstrated bilateral pleural effusions with bibasilar atelectasis. The patient was subsequently begun on a fourteen day course of Levofloxacin, on which she remains upon discharge. The patient was successfully advanced to a full regular diet and was noted to have adequate pain control provided via oral pain medications. On postoperative day number five, the patient was noted to have significant constipation secondary to opioid administration. Following aggressive administration of Colace and Dulcolax, the patient was noted to pass stool freely and was subsequently independently productive of adequate bowel movements through the duration of her stay. The patient was subsequently cleared for discharge to home with services on postoperative day number six, [**2175-5-28**]. DISCHARGE STATUS: The patient is to be discharged to home with services and with instructions for follow-up. CONDITION ON DISCHARGE: Stable. MEDICATIONS ON DISCHARGE: 1. Lasix 20 mg p.o. q12hours times ten days. 2. Potassium Chloride 20 meq p.o. q12hours times ten days. 3. Colace 100 mg p.o. twice a day. 4. Aspirin 325 mg p.o. once daily. 5. Dilaudid 2 mg one to two tablets p.o. q4-6hours p.r.n. pain. 6. Levofloxacin 500 mg p.o. once daily times seven days. 7. Captopril 6.25 mg p.o. three times a day. 8. Lopressor 50 mg p.o. twice a day. DISCHARGE INSTRUCTIONS: 1. The patient is to maintain her incisions clean and dry at all times. The patient may shower but should pat dry any incisions afterwards; no bathing or swimming until further notice. 2. The patient has been advised to limit physical activity; no heavy exertion. 3. The patient has been scheduled for home physical therapy for continued strength and endurance training, as well as with a home health aid for wound checks once daily. 4. No driving while taking pain medications. 5. Follow-up with primary care physician within one to two weeks following discharge. 6. Follow-up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] within four weeks following discharge; the patient is to call to schedule an appointment. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 1053**] MEDQUIST36 D: [**2175-5-28**] 11:01 T: [**2175-5-28**] 11:46 JOB#: [**Job Number 33081**]

[ "518.0", "511.9", "412", "401.9", "410.71", "272.4", "486", "414.01", "V10.05" ]

icd9cm

[ [ [] ] ]

[ "37.22", "88.55", "36.13", "39.61", "88.53", "36.15" ]

icd9pcs

[ [ [] ] ]

13646, 14032

10228, 13586

14056, 15061

7668, 9474

9761, 9936

9496, 9736

9953, 10210

13611, 13620

71,869

157,803

41335

Discharge summary

report

Admission Date: [**2143-2-10**] Discharge Date: [**2143-3-1**] Date of Birth: [**2091-2-26**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 78**] Chief Complaint: Dizziness slurred speech and left sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: This is a 51 yo M with h/o HTN who presented to [**Hospital6 48708**] with L sided weakness. He was having lunch with his brother and friends, when he developed dizziness, followed by L arm weakness. On initial exam at OSH ED, he had L facial droop, L arm weakness, and mild L leg weakness. Over 1 hour, he developed complete L hemiplegia, slurred speech, and became progressively less responsive. Head CT showed 2 x 2cm R frontal hemorrhage. Inital vitals were BP 190/90 (range SBP 150-200s), HR 118. FS 301. He was intubated for airway protection. He was given Cerebrex, insulin, and started on nicardipine drip. He was medflighted, and needed to be paralyzed mid-flight for pulling at lines/tubes. He received propofol, Versed, pancuronium. The patient developed transient hypotention to SBP 90, and nicardipine was stopped. On arrival to [**Hospital1 18**], patient was sedated and intubated. Past Medical History: HTN Social History: No tobacco. Drinks socially, had [**12-27**] drinks last night. Family History: mother died of ICH at age 77, brother has kidney stones Physical Exam: O: T: 99.0 BP: 92/63 HR: 78 R 18 O2Sats 100% intubated Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 1.5 to 1mm bilaterally Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: intubated, does not open eyes to sternal rub. Does not follow any midline or appendicular commands. No evidence of neglect. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,1.5 to 1mm mm bilaterally. No gaze preference. III, IV, VI: Extraocular movements intact bilaterally with normal dolls eyes. V, VII: + corneals VIII: - IX, X: strong gag and cough [**Doctor First Name 81**]: - XII: - Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Moving R upper and lower extremities spontaneously. Localizes pain with RUE. Withdraws to noxious with bilateral lower extremities, but not antigravity. Minimal flexion to noxious with LUE. Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 No clonus Toes mute bilaterally ON DISCHARGE Alert and oriented x 3 PERRL 4 to 3mm bilaterally Left upper extremity plegic Left lower extremity moves spontaneous Right upper and lower extremity [**3-28**] motor strength left facial droop Pertinent Results: CTA Head and Neck [**2-10**] Non-con CT Head: Slightly increased right basal ganglia hemorrhage, now 3.6x3.3cm. Hypodensity left lentiform nuclei likely old lacune or pvs. CTA H&N: No occlusion or flow limiting stenosis. No aneurysm >3mm. No vascular malformation. See final read following reformations. NG Tube is coiled in oropharynx. CT HEAD [**2-11**] Stable R basal ganglia bleed. CT HEAD [**2-13**] Stable R basal ganglia bleed. CXR [**2-18**]: Only a small volume of peribronchial opacification previously seen at the left lung base persists. This is probably atelectasis. The upper lungs are clear. There is no pleural effusion. Mild cardiomegaly exaggerated by lower lung volumes, probably unchanged. No pulmonary edema. [**2-23**] CXR - negative for acute cardiopulmonary abnormalities [**2-23**] LENIs - Negative for DVTs Brief Hospital Course: Mr. [**Known lastname 90001**] [**Last Name (Titles) **] presented to [**Hospital1 18**] ER intubated via EMS as transport from OSH. Upon arrival he was seen and evaluated and admitted to the ICU under the neurosurgery service for monitoring and treatment. A CTA of the head and neck was obtained which showed that his right basal ganglia hemorrhage had slightlty increased in size when compared to the OSH films however there was no evidence and vascular abnormality which would have contributed to his bleed. He remained in the ICU and had a repeat Head CT which was stable. On [**2-11**], he was started on Metoprolol for hypertension, but required Nicardipine drip. He was extubated on [**2-11**]. On [**2-12**], his exam was improved. His BP remained high and required a Nicardipine drip. His Metoprolol was increased. He had transfer orders written for the Step Down Unit but was weaning off the Nicardipine drip. He was seen by PT/OT and was bed to chair. His SBP remained greater than 160 and med changes were made but he continued to require Nicardipine. On [**2-13**] he remained in the ICU for BP management with Nicardipine. A repeat head CT was done which was stable. On [**2-13**] evening the Nicardipine was held and he was managed on PO meds, and on [**2-14**] he was transferred to the floor. [**2-15**] had a doppler of his left lower extremity to r/o of DVT for complaining of left leg pain which was negative. He remained stable on the floor. CXR for r/o silent aspiration was negative on [**2-18**]. Nystatin was started for oral thrush. On [**2-20**] while OOB he was noticed to brady down to 38bpm so he was placed on telemetry. He continued to be immobile and he had a repeat LENS test on [**2-23**]. This showed no evidence of DVT. His wbs count elevated to 14 and a chest x-ray and ua were done for work up and this showed no signs of infection. On [**2-24**] he had WBC trended down to 11.4. On [**2-25**] he had an apparent syncopal episode while attempting to stand, he became briefly unconscious and bradycardic with a SBP in the 110's. He was ruled out for an MI by enzymes. A EKG was normal, he remained on telemetry without incident. No further episodes has occurred. [**Date range (1) 90002**] Patient remained stable clinically. Medications on Admission: ? BP meds (2 different meds) ASA 325 mg daily Discharge Medications: 1. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every eight (8) hours as needed for pain for 4 doses. Disp:*4 Capsule(s)* Refills:*0* 2. Acetaminophen Extra Strength 500 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for fever . Tablet(s) 3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 5. captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 9. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for rash. 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. HydrALAzine 10 mg IV Q6H:PRN SBP >160 Discharge Disposition: Extended Care Facility: [**Hospital **] [**Name5 (PTitle) **] @ Renaissance ACUTE REHAB UNIT Discharge Diagnosis: RIGHT BASAL GANGLIA HEMORRHAGE INTRAVENTRICULAR HEMORRHAGE LEFT HEMIPLEGIA DYSPHAGIA ORAL THRUSH HYPERTENSION CONTACT DERMATITIS Azotemia Bradycardia 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 CAN SAFELY RESTART YOUR ASPIRIN ?????? 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. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: ??????Please call ([**Telephone/Fax (1) 2102**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks if you can not follow up with Dr. [**First Name (STitle) **], please follow up with a Neurologist in your area. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Completed by:[**2143-2-28**]

[ "401.9", "787.20", "342.90", "431", "692.9", "427.89", "112.0" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.91" ]

icd9pcs

[ [ [] ] ]

7178, 7273

3633, 5907

354, 361

7467, 7467

2772, 2809

8494, 8933

1413, 1470

6004, 7155

7294, 7446

5933, 5981

7643, 8471

1485, 1746

266, 316

389, 1288

1902, 2753

2818, 3610

7482, 7619

1310, 1315

1331, 1397

80,305

196,746

39776

Discharge summary

report

Admission Date: [**2188-11-28**] Discharge Date: [**2188-12-3**] Date of Birth: [**2129-11-10**] Sex: F Service: CARDIOTHORACIC Allergies: Iodine-Iodine Containing Attending:[**First Name3 (LF) 922**] Chief Complaint: Dyspnea on exertion, dizziness, Fatigue Major Surgical or Invasive Procedure: [**2188-11-28**]: 1. Aortic valve replacement with a 23-mm On-X mechanical aortic valve prosthesis, serial #[**Serial Number 87590**], reference #[**Serial Number 42227**]. 2. Primary sternal repair using Talon x4 and 1 mL of bone morphogenic protein. History of Present Illness: 58 year old obese female with dyspnea on exertion and dizziness with progressively worsening aortic stenosis. He aortic stenosis was orginally diagnosed in [**2179**] as a heart murmur was detected. She was referred to Dr. [**Last Name (STitle) 39975**] roughly one year ago where serial echocardiograms have demonstrated worsening aortic stenosis. Her current symptoms include dyspnea on exertion, palpitations, fatigue and dizziness. She has now been referred for surgical management. Past Medical History: Aortic Stenosis Atrial flutter s/p cardioversion [**2188-10-9**] Obesity GERD Diabetes mellitus type 2 - diet controlled Left lower extremity cellulitis - [**2171**] following a burn injury Hypertension Dissociative Indentity Disorder Depression Post Traumatic Stress Disorder - H/O sexual abuse as child Rheumatoid arthritis Past Surgical History: Tonsillectomy D+C Social History: Race: Caucasian Last Dental Exam: Every 6 months. Last in [**Month (only) 205**]. Lives with: Husband Occupation: Disabled Tobacco: Distant mild use 25 years ago. ETOH: Rare Family History: Father with CABGx5 in his 80's. Died of MRSA complications. Physical Exam: Pulse: 76 Resp: 20 O2 sat: 98% B/P Left: 162/53 Height: 63"-64" not sure Weight: 360LB General: NAD. A&Ox3 Skin: Warm[X] Dry [X] intact [X] HEENT: NCAT[X] PERRLA [X] EOMI [X] sclera anicteric teeth in fair repair. Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [X] Heart: RRR, Nl S1-S2, IV/VI systolic murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X]. Obese with very large panus. Extremities: Warm [X], well-perfused [X] Trace Edema Varicosities: None noted on standing Neuro: Grossly intact Pulses: Femoral Right: Left: DP Right:2 Left:2 PT [**Name (NI) 167**]: Left: Radial Right: Left: Carotid Bruit Transmitted vs bruit (B) Pertinent Results: Admission: [**2188-11-28**] 08:38AM HGB-12.5 calcHCT-38 [**2188-11-28**] 08:38AM GLUCOSE-159* LACTATE-1.5 NA+-137 K+-4.4 CL--101 [**2188-11-28**] 12:12PM PT-15.4* PTT-24.8 INR(PT)-1.3* [**2188-11-28**] 12:12PM PLT COUNT-180 [**2188-11-28**] 02:46PM UREA N-13 CREAT-1.0 SODIUM-139 POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-25 ANION GAP-12 [**2188-11-30**] 05:54AM BLOOD ALT-82* AST-539* LD(LDH)-533* AlkPhos-49 Amylase-39 TotBili-0.5 Discharge [**2188-12-2**] 04:19AM BLOOD WBC-12.5* RBC-3.32* Hgb-10.7* Hct-31.1* MCV-94 MCH-32.3* MCHC-34.5 RDW-13.7 Plt Ct-307 [**2188-12-2**] 04:19AM BLOOD Plt Ct-307 [**2188-12-2**] 04:19AM BLOOD PT-33.9* PTT-33.2 INR(PT)-3.4* [**2188-12-2**] 04:19AM BLOOD Glucose-82 UreaN-24* Creat-0.7 Na-141 K-3.8 Cl-100 HCO3-32 AnGap-13 [**2188-12-2**] 04:19AM BLOOD Mg-1.7 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 55% to 60% >= 55% Left Ventricle - Stroke Volume: 91 ml/beat Aorta - Annulus: 2.1 cm <= 3.0 cm Aorta - Sinus Level: 2.9 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.3 cm <= 3.0 cm Aorta - Ascending: *3.5 cm <= 3.4 cm Aorta - Arch: 2.7 cm <= 3.0 cm Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm Aortic Valve - Peak Velocity: *3.1 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *38 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 26 mm Hg Aortic Valve - LVOT pk vel: 1.30 m/sec Aortic Valve - LVOT VTI: 32 Aortic Valve - LVOT diam: 1.9 cm Aortic Valve - Valve Area: *1.1 cm2 >= 3.0 cm2 Findings Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. Focal calcifications in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Moderate AS (area 1.0-1.2cm2) Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [[**2-2**]+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. Conclusions PREBYPASS No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size is normal with normal free wall contractility. The aortic valve leaflets (3) 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 mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. POSTBYPASS The patient is AV paced on no vasoactive infusions. There is a new mechanical aortic valve prosthesis which is well seated. There are washing jets. There is no aortic insufficiency. Mean gradient is 13 mmHg with a cardiac output of 6.57 L/min. Trace mitral regurgitation and mild tricuspid regurgitation persist. Left ventricular function remains normal. The thoracic aorta is intact. Interpretation assigned to [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting physician Brief Hospital Course: Ms [**Known lastname 46630**] was a direct admission to the operating room for aortic valve replacement, please see operative report for details. In summary she had: 1. Aortic valve replacement with a 23-mm On-X mechanical aortic valve prosthesis, serial #[**Serial Number 87590**], reference #[**Serial Number 42227**]. Her CARDIOPULMONARY BYPASS TIME was 84 minutes. with a CROSSCLAMP TIME of 63 minutes. The plastic surgery service closed her chest immediately following the aortic valve replacement with: Primary sternal repair using Talon x4 and 1 mL of bone morphogenic protein. She tolerated the surgery well and post-operatively was transferred to the Cardiac surgery ICU in stable condition. She was hemodynamically stable in the immediate post-operative period, woke neurologically intact and was extubated on the morning after surgery. She remained hemodynamically stable but was kept in the cardiac surgery ICU to closely monitor her post-operative progress. All tubes, lines and drains were removed per cardiac surgery protocol. Coumadin and Heperin were initiated for anticoagulation given mechanical valve. On POD3 she was transferred to the stepdown floor. Once on the stepdown unit she worked with nursing and the physical therapist to increase her strength and endurance. It was felt that she would benefit from a short stay at rehabilitation and on POD 5 she was cleared for discharge. At that time she was transferred to rehabilitation at [**Hospital **]. Medications on Admission: ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day BUPROPION HCL - (Prescribed by Other Provider) - 200 mg Tablet Sustained Release - 1 Tablet(s) by mouth twice a day CANDESARTAN [ATACAND] - (Prescribed by Other Provider) - 4 mg Tablet - 1 Tablet(s) by mouth once a day CELECOXIB [CELEBREX] - (Prescribed by Other Provider) - 200 mg Capsule - 1 Capsule(s) by mouth twice daily CITALOPRAM - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth once a day DIAZEPAM - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth prn HYDROXYCHLOROQUINE - (Prescribed by Other Provider) - 200 mg Tablet - 2 Tablet(s) by mouth once a day as needed for bedtime METOCLOPRAMIDE - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth four times a day PROPOXYPHENE N-ACETAMINOPHEN - (Prescribed by Other Provider) - 100 mg-650 mg Tablet - 1 Tablet(s) by mouth twice daily RABEPRAZOLE [ACIPHEX] - (Prescribed by Other Provider) - 20 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day RAMIPRIL - (Prescribed by Other Provider) - 5 mg Capsule - 1 Capsule(s) by mouth once a day SULFASALAZINE [AZULFIDINE EN-TABS] - (Prescribed by Other Provider) - 500 mg Tablet, Delayed Release (E.C.) - 2 Tablet(s) by mouth twice a day TRAZODONE - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth qHS ZIPRASIDONE HCL [GEODON] - (Prescribed by Other Provider) - 20 mg Capsule - 1 Capsule(s) by mouth twice daily ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a day CALCIUM-MAGNESIUM-ZINC - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth twice a day COENZYME Q10 - (Prescribed by Other Provider) - 100 mg Capsule - 1 Capsule(s) by mouth twice a day ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other Provider) - 1,000 unit Capsule - 1 Capsule(s) by mouth once a day MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1 Tablet(s) by mouth once a day VIT B COMPLEX 100 COMBO NO.2 - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY (Daily): for Mechanical aortic valve, target INR 2.5-3.5. 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for yeast. 6. ziprasidone HCl 20 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. sulfasalazine 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 10. bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day). 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 12. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 14. ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 15. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 16. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 17. rabeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 18. trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 19. multivitamin Tablet Sig: One (1) Tablet PO once a day. 20. calcium-magnesium-zinc Tablet Sig: One (1) Tablet PO once a day. 21. coenzyme Q10 100 mg Capsule Sig: One (1) Capsule PO twice a day. 22. ergocalciferol (vitamin D2) 400 unit Tablet Sig: Two (2) Tablet PO once a day. 23. Vitamin B Complex Capsule Sig: One (1) Capsule PO once a day. 24. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 25. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. Discharge Disposition: Extended Care Facility: [**Hospital 87591**] Rehab Hospital Discharge Diagnosis: s/p Aortic Valve replacement PMH: Aortic Stenosis, Atrial flutter s/p cardioversion [**2188-10-9**] Obesity, GERD, Diabetes mellitus type 2 - diet controlled Left leg cellulitis '[**71**] following a burn injury, Hypertension Dissociative Indentity Disorder, Depression, Post Traumatic Stress Disorder -H/O sexual abuse as child, Rheumatoid arthritis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with assistance Incisional pain managed with Dilaudid Incisions: Sternal - healing well, no erythema or drainage Edema: trace pedal edema, no lower extremity cellulitis Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon:[**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2188-12-23**] 1:45 Cardiologist: Dr [**Last Name (STitle) 39975**] [**12-30**] @10:20AM Plastic Surgery: Dr [**First Name (STitle) **] [**Telephone/Fax (1) 1416**] Tues, [**2188-12-9**] 2:00pm Please schedule follow up with your PCP [**Name9 (PRE) **],[**Name9 (PRE) 1730**] [**Name Initial (PRE) **] [**Telephone/Fax (1) 78347**] in 4 weeks Please call to schedule appointments with your Primary Care Dr [**First Name (STitle) **],[**First Name3 (LF) 1730**] D [**Telephone/Fax (1) 78347**] in [**5-5**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2188-12-3**]

[ "V85.44", "714.0", "424.1", "V15.52", "414.01", "250.00", "309.81", "530.81", "707.05", "300.14", "311", "V15.82", "715.90", "707.22", "278.01", "V15.41", "327.23" ]

icd9cm

[ [ [] ] ]

[ "84.52", "35.22", "38.93", "78.41", "39.61" ]

icd9pcs

[ [ [] ] ]

12462, 12524

6570, 8047

333, 587

12920, 13133

2531, 6547

14058, 14941

1704, 1766

10246, 12439

12545, 12899

8073, 10223

13157, 14035

1476, 1496

1781, 2512

253, 295

615, 1104

1126, 1453

1512, 1688

81,529

154,263

51351

Discharge summary

report

Admission Date: [**2173-9-8**] Discharge Date: [**2173-9-12**] Date of Birth: [**2110-12-10**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [**2173-9-8**] coronary artery bypass x 3 (SVG to DIAG with prox "Y" to free LIMA to LAD, SVG to PDA) History of Present Illness: 62 yo F with known 2VCAD s/p DES to mid RCA [**5-22**] who presented to OSH with chest pain with rest and exertion. EKG was normal and she ruled out for MI. She was transferred to [**Hospital1 18**] for cardiac cath. Past Medical History: coronary artery disease, s/p coronary artery bypass [**2173-9-8**] PMH: Hypertension hyperlipidemia Peripheral Arterial Disease Carotid Artery Disease Bilateral subclavian stenosis s/p L stent [**5-22**] Chronic back pain/Head ache on narcotics Herpes Simplex Social History: Lives with:alone Occupation:financial planner Tobacco:quit age 32 ETOH:6 glasses/week Family History: Father died of MI age 50, mother with MI age 65 Physical Exam: Pulse:69 Resp:12 O2 sat:97%RA B/P Right:88/50 Left:108/62 Height:5'0" Weight:44.5kg (98lbs) General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] RLQ incision Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: +2 Left: +2 DP Right: +2 Left: +2 PT [**Name (NI) 167**]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: 0 Left: 0 Pertinent Results: PRE BYPASS The left atrium is mildly 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. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF = 75%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. POST BYPASS Normal biventricular systolic function. Thoracic aorta intact post decannulation. No significant changes from the pre-bypass study. Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2173-9-8**] 15:49 Brief Hospital Course: Admitted [**9-8**] and underwent surgery with Dr. [**First Name (STitle) **]. Transferred to the CVICU in stable condition on titrated phenylephrine and propofol drips. Extubated that evening and transferred to the floor on POD #1 to begin increasing her activity level. She was gently diuresed toward her preop weight and beta blockade was titrated. She was maintained on a statin and ASA. She was cleared for discharge to home on POD#4 by Dr. [**Last Name (STitle) **]. Medications on Admission: ASA 325mg po daily Plavix 75mg po daily Atorvastatin 10mg po daily Amlodipine 10mg po daily Lisinopril 10mg po daily Metoprolol Succinate 100mg po daily Imdur 60mg po daily Sertraline 150mg po daily Tizanidine 2mg po TID Bupropion 300mg po daily Minocin 100mg po PRN Acyclovir PRN Ultram PRN Vitamins Plavix - last dose:[**2173-8-19**] Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Bupropion HCl 150 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QAM (once a day (in the morning)). 9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for severe pain. Disp:*45 Tablet(s)* Refills:*0* 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 12. Psyllium Packet Sig: One (1) Packet PO TID (3 times a day) as needed for constipation. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*120 Tablet(s)* Refills:*0* 15. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): for oral lesion. 16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: coronary artery disease, s/p coronary artery bypass [**2173-9-8**] PMH: Hypertension hyperlipidemia Peripheral Arterial Disease Carotid Artery Disease Bilateral subclavian stenosis s/p L stent [**5-22**] Chronic back pain/Head ache on narcotics Herpes Simplex Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - clean and dry. Healing. bilat leg incisions- clean and dry w/ intact steristrips edema-no edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Plaese call your Surgeon Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] and schedule an appointment to seen in 4 weeks. [**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2173-9-24**] 10:40 Please call to schedule appointments Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] W. [**Telephone/Fax (1) 3329**] in [**2-13**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Provider: [**Name Initial (NameIs) 703**] (H3) [**Doctor Last Name 5034**] THYROID RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2174-1-12**] 8:00 Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2174-1-18**] 9:20 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2173-9-12**]

[ "V45.82", "447.1", "440.20", "272.4", "433.10", "401.9", "414.2", "414.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5575, 5633

3060, 3533

331, 434

5937, 6151

1807, 3037

6936, 7928

1084, 1134

3921, 5552

5654, 5916

3559, 3898

6175, 6913

1149, 1788

281, 293

462, 680

702, 964

980, 1068

7,107

162,930

8877

Discharge summary

report

Admission Date: [**2150-12-14**] Discharge Date: [**2151-1-1**] Date of Birth: [**2067-11-11**] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine / Bactrim Attending:[**First Name3 (LF) 20224**] Chief Complaint: cough, fever, AMS, and hypotension Major Surgical or Invasive Procedure: Intubation x2 History of Present Illness: 83 year old female with diastolic dysfuntion, COPD on 2L NC, OSA, afib on ASA, who presents with AMS and hypoxia. The patient notes that she had been feeling well until today. She states that around the time her neighbor picked her up to take her to her doctor's appointment that she began feeling unwell with shortness of breath and cough. She describes her cough as productive of light tan sputum. She denies any fever or chills, no N/V/D, no abd pain. She does not feel confused. . Her neighbor took her to [**Hospital1 18**] for outpt evaluation. Her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] saw her in the waiting room. Per OMR notes, Dr. [**Last Name (STitle) 30906**] stated that " She is very lethargic and falls asleep during conversation with me. She states that she feels slightly short of breath." Dr [**Last Name (STitle) **] arranged for transport to the ED. . Of note, she was recently discharged on [**12-9**] after an admission for viral gastroenteritis and renal failure. She was noted to have hypotension to SBP 80's and cr 1.5 both of which responted to fluids and was attributed to dehydration in the setting of poor PO intake. . In the ED, there was a question of facial droop in triage which was not present on evaluation in the ED. Her neighbor who was with her on arrival at the ED states the patient was wandering around mumbling.The patient had fever to 103, cough and hypotension down to SBP 80'S requiring 4L NS. Lactate nl 1.3 and 0.9. But given persisent hypotension, central line was placed and levophed started. CXR showed multifocal PNA vs edema, but given clinical picture of fever and cough, it was thought that she had PNA. The patient was given Vanc, Ceftaz and Levofloxacin as well as tamiflu. She was swabed for flu as well. She was also noted to be hypoxic to 88% on RA and required 4-5LNC to oxygenate 92%. pH 7.32 pCO252 pO2 58. . vitals on arrival: 100.6 94 89/53 20 88% RA vitals on transfer: 80/32 83 17 92% 4L NC . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Past Medical History: 1. COPD: on home oxygen 2L NC continuous 2. Paroxysmal atrial fibrillation s/p pacemaker - refuses coumadin, takes full dose aspirin instead 3. Hypertension 4. Diastolic Congestive Heart Failure 5. Stroke - [**2124**] no residual deficit - manifested as dizziness 6. Bilateral cataracts 7. Obstructive sleep apnea - uses cpap 8. Arthritis 9. s/p compression Fx T7 10. R foot and R wrist fracture . Past Surgical History: 1. Nissen 2. Partial hysterectomy 3. Multiple lumbar back procedures 4. lap CCY ([**Doctor Last Name **]) 5. ventral hernia repair w/ mesh ([**Doctor Last Name **]) 6. right knee prosthesis . Social History: Lives in [**Location 686**]. Not married and does not have any children. Uses a walker at baseline. Quit tobacco 20 years ago. Rare alcohol use. No illicit drug use. Family History: Sister has endometriosis and breast cancer. Physical Exam: Physical Exam: Vitals: T: BP: P: R: 18 O2: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated but diff to assess with central line, no LAD Lungs: speaking easily w/o labored breathing, diffusely wheezing with inspiratory crackles in right lung fields CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: AOx3, conversant, easily able to relate history, CNII-XII intact, strength intact [**6-2**] bilaterally Pertinent Results: Labs on Admission: CBC: WBC-9.4# RBC-3.55* Hgb-10.4* Hct-32.4* MCV-91 MCH-29.2 MCHC-31.9 RDW-14.2 Plt Ct-183 Neuts-82* Bands-9* Lymphs-5* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Coags: PT-12.8 PTT-30.0 INR(PT)-1.1 BMP: Glucose-100 UreaN-50* Creat-1.7* Na-138 K-4.4 Cl-100 HCO3-27 AnGap-15 LFT: ALT-15 AST-21 AlkPhos-63 TotBili-0.2 Albumin-3.7 Phos-3.8 Mg-2.1 CK-MB-2 cTropnT-0.10* MICRO: [**2150-12-14**] Nasal Swab: POSITIVE FOR INFLUENZA A VIRAL ANTIGEN. Positive for Swine-like Influenza A (H1N1) virus by RT-PCR at State Lab. [**2150-12-15**] SPUTUM CULUTRE (Expectorated) STAPH AUREUS COAG +. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- =>16 R TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S Blood cultures: [**12-14**], [**12-26**] Urine cultures: no growth [**12-14**], [**12-25**] Stool negative for c.diff [**12-29**] CXR PA & Lat ([**2150-12-14**]): There is a left-sided pacemaker with leads terminating appropriately within the right atrium and right ventricle, there are multiple surgical clips within the left upper abdomen. There is stable, mild cardiomegaly. The aorta is mildly tortuous. There is a prominent right paratracheal opacity, consistent with regional vascular ectasia. There are increased interstitial markings bilaterally, worse on the right, compatible with mild congestion. There is no pleural effusion or pneumothorax. There is diffuse osteopenia, seen in prior radiographs. CXR ([**2150-12-16**]): Worsening right upper lobe and improved right lower lobe consolidation with stable mild superimposed pulmonary edema. RUE Ultrasound ([**2150-12-16**]): No evidence of deep vein thrombosis involving the right upper extremity. Please note the right internal jugular vein was not assessed. CXR (Portable) [**2150-12-25**]: IMPRESSION: 1) Interval improvement in the mild-to-moderate pulmonary edema. 2) Unchanged small right pleural effusion with a new retrocardiac left lower lobe opacity, most likely due to atelectasis. KUB [**2150-12-27**]: Essentially unremarkable examination of the abdomen. No evidence of obstruction. CT may be helpful if further evaluation is clinically indicated. CT chest [**2150-12-31**]: Left lower lobe consolidation with bronchial wall thickening and endobronchial mucus impaction. Multiple pulmonary nodules, most of which are stable back to [**2145**]/[**2146**] with the exception of new nodules in the superior segment of the right lower lobe and in the upper lobes could be due to concurrent infection, followup chest CT is recommended in three months to evaluate interval change. Stable mediastinal lymph node enlargement. Wedge compression fractures in the thoracic spine.Pulmonary arterial enlargement suggests pulmonary arterial hypertension. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: Ms. [**Known lastname **] is a 83 yo F with COPD on 2L home O2, diastolic HF, PAF (not on coumadin) who presented with fever, cough, AMS and hypotension and was admitted to ICU. She was found to be in respiratory failure and sepsis. She required intubation and subsequently was found positive for H1N1 Flu. Her course was complicated by MRSA pneumonia and difficult extubation (She was extubated, but had to be reintubated due to ongoing respiratory failure). She finished a 10 day course of Oseltamavir and Vancomycin. Her respiratory status improved, though not back to baseline by time of discharge. She continued on 3L NC. Following the initial extubation attempt, the patient was noted to be in persistent hypotension with increased ectopy on Telemetry. Cardiac enzymes were significant for Troponins of 0.10, EKG with pseudonormalization in lateral percordial leads. Aspirin was given, outpatient simvastain 40 mg was changed to Atorvastatin 80 mg. Per cardiology, this was believed to be secondary to demand ischemia. IV Heparin was not initiated. As patient developed MSK pain, similar to past when she was on Atorvastatin, her Atorvastatin was once again changed back to Simvastatin She was noted to develop leukocystosis after completion of her antibiotics, urine and blood cultures were negative. She remained afebrile. She had a CT chest to evaluate for abscess or effusion, which were not present. Her WBC count declined. Chronic pain [**3-2**] neuropathy: Her outpatient Neurontin and Morphine PRN were transiently held due to hypotension and ARF. Neurontin was re-started upon resolution of ARF, and Morphine was restarted at a lower dose, of 15mg twice daily. She was transiently hypernatremic secondary to poor oral hydration. she was found to aspirate thin liquids post extubation period and her her fluids were modified thick liquids, which she refused to take, leading to worsening of her hypernatremia. Repeat swallow evaluation found improvement of swallow function, and restrictions were taken off. With normal oral fluid intake her serum sodium normalized. She developed acute renal failure after lasix was restarted at home dose. This medication was held and renal function improved. She was discharged off this medication. INR was noted to be 1.8, felt to be nutritional; it corrected with oral vitamin K. CT chest noted RUL nodules, likely related to acute infection, however, 3 month follow up is recommended to assess for interval change. Medications on Admission: Colace 100 mg PO BID Morphine multiphasic release 45 mg PO Q12H Aspirin 325 mg daily Cholecalciferol 800 mg daily Multivitamin daily Simvastatin 40 mg daily Fluticasone 110 mcg 2 puffs [**Hospital1 **] Salmeterol 50 mcg Q12H Calcium Carbonate 500 mg TID Alendronate 70 mg qweek Spiriva daily Tylenol 1-2 tabs PO Q6H:PRN Gabapentin 400 mg PO TId Lisinopril 5 mg daily Lasix 60 mg daily Discharge Medications: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 4. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane Q4H (every 4 hours) as needed for dry mouth. 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) unit Inhalation Q6H (every 6 hours) as needed for wheezing/SOB. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 14. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation Q12H (every 12 hours). 15. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 16. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO three times a day. 17. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. Discharge Disposition: Extended Care Facility: Bostonian - [**Location (un) 86**] Discharge Diagnosis: Primary: Acute respiratory failure due to flu MRSA pneumonia Secondary COPD: on home oxygen 2L NC continuous Paroxysmal atrial fibrillation s/p pacemaker - refuses coumadin, takes full dose aspirin instead Hypertension Diastolic Congestive Heart Failure Stroke - [**2124**] no residual deficit - manifested as dizziness Bilateral cataracts Obstructive sleep apnea Arthritis Discharge Condition: Good Discharge Instructions: You were admitted to the intensive care unit for breathing difficulty. You required intubation and mechanical ventilation. This was due to flu and you recovered, however you developed bacterial lung infection (MRSA) for which you recovered fully as well. You are being discharge to a rehabilitation center for further physical therapy. The following changes were made to your medications: Your lasix was discontinued as it caused you to be dehydrated. Your MS contin dose was reduced to 15mg twice daily. As you improve your mobility you may need to increase it. On CT scan there were some pulmonary nodules, which need follow up chest CT in 3 months, to rule out possible malignancy. . Please continue all your medication, and follow up with your appointments as instructed below. . Call your docotr or come to ED if you have any fever, chills, abdominal pain, nausea, diarrhea, or any other health concern. Followup Instructions: You have an appointment with your primary care doctor on [**2151-1-8**] at 10:00, Dr. [**Last Name (STitle) 7274**]: [**Last Name (LF) **], [**Name6 (MD) **] [**Name8 (MD) **] MD Location: [**Hospital1 **] HEALTHCARE - [**Hospital **] MEDICAL GROUP Address: [**Street Address(2) 2687**],8TH FL, [**Location (un) **],[**Numeric Identifier 822**] Phone: [**Telephone/Fax (1) 133**] Other appointments: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2151-1-12**] 10:30 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2151-2-17**] 11:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2151-2-17**] 11:40

[ "428.0", "428.33", "482.42", "356.9", "V43.65", "V45.01", "038.12", "518.84", "401.9", "491.21", "995.92", "584.9", "327.23", "427.31", "488.1", "276.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

12303, 12364

7618, 10097

329, 344

12783, 12790

4394, 4399

13748, 14566

3613, 3658

10533, 12280

12385, 12762

10123, 10510

12814, 13725

3220, 3414

3688, 4375

2375, 2755

255, 291

372, 2356

4413, 7595

2799, 3197

3430, 3597

21,213

117,190

11463

Discharge summary

report

Admission Date: [**2109-11-3**] Discharge Date: [**2109-11-12**] Date of Birth: [**2055-10-14**] Sex: F Service: CARDIOTHORACIC Allergies: Zocor / Lipitor / Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac Catherization [**2109-11-4**] Coronary Artery Bypass Graft x2 (left internal mammary artery -> Left anterior descending, saphaneous vein graft -> posterior descending artery) [**2109-11-7**] History of Present Illness: 54 yo F presented to OSH with chest pain on [**2109-11-3**] after cardiac cath with DES on [**2109-10-31**]. Transferred to [**Hospital1 18**] for further eval, cath showed three vessel disease. Past Medical History: HTN DM2 CAD s/p PCI (LCx) lipids migraines kidney stones afib s/p ablation tbal ligation Social History: recently laid off quit tobacco 1 week ago no etoh lives with son Family History: Father with MI at 30 yo Mother with MI at 40 yo Physical Exam: NAD, lying in bad PERRL EOMI sclera anicteric full dentures No cervical lymphadenopathy, no JVD, no carotid bruits lungs CTAB distant S1S2 no M/R/G Abdomen benign 1+ peripheral edema bilat LE varicosities Non focal neuro exam Pertinent Results: [**2109-11-11**] 05:50AM BLOOD Hct-27.2* [**2109-11-10**] 09:21AM BLOOD Hct-27.1* [**2109-11-9**] 10:20PM BLOOD WBC-9.5 RBC-2.92* Hgb-9.6* Hct-27.0* MCV-93 MCH-33.1* MCHC-35.7* RDW-13.8 Plt Ct-166 [**2109-11-9**] 10:20PM BLOOD Plt Ct-166 [**2109-11-9**] 05:12AM BLOOD Glucose-122* UreaN-14 Creat-0.6 Na-134 K-4.2 Cl-100 HCO3-29 AnGap-9 Brief Hospital Course: She was taken to the operating room on [**2109-11-7**] where she underwent a CABG x 2. She was transferred to the SICU in critial but stable condition. She awoke neurologically intact and was extubated by POD #1. She was transferred to the floor on POD #1. She received 2 units PRBCs on [**11-9**] for an HCT of 21. Subsequent hematacrit was stable at 27. She did well postoperatively, she had no problems with atrial dysrhythmias. She was ready for discharge on POD #5. Medications on Admission: asa, plavix, atenolol, pravachol, NTG Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 6. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10 days. Disp:*40 Capsule, Sustained Release(s)* Refills:*0* 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Coronary Artery Bypass Graft x2 Cardiac Catherization [**2109-11-4**] Medical history Coronary artery disease - crescendo angina S/P left Cx stent [**2109-10-31**] Diabetes type 2 Hypercholesteremia Hypertension Migranes Kidney Stones Atrial Fibrillation s/p ablation s/p tubal ligation Discharge Condition: good Discharge Instructions: [**Month (only) 116**] shower, 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 Followup Instructions: Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 1 week ([**Telephone/Fax (1) 250**]) please call for appointment Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10753**] in [**2-22**] weeks ([**Telephone/Fax (1) 36613**]) please call for appointment Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3633**]) Completed by:[**2109-11-12**]

[ "401.9", "411.1", "427.31", "V45.82", "285.1", "250.00", "414.01" ]

icd9cm

[ [ [] ] ]

[ "36.15", "39.61", "88.55", "99.20", "37.22", "99.04", "88.52", "36.11" ]

icd9pcs

[ [ [] ] ]

3319, 3325

1614, 2086

309, 510

3656, 3663

1254, 1591

4129, 4661

944, 993

2174, 3296

3346, 3635

2112, 2151

3687, 4106

1008, 1235

259, 271

538, 734

756, 846

862, 928

56,229

150,479

39683

Discharge summary

report

Admission Date: [**2107-1-26**] Discharge Date: [**2107-2-10**] Date of Birth: [**2062-8-16**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 29226**] Chief Complaint: SOB, cough Major Surgical or Invasive Procedure: - Balloon Pericardectomy - PICC placement - Intubation - CT surgery pericardial window with L chest tube placement and pericardial drain placement - L pleurx catheter placement History of Present Illness: 44 yo F with lung CA, metastatic to the R temporal lobe s/p cyberknife on [**1-3**], and on cisplatin and navelbine (last tx in [**10-29**]), who presents with SOB and cough x 1 week. She denies fevers or myalgias. She states she is having minimal CP w/ cough. She did see [**Name8 (MD) **] NP[**MD Number(3) 18184**] PCP's office on [**2107-1-20**], who prescribed her azithromycin and cefpodoxime, which she has been taking since [**2107-1-21**] with no improvement. . Of note, she is on decadron 2mg (last day of taper) and had been on keppra since surgery on [**1-3**] but states that she has completed course. She also has significant history of PEs and DVTs and has two IVC filters and is on lovenox. However, she developed new UE DVT while on lovenox. . In the ED, vitals 98.8 120 138/87 20 95%. CXR showed R sided infiltrate. She was given vancomycin in the ED. She also received 10mg of decadron IV in the ED. Dr [**Last Name (STitle) 6570**] [**Name (NI) 653**] in [**Name (NI) **], who requested a factor 10a level. Past Medical History: Past Medical History - Lung adenocarcinoma with known mets to brain, dx [**6-/2106**] - Malignant pleural effusion s/p drainage - PE s/p IVF on chronic lovenox and s/p IVC filter - Mycobacterium gordonae - H/o SVC syndrome, SVC filter in place . Past Surgical History: - s/p CCY - s/p pericardiocentesis Social History: Married. Worked at [**Last Name (un) 59330**]. Immigrated from the Phillipines in [**2092**]. Husband works in shipping warehouse. No smoking, alcohol, or illicit drug use. Husband, [**Name (NI) **] HCP, [**Telephone/Fax (1) 87460**] Family History: Mother with diabetes. No family hx of cancer. Physical Exam: On admission: VS: T 97.2 BP 140/84 HR 105 RR 20 O2 sat 100%RA GEN: AOx3, NAD HEENT: PERRLA. MMM. R face with swelling Cards: Tachy, RR S1/S2 normal. no murmurs/gallops/rubs. Pulm: crackles/wheezes Right sided, left lung field CTA Abd: soft, NT, +BS. no rebound/guarding. neg HSM. neg [**Doctor Last Name 515**] sign. Extremities: wwp, no edema. Skin: no rashes or bruising Neuro/Psych: Mood and affect appropriate Transfer Exam ([**2-6**]): Temp: 98.5 / BP 131/63 / Pulsus 13mmHg at 1545 (14mmHG in AM) / HR 110-120 / Sats 94-97% on 0-4L NC GENERAL: Young woman in no acute disress, appears comfortable, answering questions appropriately. Oriented x3. HEENT: NCAT, Round face, MMM CARDIAC: regular rate rhythm, distant heart sounds. No rubs or murmurs appreciated. Chest Tubes: One chest tube in pericardium sub-sternal at midline. Mostly sanginous output (far less bloody than prior) LUNGS: Resp were unlabored, no accessory muscle use. Decreased BS bilaterally right>L, otherwise CTA ABDOMEN: Soft, ND. No HSM. Mild abd discomfort- but nontender. Normoactive bowel sounds EXTREMITIES: No c/c/e. RUE slightly swollen but stable from prior (28 cm) PULSES: Right: Radial 2+ DP 2+ PT 2+ Left: Radial 2+ DP 2+ PT 2+ On discharge: VS: 97.9 130/78 96 18 93%RA Pulsus:10mmgHg GEN: AOx3, NAD HEENT: PERRL. MMM. no LAD. JVP 10cm. neck supple. Neck swollen R < L, improved. Right eye anhidrosis Cards: RR S1/S2 slightly muffled. No rubs noted. No murmurs/gallops. Substernal wound open, not draining at this time. L pleurex in place and clean. Pulm: No dullness to percussion, decreased BS at b/l bases but otherwise clear Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**] sign Extremities: wwp, no edema. DPs, PTs 2+. Skin: no rashes or bruising Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs 2+ BL. sensation intact to LT, cerebellar fxn intact (FTN, HTS). gait WNL. Pertinent Results: Admission Labs: WBC-9.1# RBC-3.45* Hgb-11.4* Hct-33.5* MCV-97 MCH-33.1* MCHC-34.1 RDW-13.8 Plt Ct-302 Neuts-88.5* Lymphs-7.5* Monos-1.8* Eos-2.0 Baso-0.3 PT-12.8 PTT-35.8* INR(PT)-1.1 Glucose-145* UreaN-15 Creat-1.1 Na-137 K-4.7 Cl-98 HCO3-28 AnGap-16 Lactate-2.2* URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004 Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG URINE UCG-NEG Transfer Labs ([**2-6**]): WBC-7.3 RBC-3.07* Hgb-10.4* Hct-29.1* MCV-95 MCH-33.8* MCHC-35.7* RDW-14.9 Plt Ct-291 Glucose-130* UreaN-18 Creat-0.9 Na-137 K-4.2 Cl-102 HCO3-29 AnGap-10 ALT-18 AST-22 LD(LDH)-256* AlkPhos-102 TotBili-0.2 Albumin-2.9* Calcium-8.3* Phos-4.4 Mg-1.9 Discharge labs: [**2107-2-10**] 05:56AM BLOOD WBC-30.6*# RBC-2.94* Hgb-9.2* Hct-28.8* MCV-98 MCH-31.4 MCHC-32.0 RDW-14.6 Plt Ct-305 [**2107-2-10**] 05:56AM BLOOD Glucose-106* UreaN-21* Creat-0.9 Na-139 K-4.4 Cl-104 HCO3-27 AnGap-12 [**2107-2-10**] 05:56AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.1 Micro: - Bcx (3/9,12,13): Neg - Ucx (3/9,12): Neg - Influenza DFA ([**1-26**]): Neg - Pericardial Fluid ([**1-27**], 11, 17): GRAM STAIN (Final [**2107-1-27**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2107-1-30**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2107-2-2**]): NO GROWTH. ACID FAST SMEAR (Final [**2107-1-28**]): No AFB ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED - Pleural Fluid ([**2-4**]): Gram Stain with no PMNs and no organisms Cultures NGTD - Sputum Cx ([**1-29**]): >25PMNs, <10 Epis Rare commensal flora Sparse yeast - Pleural fluid: Fluid Culture in Bottles (Final [**2107-2-10**]): NO GROWTH. CXR (PA & LAT) [**2107-1-26**]: There is elevation of the right hemidiaphragm which may in part be due to volume loss, although underlying small subpulmonic pleural effusion may also be present. Large area of right perihilar opacity likely relates to the patient's known underlying malignancy, although superimposed infectious process is difficult to exclude. The left lung is clear. SVC and IVC filters are noted. CTA Chest [**2107-1-26**]: CT OF THE CHEST WITH IV CONTRAST: A right paratracheal lymph node measures 1.2 cm in short axis and is stable. There is a filling defect in the left subclavian vein. This is also unchanged. A filter is seen in the SVC. Distal to the SVC, there is no evidence of clot. The right pleural effusion is significantly increased in size and is now large. There is a new left pleural effusion. There is a new pericardial effusion of moderate size. There is now near-complete atelectasis of the right upper lobe with some patchy opacities likely due to post-obstructive pneumonia. There is complete atelectasis of the right middle lobe. The right lower lobe is still aerated with some minimal atelectasis. The tumor in the right upper lobe is slightly increased in size, currently measuring 2.0 x 1.9 cm (previously 1.9 x 1.5 cm). There is some atelectasis in the lingula. No new lesions are seen in the aerated portions of the lungs; however, please note that the previously identified rounded foci in the right upper lobe and right middle lobe are now obscured by atelectasis. There is a small filling defect in a subsegmental artery to the left lower lobe (series 3, [**Female First Name (un) 899**] 51 through 54). The most proximal portions of the liver and spleen that are depicted on this examination are unremarkable. The thyroid gland is enlarged and this is stable. On bone windows, there are no concerning osteolytic or osteosclerotic lesions. IMPRESSION: 1. Increase in size of right pleural effusion which is now large and new left pleural effusion, small to moderate in size. New moderate size pericardial effusion. 2. Subsegmental PE in an artery to the left lower lobe. 3. New right upper lobe and right middle lobe collapse. Bronchi to the right upper lobe are increasingly obstructed. 4. Stable filling defects in the left brachiocephalic vein. 5. Slight increase in right paratracheal lymphadenopathy as well as mass in the right upper lobe. Please note that the known right supraclavicular lymph node metastasis is not depicted in its entirety on this examination. 6. Due to new atelectasis and pleural effusion previously seen lung nodules are obscured. Left UE ultrasound [**2107-1-27**]: FINDINGS: Grayscale and color ultrasound examination was performed on the left upper extremity. The left brachial, axillary and subclavian veins are compressible, show normal wall-to-wall filling and phasic flow. The left cephalic and basilic veins are normally compressible and show normal Doppler waveforms. The left internal jugular vein is compressible and shows normal color flow and Doppler waveforms. Minimal residual nonocclusive clot is seen in the lower left internal jugular vein. Note is made of multiple enlarged, necrotic-appearing left cervical lymph nodes as demonstrated on prior scans. IMPRESSION: No evidence of DVT in the left upper extremity. Previously seen left internal jugular venous thrombosis appears to have resolved. Small non-occlusive residual clot is seen in the lower IJ. CXR (Pa & Lat) [**2107-2-1**]: IMPRESSION: 1. Persistent postobstructive right upper and right middle lobe atelectasis likely secondary to centrally obstructing neoplasm. 2. Enlarged cardiac silhouette consistent with known pericardial effusion. 3. Persistent pneumothorax with anterior hydropneumothorax component on lateral radiograph Initial TTE [**2107-1-27**]: The left atrium is normal in 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 aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a moderate sized, circumferential pericardial effusion measuring 1.4 to 2 centimeters in greatest dimension at end diastole. There is brief right atrial diastolic collapse. There is significant, accentuated respiratory variation in tricuspid valve inflows, consistent with impaired ventricular filling. IMPRESSION: Moderate-sized, circumferential pericardial effusion with echocardiographic evidence of tamponade (RA diastolic collapse, respiratory variation on tricuspid valve inflows). Small echodense region appreciated near RV apex which is consistent with possible cellular debris (?hemorrhagic effusion in the setting of underlying malignancy versus shadow/artifact (clips 58 and 60)). Normal left ventricular cavity size and wall thickness with near-hyperdynamic biventricular systolic function. No clinically significant valvular disease. Indeterminate pulmonary artery systolic pressures. TTE [**1-29**], [**2-3**], [**2-4**] done for monitoring of pericardial effusion. Most Recent TTE [**2107-2-5**]: Conclusions Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. There is a very small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. IMPRESSION: Very small echodense pericardial effusion without echocardiographic evidence of tamponade. PCXR [**2-5**]: One portable upright view. Comparison with the previous study of [**2107-2-4**]. A moderate right pneumothorax and right upper and middle lobe atelectasis persists. The right lung base is elevated consistent with a subpulmonic effusion as before. The left lung is expanded and clear. The heart and mediastinal structures are unchanged. Superior and inferior vena caval filters and a mediastinal drain remain in place. IMPRESSION: No significant change. Right UE ultrasound [**2107-2-7**]: FINDINGS: Occlusive thrombus is noted within the right internal jugular vein. The included portions of the right subclavian vein are widely patent. A PICC line is demonstrated coursing through the right brachial and axillary veins, which are widely patent. Nonocclusive thrombus is seen in the right cephalic vein, and the region of the antecubital fossa. Limited [**Month/Day/Year 2742**] of the left subclavian vein demonstrates patency of the vein with a normal waveform. IMPRESSION: 1. Occlusive thrombus identified in the right IJ vein. 2. Nonocclusive thrombus seen in the right cephalic vein. TTE [**2107-2-10**]: Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a very small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. IMPRESSION: Very small echodense pericardial effusion without tamponade. Brief Hospital Course: Assessment/Plan: Mrs. [**Known lastname 87457**] is a 44 year-old woman with metastatic lung CA, recurrent malignant pericardial effusion, recurrent DVT and PE s/p IVC, SVC and brachiocephalic filter placement who presented with cough and dyspnea for 1 week and was found to have CTA concerning for PE and pericardial effusion with tamponade physiology. She was taken semi-urgently to the catheterization laboratory for pericardiocentesis with balloon pericardiotomy and subseqnetly required surgical creation of 2 pericardial windows with internal drainage. . # Malignant Pericardial Effusion: She presented with her third occurence of malignant pericardial effusion with evidence of tamonade physiology that required drainage and balloon pericardiotomy. 240ml of sanguineous fluid was drained from pericardial sac and she tolerated the procedure well. A pericardial drain was left in overnight but removed the next afternoon when it had drained very little overnight. However, later that day she again was noted to have an increased pulsus up to 32mmHg with doppler with recurrence of tamonade physiology with new RV collapse on bedside ECHO. Overnight she was urgently taken to CT surgery for pericardial window with internal drainage. In that surgery window was created draining into the L pleural space and a L chest tube was placed that initially drained 400cc of serosanguinous fluid. Due to technical difficulties with window placement and concern that the window might not be effective, a pericardial incision was also made just righ of midline and 200cc of bloody fluid was drained from the pericardium and a pericardial drain was placed in that incision. Pt was intubated for the proceedure and kept intubated overnight as a precaution, but was extubated without incident the next day. After 24hrs the L chest tube was removed as it had decreasing drainage but the pericardial drain was left in place due to very high output (1L over first 24hrs and 500cc/day each of the following 2 days). Pt also received 1 unit PRBC on [**2-1**] as her Hct had drifted down to 22.4. There was concern that the window might not function when the pericardial drain was removed and the pt might go back into tamponade. As a result, the pericardial tube was clamped on [**2-3**] and the patient was monitored overnight without significant change in vital signs or symptoms. On [**2-4**] interventional pulmonology placed a pleurx catheter in the L pleural space and roughly 350cc was drained from the pleurx. On [**2-5**], the pericardial drain was removed after ECHO confirmed that there was constrictive physiology but no hemodynamically significant effusion 36hrs after the tube had been clamped. Although the initial plan was to drain every other day, the pleurx was also drained on the 19th due to significant weeping on the dressing where the pericardial drain had been in place. An additional 200cc of fluid was drained at that time with process stopped as pt started to experience pain. On the floor, another 150mL of fluid was drained from pleurx which again was terminated due to pain. Prior to discharge, she was drained one last time. She was given morphine po for these drainages. She was discharged with follow-up at IP and with VNA services as well as prescription for morhine for continued drainages. Pulsus remained stable at between 10 and 14mmHg for remainder of hospital stay. Oxygen saturation remained low 90s on room air and decreased to 88-89% with ambulation. She was discharged with home oxygen. She was scheduled for outpatient cardiology follow-up with outpatient echocardiogram for monitoring. . # Pulmonary embolism: She was first diagnosed with a pulmonary embolism in [**6-/2106**] along with BUE clots. She received SVC and IVC filters and has been on chronic lovenox. She was found to have an anti-factor Xa level of >2.0 consistent with therapeutic levels. CTA on this admission identified a subsegmental PE in an artery to the left lower lobe. Because of the reaccumulation of her pericadial effusion with solid pericardial mass component, it was determined that the heparin drip should not be resumed immedicately. From time of initial pericardial window, heparin gtt or other therapeutic anticoagulation was held until pt transfered back to OMED service on [**2-6**]. Upon transfer to floor, she was started back on heparin gtt and then transitioned to lovenox upon discharge. . # R anterior/apical pneumothorax: on [**2-1**], daily PCXR noted small apical R pneumothorax. This was confirmed by CXR Pa/Lat which also noted small anterior component to R apical pneumothorax. This finding was monitored with daily PCXR and found to be stable over the next 6 days. Cause of this PTX most likely related to significant R pleural effusion/atelectasis due to underlying lung malignancy more than any of the operative proceedures that were done as none of them in theory should have involved the R lung pleura. However, with intubation and line placement, iatrogenic PTX is on the differential. . # Infectious Disease: No cultures were positive during CCU stay. Around time pt went to OR for pericardial window, she had developed a temperature of 100 and was slightly more tachycardic. There was some concern for possible post-obstructive PNA in setting of known lung mass so initially started on vanco/cefepime for this on [**1-28**] and also knowing that pt would be going to OR and receiving operative instrumentation. Abx were stopped Am [**1-31**] after 48hrs when it became apparent that there was no significant infectious process as the cause of pts symptoms. . # Metastatic lung adenocarcinoma: Adenocarcinoma of the lung was discovered in [**6-/2106**], metastatic to right temporal lobe and now s/p stereotactic radiotherapy. S/P cisplatin and navelbine last Tx 12/[**2105**]. Pt was kept on prednisone at oncology request due to her brain mets. Neuro attending recommended that keppra be stopped. Upon transfer to oncology floor, she was started on chemotherapy with taxotere which she tolerated well. She also had 3 days of increased steroids (dexamethasone 8mg [**Hospital1 **] x 3 days) at the time of chemotherapy and also received neupogen to increase her counts after chemo. . # S/P Cyberknife for brain metastasis: She was finishing a decadron taper on admission. She received increased doses at 8mg [**Hospital1 **] x 3 days around the time of chemotherapy and was discharged back on dexamethasone 2mg daily until she meets with her neuro-oncologist for the swelling around her neck secondary to SVC syndrome. She also had Horner's syndrome with right eye ptosis and anhidrosis. She will need an outpatient MRI head and C-spine for further [**Hospital1 2742**] of her horner syndrome. . # Access: Pt had known right upper extremity DVTs on admission with swelling around right arm for which she had been on lovenox. She received a right PICC at the ICU for access. Later, on the floor, RUQ ultrasound revealed right IJ and right cephalic DVTs. Left UE US had small non-occlusive residual clot is seen in the lower IJ. Discussion was held with surgery and IV nurse regarding d/c-ing this right PICC given persistent DVTs. However, pt had very poor access and it was not guaranteed that access could be obtained in left arm given clot in left IJ as well. Thus, it was decided to continue to use right PICC while pt was in house with close monitoring of right arm circumference. Right arm swelling remained stable. Right PICC was d/c-ed upon discharge. She was scheduled for outpatient MRV to evaluate for access for future chemo sessions and will likely need chest port. Medications on Admission: DEXAMETHASONE 2mg daily (last day on [**2107-1-26**]) ENOXAPARIN - 60 mg/0.6 mL every twelve (12) hours Folic acid 1mg daily Vitamin B12 injection Discharge Medications: 1. oxygen Please provide 2-4L oxygen by nasal cannula when ambulating prn 2. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: do not drive or operate machinery while on this medication; do not drive or operate machinery while on this medication. Disp:*30 Tablet(s)* Refills:*0* 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 7. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*0* 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for for wheeze. Disp:*1 inhaler* Refills:*0* 10. 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* 11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 12. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough: do not drive or operate machinery while on this medication. Disp:*250 ML(s)* Refills:*0* 13. enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg Subcutaneous Q12H (every 12 hours). Disp:*3600 mg* Refills:*0* 14. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) grams PO DAILY (Daily) as needed for contstipation. Disp:*30 packets* Refills:*0* 15. filgrastim 300 mcg/mL Solution Sig: Three Hundred (300) mcg Injection Q24H (every 24 hours) for 4 days. Disp:*1200 mcg* Refills:*0* 16. morphine 15 mg Tablet Sig: Two (2) Tablet PO every seventy-two (72) hours as needed for pain: To be used for pain from pleurex drainages; do not drive or operate machinery. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary: Pericardial effusion with tamponade Pleural effusion Secondary: Lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you in the hospital. You were admitted with shortness of breath and cough. You were found to have fluid around your lungs and around your heart. You were taken to the OR for a procedure where an incision was made in the pericardium so that the fluid around your heart could drain into your lung space. Another drain was placed in the lung space to drain this fluid. You will need to have this drained every 3-4 days. You will need follow up at Interventional Pulmonary as well as cardiology for these fluid collections. You were sent home with home oxygen because your oxygen levels may decrease particularly when ambulating. For the swelling around your neck, you should continue taking dexamethasone 2mg daily until you see Dr. [**Last Name (STitle) 6570**]. You will get a repeat MRI head and C-spine as outpatient which will be reviewed by Dr. [**Last Name (STitle) 6570**]. The following changes were made to your medications: 1) START Dexamethasone 2mg daily until you see Dr. [**Last Name (STitle) 6570**] 2) START ranitidine 150mg [**Hospital1 **] 3) START docusate sodium, senna, miralax, bisacodyl as needed for constipation 4) START benzonatate 5) START ipatropium inhalers 6) START guaifenesin-codeine for cough 7) START filgastram 300mcg/mL injection daily for 4 more days 8) START morphine 15-30mg prior to drainages from your pleurex 9) CONTINUE enoxaparin 60mg injections twice a day Followup Instructions: You will need to have an MRV to assess your veins for IV access as well as a repeat echocardiogram after discharge. Dr. [**Name (NI) 86074**] office will call you with appointment times for these. Dr. [**Last Name (STitle) 19**] will follow up on your echocardiogram. You have the following appointments scheduled for you: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2107-2-17**] at 9:00 AM With: [**First Name8 (NamePattern2) 828**] [**Name8 (MD) 829**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Hematology/Oncology: [**Last Name (LF) 766**], [**2-21**] at 10am With: Dr. [**Last Name (STitle) **] [**Name (STitle) **] (covering for Dr. [**First Name7 (NamePattern1) 2270**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]) Location: [**Hospital1 641**] Address: [**Street Address(2) 87458**], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3468**] Hematology/Oncology: [**Last Name (LF) 766**], [**2-21**] at 10:30am With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22650**], RN Location: [**Hospital1 641**] Address: [**Street Address(2) 87458**], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3468**] Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19**] When: You will be [**Last Name (NamePattern1) 653**] by Dr. [**Last Name (STitle) **] office regarding the time and date of your hospital follow up appointment that should be scheduled in [**2-25**] days after your discharge. If you have not heard from the office in 2 business days, please call the number listed below. Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2258**] Department: Radiology- MRI When: [**Telephone/Fax (1) 766**] [**2107-2-28**] at 1 PM Location: [**Hospital1 **] Address: [**Hospital Ward Name 517**] [**Location (un) **], [**Location (un) 86**], MA Phone: [**Telephone/Fax (1) 10522**] Department: Neurology Name: Dr. [**First Name8 (NamePattern2) 1151**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 6570**] When: [**Last Name (NamePattern1) 766**] [**2107-2-28**] at 2:30 PM Location: [**Hospital1 **] Address: [**Location (un) **], TCC8, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 1844**] Completed by:[**2107-2-15**]

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39634

Discharge summary

report

Admission Date: [**2179-5-14**] Discharge Date: [**2179-5-20**] Date of Birth: [**2112-10-21**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Attending Info 87299**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: ERCP History of Present Illness: 66 year-old man with metastatic lung adenocarcinoma, currently neutropenic (s/p Navelbine on [**5-4**]), presenting with 1 week of intermittent RUQ pain and vomiting, found to have acute gallstone pancreatitis. Transferred to the [**Hospital Unit Name 153**] for evaluation and management of hypotension. . In the ED, initial vs were: pain 8, 100.7, 114, 114/59, 18, 98% RA. Labs were notable for WBC of 0.5, Cr of 2 (Bl 1.8), and significant transaminitis (AST 1266, ALT 643, AlkP 333, LDH 1235, T bili 1.5). Lipase was 3360. CT A/P revealed findings concerning for gallstone pancreatitis with 16mm distal CBD dilation. Advanced endoscopy was consulted and decided to perform ERCP in AM. Additionally, sBPs fell to the 70s and improved to the 90s after a total of 6L NS. Per record, made 280 cc of UOP. Blood cultures were obtained. He was given Vancomycin and Zosyn. No CVC was placed because he has a port for access. . On presentation to the [**Hospital Unit Name 153**] the patient appeared comfortable and was answering questions appropriately. He confirmed recent abdominal pain, vomiting, and rigors. Denied hematemesis, hematochezia, or melena. . Review of sytems: (+) Per HPI, + hx of neuropathy (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied diarrhea, constipation. No dysuria. Denied arthralgias or myalgias or rashes. Past Medical History: Past Medical History: -Metastatic Lung Cancer -Chronic Obstructive Pulmonary Disease -Fe deficiency Anemia -Erosive Gastritis -Psoriasis and Psoriatic Arthritis -Hypertension -Osteoarthritis -Peripheral Vascular Disease -Diverticulosis -Hypercholesterolemia -AAA repair . Onc Hx (abbreviated) -LUL lung mass seen on CXR in [**12-8**]?, with multiple small contralateral metastases seen on following CT -CT-guided Bx at [**Hospital1 756**] on [**1-8**] showed well-differentiated adenocarcinoma with acinar and solid features -Has underwent three different chemotherapuetic regimens and currently on his 4th- Navelbine (last received on [**2179-5-4**]) Social History: -Divorced, two children -Lives with sister, independent in ADLs -Tobacco: quit 8 years ago -ETOH: 1-2 drinks weekly at most, had 2 beers last night -Illicits: None Family History: -Mother had some type of cancer. No family hx of pancreatitis. Physical Exam: Admission Physical Exam: Vitals: 98.6, 109/56, 83, 97% RA General: well-nourished, alert, oriented, no acute distress HEENT: PERRL, sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: clear to auscultation anteriorly, no wheezes, rales, rhonchi CV: regular rate and rhythm, normal S1 + S2, + SEM best heard at LUSB, radiating to clavicle and carotids b/l Abdomen: soft, bowel sounds present, diffuse tenderness with voluntary guarding to palpation on R side and epigastrium GU: + foley Ext: warm, well perfused, trace non-pitting LE edema, clubbed fingernails Neuro: moves all extremities, face symmetric, gait not observed Discharge Physical Exam: VS: Tm 99.3, Tc 98.3, BP 110/70, HR 78, RR 20, 95%RA General: well-nourished, alert, oriented, no acute distress HEENT: PERRL, sclera anicteric, MM mildly dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: clear to auscultation anteriorly, few scattered wheezes CV: regular rate and rhythm, normal S1 + S2, + SEM best heard at LUSB, radiating to clavicle and carotids b/l Abdomen: soft, bowel sounds present, No TTP Ext: warm, well perfused, trace non-pitting LE edema, clubbed fingernails Pertinent Results: Admission labs [**2179-5-14**] -WBC-0.5* RBC-3.67* Hgb-10.5* Hct-31.7* MCV-86 MCH-28.6 MCHC-33.2 RDW-17.6* Plt Ct-187 Neuts-74.2* Lymphs-21.1 Monos-3.2 Eos-0.7 Baso-0.8 -PT-12.7 PTT-30.9 INR(PT)-1.1 -Glucose-87 UreaN-43* Creat-2.0* Na-139 K-3.8 Cl-106 HCO3-24 AnGap-13 -ALT-643* AST-1266* LD(LDH)-1235* AlkPhos-333* TotBili-1.5 -Lipase-3360* -cTropnT-<0.01 -Albumin-3.5 Calcium-8.6 Phos-2.7 Mg-1.4* Cholest-130 -Triglyc-116 HDL-34 CHOL/HD-3.8 LDLcalc-73 -Lactate-1.2 -freeCa-1.08* . [**5-14**] Abdominal xray: No signs of ileus or obstruction. No signs of free air below the right hemidiaphragm . [**5-14**] CT A/P: 1. Marked extra-hepatic biliary ductal dilation to 1.6 cm with mild-to-moderate intra-hepatic biliary ductal dilation with high-density material within the distal CBD with pancreatitis in the head and neck, raising the question of gallstone pancreatitis. Consultation with ERCP service is recommended. The gallbladder is moderately distended without other secondary findings of acute cholecystitis noted. 2. Known metastatic lung cancer with partially visualized probable metastases within the right lower lobe and left lower lobe. Small left pleural effusion and trace right pleural effusion. Periosteal reaction in femoral shafts likely secondary to hypertrophic pulmonary osteoarthropathy. 3. Moderate-to-severe colonic diverticulosis with no findings of acute diverticulitis. No pneumoperitoneum. . [**5-14**] CXR: . Increasing mild vascular congestion and bilateral pleural effusions, left greater than right. 2. Decreased density of left upper lobe and left lower lobe opacities. 3. Stable position of right Port-A-Cath. No pneumothorax. 4. Multiple subcentimeter nodules in the right lung. [**2179-5-15**] ERCP report: Impression: Stone fragments and sludge in the biliary tree. Full cholangiogram not obtained given cholangitis. Normal limited pancreatogram. A biliary sphincterotomy was performed. Stone fragments and sludge were removed using a balloon. A biliary stent was placed. Normal pancreatic duct (sphincterotomy, stent placement, stone extraction) Otherwise normal ercp to third part of the duodenum [**2179-5-18**] Echo: Conclusions The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60%). 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. There is no pericardial effusion. RUQ U/S [**2179-5-18**]: IMPRESSION: 1. No evidence of gallstone. 2. Thickened and hyperemic gallbladder wall and mildly distended gallbladder. This could reflect secondary inflammatory changes from pancreatitis, though clinical correlation is suggested and HIDA scan could be performed for further clarification if indicated. 3. No evidence of choledocholithiasis, though presence of air within much of the extrahepatic biliary system limits assessment. 4. Right pleural effusion. Brief Hospital Course: 66 yo M with NSCLC s/p recent chemo, now neutropenic, presenting with abdominal pain and found to have acute pancreatitis, transferred to the [**Hospital Unit Name 153**] initially for hypotension. . S/p gallbladder pancreatitis: Patient presented with hypotension and sepsis which resolved with significant IV fluids (10L on night of admission). He also preseted with a lipase of 3360 and findings on CT suggestive of gallstone etiology (1.6 cm CBD dilation, distended gallbladder, and new transaminitis). Other etiologies entertained, but highly unlikely included alcoholic, chemotherapy-induced, or hypertriglyceridemia (labs normal). [**Last Name (un) 5063**] criteria on admission was difficult to calculate correctly given neutropenia; however, he had at least 3 points predicting a mortality of 15-20%. Advanced Endoscopy was consulted and an ERCP with sphincterotomy was performed on [**5-15**] and plastic stent was placed wo complication. LFTs continued trending down and abdominal pain improved after stent placed. Pt started liquids [**5-16**] and regular soft diet [**5-18**]. Surgery was consulted to determine if pt would benefit from prophylactic CCY. They wanted a RUQ US to determine if there were residual gallstones and pt might benefit from a perc chol tube. RUQ U/S showed no gallstones so surgery decided they would not place a decompressiont tube, and already decided he wasn't a surgical candidate for CCY. Lipase was downtrending from 3360 to 123 from [**5-14**] to [**5-18**]. Patient sent to rehab tolerating a regular diet without abdominal pain. . # Enterobacter baceteremia - patient presented with hypotension and sepsis. His BCx on [**5-14**] returned positive for ENTEROBACTER AEROGENES, that was acutely cipro sensitive. His sepsis is now resolved. He was on zosyn intially, narrowed to cipro/flagyl, then just cipro on [**5-17**] when his BCx sensitivities returned. He needs a 14 day total course, with at least 10 days of IV cipro for full treatment. He will go to rehab to finish 10 days of IV, which finishes on [**5-25**], then start PO cipro on [**5-26**], to finish [**5-29**]. . # Transaminitis: Likely secondary to his acute gallstone pancreatitis. Other possible etiologies include recent chemotherapy or other toxic medications (such as his outpatient statin). He denied any recent consumption of acetaminophen. We trended his LFTs, which improved post-procedure, and held his Simvastatin during the hospitalization and also at discharge as pt's life expectancy is 6 months and the benefit of simvastatin is over the course of many years. # Systolic Ejection Murmur: Best heard at LUSB, radiating to the clavicle and carotids bilaterally, concerning for aortic stenosis. No prior echo was available. We obtained a TTE, which showed no AS. Therefore, likely a flow murmur in the setting of lots of fluids. . # Anemia: Known Fe deficiency thought to be [**3-3**] gastritis from NSAID use for pain control of arthritis. But also in the setting of pancytopenia so may be secondary to marrow suppression. He has no s/sx of bleeding on exam throughout this admission, so we continued him on a PPI. . # CKI: Baseline Cr is 1.8-1.9. Currently 2.1, even with aggressive hydration. This will need monitoring as an outpatient. # Metastatic Adenocarcinoma of the Lung: Received Navelbine on [**2179-5-4**]. He was neutropenic on presentation and per his Primary Oncologist, Neupogen was not indicated during the nadir of his cell counts. Further management was deferred to the outpatient setting. . Code: Full Code (per outpatient Onc note "he would not want any prolonged period of intubation or any other interventions that would prolong his life in a dependent position unable to care for himself") Medications on Admission: (per records; Pt reports he only takes statin, omeprazole) -Dexamethasone 8 mg [**Hospital1 **] day prior to, on, and after chemo -Folic acid 1 mg daily -Lorazepam 1 mg q6 for nausea or insomnia -Omeprazole 20 mg daily -Zofran 8 mg q8 PRN nausea -Oxycodone 5 mg q4h for pain -Prochlorperazine 10 mg q6h for nausea -Simvastatin 80 mg daily (in am) Discharge Medications: 1. morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 2. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 3. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: One (1) Intravenous Q12H (every 12 hours): last day is [**5-25**], then pt can switch to PO cipro [**5-26**] for 4 days to finish a 14 day course. 6. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea or insomnia. 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day: Patient may refuse. 10. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location (un) 2199**] Discharge Diagnosis: Primary: Gallstone pancreatitis Secondary: Metastatic Lung adenocarcinoma 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 seen in the hospital for abdominal pain and vomiting, and were found to have gallstone pancreatitis. You were treated with an ERCP during which a biliary stent was placed, and your symtoms improved. Once you were able to tolerate a regular diet, we sent you to a rehabilitation facility to finish your intravenous antibiotics course. We made the following changes to your medications: 1) We STARTED you on MORPHINE SULFATE IR 15mg b mouth every 6 hours as needed for pain. 2) We STOPPED your OXYCODONE. 3) We STOPPED your SIMVASTATIN. 4) We STOPPED your OMEPRAZOLE. 5) We STARTED you on PANTOPRAZOLE 40mg once a day by mouth. 6) We STARTED you on CIPROFLOXACIN IV 400mg every 12hours until [**5-25**]. On [**5-26**] you will start taking CIPROFLOXACIN 500mg every 12hours by mouth, until [**5-29**], when your antibiotics course will finish. 7) We STARTED you on DOCUSATE 100mg by mouth twice a day. 8) We STARTED you on SENNA 8.6mg twice a day by mouth for contipation. You can stop taking this if you have loose stools. 9) We STARTED you on BISACODYL 5mg once a day as needed for constipation. If you experience any of the below listed Danger Signs, please alert your doctor at your rehab facility or go to the nearest Emergency Room. It was a pleasure taking care of you on this hospitalization. Followup Instructions: PLEASE NOTE MR [**Known lastname **] ARRIVED AT [**Location (un) **] AND DECIDED HE WOULD RATHER BE AT HOME. HE CALLED HIS OUTPATIENT ONCOLOGIST DR [**First Name (STitle) **] WHO ARRANGED FOR HIM TO COMPLETE THE COURSE OF ANTIBIOTICS ORALLY INSTEAD. HE HAS BEEN TOLERATING PO AND HAS NO SYMPTOMS OF PANCREATITIS ON DISCHARGE. Department: Primary Care Name: Dr. [**Last Name (STitle) **] [**Name (STitle) 2405**] When: Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3468**] Department: Hematology/ Oncology Name: Dr. [**Last Name (STitle) **] [**Name (STitle) 2405**] When: Tuesday [**2179-5-25**] at 12:30 PM Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3468**] Department: ENDO SUITES When: THURSDAY [**2179-6-17**] at 12:00 PM Department: DIGESTIVE DISEASE CENTER When: THURSDAY [**2179-6-17**] at 12:00 PM With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**] Campus: EAST Best Parking: Main Garage [**Name6 (MD) 17666**] [**Name8 (MD) **] MD [**MD Number(2) 87301**]

[ "577.0", "V15.82", "285.22", "585.9", "199.1", "038.49", "162.3", "288.00", "574.50", "995.92", "403.90", "790.4", "443.9", "272.0", "496", "584.9", "576.1" ]

icd9cm

[ [ [] ] ]

[ "51.87", "51.85", "52.93", "51.88" ]

icd9pcs

[ [ [] ] ]

12416, 12487

7204, 10960

319, 325

12605, 12605

3996, 7181

14128, 15663

2700, 2765

11358, 12393

12508, 12584

10986, 11335

12756, 13157

2805, 3442

13186, 14105

265, 281

1527, 1827

353, 1509

12620, 12732

1871, 2502

2518, 2684

3467, 3977

3,295

122,528

9052+9053

Discharge summary

report+report

Admission Date: [**2154-6-15**] Discharge Date: [**2154-6-24**] Date of Birth: [**2107-11-13**] Sex: F Service: HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 23081**] is a 46-year-old female with no significant past medical history who presented to the Emergency Department on [**2154-6-15**] complaining of the acute onset of chest pain. The patient was driving at the time of the onset and described [**5-14**] onset of tightness along the left sternal border radiating to the right breast area then up over the left shoulder. This was associated with a general feeling of uneasiness and anxiety but no shortness of breath, diaphoresis, nausea, or vomiting. The pain was not effected by movement but was slightly alleviated by sitting forward. There was no cough, fevers, or chills. The pain persisted for several hours with worsening in intensity and effecting a large of the chest. She then called her primary care physician who directed her to go to the Emergency Department. She has no history of hypertension, diabetes, coronary artery disease, hypercholesterolemia, or smoking. She had no extended plane flight or car rides, but the patient leads a sedentary lifestyle spending long hours at a desk writing. She denies any leg swelling or pain. She also denied any recent viral illnesses, and her review of systems was remarkable only for some right ear drainage which she suffers from on a chronic intermittent basis. PAST MEDICAL HISTORY: 1. Psoriasis. 2. Intermittent right ear drainage and congestion. 3. Anemia. MEDICATIONS ON ADMISSION: The only medication she takes is an over-the-counter medication. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She denies any alcohol, drug, or tobacco use. FAMILY HISTORY: Her mother with coronary artery disease at an early age. PHYSICAL EXAMINATION ON PRESENTATION: On presentation, the patient's temperature was 99.4, blood pressure was 106/78, heart rate was 93, respiratory rate was 18, and oxygen saturation was 100% on 2 liters. She had a pulsus paradoxus of 8. In general, a thin young-appearing African-American female who was calm. Alert and oriented times three. In no acute distress. Head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. Pupils were equal, round, and reactive to light. The oropharynx was clear. The mucous membranes were moist. No facial wrinkles. The neck was supple. There were mobile nontender lymph nodes in the right neck in right submandibular region; per the patient these were stable since chronic otitis media as a child. There was jugular venous distention. No thyromegaly or nodules appreciated. Cardiovascular examination revealed she was tachycardic but regular. There was a rub at the mid upper sternal border, the left sternal border, increased with expiration, best heard in the left lateral decubitus position. There was no radiation. There were no gallops appreciated. There was increased right ventricular impulse, but the patient was very thin. There was no increased P2 or prominent pulsation over the pulmonic valve area. The lungs were clear to auscultation bilaterally. Chest wall revealed no there no lesions or tenderness to palpation. The abdomen was soft, nontender, and nondistended. No hepatosplenomegaly. Normal bowel sounds. Extremities revealed no clubbing, cyanosis, or edema. No calf tenderness to palpation. PERTINENT LABORATORY VALUES ON PRESENTATION: (In the Emergency Department, the patient had the following) She had a white blood cell count of 7.5 (91% polys, 1 band, and 6% lymphocytes), hematocrit was 38.8, and platelets were 318. Her Chemistry-7 was unremarkable; save for a glucose of 140. She had three negative CKs and troponin levels. She had an initial chest x-ray which showed moderate cardiomegaly. No infiltrates or effusions. She had an EKG which showed a normal sinus rhythm at 89, borderline left atrial enlargement, and normal intervals. She had a RSR prime in V1 and V2. Low voltage across the leads in the precordium. She had peaked T waves in II suggesting a mitral equivalent. She had a flat T wave in V2. There were slightly diffuse PR depressions and PR elevations in aVR. The patient subsequently had many other laboratories including the following: On [**6-22**] hematocrit was 30.4 (after dropping to a nadir of 25.2). She had normal coagulations. She had an erythrocyte sedimentation rate of 34 and a C-reactive protein of 9.9. Reticulocyte count was 2.1. She had pericardial fluid which had a hematocrit of 9% and 900 white blood cells, 41 polys, 54% lymphocytes, and 2% mesothelial cells. She had normal liver function tests. She had normal cholesterol studies. She had a total iron-binding capacity of 3042 and an iron that was low in the 20s. She had normal thyroid studies. She had a hemoglobin A1c of 5.5 and a normal cholesterol panel. She had a positive anti-smooth muscle antibody at a titer of 1:40 and then another of 1:80. Her rheumatoid factor was negative. Her double-stranded DNA was negative. Her antinuclear antibody was negative. Human immunodeficiency virus antibody was negative. Fluid chemistry from her pericardial fluid showed a total protein of 4.8, glucose of 69, lactate dehydrogenase of 1533, amylase of 43, albumin of 2.9, and cholesterol of 106. Viral culture from the pleural fluid was no growth to [**6-22**]. Pleural fluid Gram stain showed no polys and no microorganisms (this was pleural fluid). The culture was no growth. Anaerobic culture was no growth. AFB was negative. Alpha-fetoprotein culture was pending. Fungal culture was negative. Pericardial tissue showed 1+ polys, no microorganisms, no growth on the tissue culture. No growth in the anaerobic culture. Acid-fast bacillus smear was negative. Acid-fast culture was pending. Fungal culture was negative to date. Pericardial fluid showed 2+ polys, no microorganisms. No growth in the fluid culture. No growth in the anaerobic culture. No acid-fast bacilli seen. Acid-fast culture pending. Fungal culture negative. Blood cultures times two on [**6-19**] were pending. Lyme serology was negative. Monospot was negative. Anticardiolipin antibody pending. Adenosine deaminase pending. PERTINENT RADIOLOGY/IMAGING: She had multiple radiologic studies. She had a thyroid ultrasound which demonstrated a heterogenous nodule in the lower pole of the left thyroid with increased vascularity. She a computed tomography angiogram of her chest which showed cardiomegaly and a pericardial effusion. She had multiple chest x-rays which showed pleural effusions and pericardial effusions at various stages. Please see the dictation of the images for further details. She had multiple echocardiograms; the first of which was on [**6-15**] which demonstrated an ejection fraction of 55%. Normal left ventricular wall thickness, cavity size, and systolic function. Right ventricular chamber size and free wall motion was normal. Moderate-to-large pericardial effusion, circumferential. No signs of tamponade. On [**6-17**] she had one which showed a large pericardial effusion and a left pleural effusion; unchanged in size of the effusion but partial collapse of the right ventricle. She had a cardiac catheterization during this time which demonstrated a cardiac output of 3.6, and an index of 2.4, and equalization of right and left-sided pressures; consistent with tamponade; at which point she had a pericardiocentesis with about 600 cc of serosanguineous fluid removed. She then had a follow-up echocardiogram on [**6-18**] which demonstrated resolution of the effusion, status post pericardiocentesis. She had a follow-up echocardiogram on [**6-19**] which again demonstrated a normal left ventricular ejection fraction with a reaccumulation of a moderate-sized pericardial effusion which appeared somewhat loculated. There was imaging consistent with impaired ventricular filling and elevated intrapericardial pressure and brief right atrial collapse. She then had one on [**6-19**] which again showed the moderate-sized effusion, loculated. Then she had one on [**6-20**], status post pericardial window, which demonstrated a trivial pericardial effusion, left pleural effusion, and large resolution of pericardial effusion. She had cytology sent on the pericardial fluid which showed numerous lymphocytes of various size, rare reactive mesothelial cells. The second sample showed reactive mesothelial cells and numerous neutrophils. HOSPITAL COURSE BY ISSUE/SYSTEM: 1. PERICARDITIS: The patient had a pericarditis of unknown etiology and pericardial tamponade. She underwent pericardiocentesis in Cardiac Catheterization Laboratory, followed by reaccumulation of the effusion, and then pericardial window by Cardiothoracic Surgery. She had one episode of hypotension and bradycardia in the Coronary Care Unit for which she was treated with intravenous fluids, and atropine, and temporary pressors with subsequent restoration of her blood pressure and heart rate. Following the pericardial window, until [**6-22**], the patient did well with stable blood pressures with systolic pressures between 90 and 110 and diastolic pressures in the 50s to 70s range, but she remained tachycardic with sinus tachycardia from 100 to 120. The patient was followed in consultation by the Cardiology Service. The etiology of the pericarditis and effusion was unknown as of [**6-22**]. The patient was being seen by Infectious Disease to help sort out if this was a possible viral pericarditis. 2. PLEURAL EFFUSIONS: The patient had bilateral pleural effusions; presumably from the same inflammatory process causing the pericarditis. She had bilateral chest tubes placed during the pericardial window procedure. There was a hydropneumothorax formed on the left, simple pericardial effusion on the right. The right chest tube was taken out on [**6-21**], and the left chest tube remained in place as of [**6-22**]. 3. THYROID NODULE: The patient has a thyroid nodule in the left thyroid lobe. It is unclear if this is related to a pericarditis; although this seems unlikely. The patient needs a fine-needle aspiration of this nodule which is to be arranged in house. 4. ANEMIA: The patient has iron deficiency anemia and was started on iron. She will need a colonoscopy as an outpatient. She was guaiac-negative in house. 5. SINUS TACHYCARDIA: The patient has persistent sinus tachycardia even after pericardial window. The etiology of this was unclear. The patient did not appear hypovolemic. Although she was anemic, she was not anemic to the degree that this should cause a sinus tachycardia to this degree. She was not hypoxemic, and not in pain, and her left ventricular ejection fraction was normal. This was puzzling, and the etiology was still not determined as of [**2154-6-22**]. 6. EDEMA: After aggressive fluid resuscitation to maintain her blood pressure had significant lower extremity edema bilaterally. This was likely accentuated by her low albumin, and she was encouraged to take additional protein supplementation with meals. Diuretics were avoided given the lability of her blood pressure. [**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**] Dictated By: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. MEDQUIST36 D: [**2154-6-22**] 18:54 T: [**2154-7-1**] 00:27 JOB#: [**Job Number 31294**] Admission Date: [**2154-6-15**] Discharge Date: [**2154-6-24**] Date of Birth: [**2107-11-13**] Sex: F Service: CHIEF COMPLAINT: Pleuritic chest pain. HISTORY OF PRESENT ILLNESS: This is a 46 year old female with unremarkable past medical history who presents to the Emergency Department with acute onset of six out of ten pleuritic chest pain. The patient was driving at onset. She denies any palpitations or diaphoresis though the pain radiated above shoulders. The pain worsened with deep breath but no nausea, vomiting, fever, chills, and also improved by leaning forward, no leg swelling, no recent travel, no prior episodes. The pain was relieved with Morphine and Ativan in the Emergency Department. PAST MEDICAL HISTORY: None. MEDICATIONS ON ADMISSION: Over the counter decongestant. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient denies alcohol or intravenous drug use or tobacco. PHYSICAL EXAMINATION: Vital signs revealed temperature of 98.4, pulse 95, blood pressure 122/74, respiratory rate 16, oxygen saturation 100% in room air. In general, moderate discomfort. Head, eyes, ears, nose and throat examination - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Lungs are clear to auscultation bilaterally. The heart revealed normal S1 and S2, regular rate and rhythm, no murmurs, rubs or gallops. The abdomen is soft, nontender, nondistended, no hepatosplenomegaly. Extremities - no cyanosis, clubbing or edema. Neurologically, the patient is alert and oriented times three. FAMILY HISTORY: Mother with history of coronary artery disease at early age. LABORATORY DATA: White blood cell count 7.5, hematocrit 38.8, platelet count 318,000. Sodium 142, potassium 4.8, chloride 104, bicarbonate 30, blood urea nitrogen 15, creatinine 0.8, glucose 140. CK 88. Troponin less than 0.1. Chest x-ray showed no evidence of pneumonia or congestive heart failure. Moderate cardiomegaly. Electrocardiogram showed normal sinus rhythm at 89 beats per minute. Borderline left axis, normal intervals, low voltage across limb leads and precordium. HOSPITAL COURSE: 1. Cardiovascular - The patient underwent evaluation by echocardiogram which demonstrated large to moderate pericardial effusion with no evidence of tamponade. The patient began treatment with nonsteroidal anti-inflammatory drugs, and viral serologies were sent. The patient underwent pericardiocentesis for diagnostic and therapeutic purposes and 600cc of serosanguinous fluid was drained. Ejection fraction was 60%. Normal left ventricle and right ventricle wall motion. The patient was transferred to Cardiac Care Unit for close pericardiocentesis monitoring. The patient's Intensive Care Unit course was notable for some postprocedure bradycardia treated with Atropine. The patient had second chest tube removed [**2154-6-23**], and repeat echocardiogram performed [**2154-6-24**], with unchanged pericardial effusion, small. The patient will follow-up with cardiologist, Dr. [**Last Name (STitle) **], in two weeks after discharge. Her biopsy demonstrated fibrinous pericarditis with hemosiderin. Viral studies available at the time of discharge demonstrated Lyme negative, monospot negative. The patient's cytology was negative for malignant cells and age appropriate cancer screen unremarkable. 2. Infectious disease - The patient had serologies pending at the time of discharge including HIV viral load, EBV, Parvo virus B-19, TBPCR, toxoplasma antibodies and ASO titer. The patient will follow-up with infectious disease clinic in regards to possible viral etiology. The patient will complete a ten day course of nonsteroidal anti-inflammatory medication, Motrin 800 mg three times a day for treatment of pericarditis/pain. The patient instructed to return immediately if she experiences any chest pain, shortness of breath or fevers. 3. Endocrine - The patient noted to have left lower lobe thyroid nodule with increased vascularity on CTA scan. The patient underwent further evaluation with ultrasound which again noted the same nodule with increased vascularity. TSH was low normal at 0.37 with normal limit free T4. The patient underwent evaluation by the endocrine consultation team who recommended further evaluation of her nodule in the thyroid nodule clinic. Appointment was scheduled for [**2154-8-8**], at 11:00 a.m. 4. Anemia - The patient with a history of chronic iron deficiency anemia and laboratories here demonstrated a hematocrit of 24.0 to 31.0. MCV was 88. Iron 20, TIBC 342. She will continue on iron sulfate supplement. Cervical adenopathy noted on physical examination with three small less than 1.0 centimeter fibrous lymph nodes which the patient reports unchanged over the past one year. She has a history of chronic sinus infection. She underwent evaluation with sinus CT which demonstrated no acute sinusitis. It did demonstrate calcification of the IPA. The patient will follow with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 28616**] in regards to this matter. MEDICATIONS ON DISCHARGE: 1. Iron Sulfate 325 mg p.o. once daily. 2. Senna two tablets p.r.n. 3. Motrin 800 mg p.o. three times a day. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Pericardial effusion. 2. Anemia. 3. Thyroid nodule. [**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 314**] Dictated By:[**Last Name (NamePattern1) 7485**] MEDQUIST36 D: [**2154-6-24**] 18:32 T: [**2154-7-2**] 20:45 JOB#: [**Job Number 31295**]

[ "280.9", "429.3", "423.9", "276.6", "458.9", "241.0", "288.0", "427.89", "511.9" ]

icd9cm

[ [ [] ] ]

[ "37.21", "34.99", "37.24", "37.0", "37.12" ]

icd9pcs

[ [ [] ] ]

13196, 13744

16926, 17260

16760, 16873

12365, 12435

13761, 16734

8570, 11705

12539, 13179

11723, 11746

11775, 12308

12331, 12338

12452, 12516

16898, 16905

55,534

189,258

39518

Discharge summary

report

Admission Date: [**2162-8-16**] Discharge Date: [**2162-8-20**] Date of Birth: [**2142-4-6**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2279**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Endotracheal intubation on [**2162-8-16**], extubated [**2162-8-17**] History of Present Illness: This is a 20M brought into the ED by ambulance for non-responsiveness. Per his friends, the patient is a rare-drinker and never uses marijuana. However in this instance they were smoking from a gravity bong. The patient was noted to drink one beer and then take a particularly large "bong hit," estimated at 1 liter by one of his friends. Thereafter, the patient became pale, diaphoretic, stated he didnt feel well. His friends tried to get him to lie down, but he refused, insisting on sitting up. He pointed to the middle of his chest and stated "I feel like my lung collapsed." After that he was noted to vomit. He then lay down on the floor and became unresponsive. . Per EMS he was unresponsive save for a "full body dry heave" in response to noxious stimuli. At one point in the ambulance ride he was noted to sit-up and say "it hurts" then never became responsive again. . In the ED he awoke and then reported that he was feeling anxious that he did not recall details of the events leading to his presentation. He was increasingly agitated. He received 6 liters of NS in the ER. In the ER, the patient was given one mg of PO ativan in an attempt to control his heart rate via controlling his agitation. The patient then received 0.5 mg flumazenil. At this time a diffuse macular erythematous rash was present over his body. He was intubated which was described as a difficult intubation [**12-22**] inability to visualize the chords. He was given 1 gram ceftriaxone, 10 mg decadron, 50 mg benadryl, then placed on propofol drip. [**12-22**] vent dysynchrony the patient was started on versed, propofol, and rocuronium. . He was transferred to [**Hospital Ward Name 332**] 4 for further management. Past Medical History: depression Social History: Drugs: per friends this was his first time Tobacco: per friends none Alcohol: per friends rare Family History: NC Physical Exam: General Appearance: Well nourished Eyes / Conjunctiva: PERRL, Pupils dilated Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, copious secretions, red, frothy sputum in the ET tube Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ) Abdominal: Soft, Bowel sounds present, Tender: LLQ patient goes into "bucking motion" Skin: Warm, Rash: no rash as prior Neurologic: Responds to: Verbal stimuli, Movement: Purposeful:withdraws from pain, Sedated, Tone: Normal, reflexes intact Pertinent Results: Admission Labs [**2162-8-16**] 01:30AM BLOOD WBC-11.1* RBC-4.63 Hgb-14.4 Hct-41.3 MCV-89 MCH-31.1 MCHC-34.8 RDW-12.6 Plt Ct-277 [**2162-8-16**] 01:30AM BLOOD Glucose-134* UreaN-15 Creat-1.1 Na-140 K-3.8 Cl-100 HCO3-28 AnGap-16 [**2162-8-16**] 01:30AM BLOOD ALT-41* AST-41* CK(CPK)-463* AlkPhos-102 TotBili-0.4 [**2162-8-17**] 03:54AM BLOOD Albumin-3.4* Calcium-8.1* Phos-3.4 Mg-1.8 [**2162-8-16**] 01:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2162-8-16**] 08:30AM BLOOD Type-ART Rates-/20 Tidal V-600 PEEP-10 FiO2-100 pO2-114* pCO2-57* pH-7.23* calTCO2-25 Base XS--4 AADO2-566 REQ O2-90 Intubat-INTUBATED Micro: Bcx [**8-16**] PND on transfer Imaging: [**8-16**] Head CT w/o contrast: IMPRESSION: No evidence of acute intracranial process. [**8-16**] chest PA/Lateral: The lungs are fully expanded however, density of the parenchyma of both lungs is greater than typically seen. No pleural effusion or pneumothorax is seen. The heart, mediastinal and pleural surface contours are normal. [**8-17**] Portable CXR: Slight interval worsening of pulmonary opacities in the left lung mainly due to a probable small left pleural effusion and increasing atelectasis in the left base. The rest of the opacities could represent pulmonary edema, ARDS, and less likely hemorrhage. [**8-18**] Portable CXR: Stable retrocardiac opacification. Decreased small left pleural effusion. Stable right lower lobe opacification, may represent edema [**8-17**] ECHO: IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. No valvular pathology or pathologic flow identified. Brief Hospital Course: This is a 20 y/o male with no significant medical history, who was admitted with hypoxic respiratory distress following inhalation of marijuana, most likely secondary acute lung injury. . 1. Hypoxic respiratory distress - Most likely [**12-22**] Acute lung injury from massive marijuana intake, in the setting of AMS. In the ED he was anxious and did not recall details of the events leading to his presentation. In the ER, the patient was given 1mg of PO ativan in an attempt to control his agitation/heart rate. The patient then received 0.5 mg flumazenil and became agitated. He was intubated, in the ED before being sent to the ICU. Pt also reveived 6L of fluid in the ED, and showed signs of fluid overload on CXR and exam. A TTE was checked because of this on [**8-17**] which was normal. He was extubated on [**8-17**]. Since extubation, his supplemental oxygen was weaned off and he had normal oxygen levels with and without ambulation. He was recommended to not smoke marijuana, tobacco, or other substances. Of note, he had blood cultures drawn on [**8-16**] that have been negative to date but are still PENDING and require follow-up. . 2. Drug rash: Upon extubation, patient developed a rash on his face and his chest/extremities with blanching erythema concerning for a hypersensitivity reaction. Etiology was unclear, but he did not have a cough or respiratory distress at this time and was given 125mg of IV salumederol. The rash may have been secondary to Ceftriaxone which he received initially or from the anesthetics given pre-intubation. The rash mosly resolved at the time of discharge and the patient was advised to note that he may have an allergy to penicillin and to tell future providers this. Medications on Admission: None Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: Hypoxemia Rash, drug-induced Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for shortness of breath following use of marijuana, and required a breathing tube due to low oxygen levels in the blood. Your oxygen levels improved and were normal upon discharge. You most likely had some degree of lung injury from the inhalation of marijuana. You are recommended NOT to smoke tobacco,marijuana, or any other substances, as to avoid further injury to your lungs. You developed a rash while in the hospital, which may have been secondary to a pencillin antibiotic you received when you were first admitted. Please note that you have a possible allergy to pencillin for the future. Please follow-up with your doctor as noted below. Continue to use to the incentive spirometer to help improve lung function. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) **] on Tuesday, [**8-24**] at 11:30 AM. His office has moved to [**Street Address(2) 87274**] in [**Location (un) **]. Please keep this appointment. Call his office at [**Telephone/Fax (1) 87275**] if you need to reschedule the appointment. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**] Completed by:[**2162-8-21**]

[ "861.20", "693.0", "518.82", "969.6", "E854.1", "E930.5" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6520, 6526

4704, 6436

293, 364

6599, 6599

3020, 4681

7534, 7986

2283, 2287

6491, 6497

6547, 6578

6462, 6468

6750, 7511

2302, 3001

232, 255

392, 2118

6614, 6726

2140, 2152

2168, 2267

66,957

150,735

41569

Discharge summary

report

Admission Date: [**2173-3-16**] Discharge Date: [**2173-3-28**] Date of Birth: [**2121-1-17**] Sex: M Service: CARDIOTHORACIC Allergies: Augmentin Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Coronary artery bypass grafts x3(LIMA-LAD,SVG-OM, SVG-diag) and Excision of chest wall mass on [**2173-3-22**] History of Present Illness: 52 yo male presented to OSH for diagnostic elective catherization due to chest pain in the setting of recent anterior myocardial infarction and stent placement. He was in his usual state of health until 2 weeks ago when he experienced chest tightness and dsicomfort on stairs, resolving with rest. He had also been experiencing a chronic burning discomfort in the past few weeks, precipitated by exertion. Cath at [**Hospital1 189**] revealed revealed left main and three vessel disease and was transferred to [**Hospital1 18**] for surgery. Past Medical History: Myocardial infarction [**2165**] s/p 3 marginal stents [**2172**] Anterior MI, bare metal stent to LAD Diabetes with neuropathy Hypertension Dyslipidemia + tobacco use Obesity Back pain Depression Gastroesophageal gastric reflux Erectile dysfunction Chronic kidney disease (baseline crea 1.0) s/p Laminectomy L2-4 Social History: Race: caucasian Last Dental Exam: [**2172-10-26**] Lives with: mother Occupation: disabled, worked in receiving area of scuba company Tobacco: 10 ciagarettes/day x 2mo before that 1PPD x35 years ETOH: 1-2 drinks/week Family History: non-contributory Physical Exam: Physical Exam Pulse:88 Resp: 16 O2 sat: 99%-2LNP B/P Right: Left: 140/92 Height: 5'[**72**]" Weight: 306# General: NAD, lying in bed states active chest pain Skin: Dry [x] [**Year (2 digits) 5235**] [x] HEENT: PERRLA [x] EOMI [x] multiple teeth w/caries Neck: Supple [x] Full ROM [x] no JVD Chest: Lungs clear bilaterally [x] cyst mid sternal area Heart: RRR [x] Irregular [] Murmur-none Abdomen: Obese, Soft [x] non-distended [x] non-tender [x] +BS [x] Extremities: Warm [x], well-perfused [x] Edema- none Varicosities: None [x] diabetic ulcer mid tibia on each leg Neuro: non focal exam, MAE, follows commands Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: cath Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: [**3-18**] Carotid U/S: 1. Moderate plaque at the proximal right internal carotid artery with an approximate 60-69% stenosis. 2. Unremarkable left carotid bifurcation with only a mild degree of plaque. 3. Prograde flow in both vertebral arteries. [**3-22**] Echo: Pre-CPB: Gastric views are limited and difficult to obtain, probably because of the patient's habitus. No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is mildly depressed (LVEF= 45 - 50 %), with apical hypokinesis. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic [**Month/Year (2) 5236**]. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is A-Paced, on no inotropes. Preserved biventricular systolic fxn. No AI, 1+MR. [**First Name (Titles) **] [**Last Name (Titles) 5235**]. [**2173-3-16**] 07:10PM BLOOD WBC-8.1 RBC-4.05* Hgb-11.9* Hct-35.5* MCV-88 MCH-29.3 MCHC-33.4 RDW-14.3 Plt Ct-392 [**2173-3-26**] 04:58AM BLOOD WBC-11.5* RBC-3.09* Hgb-9.1* Hct-27.0* MCV-87 MCH-29.6 MCHC-33.9 RDW-13.8 Plt Ct-364 [**2173-3-28**] 04:36AM BLOOD Hct-25.5* [**2173-3-16**] 07:10PM BLOOD PT-12.5 INR(PT)-1.1 [**2173-3-22**] 02:15PM BLOOD PT-13.6* PTT-29.2 INR(PT)-1.2* [**2173-3-16**] 07:10PM BLOOD Glucose-145* UreaN-14 Creat-1.2 Na-141 K-4.1 Cl-104 HCO3-29 AnGap-12 [**2173-3-26**] 04:58AM BLOOD Glucose-107* UreaN-19 Creat-1.1 Na-137 K-3.9 Cl-100 HCO3-28 AnGap-13 [**2173-3-28**] 04:36AM BLOOD Na-130* K-4.9 Cl-92* [**2173-3-25**] 01:49AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.9 Brief Hospital Course: The patient was admitted to the hospital and after a Plasugrel washout, he was brought to the operating room on [**2173-3-22**] where the patient underwent CABG x3 (LIMA-LAD, SVG to OM and SVG to Diag). Please see operative note for surgical details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Within 24 hours he was weaned from sedation, awoke neurologically [**Date Range 5235**] and extubated. Beta blocker was initiated and the patient was gently diuresed toward his preoperative weight. Statin therapy was resumed. 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. By the time of discharge on post-op day six the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. Keflex was started on day of discharge for a seven day course d/t some erythema at vein harvest incision. The patient was discharged to home with VNA services in good condition with appropriate medications and follow up instructions. Medications on Admission: Prasugrel 10 mg daily, Omperazole 20 mg [**Hospital1 **], Fish oil 1 capsule [**Hospital1 **], Lisinopril 10 mg daily, ASA 325 mg daily, Pravachol, Atenolol 150 mg daily, Gabapentin 300 TID Discharge Medications: 1. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 9. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO BID (2 times a day). Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2* 10. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 7 days. Disp:*28 Capsule(s)* Refills:*0* 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks: Please take 40 mg twice daily for 1 week. Then 40 mg daily for 1 week. Disp:*21 Tablet(s)* Refills:*0* 12. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO twice a day for 2 weeks: Please take 1 tablet twice dialy for 1 week. then 1 tablet daily for 1 week. Disp:*21 Tablet, ER Particles/Crystals(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Coronary artery disease s/p CABG x3 [**2173-3-22**] Past medical history: Myocardial infarction [**2165**] s/p 3 marginal stents [**2172**] Anterior MI, bare metal stent to LAD Diabetes with neuropathy Hypertension Dyslipidemia + tobacco use Obesity Back pain Depression Gastroesophageal gastric reflux Erectile dysfunction Chronic kidney disease (baseline crea 1.0) s/p Laminectomy L2-4 Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no drainage, erythema around incision Edema:trace: 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **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) 12550**]) on [**4-15**] at 1pm Cardiologist: Dr. [**Last Name (STitle) **] will call for appointment Wound check in [**Hospital Unit Name **], [**Hospital Unit Name **] on [**3-30**] at 11:15AM Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 90408**] [**Name (STitle) **] in [**3-30**] 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:[**2173-3-28**]

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icd9cm

[ [ [] ] ]

[ "36.12", "38.91", "86.3", "39.61", "36.15" ]

icd9pcs

[ [ [] ] ]

7378, 7461

4253, 5512

287, 399

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2440, 4230

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237, 249

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40,577

117,568

18947

Discharge summary

report

Admission Date: [**2146-6-15**] Discharge Date: [**2146-6-25**] Date of Birth: [**2092-8-6**] Sex: M Service: SURGERY Allergies: Zestril / Iodine; Iodine Containing Attending:[**First Name3 (LF) 1384**] Chief Complaint: end-stage renal disease Major Surgical or Invasive Procedure: living unrelated renal transplant4/28/10 History of Present Illness: 53-year-old gentleman with end-stage renal disease and multiple medical problems including obesity and coronary artery disease who presents for consideration of kidney transplantation. Past Medical History: CAD, s/p stent ([**12-19**] at [**Hospital1 1774**]), s/p CABG [**2145-9-15**] ongoing angina Hypertension, h/o hypertensive urgency Respiratory arrest [**2-/2145**] with resuscitation Chronic diastolic heart failure Chronic renal failure, secondary to ATN and diabetes Angina pectoris Diabetes Obesity, s/p laparoscopic banding ([**Doctor Last Name **], [**12-25**]), with subsequent removal of band after prolonged hospitalization in [**10/2144**] Hypercholesterolemia OSA; has not used CPAP/BIPAP for years but does use 2L NC at night Psoriasis; Psoriatic arthritis Chronic anemia h/o TIA without residual symptoms Motorcycle trauma ([**2144-11-8**]) with BL open Monteggia fractures, R knee degloving injury, hypotension, facial laceration s/p ex-lap, and s/p cervical fusion with bone graft. ORIF R and L elbows with hardware still in place, trach and peg h/o hypernatremia Social History: Lives with wife, 3 children. On disability, former truck driver. Tobacco: Former smoker, quit [**9-/2143**] after 80 pack-year history. ETOH: Former heavy drinker, currently only has one drink on occasion. Illicits: does endorse very remote history of cocaine use, no history of any drug use in many years. Family History: Father - Leukemia, [**Name2 (NI) 32071**] heart disease Mother - Diabetes [**Name2 (NI) **] type 2 Sister - Diabetes [**Name2 (NI) **] type 2 Physical Exam: PE from preop office visit Appears well. Lungs are clear bilaterally. Heart is regular. Abdomen is soft, nontender, and nondistended, but obese. He has multiple ventral hernias from his previous surgeries. His groin pulses are 2+ throughout. There is minimal peripheral edema. Pertinent Results: [**Name2 (NI) 1326**] kidney US [**6-15**]: Transplanted kidney with appropriate arterial waveforms and resistive indices. No hydronephrosis or perirenal fluid collection. Apparent slow flow within the renal vein but it appears patent. [**Month/Year (2) 1326**] kidney US [**6-16**]: 1. No hydronephrosis and no perinephric collection. 2. Elevated resistive indices in the intraparenchymal renal arteries. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Known lastname 1326**] Surgery Service and underwent Living Unrelated Donor Kidney [**Known lastname 1326**]. The kidney came from his wife. His post-operative course is summarized below by system. Neuro: Post-operatively pain was controlled on a morphine PCA and was transitioned to PO pain meds. Renal/[**Known lastname 1326**]/Immunosuppression: Mr. [**Known lastname 51792**] [**Known lastname **] was complicated by delayed graft function requiring dialysis on [**6-20**]. His CBC and chemistries were monitored daily and more often as indicated. He completed the typical post-operative course of immunosuppression except that, due to low platelet counts, his dose of ATG was given over more days in doses of 75. On [**6-21**]/5th the patient began to have increased urine output with an associated drop in creatinine, seen the day before. This continued up until his discharge with good urine output. F/E/N: In general the patient did well with regard to fluids. Because of the delayed graft function, he required dialysis on [**6-20**]. After this, however, his graft function picked up and he was able to handle his own excretory needs. On the day prior to discharge, his potassium was elevated on his AM labs, follow up showed an increasing potassium level to 6.1. This was treated with dextrose, insulin, and IV lasix with moderate response, thus he was also given kayexelate on the day of discharge after his potassium had begun trending down. There were no associated EKG changes. He will have labs checked on Monday in clinic. During his hospitalization, he had an HD line present on right, which served as IV access during the hospitalization. This will be removed in office during followup. Heme: In the context of the operation and the immediate post-operative period he required transfusion of 2 pRBCs on [**6-15**] FFP on [**6-16**] plt on [**6-16**]. He also had low platelets intermittently in response to the ATG, thus the dose was given at 75 a day. Physical Therapy: The patient was seen in house by physical therapy and considered able to go home with home PT. He was encouraged to ambulate early and often. Mr. [**Known lastname **] was discharged on POD 10 afebrile, with normal hemodynamics, making good urine, tolerating a regular diet with pain controlled on oral medications. He will follow up for lab work on Monday [**6-27**]. Medications on Admission: lipitor 80 daily, zetia 10 daily, carvedilol 25 [**Hospital1 **], citalopram 20 daily, asa 81 daily, plavix 75 daily, embrel 50 qweekly, pepcid 20 daily, folate 1 daily, thiamine 100 daily, lantus 14 qAM 20 qhs, novolog SS, synthroid 50 dialy, renagel, epogen Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: s/p living unrelated renal [**Company **] Hypertension wound drainage delayed graft function hyperkalemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Please call the [**Name8 (MD) 1326**] Office [**Telephone/Fax (1) 673**] if you experience any of the warning signs listed You will need to have lab work drawn every Monday and Thursday Visiting Nurse Agency has been arranged to assist you at home. They will call you to arrange a home visit in the next day or so Followup Instructions: Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2146-7-1**] 8:20 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name11 (NameIs) **] SOCIAL WORK Date/Time:[**2146-7-1**] 9:00 Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2146-7-7**] 10:20

[ "285.21", "583.81", "250.40", "V85.36", "428.0", "413.9", "458.29", "327.23", "583.9", "276.7", "V45.82", "996.81", "V15.82", "414.00", "428.32", "E878.0", "V45.81", "278.01", "272.0", "585.6", "696.0", "403.91", "300.29" ]

icd9cm

[ [ [] ] ]

[ "39.95", "55.69", "00.92" ]

icd9pcs

[ [ [] ] ]

5433, 5482

2707, 4734

318, 361

5631, 5631

2274, 2684

6210, 6599

1819, 1962

5503, 5610

5149, 5410

5782, 6187

1977, 2255

4752, 5123

255, 280

389, 575

5646, 5758

597, 1477

1493, 1803

58,528

196,496

7441+55834

Discharge summary

report+addendum

Admission Date: [**2190-2-12**] Discharge Date: [**2190-2-19**] Service: NEUROLOGY Allergies: Keflex / Lipitor Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: Aphasia plus R sided weakness Major Surgical or Invasive Procedure: Subdural evacuation per Dr. [**Last Name (STitle) **] History of Present Illness: The pt is an 88 year-old right-handed man well known to me from his last admission on [**2-8**]. He was discharged yesterday. Briefly, Mr. [**Known lastname 27271**] has a PMH of a recent SDH, afib off coumadin, HTN, HLD and a recent admission for transient weakness and difficulty producing speech lasting 20 minute. During his most recent admission he was evaluated for these episodes with an EEG which showed some drowsiness but no focality. He also had a CTV which did not show any venous thrombosis and carotid Dopplers which showed bilateral 60~69% stenosis. An echo was also done which showed mild LVH and an EF of 50~55%. During this hospitalization he was found to have a slightly subtherapeutic Tegretol level of 3.5 therefore his dose was increased to 300mg daily from 200. His hospital course was otherwise notable for mild hyponatremia (132), an A1c of 5.8 and an LDL of 72. In regards to his afib, he was restarted on aspirin and coumadin was to be considered at his follow-up appointment. He was discharged to rehab. Today, Mr. [**Known lastname 27271**] was at rehab when he had an episode of right face, arm, and leg hemiparesis and dysarthria. The onset abrupt around 9am. Per EMS records his BP was 183/102 HR 79-108 and his BS was 129. O2 sats were 99% on RA No LOC or limb movements were noted. He was taken to an OSH where a head CT was done which showed the stable subdural. His BP threr ranged in the 180's SB and 70-100's for the DB. His screening labs showed a negative UA, no leukocytosis and an INR of 1.0. Of note, his Na was 130, Cr of 0.98 and a troponin of 0.4. The episode resolved about 90 minutes later in the ED. He was transferred here for further care. Mr. [**Known lastname 27271**] described the event as a "funny feeling" in his chest, lightheadedness and then feeling "weak in parts" but does not identify his arm or face as being involved. He does recall that his speech was "garbled" and that his words would come out but were not easy to understand. He was able to understand others without difficulty. He feels that the episode lasted about 40 minutes. ROS: The pt denied headache, loss of vision, blurred vision, diplopia, dysphagia, vertigo, tinnitus or hearing difficulty. No bowel or bladder incontinence or retention. Denied difficulty with gait. The pt denied recent fever or chills. No night sweats or recent weight loss or gain. Denied cough, shortness of breath. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Denied rash. Past Medical History: - A-fib now off coumadin - HTN - HLD - CAD - Parkinson's ? - ? CAROTID STENOSIS - PUD - pacemaker implantation in [**2179**] - BPH - Seizure disorder (last seizure 15-20 yrs ago) with GTC - Appy - Eye surgery for congenital cataracts/lens implants - Hernia surgery - Glomerulonephritis 2 yrs ago - recent SDH as above - ? IVC filter Social History: -currently resides at rehab -EtOh: denies -tobacco: denies -drugs: denies Family History: NC Physical Exam: Vitals: T: 98.4 P: 86 R: 16 BP: 199/96-220/107 SaO2: 99% on 2L NC 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: CTAB Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: no edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive. 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 read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. CN I: not tested II,III: VFF to confrontation, pupils surgical and ovid bilaterally, slight R lid ptosis but brisk movements, unable to visualize fundi bilaterally III,IV,V: EOMI, no ptosis. No nystagmus V: sensation intact V1-V3 to LT VII: Mild L NLF flattening VIII: hears finger rub bilaterally IX,X: palate elevates symmetrically, uvula midline [**Doctor First Name 81**]: SCM/trapezeii [**5-25**] bilaterally XII: tongue protrudes midline, no dysarthria Motor: Normal bulk, increased tone throughout with slight cogwheeling; slight asterixis bilaterally; No pronator drift. Delt [**Hospital1 **] Tri WE FE Grip C5 C6 C7 C6 C7 C8/T1 L 5 5 5 5 5 5 R 5 5 5 5 5 5 IP Quad Hamst DF [**Last Name (un) 938**] PF L2 L3 L4-S1 L4 L5 S1/S2 L 5 5 5- 5 5 5 R 5 5 5- 5 5 5 Reflex: No clonus [**Hospital1 **] Tri Bra Pat An Plantar C5 C7 C6 L4 S1 CST L 2 2 2 1 0 Flexor R 2 2 2 1 0 Flexor -Sensory: No deficits to light touch, but significantly reduced vibratory sense and proprioception in LE. No extinction to DSS. -Coordination: + resting tremor, R>L as well as postural tremor and intention tremor. No dysmetria on FNF or HKS bilaterally. -Gait: deferred given concern for severe HTN Pertinent Results: [**2190-2-19**] 05:40AM BLOOD WBC-6.7 RBC-3.17* Hgb-10.1* Hct-27.8* MCV-88 MCH-31.9 MCHC-36.5* RDW-14.2 Plt Ct-222 [**2190-2-19**] 05:40AM BLOOD Glucose-97 UreaN-12 Creat-0.8 Na-129* K-3.6 Cl-94* HCO3-28 AnGap-11 [**2190-2-12**] 03:05PM BLOOD cTropnT-<0.01 [**2190-2-16**] 05:30AM BLOOD CK-MB-NotDone cTropnT-<0.01 CT HEAD pre-operation: 1. Stable left frontoparietal subdural hematoma, subacute on chronic. No new hemorrhage is identified. 2. Stable mass effect. No herniation identified. 3. Stable chronic microangiopathic small vessel ischemic changes. Mild diffuse parenchymal volume loss. CT HEAD post-opeartion: Status post partial evacuation of left subdural collection via left burr holes, with expected postoperative changes and with decreased mass efect on the subjacent left frontoparietal brain and the left lateral ventricles. Small subdural collection remains, mainly along the superior convexity, where it is isodense. No evidence of new hemorrhage. Brief Hospital Course: The pt is an 88 year-old RH man with a complex PMH including seizures, CAD and afib off coumadin, recent traumatic SDH and very recent admission for transient difficulty producing speech and R hand weakness. He now presents with a similar episode although the symptoms were more extensive involving right face, arm, and leg hemiparesis and dysarthria. The duration of symptoms is also longer and he now has a L facial droop. The remainder of his exam is stable. Given the recurrence of his symptoms for over an hour, seizure is less likely and there was more concern of the mass effect from his SDH hence he was evaluated per neurosurgery. Cardiology consult cleared him for the operation. Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] performed the left-sided burr hole craniotomy for evacuation of the symptomatic left SDH without complication. Post-op imaging showed expected post surgical changes. Given his risk factors including CAD and Afib, aspirin 81mg was started the next morning and he remained symptom free including speech and R arm weakness for the remainder of the admission. He was re-evalauted per PT who recommended returning to rehab for inpatient physical therapy and he is, once again discharged to [**Hospital 5130**] Rehab for acute therapy. He is to follow up with Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (neurology) on [**2190-3-15**] 2:30pm at [**Hospital Ward Name 23**] Center [**Location (un) 858**]. Per Dr. [**Last Name (STitle) **], neurosurgery, the patient should not restart Coumadin until 3 months after the left SDH evacuation. The patient/family have been recommended to call Dr.[**Name (NI) 9034**] office to schedule a follow-up appt in 4 weeks with repeat CT of head without contrast. During this admission, his blood pressure consistently remained > 150 hence his atenolol has been increased to 100mg [**Hospital1 **]. Given mild hyponatremia, his Tegretol has been decreased to 200mg in the morning and 300mg at night. Patient should have weekly labs and he needs to follow-up with PCP upon discharge from the rehab. Medications on Admission: 1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: One (1) Injection ASDIR (AS DIRECTED). 3. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed. 4. Docusate Sodium 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 6. Prevacid 30mg PO QHS 7. Doxazosin 4 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime). 8. Aliskiren 150 mg Tablet [**Hospital1 **]: One (1) Tablet PO Qday (). 9. Furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 10. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: [**1-22**] Inhalation Q6H (every 6 hours) as needed. 12. Simvastatin 40 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 13. Diltiazem HCl 180 mg Capsule, Sustained Release [**Month/Day (2) **]: One (1) Capsule, Sustained Release PO DAILY (Daily). 14. Carbamazepine 100 mg Tablet Sustained Release 12 hr [**Month/Day (2) **]: Three (3) Tablet Sustained Release 12 hr PO DAILY (Daily). 15. Aspirin 81 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable PO DAILY (Daily). 16. Lisinopril 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily). 17. Atenolol 25 mg Tablet [**Month/Day (2) **]: Three (3) Tablet PO BID (2 times a day). 18. Polyvinyl Alcohol 1.4 % Drops [**Month/Day (2) **]: 1-2 Drops Ophthalmic PRN (as needed). 19. Cardizem 180mg PO QD Discharge Medications: 1. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a day) as needed: Hold for loose stools. 3. Docusate Sodium 100 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO BID (2 times a day): Hold for loose stools. 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 6. Doxazosin 4 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime). 7. Aliskiren 150 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Qday (). 8. Furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 9. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Simvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 12. Diltiazem HCl 180 mg Capsule, Sustained Release [**Last Name (STitle) **]: One (1) Capsule, Sustained Release PO DAILY (Daily). 13. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 14. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Last Name (STitle) **]: [**1-22**] Drops Ophthalmic PRN (as needed). 15. Zolpidem 5 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO HS (at bedtime) as needed. 16. Aspirin 81 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable PO DAILY (Daily). 17. Carbamazepine 100 mg Tablet Sustained Release 12 hr [**Month/Day (2) **]: Three (3) Tablet Sustained Release 12 hr PO HS (at bedtime). 18. Carbamazepine 200 mg Tablet Sustained Release 12 hr [**Month/Day (2) **]: One (1) Tablet Sustained Release 12 hr PO DAILY (Daily). 19. Atenolol 50 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO BID (2 times a day). 20. Outpatient Lab Work Please check chem 7 (Na+, K+, HCO3-, Cl-, BUN, Cr and Glucose) every Monday. 21. CT head without contrast prior to seeing Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (neurosurgery) in 4 weeks Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: L SDH s/p evacuation Atrial fibrillation Discharge Condition: Stable - Slight R sided weakness including mild facial droop plus occaional difficulty with words. Discharge Instructions: You returned soon after discharge with another transient episode of slurred speech, R hand weakness in the morning. Although transient, given the duration of the deficit and its recurrence plus the CT of head showing some mass effect from the subdural hemorrhage, you underwent the evaucation per Dr. [**Last Name (STitle) **] on [**2190-2-17**] without complications. You remained without events since the surgery and your aspirin was restarted the morning after the surgery. You were continued on your seizure medication, Tegretol and its level was monitored but given the level mildly supratherapeutic, it was decreased to 200mg in the morning and 300mg in the evening. Again, you were evaluated per physical therapy during this admission who recommended for you to return to [**Hospital 5130**] Rehab for continued acute, intense therapy. You will be following up with Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (neurology) on [**2190-3-15**] during which time he will be advising you about when to restart Coumadin given your atrial fibrillation. As for your surgery, please call Dr.[**Name (NI) 9034**] office [**Telephone/Fax (1) 2731**] to schedule follow-up in 4 weeks from discharge. You will get a repeat head CT before the appointment. Please take your meds as prescribed. Given that you are on Tegretol, you will be getting weekend blood draw including Na+. Also, please follow-up with your physicians as scheduled. Please call your doctor or go to the nearest ED if you have worsening weakness or speech problems, new numbness or visual problems, fever and/or unabating headache. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2190-3-10**] 8:40 Neurology: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2190-3-15**] 2:30 Please call Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] office at [**Telephone/Fax (1) 2731**] to schedule follow-up in 4 weeks from discharge with repeat CT head prior to the appointment. Provider: [**Name10 (NameIs) 27270**] [**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2190-7-8**] 9:00 Completed by:[**2190-2-19**] Name: [**Known lastname 4695**],[**Known firstname 133**] Unit No: [**Numeric Identifier 4696**] Admission Date: [**2190-2-12**] Discharge Date: [**2190-2-19**] Date of Birth: [**2101-2-13**] Sex: M Service: NEUROLOGY Allergies: Keflex / Lipitor Attending:[**Last Name (NamePattern1) 4697**] Addendum: As for the restarting of Coumadin, Dr. [**Last Name (STitle) 3424**] discussed with Dr. [**Last Name (STitle) **] and given his risk factors including hx of traumatic SDH and his atrial fibrillation/CAD, Coumadin is to be restarted in 3 months after the evacuation of the left SDH. Discharge Disposition: Extended Care Facility: [**Hospital3 1933**] [**First Name8 (NamePattern2) 77**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern4) 4698**] MD [**MD Number(2) 4699**] Completed by:[**2190-2-19**]

[ "428.0", "583.9", "414.01", "781.94", "728.87", "332.0", "401.9", "533.90", "345.90", "600.00", "E936.3", "432.1", "V45.82", "V45.01", "276.1", "427.31", "784.3", "272.4" ]

icd9cm

[ [ [] ] ]

[ "01.31" ]

icd9pcs

[ [ [] ] ]

16202, 16438

6534, 8679

263, 319

13026, 13127

5540, 6511

14840, 16179

3405, 3409

10491, 12871

12962, 13005

8705, 10468

13151, 14817

3424, 3873

194, 225

347, 2941

3888, 5521

2963, 3297

3313, 3389

2,349

132,788

47251

Discharge summary

report

Admission Date: [**2161-7-21**] Discharge Date: [**2161-8-8**] Date of Birth: [**2111-3-20**] Sex: F Service: SURGERY Allergies: Iodine / Shellfish Attending:[**First Name3 (LF) 301**] Chief Complaint: persistent gastric ulcer Major Surgical or Invasive Procedure: Partial gastrectomy with Billroth II gastrojejunostomy, appendectomy, repair of ileal enterostomy, upper GI endoscopy, [**2161-7-21**]. Exploratory laparotomy, evacuation of hemoperitoneum, splenectomy, [**2161-7-26**]. History of Present Illness: 50yo woman with a history of peptic ulcer disease and GERD s/p Nissen fundoplication in [**2160-3-15**] who developed an upper GI bleed in [**2161-2-13**] requiring significant transfusions. Surgical resection was recommended at that time but the patient declined and opted for conservative medical management. She had been closely followed by the gastroenterology service but on follow-up has a persistent 1.5-2cm nonhealing type I gastric ulcer seen on endoscopy, with biopsies negative for malignancy. She experiences epigastric abdominal pain associated with eating and now presents for elective subtotal gastrectomy for treatment of refractory gastric ulcer. Past Medical History: UGI bleed [**3-18**] secondary to benign gastric ulcer GERD paraesophageal hernia s/p laparoscopic repair and nissen fundoplication [**3-18**] PUD depression facial and abdominal burns, [**2156**] cervical dysplasia Social History: Tobacco: 20 pack-years. denies alcohol abuse. lives with her mother; does not work Family History: CAD Father passed from prostate cancer Mother with asthma Physical Exam: In outpatient clinic: HR 111, BP 107/70 A&Ox3, NAD. mildly cachectic appearing. supple CTAB RRR soft, non-tender, non-distended. well-healed surgical scars. neuro exam intact, FROM x4 notable burn scars. Pertinent Results: [**2161-7-22**] 02:27AM BLOOD WBC-20.0*# RBC-3.41* Hgb-11.0* Hct-33.9* MCV-99* MCH-32.4* MCHC-32.6 RDW-12.6 Plt Ct-207 [**2161-7-25**] 05:45AM BLOOD WBC-6.5 RBC-2.81* Hgb-9.2* Hct-27.1* MCV-97 MCH-32.6* MCHC-33.7 RDW-12.5 Plt Ct-132* [**2161-7-26**] 01:11PM BLOOD WBC-14.4*# RBC-2.04*# Hgb-6.5*# Hct-19.9*# MCV-97 MCH-31.7 MCHC-32.6 RDW-12.7 Plt Ct-212# [**2161-7-26**] 01:56PM BLOOD Hct-18.6* [**2161-7-27**] 12:00AM BLOOD Hct-39.4 [**2161-7-27**] 03:37AM BLOOD WBC-20.2* RBC-4.04*# Hgb-12.3# Hct-35.6* MCV-88# MCH-30.4 MCHC-34.5 RDW-14.3 Plt Ct-104*# [**2161-8-7**] 06:11AM BLOOD WBC-22.7* RBC-3.74* Hgb-11.3* Hct-34.6* MCV-93 MCH-30.2 MCHC-32.6 RDW-13.5 Plt Ct-973* [**2161-7-26**] 01:11PM BLOOD PT-12.8 PTT-26.3 INR(PT)-1.1 [**2161-7-22**] 02:27AM BLOOD Glucose-99 UreaN-6 Creat-0.5 Na-139 K-4.7 Cl-107 HCO3-26 AnGap-11 [**2161-7-22**] 02:27AM BLOOD Calcium-8.7 Phos-3.2# [**2161-7-22**] 01:03PM BLOOD Mg-0.8* [**2161-8-7**] 06:11AM BLOOD Glucose-80 UreaN-14 Creat-0.5 Na-138 K-4.6 Cl-100 HCO3-26 AnGap-17 [**2161-8-7**] 06:11AM BLOOD Calcium-9.5 Phos-4.4 Mg-1.9 [**2161-7-22**] 02:27AM BLOOD CK(CPK)-127 [**2161-7-22**] 02:27AM BLOOD CK-MB-4 cTropnT-<0.01 [**2161-7-28**] 02:01AM BLOOD TSH-0.99 [**2161-7-28**] 02:15PM BLOOD T4-5.8 T3-76* [**2161-8-6**] 09:35AM BLOOD Cortsol-43.1* Pathology: Sub-total gastrectomy [**2161-7-21**]: Chronic gastric body ulcer with marked subjacent submucosal fibrosis and fibrous obliteration of the muscularis propria, Six reactive lymph nodes (0/6), No malignancy identified, Gastric corpus mucosa is present at the proximal resection margin. Stain negative for H.pylori. Appendectomy [**2161-7-21**]: Fecaliths present; otherwise no diagnostic abnormalities recognized. Splenectomy [**2161-7-26**]: Spleen with interrupted capsule and subcapsular hemorrhage. The white and red pulp elements are within normal limits. Brief Hospital Course: This 50yo F was admitted to the MIS surgery service post-operatively from sub-total gastrectomy with Billroth 2 gastrojejunostomy; please see operative report for details. An NGT, Foley catheter, and Epidural anesthetic catheter were in place. She was kept in the PACU overnight in extubated condition; mild hypotension was addressed with adjustment of the epidural and initiation of PCA. Further mild hypotension and tachycardia were addressed with IVF and electrolyte repletion with success. The patient was transferred to the regular floor on POD 1; a PICC line was placed and TPN initiated. With scant NGT output, the tube was removed and clear liquid diet initiated. This was well tolerated and advanced on POD 3 to full liquid diet with boost supplements. A fever to 101.9 warranted pan-cultures, which were negative. Intermittent episodes of sinus tachycardia were noted but with stable and normal blood pressures and no evidence of hypovolemia. The pain service removed the epidural catheter and switched the PCA to oral medications on POD 4. POD 5 was notable when the patient developed severe abdominal pain with tenderness and distension on exam. Tachycardia was accompanied now by hypotension. The hematocrit was 19 where it previously had been between 28-33. IVF resuscitation was initiated with a Foley catheter in place, although clinical improvement was marginal. A central line was placed and the patient was brought emergently to the OR for concern of post-operative bleeding on POD 5, [**2161-7-26**]. An exploratory laparotomy revealed a splenic capsule tear and a splenectomy was performed; please see operative report for details. A total of 6 unit of packed red blood cells were transfused over the pre- and intra-op time period. Post-operatively the patient was brought to the SICU in intubated condition with NGT, Foley, and JP drains in place. Fluid status was optimized, HCTs remained stable subsequently, although she remained in sinus tachycardia. Cardiology consult was obtained at this time; b-blockade was utilized. TPN was restarted. Ventilator management yielded successful extubation on POD [**1-20**]. The pre-operative CVL was removed and a new CVL placed. She remained hemodynamically stable and was transferred to the floor on POD [**2-21**]. A PCA was provided for satisfactory pain relief, diet initiated and advanced progressively. Physical therapy consult assisted with ambulation, oral medications begun, and foley catheter eventually discontinued. An episode of abdominal pain, associated with elevated WBC count, prompted a CT scan. No intrabdominal abscess or infection was found, although a left lower lobe pneumonia was observed and treated with levaquin and flagyl. She continued to have episodes of sinus tachycardia between 100-130, which remained asymptomatic and associated with normal blood pressures. With confirmation of euvolemia and adequate pain control, cardiology and medical consults were instituted with ultimate transfer to the medical service with the surgery service following on POD [**8-29**] to expound upon the cardiac work-up. This included telemetry, unremarkable echocardiogram, negative LENI, and a low-probability V-Q scan result. All cultures were negative for infection and a suspected nosocomial pneumonia from earlier in the hospitalization had clinically resolved. She was deemed safe for discharge with a Holter monitor after appropriate follow-up with Surgery, Cardiology, and Medicine were secured. Medications on Admission: COLACE 100MG--One capsule(s) by mouth twice a day DULCOLAX 5MG--Take two a day as needed for constipation FAMOTIDINE 20MG--One tablet by mouth every day FLUOXETINE HCL 10 mg--1 capsule(s) by mouth daily KLONOPIN 0.5 mg--1 tablet(s) by mouth three times a day MIRTAZAPINE 45 mg--1 tablet(s) by mouth at bedtime OXYCODONE HCL 5MG--One tablet by mouth twice a day as needed PROTONIX 40 mg--1 tablet(s) by mouth twice a day ROXICET 5-325MG--[**11-16**] by mouth q 4-6 hours as needed for for headache SENNA 8.6MG--2 tablets by mouth every day Tylenol-Codeine #3 300-30 mg--1 tablet(s) by mouth three times a day as needed for pain Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*10 Tablet(s)* Refills:*2* 3. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours) as needed for pain. Disp:*30 Tablet Sustained Release 12HR(s)* Refills:*0* 4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for BREAKTHROUGH PAIN. Disp:*45 Tablet(s)* Refills:*0* 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*45 Tablet(s)* Refills:*0* 7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 8. Olanzapine 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*45 Tablet(s)* Refills:*2* 9. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*15 Capsule(s)* Refills:*2* 10. Mirtazapine 45 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO HS (at bedtime). Disp:*15 Tablet, Rapid Dissolve(s)* Refills:*2* 11. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: refractory gastric ulcer acute blood loss, hypovolemic shock, splenic rupture sinus tachycardia nosocomial pneumonia depression Discharge Condition: stable Discharge Instructions: Please seek medical attention if you experience fever > 101.5, severe nausea, vomitting, and severe pain. Wear a loop monitor per Holter nurse recommendations. Please follow up with appointments as scheduled. Please take new meds as directed; may resume home meds. Remain on full liquid diet with boost plus supplementation. No driving while on narcotic pain meds. No heavy lifting for 6 weeks. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] at his surgical clinic on [**8-28**] 8:15am surgical specialties [**Hospital Ward Name 23**] 3, [**Hospital1 827**] [**Location (un) 830**], TCC 140. If you have any questions or need to make changes please call Phone: [**Telephone/Fax (1) 2723**]. Please Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at his electrophysiology clinic on [**9-18**] at 10:00am [**Hospital1 771**] [**Street Address(2) 8667**], Cardiology, [**Hospital Ward Name **] [**Hospital Ward Name **] 4. If you have any questions or need to make changes please call Phone: [**Telephone/Fax (1) 2934**]. Schedule appointments: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2161-8-20**] 1:30 Follow up with Cardiologist. Call [**Telephone/Fax (1) **] to schedule an appointment with Dr. [**Last Name (STitle) **] and/or Dr. [**First Name (STitle) **] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Where: [**Hospital6 29**] SURGICAL SPECIALTIES Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2161-8-28**] 8:15 Provider: [**Name10 (NameIs) 8694**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26**] Where: RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) NUTRITION Phone:[**Telephone/Fax (1) 3681**] Date/Time:[**2161-9-3**] 1:00

[ "427.89", "289.59", "997.3", "998.2", "568.81", "997.1", "486", "531.70", "276.7" ]

icd9cm

[ [ [] ] ]

[ "99.04", "43.7", "38.93", "45.13", "54.95", "46.73", "99.15", "47.09", "41.5", "44.13" ]

icd9pcs

[ [ [] ] ]

9457, 9463

3761, 7288

302, 523

9635, 9643

1872, 3733

10087, 11617

1573, 1632

7966, 9434

9484, 9614

7314, 7943

9667, 10064

1647, 1853

237, 264

551, 1218

1240, 1457

1473, 1557

76,923

157,044

13568

Discharge summary

report

Admission Date: [**2121-6-25**] Discharge Date: [**2121-7-5**] Date of Birth: [**2052-8-1**] Sex: M Service: MEDICINE Allergies: Crestor Attending:[**First Name3 (LF) 16115**] Chief Complaint: RUQ pain after a fall, transfer from OSH for management of sepsis and respiratory failure Major Surgical or Invasive Procedure: Bronchoscopy with BAL CT-guided placement of catheter in intra-abdominal abscess History of Present Illness: 68 year old gentleman retired judge past medical history of DM, AFlutter s/p ablation on pradaxa, EtOH abuse was transferred from [**Hospital3 3765**] to [**Hospital6 2910**] on [**2121-5-25**] after right mid quadrant abdominal pain from a recent fall a week prior. At that time, he had "resistant" E coli UTI (to cipro, levo, bactrim, augmentin), complicated by acute renal failure (Cr 2, BUN 17), mild sepsis/SIRS associated with hypotension and lactic acidosis. Initially treated at [**Hospital1 **] with flouroquinolone transitioned to ertapenem at NEBH. His initial presentation improved and EtOH withdrawal was managed by ativan however this was followed by progressive somnolence and SOB. There was concern for aspiration pneumonia and acute respiratory failure given bilateral parenchymal infiltrates andworsening hypoxemia on ABG requiring intubation. He was placed on ertapenam and levaquin to cover atypical organisms given his recent admission from community. Given improvement in leukocytosis (initially WBC 19 PMN 72 BAND 15), but persistence of fever, levaquin was discontinued. Multiple cultures including blood, urine , stool, sputum cultures were unrevealing except for [**Female First Name (un) **] albicans on sputum. HIV, cryptococcal Ag negative. Hep serologies were negative. Vancomycin was added. Multiple attempts of us guided thoracocentesis failed due to minimal amount of fluid. This eventually ended up a thoracic surgeon placing a left chest tube on [**6-12**] with VATS procedure (CT guided failed as well). It was noted that the pleural surface was reddened and consistent with exudative but cultures and cytology were unremarkable. Bronchoscopy on [**2121-5-29**] was unrevealing in terms of cultures. PICC line was changed with persistently non-significant blood cultures. Had elevated lipase in the pleural fluid consistent with elevation in blood lipase up to 5000's. Five CT were done and did not reveal pancreatic inflammation, necrosis or pseudocyst. After 18 day of antibiotics, they were discontinued since no source of infection identified (staph epi on one of the cultures and Ecoli as noted previously). Unfortunately, fever persisted. Holding tube feeds, psych meds and diuretic didn't help to stop fever. Multiphasic CT showed lesion at the lower pole of the liver with exophytic cyst off the right kidney concern for possible undrained infection or underlying HCC (AFP 97.7) with MR abdomen more consistent with solid tumor than hemangioma. Eventually, tumor fever was concerning renal cyst biopsy was discussed. on [**6-24**] prior to preparation to transfer to [**Hospital1 18**], pt had fever, tachypnic with tube feeds emanating from around the trach. Tube feeds were discontinued. Vancomycin and zosyn were started. Transitioned from pressure support to assist control. During his stay, he had complete lower lobe collapse in his lower lobes with surrounding effusion in the setting of hypoalbuminemic state and a chest tube was placed as above with right lower lobe re-expansion but still was unable to wean. Bronchoscopy was performed which showed tracheobroncomalacia possibly more than 80% of the lumen was narrowed by positive pressure ventilation. Due to this, tracheostomy and PEG tube was placed [**2121-6-12**]. Prior to presentation to OSH, he had a fall with abdominal pain, found to have rectal muscle hematomta, pradaxa was held. He remained in sinus per dc summary with diltaizem 30 mg q 6 hour and lopressor 25 mg twice daily. He received DVT prophylaxis throughout his stay per dc summary (was on lovenox 40 mg sc daily per dc summary). His last few days of stay was notable for higher insulin requirements which was somehow concerning for underlying infection however tube feeds were increased as well to meet his caloric needs. Prior to transfer, T 98.3, SBP 140/80. Central line inserted [**6-8**]. Foley inserted [**5-25**]. Trach tube placed [**6-12**]. I/O: 2579/2451. Height 5'8". Admission weight at OSH noted to be 111 kg. FiO2 40%, PEEP 5, RR 26, TV 400, PH 7.55, PCo2 27, PO2 81, total CO2 24.4 O2sat 97% On arrival to the MICU, patient's VS. HR 84bpm, BP 140/70, Sat 98% Mechanical Ventilation: Assist control (Volume Targeted), Tidal volume: 450 cc Respiratory rate: 18 PEEP: 5 cm/h2o FIO2: 50 % Past Medical History: DM-2 HYPERTENSION ATRIAL FLUTTER s/p ablation on pradaxa HYPOTHYROIDISM MIXED HYPERLIPIDEMIA colonic polyp removal CYST OF KIDNEY, ACQUIRED CALCULUS OF KIDNEY PROTEINURIA BLADDER NEOPLASM OBESITY CARDIOMEGALY OSA Social History: Patient is single without children. He is semi-retired as an attorney/judge. Tobacco: Remote cigarettes in the [**2078**]'s. Strong history for cigar use and alcoholism. Family History: non-contributory Physical Exam: On Admission: General: arousable, moves all limbs, follows commands, nods yes or no HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: insp and exp rhonchi. no axillary insp crackles. air entry reduced at bases on both sides Abdomen: soft, bowel sounds present, no organomegaly appreciated, no tenderness to palpation, no rebound or guarding. PEG tube. GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. mild trace pitting edema at the feet. Neuro: moving all extremities, following commands On Discharge: T 97.6 T max 98.9 HR 72 BP 144/76 RR 18 100% RA with trach abdominal drain with 10 cc of output in 24 hours yesterday General: A and O x 3, although intermittently confused at times (sometimes forgets place) HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated. trach in place, minimal erythema, signficantly improved from earlier this week CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: rare rhonchi. no axillary insp crackles. Abdomen: soft, bowel sounds present, no organomegaly appreciated, no tenderness to palpation, no rebound or guarding. PEG tube and intra-abdominal drain in place, no erythema around either GU: foley in place Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. mild trace pitting edema at the feet. Neuro: CNs intact, moving all extremities, following commands Pertinent Results: Admission Labs: [**2121-6-25**] 07:22PM WBC-9.4# RBC-3.02*# HGB-9.6*# HCT-29.2*# MCV-97 MCH-31.7 MCHC-32.8 RDW-16.3* [**2121-6-25**] 07:22PM NEUTS-79.4* LYMPHS-14.1* MONOS-4.2 EOS-2.1 BASOS-0.2 [**2121-6-25**] 07:22PM PLT COUNT-188 [**2121-6-25**] 07:22PM PT-14.5* PTT-28.8 INR(PT)-1.4* [**2121-6-25**] 07:22PM FDP-40-80* [**2121-6-25**] 06:54PM TYPE-ART RATES-18/4 TIDAL VOL-450 PEEP-5 O2-50 PO2-91 PCO2-33* PH-7.44 TOTAL CO2-23 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED [**2121-6-25**] 06:54PM LACTATE-1.3 [**2121-6-25**] 06:54PM O2 SAT-96 [**2121-6-25**] 07:22PM ALT(SGPT)-79* AST(SGOT)-64* LD(LDH)-225 ALK PHOS-149* AMYLASE-156* TOT BILI-1.4 [**2121-6-25**] 07:22PM LIPASE-487* [**2121-6-25**] 07:22PM ALBUMIN-2.4* CALCIUM-7.8* PHOSPHATE-4.3 MAGNESIUM-2.1 [**2121-6-25**] 07:22PM GLUCOSE-100 UREA N-30* CREAT-1.0 SODIUM-145 POTASSIUM-4.0 CHLORIDE-114* TOTAL CO2-22 ANION GAP-13 [**2121-6-25**] 07:44PM URINE MUCOUS-RARE [**2121-6-25**] 07:44PM URINE HYALINE-2* [**2121-6-25**] 07:44PM URINE RBC-2 WBC-4 BACTERIA-FEW YEAST-NONE EPI-0 [**2121-6-25**] 07:44PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-5.0 LEUK-SM [**2121-6-25**] 07:44PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019 Discharge Labs: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 7.8 2.85* 9.3* 28.4* 100* 32.7* 32.9 19.6* 119* INR 1.3 Glucose UreaN Creat Na K Cl HCO3 AnGap 132 23 0.6 139 3.5 (given 60 KCl PO) 107 28 8 ALT AST AlkPhos TotBili 46 35 152 0.7 Albumin Calcium Phos Mg 2.6 8.3 3.2 1.9 ASPERGILLUS ANTIGEN 0.1 <0.5 RESULT INTERPRETATION: An Index <0.5 is considered to be negative. An Index >=0.5 is considered to be positive. Test ---- Fungitell (tm) Assay for (1,3)-B-D-Glucans Results Reference Ranges ------- ---------------- <31 pg/mL Negative Less than 60 pg/mL Indeterminate 60 - 79 pg/mL Positive Greater than or equal to 80 pg/mL blood cultures: [**2121-6-29**] 3:03 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days -> suspected contaminant blood cultures from [**2121-6-30**] and [**2121-7-3**] still pending as of [**2121-7-5**] [**2121-6-27**] 4:23 pm ABSCESS Source: R peri-nephric abscess. GRAM STAIN (Final [**2121-6-27**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). FLUID CULTURE (Final [**2121-6-30**]): ESCHERICHIA COLI. MODERATE GROWTH. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R ANAEROBIC CULTURE (Final [**2121-7-1**]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [**2121-6-26**] 4:31 pm BRONCHOALVEOLAR LAVAGE RIGHT MIDDLE LOBE BRONCHUS. GRAM STAIN (Final [**2121-6-26**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2121-6-28**]): Commensal Respiratory Flora Absent. YEAST. 10,000-100,000 ORGANISMS/ML.. YEAST. ~[**2108**]/ML. 2ND MORPHOLOGY. FUNGAL CULTURE (Preliminary): YEAST. ACID FAST SMEAR (Final [**2121-6-27**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. C. difficile DNA amplification assay (Final [**2121-6-27**]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). [**2121-6-25**] 7:44 pm URINE Source: Catheter. **FINAL REPORT [**2121-6-28**]** URINE CULTURE (Final [**2121-6-28**]): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. sensitivity testing confirmed by Microscan. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 32 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Imaging: ECGL: Sinus rhythm. Left atrial abnormality. Compared to the previous tracing of [**2120-2-15**] the P-R interval is less prolonged and the ventricular rate is faster. CT ABD & PELVIS WITH CONTRAST Study Date of [**2121-6-27**] IMPRESSION: 1. Bilobed retroperitoneal collection of fluid. This fluid may be related to the right kidney where a small non-specific irregular hypodensity is present. Additional intraperitoneal fluid is seen in perihepatic and perisplenic regions. The perihepatic fluid appears to be contiguous with a not fully characterized hypodensity in segment VI of the liver. 2. Bilateral moderate pleural effusions. 3. Mildly thickened bladder wall, nonspecific in the setting of bladder collapse, though thickening due to infectious or inflammatory process cannot be excluded. CT CHEST W/CONTRAST Study Date of [**2121-6-27**] IMPRESSION: 1. Bilobed retroperitoneal collection of fluid. This fluid may be related to the right kidney where a small non-specific irregular hypodensity is present. Additional intraperitoneal fluid is seen in perihepatic and perisplenic regions. The perihepatic fluid appears to be contiguous with a not fully characterized hypodensity in segment VI of the liver. 2. Bilateral moderate pleural effusions. 3. Mildly thickened bladder wall, nonspecific in the setting of bladder collapse, though thickening due to infectious or inflammatory process cannot be excluded. CT NECK W/CONTRAST (EG:PAROTIDS) Study Date of [**2121-6-27**] IMPRESSION: Secretions at the tracheostomy site and extending into the subglottic region with no mass or abscess. US HEMATOMA SUBCUT DRAIN INCISION Study Date of [**2121-6-27**] IMPRESSION: Technically successful ultrasound-guided percutaneous drain placement of right flank hematoma, possibly infected. Culture grew E. coli sensitive to ceftriaxone as noted above Repeat CT abdomen/pelvis on [**2121-7-4**] showed resolving right peri-nephric abscess, only 2 cm x 2 cm, compared to 6 x 4 cm, final read pending at time of discharge, but did discuss findings and improvements with attending radiologist. The drain remains in place, with intent to remove in coming days when output is scant. Brief Hospital Course: # Respiratory failure: The patient was transferred here with tracheostomy on mechanical ventilation for presumed HCAP and aspiration pneumonia. The patient had a bronchoscopy here which did not show evidence of tracheobronchomalacia. A bronchoalveolar lavage was done; results consistent with respiratory flora. Antibiotics were subsequently tailored to ceftriaxone and flagyl from Vancomycin and zosyn. The patient was diuresed with IV lasix for pulmonary edema and b/l pleural effusions. The patient improved and was able to be transitioned to trach mask. Patient was tolerating trach mask well when he was transferred to the floor. Periodic diuresis was continued with Lasix 60 mg IV daily to [**Hospital1 **], with lyte repletion. Trach site cellulitis improving, vancomycin and fluconazole for trach site cellulitis should finish on [**2121-7-7**]. # Fever: The patient was having fevers at the outside hospital and continued to have fevers here. A CT showed a perihepatic abscess that was drained, however there were multiple pockets and all may not be adequately drained. The fluid grew 2+ GNRs that speciated to E coli sensitive to ceftriaxone. He also had an E coli UTI that is pan-sensitive based on OSH biogram and our sensitivities here. Antibiotics were transitioned from Vancomycin and Zosyn to ceftriaxone and flagyl based on sensitivities. The patient continued to spike fever, however the fever curve improved, and this is not suprising given perihepatic abscess that is still draining. Additionally, the patient had some erythema around the site of his trach. He was started on Fluconazole, IP was consulted who determined it was not necessary to change the trach. Vanc and fluconazole as noted above. Regarding abdominal drain, patient has been afebrile for over 5 days, with abscess improving, and only scant output over 24 hours on [**2121-7-4**]. Patient will continue on ceftriaxone and Flagyl. Expect the drain can be removed in coming days after outpt approaches zero for 24 hours. Ceftriaxone and Flagyl should be continued, and consideration given to repeat CT abdomen/pelvis to ensure continued resolution of right peri-nephric abscess. # Altered mental status: On arrival, the patient was arousable but very sedated. This was likely multifactorial and a combination of toxic/metabolic, delirium and sedation. Patient had been on heavy benzos for possible EtOH withdrawal at outside hospital. Sedating medications were discontinued and the patient's mental status improved. On the floor, the patient continued to improve, and was A and O x 3 with occasional confusion, and is a very pleasant man. # Coagulopathy: Patient had INR of 1.4 on admission. This was thought to be [**12-19**] to alcoholic liver disease vs. malnutrition. INR was monitored. Patient's anticoagulation was held due to rectus sheath hematoma that developed after his initial fall. INR 1.3 at discharge, should continue to improve as nutrition status improves. # Aflutter s/p ablation: Patient has history of atrial flutter s/p ablation. He was intermittently in atrial fibrillation with rapid ventricular response which was treated with IV diltiazem. His oral medications were tailored to cardizem 60mg PO QID and Lopressor 50mg [**Hospital1 **]. He remained in sinus rhythm with occasional ventricular ectopy. Anticoagulation was held in the setting of rectus sheath hematoma at the OSH. Anticoagulation was discussed with his PCP, [**Name10 (NameIs) **] given his recent fall, hematoma, infection, and long hospital course, decision was made to defer restarting anti-coagulation at this time. # Hyperglycemia: Patient has known Type II Diabetes. Per records, it was difficult controlling his blood sugar at OSH requiring twice daily lantus regimen in addition to ISS. Patient was treated with insulin sliding scale. # Hypertension: Patient was intermittently hypertensive with pressures running 160s-180s systolic. His medications were tailored as above to cardizem 60mg PO QID and Lopressor 50mg [**Hospital1 **]. Access- right PICC, PIV Full code *****Temporary guardians - Exp [**2121-9-11**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39211**] - [**Location (un) 86**] [**Telephone/Fax (1) 40980**] [**First Name5 (NamePattern1) 122**] [**Last Name (NamePattern1) 40981**] - [**Hospital1 **] [**Telephone/Fax (1) 40982**] *****Advanced directive: [**Name (NI) **] [**Name (NI) **] (sister) [**Telephone/Fax (1) 40983**] Medications on Admission: MEDS ON ADMISSION TO OSH AMITRIPTYLINE - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth every evening ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth daily DABIGATRAN ETEXILATE [PRADAXA] - (Prescribed by Other Provider) - 150 mg Capsule - 1 Capsule(s) by mouth twice a day DILTIAZEM HCL [CARDIZEM CD] - (Prescribed by Other Provider) - 120 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth daily FENOFIBRATE MICRONIZED - (Prescribed by Other Provider) - 200 mg Capsule - 1 Capsule(s) by mouth every morning GLYBURIDE - (Prescribed by Other Provider) - 5 mg Tablet - 2 Tablet(s) by mouth every morning HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 12.5 mg Capsule - 1 Capsule(s) by mouth daily LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth daily LORAZEPAM - 3 mg daily qHS METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - 2 Tablet(s) by mouth twice a day SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth daily at night TRAZODONE - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth every evening VENLAFAXINE - (Prescribed by Other Provider) - 100 mg Tablet - 1.5 Tablet(s) by mouth twice a day Medications - OTC ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other Provider) - 1,000 unit Capsule - 1 Capsule(s) by mouth once a day MULTIVITAMIN - (Prescribed by Other Provider) - Dosage uncertain OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider) - 1,000 mg Capsule - 1 Capsule(s) by mouth twice a day MEDICATIONS ON TRANSFER FROM NEBH: fentanyl 1000 mcg iv q 24 hr vancomycin iv 1 gram q 12hr last given 2pm [**2121-6-25**] zosyn 3.375 mg iv q6hr ativan 0.5 mg q8hr po bumex 1 mg daily cardizem 30 mg q 6hr combivent [**4-25**] puff through ET tube for resp distress cosopt [**First Name9 (NamePattern2) **] [**Male First Name (un) **] 1 drop twice daily venlafaxine 100 mg q 8 hr folic 1 mg po daily thiamine 100 mg po daily potassium chloride ER 30 q 12 hr lantus 40 u twice daily novolin IR humalog sliding scale q 6 hr lovenox 40 mg sc daily at 12 MVI 5 ml daily mycostatin powder apply to groin tid x 7 days neosporin oint apply to trach area twice daily lansoparzole disintegrating 30 mg q 24 hr vitamin d 400 IU po daily zofran 4 mg q 6 hr Tube feeding - held given aspiration Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN fever please inform HO if fever thanks. max daily dose 2 gram 2. Albuterol-Ipratropium [**4-25**] PUFF IH Q6H:PRN SOB/wheeze through ET tube 3. CeftriaXONE 1 gm IV Q24H 4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 5. Diltiazem 60 mg PO QID please hold for SBP < 100 or HR < 60 6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [**Hospital1 **] 7. Fluconazole 400 mg PO Q24H Duration: 3 Days 8. FoLIC Acid 1 mg PO DAILY 9. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 10. Heparin 5000 UNIT SC TID 11. 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. 12. Glargine 10 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 13. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 14. Metoprolol Tartrate 50 mg PO BID please hold for SBP < 100 or HR < 60 15. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 16. Multivitamins 1 TAB PO DAILY 17. Ondansetron 4 mg IV Q8H:PRN nausea 18. 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. 19. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 20. Thiamine 100 mg PO DAILY 21. Vancomycin 1000 mg IV Q 12H 22. Venlafaxine 100 mg PO TID 23. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Primary diagnosis: Sepsis from UTI complicated by peri-nephric and peri-hepatic abscess Delerium Tremens (at OSH, fully resolved) Respiratory failure, likely due to sepsis s/p tracheostomy Malnutrition ICU delerium Secondary diagnosis: alcohol dependence a. flutter s/p ablation, in sinus rhythm throughout Discharge Condition: Mental Status: Confused - sometimes. Usually A and O x 3, but occasionally confused in the evening and morning Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were transferred from another hospital for management of fever. You underwent a bronchoscopy that did not show any lung infection. CT scan of your abdomen showed fluid abscesses around your kidney and liver. A drain was placed, and you were placed on antibiotics. Your fever improved. You also had a tracheostomy and stomach tube placed because of the length of time you were on the ventilator and to help improve your nutrition. You also received antibiotics to treat a skin infection around you tract site. You will continue your recovery from your long hospitaliztion at [**Hospital1 **] [**Last Name (LF) 86**], [**First Name3 (LF) **] acute rehab facility. Followup Instructions: You will follow up with your PCP after discharge from rehab.

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27148

Discharge summary

report

Admission Date: [**2148-7-18**] Discharge Date: [**2148-8-3**] Date of Birth: [**2089-11-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 6169**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Central line placed and removed. bronchoscopy on [**7-24**] History of Present Illness: 58 yo M recently diagnosed with myeloproliferative/ myelodysplastic syndrome overlap syndrome, R thigh wound s/p failed/reversed skin graft, presents with fever and SOB. He has been seen [**2148-7-17**] in clinic with WBC 79.000 16% blast. He has been receiving hydrea 2 g/da and low dose ARA c for the last 3 days. Per clinic notes, he had an episode of shortness of breath with wheezing in clinic, receive albuterol and apparently felt better. he also had an echo that showed LVEF >75%, and small pericardial effusion, but no tamponade physicology. PA pressures 24 mm HG . Patient went home and at about 1 am on [**2148-7-18**], he presented to the ED with increasing shortness of breath and fever. He states that he has been getting episodes of "indigestion" with some shortness of breath everytime after lunch but patient is unclear how long they last. He feels that this time is worse, and he could actually here himself wheezing. He refers cough with withish sputum over the last 2 days. In the ED, patient receieved nebs and was started on antibiotics cefepime-vancomycin. At some point during his ED stay, there was a concern for a septic component, his blood pressure went down to 85/46, that he responded well to IV fluids. Chest x ray revela fluid in the fissure and a sm right effusion. Received about 5.7 L of IV fluids in the ed. lactate 4.3 that later on trended down to 2.1. His sats improved with 5L nasal cannula to 93-94 and then to 97-98 on 40% ventury and transfered to the [**Date Range 3242**] floor. . During the day on [**Date Range 3242**] floor, patient contiued to be tachypnea with RR in 30's, sat 98% on VM. (40-50%). Was started on Hydrea, and continued on Vanc, Cefipime, azithromycin for ? of CAP. (Was on bactrium PCP prophylaxis as outpatient). Receieved Lasix 20mg IV xTT, with 350cc then an additional 350cc at 7:30pm (patient refusing foley placement).and Atrovent/albuterol with minimal improvement in SOB. Of note, patients weight was 200 ~4 weeks ago and currenrly 223#. Patient receieved 1 U PRBC's on [**2148-7-17**] per OMR . Of note, pt had prior admission to [**Date Range 3242**] service/[**Hospital Unit Name 153**] earlier in [**Month (only) 116**]. During this admission, he had 2 hypoxic episodes, with desaturations to 85% on room air, and 4 liter oxygen requirement. He was transferred to the [**Hospital Unit Name 153**] for concerns of respiratory demise from leukostasis. Respiratory status stabilized and did not require intubation. After a short stay in ICU, patient was transferred back to [**Hospital Unit Name 3242**] floor on nasal canula oxygen. Pulmonology was consulted and felt that hypoxia was likely from fluid overload based on Chest CT findings. Patient's symptoms improved with diuresis and was weaned off supplemental oxygen. . Currently, the patient states, "I just need some sleep, I just can't get my breath." . Denies any CP, N/V, + LE edema and PNA and 4 pillow orthopnea. Past Medical History: Past Medical History: MDS/myeloproliferative disorder overlap Glaucoma htn GERD . Onc History: - presented on [**6-/2148**] with a WBC of 69,000 with 10-15% blast forms - he was treated with hydra and ARAC. - bone marrow biopsy showed 8% blast. - On hydrea to control WBC Social History: Custodian at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Occasional ETOH. No drug use. 30 year smoking history, at least 3 packs/week. Family History: Older sister with some type of cancer, not very close Physical Exam: VS: Tc 96.9 BP 100/60 Hr 112 Sats 98% on 50% Ventury mask. Peak flow 150 RR 26-34: I/O's: 520/625 (after Lasix 20mg IV x2) Gen - Alert and oriented to Name, date, and "hosptial", m+ respiratory distress, using supraclavicular muscles and sitting bolt upright. HEENT - JVP difficult to appreciate given neck girth. no lymphadenopathies. CV - RR, tachycardic, No MRG appreciated Chest: + Insp and Exp wheeze on L lung field with prolonmged exp phase. bibasilar crackles appreciated. No egophony Abd - BS+, soft, non-tender, obese, spleen 8-10 cm below LCM. Extremity: distal pulses ok bilaterally, pitting edema +2 lower extremities. Right thigh wound dressing with serosanginous drainage. Pertinent Results: [**2148-7-18**] 7:28p 7.37/ 36/ 160 on Ventimask; FiO2%:50 [**2148-7-18**] 3:12p 7.34/40/84 Ventimask FiO2%:40 Lactate:1.9 [**2148-7-18**] 05:24a 7.37/41/67 . . PT: 14.2 PTT: 31.9 INR: 1.3 . ColorYellow AppearClear SpecGr1.022 pH 5.0 UrobilNeg BiliNeg LeukNeg BldNeg NitrNeg ProtTr GluNeg KetTr RBC0-2 WBC3-5 BactOcc YeastNone Epi0-2 . Lactate:2.1 Comments: Green Tube . 140 102 15 184 AGap=15 3.5 23 1.1 . CK: 40 MB: 1 Trop-*T*: <0.01 . Ca: 8.5 Mg: 1.6 P: 4.6 LDH: 611 UricA:6.5 . proBNP: 2291 . ...9.2 81 104.9>---< 52 ......27.1 N:26 Band:0 L:10 M:41 E:0 Bas:0 Atyps: 5 Myelos: 1 ***Blasts: 17*** . [**2148-7-18**] 03:13AM 104.9*1 [**2148-7-17**] 01:48PM 79.1* [**2148-7-16**] 01:47PM 88.0* [**2148-7-15**] 01:45PM 73.7* [**2148-7-11**] 01:53PM 21.6* [**2148-7-8**] 08:58AM 4.3 . Micro: Blood and Urine Cx NGTD . [**2148-6-13**] Bone marrow Bx: expanded population of myelomonocytic precursor with increased myeloblasts (12% of total events) consistent with myeloproliferative/myelodysplastic syndrome . Echo [**2148-7-17**]: EF > 75%. Small pericardial effusion without tamponade. PA pressures 24 mm hg . EKG: ST 112 with nl axis, nl intervals, frequent PAC, PRWP, no s1q3t3. . [**2148-7-18**] CXR: Bilateral lower lobe intralobular septal thickening, which may represent atypical infection from viral process or PCP, [**Name10 (NameIs) **] mild interstitial pulmonary edema. Small right pleural effusion. Emphysema. Probable mediastinal and right hilar lymphadenopathy. Brief Hospital Course: A/P: 58 y/o with MDS/MPS admitted in setting of rising WBC count over past week and fevers, and profound SOB. . # Respiratory Distress: Patient was transferred from the [**Name10 (NameIs) 3242**] service to the [**Hospital Unit Name 153**] for persistent respiratory distress/increased work of breathing with RR in 30's and satting 98% on 50% oxygen by ventimask. Of note, patient has had two previous hypoxic episodes in [**Month (only) 116**], both of which required transfer to [**Hospital Unit Name 153**] and were eventually attributed to volume overload and resolved with diuresis. On this occaision, patient was admitted with a hypoxic episode, with fevers, in the setting of a 23 pound weight gain over the two weeks prior to admission. He had 2+ pitting pedal edema, crackles on lung exam and CXR with increase septal markings consistent with pulmonary edema and hyperinflation suggestive of emphysema. Patient was transiently supported on BiPAP (less than 1 hour) and started on continuous nebulizers with improvement in his respiratory rate and exam. He was transitioned to supplemental oxygen by face mask and diuresed with lasix. He was also started on Vanco/Cefapime/Azithro for presumptive PNA as well as daily IV lasix. He continued to receive regular nebulizers and steroids to treat COPD. His oxygen requirement decreased steadily until he was maintaining his O2 sats on nasal cannula. . Patient was transfered to the floor on 6 L nasal canula. Chest CT was done on ([**2148-7-22**]) arrival to the floor and showed improvement in previous lower lobe pneumonia, but worsening of right upper lobe ground- glass alveolar opacities and consolidation. New lung nodules elsewhere were also noted. Pulmonary was consulted. Voriconazole was started. BAL was perfomed and all cultures were negative. Repeat Chest Ct was perfomed on [**2148-7-29**] that showed interval improvment of the infiltrates. After continuing nebs, steroids and antibiotics his o2 requirment trended down until reaching his baseline on RA on discharge. . #ID: Febrile to 103.5. Given his MDS, there was concern that the patient was functionally neutropenic. His initial lactate was 4.3-->2.1 in the ED. Although he was afebrile on arrival to the [**Hospital Unit Name 153**], blood, urine, and induced sputum was sent for cultures, as was a wound culture of his upper thigh. Blood and urine were also sent for PCP and legionella. He was broadly covered with Vanco/Cefepime/Azithro for presumptive PNA. . On the floor, patient was started on Voriconazole for concern on fungal origin for his CT infiltrates. Given remarkable clinical improvment, Cefepime was discontinued. About 5 days later, patient started spiking again. CT chest showed improvement of infiltrates. PICC line looked clean. He also developed a left upper quadrant pain and CT abdomen showed possible splenic infaction, questionable splenic tear and no evidence of abscess. His HCT was followed carefully and remained stable at time of discharge. . On [**2148-8-1**] after worsening of pain, U/S was performed and showed defect already seen on CT in the spleen. Spleen vasculature patent. Renal u/s normal. . # Heme/Onc: Patient has known MDS and concern for transformation to AML given elevated white count with increased blast forms. Hydroxyurea and allopurinol were continued. Tumor lysis labs were checked Q day and were negative. Patient's hematocrit remained stable and no transfusions were required during his [**Hospital Unit Name 153**] time. Upon transfer to the flooor, it was decided to start chemotherapy with arac 40mg [**Hospital1 **] SC. He received a total of 12 doses, given that the last two were held after concern for splenic bleeding. His counts trended down and have remained stable since then. He was supported with PRBC and platelet transfussions. . #CV: He was tachycardic while in the [**Hospital Unit Name 153**]. Lower extremits ultrasound obtained to assess for DVT and were negative. Patient has hx of a-fib and was re-started on BB for rate control. Beta blocker was titrated up to the current dose. No episodes of afiv or RVR were noticed on [**Hospital Unit Name 3242**] flood. . # Thight wound. He was seen by wound care nurse on [**2148-7-18**], and the recommendation was to watch the wound carefully. There were no signs of infection. . # Knee Pain: Patient had an episode of right knee pain. Echymosis on the site but no recollection of trauma. X ray revealed no evidence of effusion. MRI was normal. It was likely traumatic. His pain was controlled with pain medications. Medications on Admission: Meds at Home: Hydroxyurea 2 gm qd Recently receieved Ara-C [**2148-7-16**] Prilosec qd Allopurinol 300 daily Metoprolol 25 mg [**Hospital1 **] Prednisone 10 mg [**Hospital1 **] Eye drops R thigh wound: wet to dry dsg changes daily . Medications on [**Hospital1 3242**]: Hydroxyurea [**2142**] mg PO BID Allopurinol 300 mg PO DAILY Ipratropium Bromide Neb 1 NEB IH Q4H Order date: [**7-18**] @ 1853 Albuterol 0.083% Neb Soln 1 NEB IH Q3-4H:PRN Lorazepam 0.5 mg PO ONCE Duration: Aluminum-Magnesium Hydrox.-Simethicone 15-30 ml PO QID:PRN MethylPREDNISolone Sodium Succ 60 mg IV ONCE Azithromycin 250 mg PO Q24H Pantoprazole 40 mg PO Q24H Cefepime 2 gm IV Q8H Prednisone 10 mg PO BID Dolasetron Mesylate 12.5 mg IV Q8H:PRN Furosemide 20 mg IV ONCE Duration: 1 Doses Vancomycin HCl 1000 mg IV Q 12H Furosemide 20 mg IV ONCE Duration: 1 Doses Discharge Medications: 1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 14 days: discuss with Dr. [**First Name (STitle) 1557**] duration of this med . Disp:*28 Tablet(s)* Refills:*0* 4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. Hydroxyurea 500 mg Capsule Sig: Three (3) Capsule PO Q 24H (Every 24 Hours). Disp:*90 Capsule(s)* Refills:*2* 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). Disp:*1 bottle* Refills:*2* 8. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*30 Capsule(s)* Refills:*1* 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* 10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Primary diagnosis: Fever hypoxia leukocytosis Secondary diagnosis: MDS/MPS Splenic infarct 2x2cm Discharge Condition: Afebrile, hemodynamically stable, counts improved, no active bleeding Discharge Instructions: Please take all meds as described and discuss each of these medications, especially voriconazole duration with Dr. [**First Name (STitle) 1557**] this week. Follow up with all your appointments. Please call your doctor or go to the Emergency Department if you exprience chest pain, shortness or breath, if you notice any bleeding or bruises, or any other worrisome symptoms. Followup Instructions: Follow up with Dr. [**First Name (STitle) 1557**]. ******Call his office Monday morning to schedule at time to see him this coming week. Provider: [**Name10 (NameIs) **],[**Known firstname 1730**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) **] Call to schedule appointment Completed by:[**2148-11-12**]

[ "427.31", "054.2", "428.0", "289.59", "365.9", "284.8", "238.7", "707.11", "V58.65", "518.82", "401.9", "491.22", "530.81", "719.46" ]

icd9cm

[ [ [] ] ]

[ "99.05", "99.25", "38.93", "99.04", "33.24" ]

icd9pcs

[ [ [] ] ]

12979, 13050

6194, 10782

333, 396

13192, 13264

4645, 6171

13690, 14007

3865, 3920

11673, 12956

13071, 13071

10808, 11650

13288, 13667

3935, 4626

274, 295

424, 3378

13139, 13171

13090, 13118

3422, 3674

3690, 3849

15,749

195,969

44594

Discharge summary

report

Admission Date: [**2181-6-24**] Discharge Date: [**2181-6-27**] Date of Birth: [**2119-3-9**] Sex: F Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 800**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: mrs. [**Known lastname **] is a 62-year-old female with CAD, severe CHF EF 20%, s/p MVR, s/p AICD for torsades, afib, h/o CVA, h/o HIT, h/o hydrocephalus s/p VP shunt admitted to MICU for gastroenteritis and hypotension now transferred to [**Hospital1 1516**] service. She had three days of abd pain, n/v/d and presented to the ED yesterday. She had a CT abd and RUQ ultrasound that showed cholelithiasis but no cholecystitis. She had elevated lactate and BP's were in the 70's (baseline 90's) and so she was admitted to the MICU. She had mild tranaminitis, hyponatremia and renal failure and clinical picture was thought to be viral gastroenteritis with dehydration. Her diuretics were stopped but she was not given more IVF since she has very low EF and clinically did not seem dry. Her BP improved to SBP 100 and her labs improved. She now feels better and abd pain resolved. Abd exam was unremarkable and she tolerated dinner. However, she had 3 loose BM's today. Otherwise she feels well. . On review of systems, she denies any prior history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: [**2177**], see below -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: # CAD - chronic stable angina # CHF EF 20% per TTE [**4-/2181**] # Rheumatic heart disease s/p MVR [**92**] years ago and redo in [**2175**] with Carbomedics mechanical valve # AICD for VT/torsades [**8-/2175**] # Chronic atrial fibrillation # Heparin induced thrombocytopenia # Hydrocephalus s/p VP shunt [**2175**] # History of CVA # History of right subdural hematoma # External fixation wrist fracture [**2170**] # Recurrent urinary tract infections # Hypothyroidism # Osteoporosis Social History: mrs. [**Known lastname **] lives with her husband in [**Name (NI) 3146**] in an apartment below one of her daughters. Moved to the United States from [**Country 2559**] over 30 years ago. She is a retired medical assistant. She denies any prior tobacco use and denies alcohol or other illicit drug use. . Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: temp 96.3F, BP 100/58, HR 91, RR30, 97%RA GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. L pupil larger than R and less reactive. L EOMI and R movements more limited. Vision normal. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP to angle of jaw. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Irregularly irregular, normal S1, S2. Soft mechanical S2. III/VI murmur at apex and soft SEM along sternal border. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Mild crackles at L base. 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: [**2181-6-24**] 05:37PM GLUCOSE-158* UREA N-37* CREAT-1.6* SODIUM-130* POTASSIUM-3.2* CHLORIDE-94* TOTAL CO2-19* ANION GAP-20 [**2181-6-24**] 05:37PM CK(CPK)-54 [**2181-6-24**] 05:37PM CK-MB-NotDone cTropnT-0.10* [**2181-6-24**] 05:37PM CALCIUM-9.1 PHOSPHATE-3.6 MAGNESIUM-2.0 [**2181-6-24**] 05:37PM HCT-35.7* [**2181-6-24**] 05:37PM PT-71.3* PTT-39.4* INR(PT)-8.8* [**2181-6-24**] 04:53AM LACTATE-1.6 [**2181-6-24**] 04:32AM GLUCOSE-88 UREA N-39* CREAT-1.6* SODIUM-132* POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-20* ANION GAP-19 [**2181-6-24**] 04:32AM ALT(SGPT)-39 AST(SGOT)-45* CK(CPK)-73 ALK PHOS-48 TOT BILI-2.2* DIR BILI-1.4* INDIR BIL-0.8 [**2181-6-24**] 04:32AM CK-MB-NotDone cTropnT-0.14* [**2181-6-24**] 04:32AM ALBUMIN-3.9 CALCIUM-9.6 PHOSPHATE-3.6 MAGNESIUM-2.1 [**2181-6-24**] 04:32AM WBC-10.7 RBC-4.28 HGB-11.8* HCT-36.2 MCV-85 MCH-27.7 MCHC-32.7 RDW-17.0* [**2181-6-24**] 04:32AM PLT COUNT-186 [**2181-6-24**] 04:32AM PT-61.1* PTT-39.3* INR(PT)-7.3* [**2181-6-23**] 10:38PM LACTATE-2.1* [**2181-6-23**] 06:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008 [**2181-6-23**] 06:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2181-6-23**] 06:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-<1 [**2181-6-23**] 06:45PM URINE HYALINE-[**7-4**]* [**2181-6-23**] 06:14PM LACTATE-5.8* [**2181-6-23**] 06:05PM GLUCOSE-129* UREA N-39* CREAT-1.8* SODIUM-131* POTASSIUM-5.6* CHLORIDE-93* TOTAL CO2-21* ANION GAP-23* [**2181-6-23**] 06:05PM estGFR-Using this [**2181-6-23**] 06:05PM ALT(SGPT)-53* AST(SGOT)-53* CK(CPK)-84 ALK PHOS-61 TOT BILI-2.3* [**2181-6-23**] 06:05PM LIPASE-42 [**2181-6-23**] 06:05PM CK-MB-8 cTropnT-0.06* proBNP-[**Numeric Identifier 95482**]* [**2181-6-23**] 06:05PM WBC-12.2*# RBC-5.03 HGB-13.7 HCT-43.8 MCV-87 MCH-27.2 MCHC-31.3 RDW-16.8* [**2181-6-23**] 06:05PM NEUTS-76.6* LYMPHS-16.6* MONOS-6.2 EOS-0.3 BASOS-0.3 [**2181-6-23**] 06:05PM PLT COUNT-260 [**2181-6-23**] 06:05PM PT-49.9* PTT-34.9 INR(PT)-5.7* Brief Hospital Course: Ms. [**Known lastname **] is a 62yo female with CAD, severe CHF (EF ~20%), s/p MVR, s/p AICD for torsades, atrial fibrillation, CVA, h/o HIT, and h/o hydrocephalus (s/p VP shunt placement) admitted to MICU for abdominal pain and hypotension who is now transferred to [**Hospital1 1516**] service for additional workup. . # CORONARIES / CAD : One vessel coronary artery disease by catheterization done in [**2177**] that showed 20% in OM. Continues to be chest pain free since admission. Recent troponin elevattion attributed to renal failure rather than ACS as her CK levels are normal and she has no concerning EKG abnormalities. She was continued on daily aspirin and beta-blocker therapy. Statin not given as her LDL <80 and no significant dyslipidemia. No chest pain complaints during her stay. . # PUMP: Non-ischemic dilated cardiomyopathy with EF 20%, history of rheumatic mitral valve disease with updated MVR in [**2175**] (mechanical), and also status-post BiVentricular pacer for synchrony. Euvolemic on exam to slightly fluid overloaded as she has mild crackles at lung bases and JVP near 9cm. Suspect low EF and hypoperfusion playing a role in ARF. She had diuretics held for a few days initially due to concern for dehydration and low blood pressures but soon restarted her torsemide and aldactone as she began to have slight fluid overload on exam. Monitored strict I/O's, daily weights checked and she was placed on a low sodium diet. INR goal 2.5-3.5 for mechanical valve ( MVR for her MR history from rheumatic disease in childhood ). . # RHYTHM: telemetry showing background native atrial fibrillation with demand pacing. She is s/p BiV pacemaker. Continued on metoprolol therapy. Because initial BPs were marginal team did not increase dose as her rate was within normal ranges. She had supratherapeutic INR near 8 range so held coumadin for several days until her level corrected. . # Anticoagulation: initially supratherapeutic INR and warfarin held for two days. INR subsequently 2.0 and thus argatroban bridge for one day. On discharge INR was 4.9. . # Abdominal pain: She reported additional weakness, diarrhea x 2 days and nausea at admission. Once on medical floor she had no additional diarrhea or emesis but some mild nausea persisted with moderate relief from IV Zofran. Poor appetite slowly improved and by time of discharge she was tolerating a PO diet well and her symptoms had resolved as patient stated she was not having any active nausea or emesis. Elevated bilirubin, gallstones on CT, lactate near 5 and US were initially concerning for cholecystitis but per reports no definite findings of acute cholecystitis on multiple imaging studies whch showed non-distended gallbladder and no pericholecystic fluid or biliary ductal dilatation noted. Ultimately her andominal pain may have been related to intermittent biliary colic vs. alternate differential of viral gastroenteritis. By hospital day [**2-27**] total bilirubin trended down and transaminitis improved. No elevated ALP and benign belly exam reassuring. C.difficile studies negative. Leukocytosis resolved from 12--> 9 range and there were no persistent fevers. Surgery consult was called and she was started on Cipro/Flagyl coverage despite low chance of cholecystitis given her multiple surgical risk factors should a biliary source flare-up and to cover any potential gastroenteritis bugs. . # ARF: Likely from dehydration from gastroenteritis. Usual baseline creatinine near 1.1 and now up near 1.8 at admission but trended down by hospital day #2 with Cr 1.5 range. Initally diuretics held but then restarted home torsemide and aldactone as dehydration, GI symptoms, BP and renal function all improving. At discharge her renal function was at baseline. . # Hyponatremia. Felt to be from combination of both dehydration and underlying CHF. Encourage PO fluids and restarted diuretics once she was eating and drinking well. . # Hypothyroidism: No acute issues. Continued usual home dose of levothyroxine. . # Depression: No acute issues. Continued home zoloft therapy and patient seen by social work for coping and counseling. . # Osteoporosis: No acute issues. Continued on usual calcium and vitamin D supplements. Held her alendronate given renal failure as above but once her Cr back to baseline she will plan to restart as an outpatient. Medications on Admission: Warfarin 1 mg PO DAILY Spironolactone 25 mg PO DAILY Torsemide 80 mg PO BID Aspirin 81 mg PO DAILY Sertraline 100 mg PO DAILY Trazodone 25 mg PO HS:PRN insomnia Levothyroxine 150 mcg PO DAILY Alendronate 70 mg PO once a week Calcium Carbonate 500 mg PO DAILY Vitamin D 400 unit PO DAILY Multivitamin PO DAILY K-Dur 40 mEq PO BID Metoprolol Succinate 100 mg PO DAILY Discharge Medications: 1. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: Please follow-up at [**Hospital 197**] clinic within 2-3 days for INR level check. 2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 3. Torsemide 20 mg Tablet Sig: Four (4) Tablet PO twice a day. 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 6. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 8. Alendronate 70 mg Tablet Sig: One (1) Tablet PO every seventy-two (72) hours. 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 12. Multivitamins Oral 13. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO twice a day. 14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 days. Disp:*15 Tablet(s)* Refills:*0* 15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:*5 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: -Gastroenteritis -Acute Renal Failure -Congestive Heart Failure -Cholelithiasis Discharge Condition: Stable. At time of discharge the patient had no apparent disress and appeared clinically stable. Discharge Instructions: It was a pleasure taking care of you here at [**Hospital1 771**]. . You were admitted with abdominal pain, nausea, poor appetite and some diarrhea. You also had some low blood pressures as well. The medical team felt that you had a brief gastrointestinal infection or stomach upset which may have been from a virus or bacteria. You also had some low blood pressures initially, so some of your usual congestive heart failure medications called diuretics ( Torsemide and Aldactone) were held for a few days until your blood pressures improved and your dehydration subsided. You should start these medications when at home. . Lab studies also showed you had some impaired kidney function and low sodium levels. This was felt to be secondary to your recent infection and your underlying congestive heart failure. . Please take all of your prescribed medications as listed below and follow-up with your doctors as advised. . Your coumadin level was elevated and this medication was initially stopped and resumed before discharge from hospital. You should have the coumadil level measured and forward the results to your doctor. . Due to your history of congestive heart failure it is very important that you weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to less than 2 gm/day sodium diet and please do not exceed 2L daily fluids. . If you develop any additional shortness of breath, dizziness, chest pains, vomiting, nausea, recurrent diarrhea , additional abdominal pains or any other health concerns then please return to the emergency room promptly or call your primary care physician. Followup Instructions: Please follow-up in the Device Clinic at [**Hospital1 18**] for a routine follow-up on [**7-24**] at 11:30am. Phone:[**Telephone/Fax (1) 62**] . Please follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP. Phone:[**Telephone/Fax (1) 62**], on [**7-3**] a 1:30 pm after you finish your Device Clinic visit. . Please call #[**Telephone/Fax (1) 62**] to make a follow-up appointment with Dr. [**First Name (STitle) 437**] within 1-2 weeks of discharge from the hospital. . Call #[**Telephone/Fax (1) 133**] to make a follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], over the next 1-2 weeks. . [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**] Completed by:[**2181-6-28**]

[ "427.31", "428.32", "V45.02", "276.51", "584.9", "414.00", "V45.2", "008.8", "V45.81", "428.0", "V43.3", "244.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12212, 12287

6097, 10444

288, 294

12412, 12511

3994, 6074

14178, 15014

2880, 2995

10861, 12189

12308, 12391

10470, 10838

12535, 14155

3010, 3975

1941, 2021

234, 250

322, 1839

2052, 2540

1883, 1921

2556, 2864

12,759

181,544

18878

Discharge summary

report

Admission Date: [**2147-8-18**] Discharge Date: [**2147-8-25**] Service: Neurosurgery HISTORY OF PRESENT ILLNESS: Patient is an 85-year-old female transferred from [**Hospital3 **], who was previously healthy and independent with activities of daily living. On the morning of [**2147-8-18**], the patient complained of feeling ill, nothing specific. She then had lunch, went to a movie, and later had a sudden onset of headache in her right occipital region with radiation to her neck, upper back. The patient then went to the [**Hospital3 **] Emergency Department. She had a GCS of 14 at the hospital, nausea, and vomiting suddenly. The patient's GCS decreased to 12, and she was intubated and transferred to [**Hospital1 **] Hospital. Upon arrival, the patient did not open her eyes, but localized bilaterally. The patient received a ventriculostomy in the Emergency Department. After CSF diversion her examination failed to improve and she had a Hunt [**Doctor Last Name 9381**] Grade IV status. PAST MEDICAL HISTORY: 1. Atrial fibrillation. 2. Diabetes mellitus - diet controlled. 3. Esophageal strictures. ALLERGIES: Sulfa drugs. MEDICATIONS: 1. Digoxin 25 mg. 2. Cozaar. 3. Multivitamins. PHYSICAL EXAMINATION: Pupils 3 unreactive. Positive corneal reflex bilaterally. Positive gag reflex. Localizing on right side to central stimuli. Moving all four extremities to pain. Upgoing plantar reflexes bilaterally. LABORATORIES AND STUDIES: CTA showed subarachnoid hemorrhage and possible anterior communicating artery aneurysm, and right frontal intraparenchymal hemorrhage. INR 1.1. Platelets 221. HOSPITAL COURSE: On [**8-20**], an angiogram showed a 2 mm anterior communicating artery aneurysm and a 3.5 mm left posterior communicating artery aneurysm. Neither were amenable to endovascular therapy. A discussion with the family was undertaken especially given her poor neurological condition which failed to improve despite EVD placemement. It was decided that she undergo treatment of her aneurysm in order to prevent her from rebleeding. On [**8-20**], the patient was taken to the operating room for craniotomy. Her posterior communicating artery was examined and noted not to have any blood around it. The anterior communicating aneurysm was then examined and noted to have significant surrounding [**Last Name (un) 22761**]. The small aneurysm was then isolated and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 51664**] [**Hospital1 5832**] mini clip was placed on the ACOm aneurysm. During placement of the clip and after releasing the blades, intraoperative bleeding began from a rent near the clip site. This was packed with Surgicel and irrigated with no further bleeding. The patient was brought back to the ICU after the surgery. On Post-op day 1, a repeat CT scan was obtained, which showed a subacute large left inferior cerebellar infarct aged at 24-48 hours of age. An angiogram was performed which showed the tip of the Acom aneurysm to be clipped with a 1 mm residual at the base. The posterior circulation was patent. The etiology of the cerebellar infarct was not determined but could have been the result of intermittent atrial fibrillation. On [**8-22**], the patient's examination was significant only for brain stem responses completely off sedation. A new CT scan was obtained which showed no changes. Given the patient's poor neurological condition and poor prognosis from her high grade SAH and new cerebellar infarct, a decision was made to provide comfort measures only by the family. The patient remained neurologically stable until the 15th, when it was decided to provide comfort measures only. The patient died on [**8-25**]. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 14345**] MEDQUIST36 D: [**2147-8-25**] 12:29 T: [**2147-8-28**] 08:51 JOB#: [**Job Number 51665**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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26996

Discharge summary

report

Admission Date: [**2117-9-13**] Discharge Date: [**2117-9-23**] Date of Birth: [**2063-3-16**] Sex: M Service: MEDICINE Allergies: Tenofovir Disoproxil Fumarate Attending:[**First Name3 (LF) 13256**] Chief Complaint: fatigue, weakness Major Surgical or Invasive Procedure: upper endoscopy History of Present Illness: 54 yo M with hx of HIV (last CD4 count of 97 in [**8-5**]) and Hep C cirrhosis s/p liver transplant 4 years ago. He has undergone 2 treatment trials for hepatitis C and has had multiple liver bx, most recently on [**8-24**] showing findings consistent with an ongoing chronic allograft rejection vs cholestatic variant of viral hep C. He has been treated in the past with steroids, ATG, IVIG, and plasmapheresis with only transient improvement. He presents today from clinic with complaints of increased lethargy, fatigue, DOE, abdominal and lower extremity swelling for the last week. Patient says that he is now unable to walk up a flight of stairs or very far without having to stop to catch his breath. He also noticed dark stools over the last 1-2 weeks, denies bright red blood. Also reports feeling dizzy with quick changes in position. Pt also says he has noticed periodic cramping over lower extremities and fingers which resolve with movement. Reports good po intake, but feels bloated with enlarged abdomen. Pt denies fevers, chills, n/v/d, CP, SOB, abdominal cramping. Past Medical History: HIV HCV cirrhosis HCC s/p RFA [**3-31**] (4.5x3.4 cm hepatoma, which was biopsy-proven hepatocellular carcinoma (HCC).) OLT [**6-1**] c/b portal vein thrombectomy and roux en y [**2113-6-25**]; c/b acute rejection vs HSV infection in [**6-5**] - treated with steroids, ATG, IVIg, Acyclovir, and Foscarnet Recurrent HCV Portal vein thrombosis - on coumadin DM II Appendectomy at age 18 multiple R inquinal hernia repairs x4 PTC [**2113-11-23**] [**2114-1-1**] dilatation of hepaticojejunostomy site Fanconi's syndrome [**1-27**] Tenofovir HSV Social History: - lives alone in an apartment in [**Location 57226**]. No children - high school graduate, previously worked as disk jockey in [**Location (un) 86**] area - on medical disability, unemployed - denies current ETOH, tobacco or drug abuse (prior IV cocaine use) Family History: unknown Physical Exam: ADMISSION EXAM Vitals: 96.4 128/76 84 20 100% RA General: jaundiced male in NAD HEENT:NC/AT, sclera icteric, dry MM, OP clear Neck: supple, no cervical lymphadenopathy Heart: RRR, normal s1/s2, no murmurs appreciated Lungs: CTAB, no wheezes Abdomen:+BS, distended, +shifting dullness, non tender, no rebound or guarding Extremities: 1+ LE edema bilaterally Neurological:A&Ox3, CN II-XII intact, no asterixis noted Physical Exam on Discharge: Vitals: 97.7, 97.3, 92/56, 72, 18, 96RA FBS 340 I/O=1900/1000+7BM General: jaundiced male in NAD, comfortable appearing, sitting up in his chair HEENT: NC/AT, sclera icteric, dry MM, OP clear Neck: supple, no cervical lymphadenopathy Heart: RRR, normal s1/s2, no murmurs appreciated Lungs: CTAB, scattered wheezes bilaterally. Abdomen:+BS, distended, non tender, no rebound or guarding Extremities: 3+ edema feet, taught/shiny skin, sensation intact- ROM intact. Pitting edema above the knees as well. Neurological:A&Ox3, CN II-XII intact, no asterixis noted Pertinent Results: ADMISSION LABS: [**2117-9-13**] 04:25PM BLOOD WBC-4.0 RBC-2.12*# Hgb-5.9*# Hct-19.1*# MCV-90 MCH-27.9 MCHC-31.0 RDW-17.8* Plt Ct-109* [**2117-9-13**] 04:25PM BLOOD PT-21.2* PTT-30.5 INR(PT)-1.9* [**2117-9-13**] 04:25PM BLOOD Glucose-518* UreaN-36* Creat-0.8 Na-132* K-4.0 Cl-104 HCO3-17* AnGap-15 [**2117-9-13**] 04:25PM BLOOD ALT-85* AST-68* LD(LDH)-140 AlkPhos-526* TotBili-24.7* DirBili-20.7* IndBili-4.0 [**2117-9-13**] 01:05PM BLOOD Albumin-2.7* Calcium-8.1* Phos-1.9* Mg-1.9 [**2117-9-13**] 04:25PM BLOOD Hapto-26* [**2117-9-13**] 01:05PM BLOOD tacroFK-9.6 Discharge Labs: [**2117-9-23**] 04:35AM BLOOD WBC-3.3* RBC-2.82* Hgb-8.2* Hct-25.6* MCV-91 MCH-28.9 MCHC-32.1 RDW-18.4* Plt Ct-82* [**2117-9-23**] 04:35AM BLOOD PT-15.2* INR(PT)-1.3* [**2117-9-23**] 04:35AM BLOOD Glucose-294* UreaN-38* Creat-1.9* Na-136 K-4.0 Cl-108 HCO3-15* AnGap-17 [**2117-9-23**] 04:35AM BLOOD ALT-44* AST-60* LD(LDH)-171 AlkPhos-620* TotBili-36.6* [**2117-9-23**] 04:35AM BLOOD Albumin-3.2* Calcium-8.3* Phos-2.0* Mg-2.4 [**2117-9-23**] 04:35AM BLOOD tacroFK-10.7ertinent labs: [**2117-9-18**] 12:38PM ASCITES WBC-40* RBC-225* Polys-46* Lymphs-13* Monos-41* [**2117-9-18**] 12:38PM ASCITES TotPro-0.3 Glucose-168 Creat-1.3 LD(LDH)-55 Amylase-236 TotBili-2.4 Albumin-LESS THAN [**2117-9-14**] 04:45AM BLOOD tacroFK-7.7 [**2117-9-15**] 04:27AM BLOOD tacroFK-21.9* [**2117-9-16**] 02:30AM BLOOD tacroFK-24.9* [**2117-9-17**] 04:30AM BLOOD tacroFK-22.6* [**2117-9-18**] 04:30AM BLOOD tacroFK-18.2 [**2117-9-20**] 10:28PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016 [**2117-9-20**] 10:28PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-TR Ketone-NEG Bilirub-LG Urobiln-NEG pH-5.5 Leuks-NEG [**2117-9-20**] 10:28PM URINE RBC-0 WBC-2 Bacteri-MOD Yeast-NONE Epi-0 TransE-<1 [**2117-9-20**] 10:28PM URINE Mucous-RARE [**2117-9-17**] 10:16PM URINE Hours-RANDOM UreaN-780 Creat-72 Na-27 K-39 Cl-15 [**2117-9-17**] 10:16PM URINE Osmolal-539 Micro: Ascites Fluid: GRAM STAIN (Final [**2117-9-18**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2117-9-21**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2117-9-24**]): NO GROWTH. Fluid Culture in Bottles (Final [**2117-9-24**]): NO GROWTH. HELICOBACTER PYLORI ANTIBODY TEST (Final [**2117-9-20**]): NEGATIVE BY EIA. (Reference Range-Negative). IMAGING: [**2117-9-13**] RUQ ULTRASOUND WITH DOPPLERS 1. Patent hepatic vasculature with appropriate waveforms and direction of flow. No evidence of thrombus. 2. Findings consistent with known cirrhosis. 3. Stable splenomegaly. 4. Stable dilated intrahepatic ducts and pneumobilia, predominantly in the left lobe of the liver. [**2117-9-20**] Abdominal Ultrasound Thin pockets of ascitic fluid are seen in the lower quadrants bilaterally adjacent to bowel loops without sufficient quantity for safe paracentesis. 9/20/11EGD: Varices at the lower third of the esophagus Varices at the fundus Food in the fundus Ulcer in the antrum Normal mucosa in the whole duodenum Otherwise normal EGD to second part of the duodenum [**9-15**] EGD Varices at the lower third of the esophagus Varices at the fundus Food in the fundus Ulcer in the antrum Normal mucosa in the whole duodenum Otherwise normal EGD to second part of the duodenum [**2117-9-21**] EGD Varices at the lower third of the esophagus. Gastric varices were seen on retroflexed view in the gastric cardia. There was no evidence of bleeding. There was a single overlying ulcer visualized on the mucosal surface. This finding was reviewed the hepatology attending and the decision was made not to attempt additional intervention. Mild portal hypertensive gastropathy was seen. [**9-21**] Colonoscopy Large rectal varices were seen in the distal rectum. The rectum and sigmoid colon appeared otherwise normal. Solid stool was encountered in the descending colon. There was no evidence of blood Brief Hospital Course: 54 yo M with hx of hep C cirrhosis s/p transplant who presents with worsening fatigue and weakness found to have anemia from gastric variceal bleed. . ACTIVE ISSUES # Gastric Variceal Bleed: The patient had 4 EGDs. On the initial EGD the source of active bleeding was injected with epinephrine however the patient's HCT continued to drop. During the third EGD hemostasis was achieved with dermabond injections into the large varix in the gastric fundus. He required a total of 6 units of pRBCs. Patient was started on octreotide gtt and protonix IV BID. He was also started on cefrtiaxone for prophylaxis. Patient remained hemodynamically stable and was transferred back to the floor. His PPI was switched to po. Ceftriaxone was switched to po cipro at treatment doses to complete 5 day course and ultimately transitioned to prophylactic doses. Later in his hospitalization he developed marroon stools with a subsequent hct drop. He underwent a colonoscopy and endoscopy which showed no sources of active bleeding. He was continued on his octreotide which he completed 72 hours of, without any further episodes of hematochezia or melena. He was tolerating a PO diet and had a stable HCT at the time of discharge. . # [**Last Name (un) **]: Cr up to 1.7 from 0.9. Unclear etiology but thought to be either prerenal given blood losses and poor po intake or secondary to tacrolimus toxicity. FeNa showd 0.44%. His Tacrolimus was held along with other medications that interfere with clearance (HAART and fluconazole). . # Hep C s/p liver transplant: most recent viral load 13,900,000 IU/mL on [**8-24**]. Most recent bx c/w chronic rejection vs cholestatic variant of Hep C. Patient was continued on cellcept and prednisone. He was initially given tacro dose but this was d/c after levels were in the 20s. At the time of discharge his tacrolimus was still being held to be restarted as an outpatient. Patient was also volume overloaded [**1-27**] cirrhosis with ascites and lower extremity edema. Diuretics were not initially started in the setting of GI bleed and later held because of worsening renal function. He became more short of breath following his blood transfusions and received lasix which some improvement in his breathing, he never had an increased oxygen requirement. Patient had multiple paracenteses, none of which showed evidence of SBP however with his low total protein he was started on cipro for SBP prophylaxis. . # Dermabond Pulmonary Embolisms: After the patient's dermabond procedure a CXR showed multiple opacities that were consistent with dermabond pulmonary embolisms. Likely occured from vascular translocation during appication of dermabond to gastric varix. Patient remained stable throughout hospital course. . # Elevated INR: Improved from 2.2 to 1.2 after vitamin K IV 5mg X 2. Likely a combination of synthetic dysfunction with vitamin K deficiency given longstanding poor PO intake. Unlikely to absorb PO vitamin K given severe cholestasis. . # Diabetes: Started on home dose of NPH however was still having very elevated sugars. Started NPH [**Hospital1 **]. His blood sugars were difficult to control during his stay, and it was felt that running a little on the higher side was better than him having hypoglycemia. He was discharged on 35units NPH in the AM and 10 in the PM. . # Hyponatremia: Likely hypervolemic hyponatremia from liver dysfunction. Remained stable throughout hospital stay. . # HIV (last CD4 count of 97 in [**8-5**]). Initially restarted on HAART regimen, however held in the setting of elevated tacro levels. His home regimen was restarted prior to discharge. Also continued on ppx with bactrim, azithromycin and fluconazole. . # Herpes lesions: He was treated with acyclovir while in the hospital but can go back on valtrex as an outpatient. Wound care saw the patient and made the following recs: - Cleanse wound with wound cleanser then [**Date Range **] dry - apply aloe vesta as needed to moisturize dry skin - apply Xeroform dressing to provide antimicrobial coverage and dry out wound, place under pt - no need for additional dressing or securement. change daily and prn - Can use critic aid clear barrier ointment as well if pt becomes incontinent of stool . # Hypothyroidism: continued synthroid . Transitional Issues: The following medication changes were made: -START Ciprofloxacin 250mg by mouth once daily -START Pantoprazole 40mg by mouth twice daily -START Nadolol 20mg by mouth once daily -CHANGE NPH insulin dose to 35U in the morning and 10U at night. This should be further adjusted by your doctors to ensure [**Name5 (PTitle) **] blood sugar control. Please continue to check your blood sugars 4 times a day at home and continue your sliding scale. -STOP Famotidine -STOP Fluconazole due to high tacrolimus levels until you meet with Dr. [**Last Name (STitle) 497**] and Dr. [**Last Name (STitle) 724**] [**Name (STitle) 66360**] Tacrolimus (prograf) until further instructed by Dr. [**Last Name (STitle) 497**] Medications on Admission: abacavir 300mg [**Hospital1 **] azithromycin 1200mg po qThursday famotidine 20mg po q12 hr prn - does not take regularly fluconazole 400mg po daily levothyroxine 25mcg po daily lopinavir-ritonavir 50-200mg 2 tabs [**Hospital1 **] cellcept 500mg po bid raltegravir 400mg po bid bactrim 800/160 [**12-27**] tab by mouth daily tacrolimus 2mg po q tuesday night valcyclovir 1000mg po TID Tylenol PRN (do not exceed 2g daily) calcium carbonate/D3 regular insulin SS NPH 36U daily Discharge Medications: 1. azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK (TH). 2. levothyroxine 25 mcg 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. prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO three times a day. 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. NPH insulin human recomb 100 unit/mL Suspension Sig: Thirty Five (35) Units Subcutaneous each morning. 10. NPH insulin human recomb 100 unit/mL Suspension Sig: Ten (10) Units Subcutaneous each night. 11. insulin regular human 100 unit/mL Solution Injection 12. calcium carbonate-vitamin D3 Oral 13. nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 14. abacavir 300 mg Tablet Sig: One (1) Tablet PO twice a day. 15. raltegravir 400 mg Tablet Sig: One (1) Tablet PO twice a day. 16. lopinavir-ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: Caregroup VNA Discharge Diagnosis: Primary: -Gastric variceal bleed -Hepatitis C cirhossis -Tacrolimus toxicity -Acute renal failure -Diabetes Secondary: -Human immunodeficiency virus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 34850**], You were admitted to the hospital for a gastrointestinal bleed. The bleeding was stopped with an endoscopic procedure. Your blood levels continued to decrease after this, but subsequently stabilized and you have no further bleeding that was seen. Your tacrolimus levels were also very high, which may be partly to to interactions with your fluconazole, HIV medications, and a recent tacrolimus dose increase. We temporarily held these medications for a few days in the hospital. Please continue to hold your tacrolimus and fluconazole after discharge, but please restart your HIV medications TONIGHT (lopinavir-ritonavir, raltegravir, abacavir) as previously prescribed. You have scheduled follow up with Dr. [**Last Name (STitle) 497**] and Dr. [**Last Name (STitle) 724**] next week at which point your labs will be checked. Your blood sugars were also very high, and we have increased your insulin doses. It is very important that you check your blood sugars while at home and that your doctors monitor this at follow up. PLEASE call your doctors if [**Name5 (PTitle) **] experience any of the symptoms listed below. The following medication changes were made: -START Ciprofloxacin 250mg by mouth once daily -START Pantoprazole 40mg by mouth twice daily -START Nadolol 20mg by mouth once daily -CHANGE NPH insulin dose to 35U in the morning and 10U at night. This should be further adjusted by your doctors to ensure [**Name5 (PTitle) **] blood sugar control. Please continue to check your blood sugars 4 times a day at home and continue your sliding scale. -STOP Famotidine -STOP Fluconazole due to high tacrolimus levels until you meet with Dr. [**Last Name (STitle) 497**] and Dr. [**Last Name (STitle) 724**] [**Name (STitle) 66360**] Tacrolimus (prograf) until further instructed by Dr. [**Last Name (STitle) 497**] Followup Instructions: Department: TRANSPLANT When: MONDAY [**2117-9-27**] at 11:40 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: TRANSPLANT When: MONDAY [**2117-9-27**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Name: [**Last Name (LF) 11006**],[**First Name3 (LF) 251**] P Specialty: INTERNAL MEDICINE Location: [**Hospital **] HEALTHCARE CENTER Address: [**Street Address(2) **], [**Location **],[**Numeric Identifier 66357**] Phone: [**Telephone/Fax (1) 11329**] Appointment: WEDNESDAY [**10-7**] AT 4:15PM Department: DERMATOLOGY When: TUESDAY [**2118-8-23**] at 11:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2762**], 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

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icd9cm

[ [ [] ] ]

[ "45.13", "44.43" ]

icd9pcs

[ [ [] ] ]

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43841

Discharge summary

report

Admission Date: [**2184-5-14**] Discharge Date: [**2184-7-19**] Date of Birth: [**2131-7-16**] Sex: M Service: CARDIOTHORACIC Allergies: Codeine / Percocet / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 5790**] Chief Complaint: dyspnea and coughing Major Surgical or Invasive Procedure: 1. [**2184-5-14**] - Right thoracotomy and intrathoracic tracheoplasty with mesh, right mainstem bronchus and bronchus intermedius bronchoplasty with mesh, left mainstem bronchus bronchoplasty with mesh, bronchoscopy with bronchoalveolar lavage ([**Doctor Last Name **]) 2. [**2184-5-14**] - Flexible bronchoscopy ([**Doctor Last Name 7343**]) 3. [**2184-5-19**] - Cricothyroidotomy ([**Doctor Last Name 853**]) 4. [**2184-5-19**] - Revision of tracheostomy tube to 6.0 XL T Shiley ([**Doctor Last Name **]) 5. [**2184-5-21**] - Flexible bronchoscopy with bronchoalveolar lavage ([**Doctor Last Name **]) 6. [**2184-5-29**] - Exploratory laparotomy with closure of perforated gastric ulcer with modified [**Location (un) **] patch ([**Doctor Last Name **]) 7. [**2184-6-21**] - Left IJ tunnelled HD catheter 8. [**2184-6-28**] - Right basilic DL PICC History of Present Illness: 52M with a history of diabetes, kidney transplant in [**2162**] and [**10/2182**], pancreas transplant in [**2167**], colon cancer, and tracheobronchomalacia status post Y stent placement [**2183-11-27**] removed [**2184-2-25**] for excessive granulation tissue with a subsequent hospital stay through [**2184-3-1**] for respiratory failure and discharged on Bipap and home oxygen. Since hospital discharge [**2184-3-1**], he [**Month/Day/Year 1834**] a repeat flexible bronchoscopy showing considerable regression of bilateral mainstem granulation tissue. He endorses improvement in cough and breathing, although continues with occasional paroxysms that seem to be abated some with supplemental oxygen. He was taken off oxygen for 20 min in [**Hospital 3390**] clinic with [**Name Initial (PRE) **] lap around the office and tells me his oxygen did not dip below 94% on room air. Dyspnea occurs after ambulation of a block. He also continues to use Bipap at night that he finds gives him refreshing sleep. This has had severe impact on his quality of life and as he had had a excellent response to stent placement with notable improvement in his dyspnea and a difference in his cough it was felt he would benefit from tracheoplasty. Past Medical History: # Diabetes mellitus type I, now Diabetes mellitus type II post pancreas transplant (failed) # Status post renal ([**2162**]), pancreas transplants ([**2167**]), kidney transplant [**2182-11-12**] # Tracheobronchomalacia, severe. medical optimization since [**5-/2183**] # CKD Baseline Cr 1.1-1.5 this year # Hypertension # GERD # HLD # Peptic ulcer disease # [**Female First Name (un) 564**] esophagitis # Right lower extremity cellulitis # Left fifth toe amputation for Gangrene # Charcot Arthropathy- Septic left subtalar joint # Urinary tract infections # Retinopathy, status post vitrectomy # Esophageal achalasia # Post-strep GN # h/o stage 1 colon ca s/p resection in [**2178**] # s/p venous graft surgery Social History: -Tobacco history: None -ETOH: None -Illicit drugs: None -Home: Lives with Wife [**Name (NI) **] ([**Telephone/Fax (1) 94038**], [**Telephone/Fax (1) 94039**]) -Work: disabled, former business owner Family History: No lung cancer or congenital lung disease. Mother had frequent bronchitis Physical Exam: BP: 180/67. Heart Rate: 98. Weight: 222. BMI: 32.8. Temperature: 98.7. O2 Saturation%: 93. GENERAL [x] All findings normal [ ] WN/WD [ ] NAD [ ] AAO [ ] abnormal findings: HEENT [x] All findings normal [ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric [ ] OP/NP mucosa normal [ ] Tongue midline [ ] Palate symmetric [ ] Neck supple/NT/without mass [ ] Trachea midline [ ] Thyroid nl size/contour [ ] Abnormal findings: RESPIRATORY [] All findings normal [ ] CTA/P [ ] Excursion normal [ ] No fremitus [ ] No egophony [ ] No spine/CVAT [ ] Abnormal findings: rhonchorus; decreased at bases CARDIOVASCULAR [x] All findings normal [ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema [ ] Peripheral pulses nl [ ] No abd/carotid bruit [ ] Abnormal findings: GI [x] All findings normal [ ] Soft [ ] NT [ ] ND [ ] No mass/HSM [ ] No hernia [ ] Abnormal findings: scars present GU [x] Deferred [ ] All findings normal [ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE [ ] Abnormal findings: NEURO [x] All findings normal [ ] Strength intact/symmetric [ ] Sensation intact/ symmetric [ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact [ ] Cranial nerves intact [ ] Abnormal findings: MS [x] All findings normal [ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl [ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl [ ] Nails nl [ ] Abnormal findings: some edema of ankles; LYMPH NODES [x] All findings normal [ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl [ ] Inguinal nl [ ] Abnormal findings: SKIN [x] All findings normal [ ] No rashes/lesions/ulcers [ ] No induration/nodules/tightening [ ] Abnormal findings: PSYCHIATRIC [x] All findings normal [ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect [ ] Abnormal findings: Pertinent Results: [**2184-5-14**] 09:29PM TYPE-ART PO2-117* PCO2-42 PH-7.29* TOTAL CO2-21 BASE XS--5 [**2184-5-14**] 09:29PM GLUCOSE-114* LACTATE-1.3 K+-4.3 [**2184-5-14**] 09:29PM freeCa-1.15 [**2184-5-14**] 06:23PM TYPE-ART TEMP-36.7 PEEP-5 O2-50 PO2-79* PCO2-50* PH-7.22* TOTAL CO2-22 BASE XS--7 INTUBATED-INTUBATED [**2184-5-14**] 06:23PM LACTATE-0.9 [**2184-5-14**] 06:23PM freeCa-1.18 [**2184-5-14**] 06:15PM GLUCOSE-209* UREA N-47* CREAT-1.8* SODIUM-140 POTASSIUM-6.0* CHLORIDE-112* TOTAL CO2-19* ANION GAP-15 [**2184-5-14**] 06:15PM estGFR-Using this [**2184-5-14**] 06:15PM CK(CPK)-3790* [**2184-5-14**] 06:15PM CK-MB-30* MB INDX-0.8 cTropnT-<0.01 [**2184-5-14**] 06:15PM CALCIUM-8.5 PHOSPHATE-5.0* MAGNESIUM-2.0 [**2184-5-14**] 06:15PM WBC-5.4 RBC-3.64* HGB-10.3* HCT-34.7* MCV-95 MCH-28.2 MCHC-29.6*# RDW-14.2 [**2184-5-14**] 06:15PM NEUTS-83.6* LYMPHS-7.5* MONOS-7.3 EOS-1.3 BASOS-0.3 [**2184-5-14**] 06:15PM PLT COUNT-337 [**2184-5-14**] 06:15PM PT-11.1 PTT-31.4 INR(PT)-1.0 [**2184-5-14**] 05:01PM TYPE-ART PO2-143* PCO2-75* PH-7.09* TOTAL CO2-24 BASE XS--8 INTUBATED-INTUBATED VENT-CONTROLLED [**2184-5-14**] 05:01PM GLUCOSE-212* LACTATE-1.3 NA+-139 K+-5.7* CL--112* [**2184-5-14**] 05:01PM freeCa-1.18 [**2184-5-14**] 05:01PM freeCa-1.18 [**2184-5-14**] 03:54PM GLUCOSE-237* LACTATE-0.9 NA+-136 K+-5.9* CL--113* TCO2-19* [**2184-5-14**] 03:54PM freeCa-1.17 [**2184-5-14**] 02:45PM TYPE-ART PO2-95 PCO2-47* PH-7.26* TOTAL CO2-22 BASE XS--5 INTUBATED-INTUBATED VENT-CONTROLLED [**2184-5-14**] 02:45PM GLUCOSE-254* K+-6.2* [**2184-5-14**] 02:45PM HGB-10.3* calcHCT-31 [**2184-5-14**] 01:11PM TYPE-ART PO2-90 PCO2-68* PH-7.13* TOTAL CO2-24 BASE XS--7 INTUBATED-INTUBATED [**2184-5-14**] 01:11PM GLUCOSE-258* LACTATE-0.6 NA+-137 K+-5.9* CL--112* [**2184-5-14**] 01:11PM HGB-10.5* calcHCT-32 [**2184-5-14**] 01:11PM freeCa-1.20 [**2184-5-14**] 11:13AM TYPE-ART PO2-84* PCO2-56* PH-7.22* TOTAL CO2-24 BASE XS--5 INTUBATED-INTUBATED VENT-CONTROLLED [**2184-5-14**] 11:13AM GLUCOSE-255* LACTATE-0.7 NA+-137 K+-5.8* CL--106 TCO2-22 [**2184-5-14**] 11:13AM HGB-10.9* calcHCT-33 O2 SAT-93 [**2184-5-14**] 11:13AM freeCa-1.29 [**2184-5-14**] 09:33AM TYPE-ART PO2-78* PCO2-57* PH-7.21* TOTAL CO2-24 BASE XS--5 INTUBATED-INTUBATED VENT-CONTROLLED [**2184-5-14**] 09:33AM GLUCOSE-189* LACTATE-1.1 NA+-141 K+-4.6 CL--108 [**2184-5-14**] 09:33AM HGB-11.6* calcHCT-35 O2 SAT-92 [**2184-5-14**] 09:33AM HGB-11.6* calcHCT-35 O2 SAT-92 [**2184-5-14**] 09:33AM freeCa-1.25 [**2184-5-19**] CXR : A single portable semi-erect chest radiograph is obtained. The endotracheal tube tip remains 4 cm above the carina. An enteric catheter passes out of the field of view. A right pleural catheter is in unchanged position. Central pulmonary vasculature congestion has worsened since the prior exam 24 hours ago, contributing to apparent mediastinal widening. Retrocardiac opacity is unchanged. A moderate left and small right pleural effusion is similar. [**2184-5-29**] CT Chest/abd/pelvis : 1. Moderate pneumoperitoneum due to distal gatric or duodenal bulb ulcer. 2. Secondary moderate amount of free fluid and secondary inflammatory wall thickening of the proximal small bowel loops. 3. Right renal pelvis transplant without evidence of hydronephrosis or perinephric fluid collections. 4. Bilateral lower lobe atelectatic changes. Tracheal abnormality likely due to tracheomalacia and recent surgeries, not well evaluated here. [**2184-6-5**] CT Chest/abd/pelvis : 1. New bilateral pleural effusions, right greater than left. Overlying compressive atelectasis. 2. Linear area of contrast at previous site of leak adjacent to first portion of duodenum/distal pylorus. Given the lack of significant surrounding fluid and lack of pneumoperitoneum, this could represent residual oral contrast from previous CT which demonstrated original leak at the site. However, a persistent leak at this site cannot be completely excluded [**2184-6-8**] MRI T & L spine : 1. Abnormal cord signal and mild expansion from levels T2 through T6 which is incompletely imaged in the absence of axial slices and gadolinium and may represent ischemic infarct (in the setting of advanced atherosclerotic disease involving the aorta and its branches), transverse myelitis, intramedullary neoplasm and vascular abnormality cannot be completely excluded. Further characterization by dedicated contrast-enhanced exam is advised. 2. Relatively mild degenerative changes of the lumbar spine as detailed above, most notably with bilateral lateral recess stenosis at L4/L5. [**2184-6-7**] EEG : This is an abnormal awake and sleep EEG, because of diffusely attenuated and slow background with generalized bursts of further slowing. These findings are indicative of moderate diffuse cerebral dysfunction of nonspecific etiology. No epileptiform discharges or electrographic seizures are present. Note is made of rare wide-complex premature cardiac beats. [**2184-6-8**] Cardiac echo : The left atrium is mildly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast (single injection). There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF 75%). Right ventricular chamber size and free wall motion are normal. The aortic 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. An eccentric, posteriorly directed jet of mild (1+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. [**2184-6-8**] upper ext duplex : No evidence of deep vein occlusive thrombus. Non-occlusive thrombus is seen within the right IJ with no evidence of central extension [**2184-6-8**] Renal ultrasound : Satisfactory appearance of the more recent midline renal transplant graft with satisfactory flow noted and Doppler waveforms in the main renal artery and vein. Satisfactory arterial waveforms are identified in the upper, mid and lower pole arcuate arteries with moderately elevated resistive indices as described. [**2184-6-9**] MRA Head/neck : 1. Limited evaluation of the neck MRA for stenosis, but no occlusion is seen in carotid or vertebral arteries. 2. Limited evaluation of the MRA of the head, but no evidence of occlusion seen in the anterior or posterior circulation or evidence of stenosis seen in the anterior or middle cerebral artery or posterior cerebral arteries or distal vertebral arteries. [**2184-6-10**] EMG : Abnormal study. The electrophysiologic findings are suggestive of a generalized sensorimotor polyneuropathy characterized by motor > sensory abnormalities with axonal > demyelinating features. These findings are consistent with critical illness polyneuropathy/myopathy; however, another cause for these abnormalities, including diabetic polyneuropathy, is also possible. The decreased activation in all muscles is consistent with the patient's known central nervous system abnormalities. [**2184-6-17**] CT Abd/pelvis : New findings of extraluminal contrast around the gallbladder and increasing amount of free air at the site of previous surgery is suspicious for ongoing leak. No intra-abdominal fluid collections to suggest abscess. Persistent atelectasis versus pneumonia involving the lower lobes of the lungs. Additional similar findings of atrophic native kidneys with acquired renal cyst, subcutaneous and pelvic transplant kidneys and extensive atherosclerotic vascular disease. [**2184-6-21**] CT Abd/pelvis : 1. Findings concerning for persistent enteric leak with extraluminal pockets of gas identified along the anterior aspect of the [**Location (un) **] patch and tracking between the anteromedial gallbladder and second portion of the duodenum and to a lesser degree down into the mesentery. Persistent extraluminal contrast approximates second portion of the duodenum, unclear if residual from prior study or related to current oral contrsat administration. 2. Air identified within the fundus of the gallbladder at the site of anterior inflammatory change and proximal to the persistent anterior abdominal wall tract at site of prior drain. These findings in conjunction with report of biliary drainage through drain tract are concerning for communication with biliary system. Secondarily, air in gallbladder alone (and not remainder of biliary tree) may be related to recent catheterization/interventional attempt. 3. Small pocket of fluid identified anteromedial to gallbladder, too small for drainage. No other loculated fluid collection identified. 4. Otherwise, unchanged exam with atrophic bilateral native kidneys, abandoned transplanted kidney in the right pelvis and a perfused, nonedematous transplanted kidney in the superficial tissues of the right lower quadrant. [**2184-6-22**] Fistulogram : Enterocutaneous fistula involving the duodenum [**2184-6-27**] CT Chest/abd/pelvis : 1. Enlarging bilateral effusions with bilateral airspace opacities,bibasal consolidations and reactive mediastinal lymphadenopathy, new from the prior study of [**2184-6-21**]. These likely represent multifocal pneumonia. 2. There is a a gas-fluid collection anterior the gallbladder, in continuity with the enterocutanous fistula tract, measuring a maximum dimension of 7.2 cm craniocaudal extension, only sightly larger compared to the the prior studies. Stable smaller phlegmonous changes and periduodenal collections. Unchanged appearance of the transplanted kidney which is not fully evaluated given the lack of intravenous contrast, however, does not demonstrate any evidence of hydronephrosis or perinephric collection. [**2184-6-28**] US for PICC line : Uncomplicated ultrasound and fluoroscopically guided double lumen PICC line placement via the right basilic venous approach. Final internal length is 40 cm, with the tip positioned in SVC. The line is ready to use. [**2184-7-6**] CY Abd/pelvis : 1. Hyperdense contrast material layering at the medial aspect of the gallbladder, also seen on prior examinations, but appearing extraluminal, suspicious for a tiny leak, but minimally changed since the prior CT examination. 3. Unchanged loculated anterior abdominal collection with possible cutaneous fistula, remaining too small for drainage. 4. Moderate bilateral pleural effusions with adjacent compressive atelectasis, minimally changed since [**2184-6-27**]. Underlying pneumonia cannot be excluded. 5. Post multiple kidney transplants. No acute intrapelvic process. Brief Hospital Course: Mr. [**Known lastname 410**] [**Last Name (Titles) 1834**] tracheobronchoplasty on [**2184-5-14**] without issue. Postoperatively he was brought to the surgical ICU in good condition. Post-operatively the patient had a prolonged requirement for mechanical ventilation. Several CPAP trials failed due to respiratory acidosis. In addition the patient continued to have severe swelling of his airway despite methylprednisone treatment. Renal transplant was consulted during the post-operative phase and continued to manage the patient's immunosuppressant dosing. On [**5-15**] POD1 the patient [**Month/Year (2) 1834**] bronchoscopy, which suggested that the degree of swelling at improved. His chest tube was placed to water seal. Despite continued diuresis, the patient continued to require mechanical ventilation. He again weaned to CPAP and on [**5-19**] POD5 extubation was attempted and failed. The patient was tachypneic, reintubation also failed, emergent crichothyrotomy was performed at the bedside by ACS. This was later exchanged to tracheostomy tube in the OR by Dr.[**Last Name (STitle) **]. A dobhoff tube was also placed in OR - and home immunosupression. VAP protocol started for GPC found on sputum culture. Tube feeding was advanced on POD 8, which the patient tolerated well. On POD 10 the patient failed PMV evaluation due to pharyngeal edema. The patient also had high TF residuals and so tube feeding was held for one day. ENT performed laryngoscopy to determine if swelling would account for the patient's inability to use a PMV valve. Supraglottic swelling was noted by ENT. The patient's tube was down size to a fenestrated tracheostomy tube to allow for greater air flow. However the diameter of the tube was smaller and resulted in some derecruitment. On the evening of POD 12 on [**5-28**], the patient acutely decompensated on the floor with an abrupt desaturation to 88%. The patient was transferred back to the SICU, bronchoscopy performed at the bedside was negative for mucus plugs. In the early hours of POD 13 the patient abruptly began to have abdominal pain. Translant surgery was consulted and a CT A/P w PO contrast done which was significant for free air. Neosynephrine was started for hypotension, and the patient was given stress dose steroids for possible renal insufficiency and was taken emergently to the OR for emergent laparotomy. He [**Month/Day (4) 1834**] [**Location (un) **] patch repair of a gastric perforation. Post operatively the patient was transfused packed red blood cells as needed and was weaned off levophed. Insulin and bicarbonate gtts were initiated for blood glucose control and acidosis respectively. The patient was weaned off steroids. On POD [**11-21**] (aka POD 12 and POD 2) from tracheobronchoplastyand the [**Location (un) **] patch repair respectively, the patient was initiated on tube feeding. During the post operative period the patient required CVVH. Over the course the next week the patient progressively improved. CVVH was continued and the patient was again weaned from mechanical ventilation. On [**6-5**] POD 16/6 the patient spiked Fever to 102. He was pan-cultured and all lines were removed. CT ab/pelvis did not show intraabdominal fluid collection. On POD 17/7, It was noted that the patient was not moving his lower extremity in the PM, although his neurological exam was inconsistent. MR T and L spine obtained per neurology and revealed increased T2 signal ranging from approximately T3-T7. On POD 18/8, MR T spine suggested an abnormal signal T1-T2 level and extending below the field of view is concerning for a spinal cord infarction. Currently patient has not recovered function of his legs. Again on POD 28/23/13 the patient was unable to successfully use a PMV and it was felt to be due to a lack of airflow. On POD 29/24/14, ENT was called to reevaluate for airway edema and for possible assistance in downsizing tracheal collar. His quetiapine was decreased, and the central venous line discontinued. Because Mr. [**Known lastname 410**] was euvolemic, he did not receive dialysis. His vancomycin was held for a trough of 15. On POD 30/25/15, the patient developed copious, thick secretions, which were suctioned from tracheal collar. During the day his oxygen saturation fell to the 70s. He subsequently was aggressively suctioned. A chest xray showed no difference from previous CXR. As night progressed, Mr. [**Known lastname 410**] began to have increasing respiratory distress and required increasing amount of tracheal care. An ABG showed pH 7.15/73/92. As such, he was placed back on the ventilator. On POD 31/26/16, Mr. [**Known lastname 410**] was unable to tolerate CPAP and was put back on CMV. His JP drain was discontinued. he was started on cefepime. In addition, ENT attempted a supraglottic scope; however, visualization was poor secondary to secretions. Tube feeds were restarted. On POD 32/27/17, Mr. [**Known lastname 410**] was weaned from CMV to trach collar throughout day, which he tolerated well. He received HD via a new femoral HD line placed that day, and the prior LIJ HD line was discontinued. His NPH was increased to 25u [**Hospital1 **] and he continued sliding scale insulin. He developed a temperature of 101.2 in the early AM, for which acetaminophen was given. MiniBAL cultures negative for Pneumocystis jirovecii. On POD 33/28/18, Mr. [**Known lastname 410**] developed increased abdominal pain, temp 100.5, KUB without evidence of definite free air. Deffervesced to 98.5. Cx no growth to date. On POD 34/29/19, the Dobhoff tube became occluded and was replaced by IR. A CT of the abdomen/pelvis with PO contrast showed persistent leak at the pylorus, unchanged since [**2184-6-5**]. Mr. [**Known lastname 410**] also developed a 101 temperature, for which he was pan-cultured. He developed hypotension that evening but responded well to albumin. On POD 35/30/20, bedside broncoscopy was performed. It revealed abundant respiratory secretions, which were suctioned, and a BAL was sent. A post-bronchoscpoy CXR was without evidence of pneumothorax. Transplant discontinued staples from the midline abdominal incision and signed off. On POD 36/31/21, Mr. [**Known lastname 410**] had hemodialysis, where there was concern raised for high pressures on the femoral HD line; thus, a request was put in for a tunneled HD catheter via IR. He was started on sertraline for depression. The Dobhoff tube was found to be blocked secondary to bridal kinking tube, but this issue was resolved. On POD 37/32/22, patient noted to be tolerating tube feeds as well as tracheal collar all day. On POD 38/33/23, a tunneled HD line was placed by IR on L side [**1-22**] incidental finding of thrombosed R IJ CVL (started Tx w/ hep gtt). Mr. [**Known lastname 410**] also developed copious bilious drainage from old surgical drain site. So, on POD 39/24, a sinogram was performed that revealed the presence of of an enterocutaneous fistula involving the duodenum. As such, the patient was made NPO. Also on POD 39/34/24, a triple lumen catheter was placed as patient required additional access for things like TPN. He received hemodialysis, and because of the thrombus found during insertion of the tunneled line, he was started on a heparin drip. On POD 40/35/25, his fungal culture grew out [**Last Name (LF) 23087**], [**First Name3 (LF) **] he was started on fluconazole. Bronchoscopy was performed to remove mucus plugs. On POD 41/36/26, he was reevaluated by speech and swallow for a PMV but failed. His tacrolimus was decreased from 2mg to 1mg twice daily. His cellcept was also decreased from 500 to 250 twice daily. Hemodialysis was performed, and approximately 3 liters were removed. At this time, there was questionable movement of his right foot, which was a new finding considering the presumed thoracic spine infarct. POD42/37/27 was unremarkable. On POD43/38/28, hemodialysis was performed but no fluid removed secondary to systolic blood pressures in the 70's; in addition, he became hypothermic to 95 degrees farenheit. He became dyspnic, and an ABG showed hypoxic, hypercapnic respiratory failure (PCO2 = 72, PO2 = 50), and a CXR revealed pulmonary edema. As such, his ventilator settings were changed from PSV 10/5 with 50% FiO2 to PSV 10/10 with 60% FiO2. Given his hypotension, he was started on continuous [**Last Name (un) **]-venous hemodialysis to manage fluid balane. From a neurologic perspective, Mr. [**Known lastname 410**] was moving his toes on physical exam. In terms of GI, his dobhoff tube was discontinued. On POD44/39/29, concern for his worsening respiratory status from the day before without a clear etiology prompted expansion of antibiotic coverage to vancomycin, meropenem, and micafungin. A CT scan of the torso was performed, which revealed development of new bilateral opacities and complete collapse of the left lower lobe. On POD45/40/30, a double lumen PICC line and peripheral IV were placed. Out of concern for possible line sepsis, the femoral line was discontinued. Our service performed bronchoscopy in an effort to optimize his respiratory status. We removed thick mucous secretions, most heavily concentrated in his right and left lower lobes. The BAL was cultured and grew out 1+PMNs. From an endocrine standpoint, Mr. [**Known lastname **] blood sugars were found to be in the 300s, so an insulin drip was started. For hypertension control of systolic blood pressures in the 180s, he was started on IV hydralazine PRN. On POD46/41/31, during CVVH the system clotted and was ultimately unable to return ~200 cc of blood that were taken during the cycle. He was restarted on olanzapine, and started on lantus 20 [**Hospital1 **]. On POD47/42/32, thoracentesis of the left chest was performed, which drained about 400mL. He was weaned to trach collar during the day but ultimately required a return to CPAP overnight for poor ability to clear secretions. On POD48/43/33, his meropenem was decreased secondary to being off CVVH, which was held in hopes that the patient would stabilize and return to clinical status eligible for hemodialysis. On POD49/44/34, from a neurologic standpoint, Mr. [**Known lastname 410**] continued to move his legs arbitrarily on exam. His TPN was decreased from 65 to 40 and RISS added. He was able to wean to a trach collar. On POD50/45/35, no further drainage from his enterocutaneous fistula was noted, and finalized thoracentesis cultures were negative. On POD51/46/36, an upper GI study was performed to assess for contrast leak; however, the cotrast pooled in the stomach. At this point, serial KUBs were performed to monitor for emptying of contrast into the duodenum. After contrast was empyting, a CT of the abdomen was performed under this less-than-ideal study. The CT scan reveals contrast that was extraluminal; however, the read was preliminary at the time. On POD52/47/37, our service downsized Mr. [**Known lastname 13207**] trach from a Shiley 6 to a Portex 6, which is actually a bit smaller. A final read on the CT of the abdomen confirmed a leak did exist. On POD53/48/38, a repeat PMV evaluation was successful. An attempt was made by IR to advance the Dobhoff tube; however, a stricture in the antrum of the stomach prevented this advancement. On POD54/49/39, the NGT was discontinued due to failure to advance the tube post-pylorically. This failure was felt to be secondary to the antral stricture vs. possible post-operative swelling from [**Last Name (un) 84719**] patch repair. The hemodialysis line was found to have increased moistness and erythema, so a wound swab was sent for culture. On POD 60, the patient reported poor pain control with morphine alone. He was initiated on a fentanyl patch, 75 mcg. On POD 61, patient became obtunded. He was transferred to the ICU, where he was put on a ventilator. He also spiked a fever of 102.5, for which blood, urine, and sputum cultures were sent. He was continued on his current antibiotic regimen. On POD 62, patient tolerated PS trial early am, and had 3L removed in HD. He remained afebrile throughout the day. On POD 63, patient was taken off ventilation, and his tracheostomy cuff was deflated, which he tolerated well. On POD 64, all the antibiotics were discontinued on POD 65, patient was sent to rehab Medications on Admission: albuterol 180q6prn, alendronate 70qweek, amlodipine 10', fluticasone 50', folic acid 1', lasix 20", Lantus [**10-9**]", Humalog SS, labetolol 200''', losartan 25', MMF 750", omeprazole 20', pantop 40', prednisone 5', tacrolimus 3.5", tamsulosin 0.4', trazodone 50prn, ASA 81' Discharge Medications: 1. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob/ wheeze 3. Albuterol-Ipratropium [**5-28**] PUFF IH Q6H:PRN wheezing/dyspnea 4. Artificial Tear Ointment 1 Appl BOTH EYES PRN eye care 5. Bisacodyl 10 mg PR PRN constipation 6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **] 7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 8. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 9. Heparin Flush (1000 units/mL) 4000-[**Numeric Identifier 2249**] UNIT DWELL PRN line flush Dialysis Catheter (Temporary 3-Lumen): DIALYSIS Lumens/ DIALYSIS NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL NS followed by Heparin as above according to volume per lumen. 10. Lorazepam 0.5-1 mg IV Q6H:PRN Anxiety 11. Pantoprazole 40 mg IV Q24H 12. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Tunneled Access Line ([**Initials (NamePattern5) **] [**Last Name (NamePattern5) **]), non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 13. Tacrolimus 1.5 mg SL Q12H Duration: 2 Doses 14. Acetaminophen IV 1000 mg IV Q6H:PRN fever/pain 15. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QFRI 16. Fluticasone Propionate 110mcg 4 PUFF IH [**Hospital1 **] 17. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 18. Albuterol Inhaler [**1-24**] PUFF IH Q2H:PRN wheezing 19. Haloperidol 1 mg IV HS:PRN insomnia 20. Haloperidol 1 mg IV BID:PRN anxiety 21. Heparin Flush (1000 units/mL) 4000-[**Numeric Identifier 2249**] UNIT DWELL PRN line flush Dialysis Catheter (Tunneled 2-Lumen): DIALYSIS NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL NS followed by Heparin as above according to volume per lumen. 22. MethylPREDNISolone Sodium Succ 4 mg IV DAILY 23. Metoprolol Tartrate 5 mg IV Q6H HOLD FOR BP< 110, HR <60 24. Mycophenolate Mofetil 250 mg IV BID 25. Ondansetron 4 mg IV Q8H:PRN nausea 26. Heparin IV per Weight-Based Dosing Guidelines Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Hospital1 8**] Discharge Diagnosis: 1. Severe diffuse tracheobronchomalacia. 2. Respiratory failure 3. Perforated gastric ulcer 4. Spinal cord infarct T1-T5 5. Left occipital embolic stroke 6. Right cerebellar stroke 7. Right IJ thrombus 8. Multifocal pneumonia 9. Enterocutaneous fistula 10.Sepsis 11.Depression/delirium 12.Stage 3 decubitus ulcer 13. Critical illness polyneuropathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Non-ambulatory secondary to paraplegia 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 hospital for tracheoplasty but unfortunately you developed multiple post op complications including respiratory insufficiency requiring a tracheostomy, renal failure, a perforated ulcer and a spinal cord infarct causing paralysis of your lower extremities. * You will need vigorous physical therapy and respiratory therapy indefinitely. * Currently your nutritional intake is strictly with IV hyperalimentation. You will be able to eat in time after your fistula heals. * You also need to be anticoagulated due to a clot in your jugular vein. Currently you are on IV heparin but when you are able to take medication orally , you will be placed on Coumadin. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2184-7-29**] at 2:30 PM With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Please report 30 minutes prior to your appointment to the Radiology Department on the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinical Center for a chest xray. Department: TRANSPLANT CENTER When: MONDAY [**2184-8-2**] at 10:45 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14955**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: TRANSPLANT CENTER When: TUESDAY [**2184-11-2**] at 11:00 AM With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**] Date/Time:[**2184-7-29**] 2:30 Provider: [**Name10 (NameIs) **],DIALYSIS SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2184-7-20**] 7:30 Completed by:[**2184-7-19**]

[ "V42.83", "933.1", "585.6", "569.81", "997.02", "707.03", "E878.8", "531.50", "V45.11", "276.0", "998.59", "998.30", "997.79", "453.86", "785.52", "250.61", "434.11", "518.51", "519.19", "995.92", "996.81", "272.4", "276.2", "486", "336.1", "276.69", "707.23", "530.81", "356.9", "038.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.95", "34.91", "03.31", "44.41", "31.74", "39.95", "31.1", "96.72", "31.79", "33.22", "33.48", "33.24", "99.15", "38.97" ]

icd9pcs

[ [ [] ] ]

31134, 31199

16311, 28703

340, 1194

31592, 31592

5483, 16288

32615, 33974

3433, 3509

29029, 31111

31220, 31571

28729, 29006

31906, 32592

3524, 5464

280, 302

1222, 2462

31745, 31882

2484, 3199

3215, 3417

20,106

191,491

29339+57636

Discharge summary

report+addendum

Admission Date: [**2103-12-17**] Discharge Date: [**2103-12-24**] Date of Birth: [**2026-3-28**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: Severe, acute onset HA starting [**2103-12-17**] at 0800 Major Surgical or Invasive Procedure: None History of Present Illness: Patient is 77 y.o. male with h/o myeloproliferative d/o (possibly CML) who had sudden onset "Worst headache of my life." Reports that he was driving to a scheduled fluoro guided LP at the VA, when he had acute onset sensation of pressure and pain, as if being stabbed in the back of the neck. Pain radiated up occiput and to temples bilaterally. Reports no head trauma (not even slight bump while getting into car), and denies any recent trauma or falls. Was in marked distress and sent to ER where CT was reportedly negative. Was medicatd and sent for fluor guided LP which was markedly bloody and did not clear. Had 192,000 RBCs in tube #4. Was evaluated by neurology/neurosurg at the VA and no neurological deficits. Was recommended for Dilantin, Nimodipine, strict BP control, CTA and MRI of spine. He was then transferred to [**Hospital1 18**] for further management. Patient was also febrile to 101 at the VA. After transfer to [**Hospital1 18**] he was started on vanc, ceftriazone, acyclovir for a possible meningitis. CT head showed findings c/w SAH, and CTA showed possibility of anterior comm artery aneurysm. The patient was admitted to the Neurosurgery service in the SICU for further monitoring. Scheduled for angiography this AM. Heme/onc consult requested to answer question of whether CNS leukemia could be cause of SAH. ROS: HA as above. No visual changes. No weakness, numbness or tingling. No vomitting but nausea present. No seizures. Past Medical History: Myeloproliferative disorder (possibly CML) HTN CAD Hyperlipidemia Afib s/o cardioversion not on anticoagulation GERD Anxiety BPH s/p cholecystectomy cataract surgery R Knee Surgery h/o MRSA ([**2102**]) h/o C. Diff Social History: No tob, occ etoh, lives alone in [**Location (un) **]. Family History: No h/o stroke or hemorrhage. no h/o renal disease. mother had breast ca. Physical Exam: T-97.4 BP- 111-124/38-43 HR-64-71 RR-13-42 O2Sat 96-100% Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and date. Attentive, says [**Doctor Last Name 1841**] backwards. Speech is fluent with normal comprehension and repetition; naming intact. No dysarthria. [**Location (un) **] and writing intact. Registers [**3-30**], recalls [**3-30**] in 5 minutes. No right left confusion. No evidence of apraxia or neglect. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Visual fields are full to confrontation. Extraocular movements intact bilaterally, no nystagmus. Sensation intact V1-V3. Facial movement symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline, movements intact. Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor. No pronator drift. [**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, pinprick, vibration and proprioception throughout. No extinction to DSS Reflexes: +2 and symmetric throughout. Toes downgoing bilaterally. Coordination: finger-nose-finger normal, heel to shin normal, RAMs normal. Gait: unable to assess secondary to s/p angio Romberg: not assessed Pertinent Results: 134 99 20 120 AGap=14 ------------< 5.0 26 1.2 Ca: 8.4 Mg: 2.3 P: 5.2 Phenytoin: 25.2 11.0 48.5 >< 410 N:83 Band:3 L:2 M:3 E:1 Bas:0 Metas:3 32.2 PT: 13.7 PTT: 25.5 INR: 1.2 UA negative. LP at OSH: 192,000 RBCs in tube 4. 127 nucleated cells with diff of 56 segs, 18 lymph, 1 mono, 12 Bands. Glucose 51, Protein 361. Serum gluc 108. Imaging: CTA Head: Probable minute anterior communicating artery aneurysm. However, such an abnormality does not likely account for the multiple areas of hemorrhage, with the largest collection seen in relation to the left side of the cervicomedullary junction of the neuraxis. While no definite enhancement is seen to suggest an alternative diagnosis for the foramen magnum lesion, such as a meningioma or leukemic deposit, after discussing the case with the attending neurosurgeon, Dr. [**Last Name (STitle) 25918**], consideration for a followup MR study using gadolinium enhancement was suggested, as well as consideration for standard catheter cerebral angiography. ADDENDUM: There are minor atherosclerotic calcifications involving the distal left internal carotid artery, immediately proximal to the carotid foramen. MRI/MRA Head and Neck: no official read available. No DWI abnormalities. Angio: tiny several mm Acom aneurysm . No [**Country **] abnormailty. All 4 vessels patent. Brief Hospital Course: 77 y.o. male with h/o myeloproliferative d/o, HTN, acute onset severe HA and subarachnoid hemorrhage in mulitple areas with no associated trauma. Angio showed tiny 4mm acommunicating artery aneurysm. Exam is currently negative. Neuro: OSH head CT negative for bleed however, head CT in ED showed regions of subarachnoid hemorrhage at the left cervicomedullary junction (level of foramen magnum) and bilateral posterior temporal lobes. Additionally, there was a intra-ventricular hemorrhage within the right occipital [**Doctor Last Name 534**]. CTA head showed a 1mm sessile aneurysm from the anterior communicating artery and minor atherosclerotic calcifications involving the distal left internal carotid artery, immediately proximal to the carotid foramen. Differential diagnosis included meningioma or leukemic deposit, after discussing the case with the attending neurosurgeon, Dr. [**Last Name (STitle) **], consideration for a followup MR study using gadolinium enhancement was suggested, as well as standard catheter cerebral angiography. Dilantin was held. Patient was treated with triple H therapy including elevation of the blood pressure (induced Hypertension), Hemodilution to improve cerebral blood flow, and maintenance of high normal circulating blood volume (Hypervolemia). Patient was maitained on calcium channel blocker nimodipine is given at a dose of 60 mg by mouth every 6 hours. Dilantin was held. Antibiotics were discontinued given negative gram stain on CSF and low suspicion for infection. CVS: Patient was kept on telemetry without events. On nimodipine as above. Resp: No acute issues Renal: Increased intravasculature volume with IVF NS 100cc/hr. While on Acyclovir also received fluid boluses prior to administration. Endo: Regular insulin sliding scale. ID: IV Acyclovir continued due to fever and intracranial hemorrhage at presentation and discontinued on [**12-19**] given low clinical suspicion. Prohpylaxis: Heparin SC, Zantac, RISS Medications on Admission: Tramadol 50mg PO Q6H Aspirin 325mg PO QD Lisinopril 20mg PO QD Terazosin 2mg PO QHS Ranitidine 150mg PO BID Amiodarone 200mg PO QD Simvastatin 20mg QHS Diazepam 5mg PO QHS Discharge Disposition: Home with Service Discharge Diagnosis: Primary diagnosis: Subarachnoid hemorrhage Hemorrhage at cervicomedullary junction on the left Secondary diagnosis: Myeloproliferative disease Hypertension Hyperlipidemia Atrial fibrillation status post cardioversion Gastroesophageal reflux disease Anxiety History of MRSA in [**2102**] Discharge Condition: Patient left again medical advice. His condition and work-up results were explained to him to date. Furthermore, he was told that his work-up was not completed and that he still needed an MRI of the brain with and without contrast and that neuro-oncology was asked to evaluate him. It was explained that it was unsafe for him to leave. The team spoke with his daughter in an attempt to convince the patient to stay. However, despite our efforts, patient left AMA. He has a follow-up appointment scheduled with Dr. [**First Name (STitle) **] in [**Hospital 878**] Clinic in [**2-3**]. That patient understand what was explained to him and was competent to maek this informed decision as determined by the Stroke team. Patient was neurologically stable at the time he left AMA. Discharge Instructions: Please take medications as prescribed. Please keep your follow-up appointments. If you have any worsening headaches, weakness, falls, change in mental status or any other worrying symptoms, please call your primary care physician or return to the emergency room. Followup Instructions: PROVIDER: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone: [**Telephone/Fax (1) 2574**] Date/Time: [**2104-2-12**] 9:00AM PROVIDER: [**Name10 (NameIs) 5005**] [**Name11 (NameIs) **], MD (NEURO-ONCOLOGY) Phone: [**Telephone/Fax (1) 45043**] Please call and make an appointment within 2 weeks of discharge. Patient will need repeat conventional cerebral angiogram in 3 weeks to re-evaluate for etiology of subarachnoid bleed. MRI with gadolinium Date/Time: [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2103-12-25**] Name: [**Known lastname 11928**],[**Known firstname 126**] Unit No: [**Numeric Identifier 11929**] Admission Date: [**2103-12-17**] Discharge Date: [**2103-12-24**] Date of Birth: [**2026-3-28**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 608**] Addendum: Additional Follow-up Appointments Scheduled: [ ] MRI brain with gadolinium Date/Time: [**2104-12-29**] 7:15AM Location: [**Hospital Ward Name 3621**] [**Hospital **] Care Center Basement Phone: [**Telephone/Fax (1) 491**] [ ] Provider: [**First Name8 (NamePattern2) 55**] [**Last Name (NamePattern1) 25**], MD (NEURO-ONCOLOGY) Date/Time: [**2104-1-14**] 1:00PM Phone: [**Telephone/Fax (1) 602**] **Patient's Oncologist at VA [**Location (un) 164**] [**First Name11 (Name Pattern1) 933**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 11930**] FAX #[**Telephone/Fax (1) 11931**] Discharge Disposition: Home with Service [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 610**] Completed by:[**2103-12-25**]

[ "530.81", "401.9", "427.31", "300.00", "430", "272.4", "238.79" ]

icd9cm

[ [ [] ] ]

[ "88.97", "88.41", "88.91", "87.03" ]

icd9pcs

[ [ [] ] ]

10806, 10947

5501, 7495

374, 381

8068, 8852

4116, 5478

9165, 10783

2211, 2287

7757, 7757

7521, 7694

8876, 9142

2302, 2665

278, 336

409, 1884

3118, 4097

7874, 8047

7776, 7853

2704, 3102

2689, 2689

1906, 2123

2139, 2195

2,691

106,022

13138

Discharge summary

report

Admission Date: [**2103-12-29**] Discharge Date: [**2104-1-17**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: PICC line placement [**2104-1-11**] History of Present Illness: 83 yo male who 3 days prior to admission had undergone an endovascular procedure was on Coumadin, who was found by his family lying in bed confused and complaining of chills. He was taken to an area hospital where he vomitted large amounts of coffee ground emesis; an NG tube was placed. He was transfused with 2 units PRBC's and given IV fluids and then transferred to [**Hospital1 18**] for further care. Past Medical History: CABG, LE PTA, L CEA, AAA repair, R fem aneurysm repair, cataract surgery. Social History: Married, resides with his wife Family History: Noncontributory Physical Exam: 99.8, 92, 137/55, 22, 96%2L NC HEENT: PEERRLA, mucosase moist Cor: RRR, II/VI SEM Chest: CTAB Abd: minimally distended, + BS, nontender, no masses, no bruits Ext: 1+ edema BLE, L groin/arm incisions Pertinent Results: [**2103-12-29**] 01:41PM WBC-5.3 RBC-3.85* HGB-12.4* HCT-36.7* MCV-95 MCH-32.1* MCHC-33.7 RDW-18.1* [**2103-12-29**] 01:41PM PLT COUNT-222 [**2103-12-29**] 08:17AM GLUCOSE-162* UREA N-37* CREAT-1.4* SODIUM-139 POTASSIUM-5.3* CHLORIDE-105 TOTAL CO2-21* ANION GAP-18 [**2103-12-29**] 08:17AM ALT(SGPT)-51* AST(SGOT)-55* CK(CPK)-111 ALK PHOS-224* AMYLASE-224* TOT BILI-1.3 CHEST (PORTABLE AP) Reason: - please include upper abdomen on CXR- please eval for NGT p [**Hospital 93**] MEDICAL CONDITION: 82 year old man with UGIB, hematemesis s/p EGD, gram neg bacteremia, now s/p placement of new NG tube REASON FOR THIS EXAMINATION: - please include upper abdomen on CXR- please eval for NGT placement REASON FOR EXAMINATION: Evaluation of the NG tube placement. Portable AP chest radiograph compared to [**2104-1-8**]. The NG tube passes below the diaphragm, enters the stomach with its tip terminating below the field of view, most likely at the level of the _____ or in proximal duodenum. The heart size and the mediastinal contours are unremarkable. There is increase in left retrocardiac atelectasis with no significant change in right and left small pleural effusions. There is increased opacity in the right upper lobe which might be due to layering pleural effusion but underlying infectious process cannot be excluded. ABDOMEN (SUPINE & ERECT) Reason: Eval for obstruction, free air [**Hospital 93**] MEDICAL CONDITION: 83 year old man with likely ischemic bowel, also w/ SB dilation/ ?obstruction REASON FOR THIS EXAMINATION: Eval for obstruction, free air HISTORY: 83-year-old man with likely ischemic bowel and small bowel dilatation. Evaluate for obstruction or free air. Comparison is made to prior radiograph dated [**2104-1-5**], and prior CT dated [**2104-1-2**]. TECHNIQUE: Supine and left lateral decubitus abdominal radiographs. Residual barium from prior examination is identified within the ascending colon, rectosigmoid region and within multiple diverticula in the sigmoid and descending colon. The colon appears slightly more dilated when compared to prior examination, measuring approximately 7.6 cm in the region of the cecum/ascending colon on today's exam with prior measurement of 6.8 cm. The transverse colon is also slightly more dilated measuring approximately 6.7 cm on today's examination with prior measurement of approximately 5 cm. Slightly increased dilatation is also noted within the region of the sigmoid. Small bowel appears grossly unremarkable and may be decreased slightly in caliber. The patient is noted to be status post median sternotomy, and an NG tube is noted within the distal stomach or proximal duodenum. Surgical clips are again identified within the pelvis bilaterally and a right-sided stent is again identified. There are degenerative changes of the lumbar spine and mild levoscoliosis. No evidence of pneumatosis or free air. IMPRESSION: 1. Dilated ascending/transverse colon may be sequela of ileus in a patient with an ischemic event or represent pseudoobstruction ([**Last Name (un) 3696**] syndrome). Given the collapse of the sigmois colon and descending colon, mechanical obstruction is less likely. Contrast from prior exams has also progressed to the sigmoid colon 2. Diverticulosis Cardiology Report ECHO Study Date of [**2104-1-1**] PATIENT/TEST INFORMATION: Indication: Evaluate for endocarditis. Height: (in) 75 Weight (lb): 173 BSA (m2): 2.07 m2 BP (mm Hg): 153/62 HR (bpm): 94 Status: Inpatient Date/Time: [**2104-1-1**] at 13:45 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007W000-0:00 Test Location: West MICU Technical Quality: Adequate REFERRING DOCTOR: DR. [**Known firstname **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] MEASUREMENTS: Left Atrium - Four Chamber Length: 4.7 cm (nl <= 5.2 cm) Right Atrium - Four Chamber Length: *5.7 cm (nl <= 5.0 cm) Left Ventricle - Ejection Fraction: >= 60% (nl >=55%) Aortic Valve - Peak Velocity: *2.3 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 20 mm Hg Aortic Valve - Mean Gradient: 10 mm Hg Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.8 m/sec Mitral Valve - E/A Ratio: 1.00 Mitral Valve - E Wave Deceleration Time: 176 msec TR Gradient (+ RA = PASP): *33 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Focal calcifications in aortic root. AORTIC VALVE: Mildly thickened aortic valve leaflets. Minimally increased gradient c/w minimal AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to moderate ([**1-1**]+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is normal in size. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-1**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. No definite vegetation seen but cannot exclude. Brief Hospital Course: He was transferred to the Surgical Service after being consulted by the Medicine service for hematemesis. He underwent EGD which showed gastritis; there was an area of active bleeding which was injected with Epinephrine and cauterized. On abdominal CT imaging it was revealed that there was diffuse mural thickening of the descending colon, sigmoid and rectum. KUB showed dilated small bowel. He was placed on IV antibiotics; initially Levo and Flagyl; this was later changed to Zosyn. He was given IV fluids and was made NPO. A Nutrition consult was placed, he was started on TPN; this was later stopped and his diet was advanced slowly. He will require ongoing nutritional support once at rehab facility; calorie counts and monitoring his weight are being recommended. He did have a drop in his hematocrit down to 21.8 and was transfused with 2 units packed red cells; hematocrit was 29.7 on day of this dictation. He is not having any dark stools and no hematemesis has been noted. Physical therapy was consulted and have recommeded short term rehab stay. Medications on Admission: Pantoprazole Felodipine Ranitidine Metoprolol Donepizil Lisinopril Cyclobenzaprine ASA Phenytoin Azathioprine Oxybutinin Chloride Discharge Medications: 1. Azathioprine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO at bedtime. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose Injection [**Hospital1 **] (2 times a day). 4. Acetaminophen 650 mg Suppository Sig: [**1-1**] Suppositorys Rectal Q4-6H (every 4 to 6 hours) as needed for pain. 5. Phenytoin 100 mg/4 mL Suspension Sig: Eight (8) ML's PO Q8H (every 8 hours). 6. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose Injection four times a day as needed for per sliding scale. 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for HR <60; SBP <110. 8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily): PICC line flush. 9. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): apply to left groin. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Gastrointestinal bleed Gram negative bacteremia Ischemic colitis Discharge Condition: Stable Discharge Instructions: Per Page One Followup Instructions: Follow up in 1 week with Dr. [**Last Name (STitle) **] in Surgery Clinic, call [**Telephone/Fax (1) 600**] for an appointment. Follow up with Dr. [**Last Name (STitle) **], Vascular Surgery as previously directed. Call [**Telephone/Fax (1) 1237**] for an appointment. Completed by:[**2104-1-17**]

[ "533.40", "584.9", "557.1", "427.31", "780.6", "293.0", "041.3", "401.9", "790.7", "V15.82", "443.9", "535.51", "V45.81", "780.39" ]

icd9cm

[ [ [] ] ]

[ "43.41", "38.93", "00.14", "99.29", "99.04", "99.15" ]

icd9pcs

[ [ [] ] ]

9082, 9154

6917, 7980

274, 312

9263, 9272

1161, 1631

9333, 9633

909, 926

8160, 9059

2599, 2677

9175, 9242

8006, 8137

9296, 9310

4509, 6894

941, 1142

223, 236

2706, 4483

340, 748

770, 845

861, 893

15,182

106,451

25315

Discharge summary

report

Admission Date: [**2119-8-22**] Discharge Date: [**2119-8-31**] Date of Birth: [**2053-4-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: Epigastric pain Major Surgical or Invasive Procedure: central line placement History of Present Illness: 66 year old hx of DM, ?compliance on oral meds, hx of depression/schizoaffective d/o presented w/ pancreatitis and DKA. . Patient reported starting to have epigastric pain on [**Name (NI) 1017**] PTA. He described the pain as constant sharp [**5-23**] epigastric pain with no radiation. He has not experienced such pain before. THis was associated with nausea and decreased appetite. He went to [**Hospital1 **] on Monday and was subsequently transferred to [**Hospital1 18**] for further management of pancreatitis. . His initial lipase was 1330. In the ED, he was afebrile and with stable vital sign. He was found to have a slightly widened anion gap w/ ketones in association with gluocose in 400s and was then transferred to [**Hospital Unit Name 153**] for insulin drip. Past Medical History: DM2 Depression-admit in [**2116**] dx prob schizoaffective dx. h/o major depression. Hyperlipidemia GERD s/p CCY last EGD 5 years ago esophageal ring w/ gastritis fatty liver on u/s Social History: occasional alcohol, denies tobacco/IVDU Family History: non-contributory Physical Exam: 99.4 98 143/76 17 100% 2L NAD M dry, poor oral dentition, NC/AC, PERRL neck supple, no LAD RRR CTAB abd soft, mildly tender to palpation over epigastrum, obese extr WWP, no edema, resolving sores over shins A+O X 3, CN II-XII intact, motor + sensory intact over lower extremities; flat affect Pertinent Results: [**2119-8-22**] 02:55AM PLT COUNT-252 [**2119-8-22**] 02:55AM PLT COUNT-252 [**2119-8-22**] 02:55AM WBC-18.3* RBC-4.24* HGB-13.0* HCT-37.3* MCV-88 MCH-30.7 MCHC-34.9 RDW-12.9 [**2119-8-22**] 02:55AM ALBUMIN-4.1 CALCIUM-8.5 PHOSPHATE-1.1* MAGNESIUM-2.0 [**2119-8-22**] 02:55AM LIPASE-1336* [**2119-8-22**] 02:55AM ALT(SGPT)-25 AST(SGOT)-21 ALK PHOS-60 AMYLASE-786* TOT BILI-0.5 [**2119-8-22**] 02:55AM GLUCOSE-437* UREA N-38* CREAT-1.2 SODIUM-134 POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-16* ANION GAP-17 [**2119-8-22**] 03:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2119-8-22**] 03:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.029 [**2119-8-22**] 03:00AM PT-13.5* PTT-23.3 INR(PT)-1.2 [**2119-8-22**] 03:15AM GLUCOSE-424* LACTATE-4.0* K+-4.3 [**2119-8-22**] 04:45AM CALCIUM-7.0* PHOSPHATE-1.2* MAGNESIUM-1.7 [**2119-8-22**] 04:45AM GLUCOSE-267* UREA N-32* CREAT-0.9 SODIUM-138 POTASSIUM-3.7 CHLORIDE-112* TOTAL CO2-15* ANION GAP-15 [**2119-8-22**] 06:35AM CALCIUM-7.1* PHOSPHATE-1.2* MAGNESIUM-1.8 [**2119-8-22**] 06:35AM GLUCOSE-186* UREA N-30* CREAT-0.9 SODIUM-138 POTASSIUM-3.3 CHLORIDE-112* TOTAL CO2-17* ANION GAP-12 [**2119-8-22**] 06:51AM K+-3.0* [**2119-8-22**] 02:54PM PLT COUNT-225 [**2119-8-22**] 02:54PM WBC-20.1* RBC-3.75* HGB-11.6* HCT-31.6* MCV-84 MCH-31.0 MCHC-36.8* RDW-12.6 [**2119-8-22**] 02:54PM CALCIUM-7.4* PHOSPHATE-1.7* MAGNESIUM-2.3 [**2119-8-22**] 02:54PM GLUCOSE-124* UREA N-21* CREAT-0.7 SODIUM-137 POTASSIUM-3.1* CHLORIDE-107 TOTAL CO2-18* ANION GAP-15 [**2119-8-22**] 06:02PM CK-MB-5 cTropnT-<0.01 [**2119-8-22**] 06:02PM CK(CPK)-329* [**2119-8-22**] 06:02PM GLUCOSE-57* UREA N-15 CREAT-0.7 SODIUM-137 POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-20* ANION GAP-18 [**2119-8-22**] 06:02PM ALBUMIN-3.9 CALCIUM-7.9* PHOSPHATE-1.3* MAGNESIUM-2.3 [**2119-8-22**] 06:02PM WBC-22.9* RBC-3.84* HGB-11.7* HCT-32.4* MCV-84 MCH-30.5 MCHC-36.2* RDW-12.6 [**2119-8-22**] 06:02PM PLT COUNT-259 [**2119-8-25**] 06:55AM BLOOD WBC-8.7 RBC-3.28* Hgb-10.0* Hct-29.3* MCV-89 MCH-30.4 MCHC-34.1 RDW-13.1 Plt Ct-171 [**2119-8-25**] 06:55AM BLOOD Plt Ct-171 [**2119-8-25**] 06:55AM BLOOD Glucose-223* UreaN-10 Creat-0.8 Na-134 K-4.3 Cl-102 HCO3-22 AnGap-14 [**2119-8-25**] 06:55AM BLOOD ALT-25 AST-27 AlkPhos-116 Amylase-56 TotBili-0.7 [**2119-8-25**] 06:55AM BLOOD Calcium-8.0* Phos-2.1* Mg-1.9 . [**8-22**] CT abd/pelvis: 1. Pancreatitis, with non-enhancement of the pancreatic neck. This finding is concerning for necrosis of the pancreatic neck. The pancreatic body and tail enhance with contrast, however. Less than one-third of the gland is affected. 2. Distention of the stomach and prominence of the duodenum bowel wall, especially in the second portion near the pancreatic head. There is surrounding mesenteric stranding, which may be related to the pancreatitis. However, duodenitis is another diagnostic consideration. 3. Small bilateral pleural effusions with associated atelectasis. 4. Rounded lesion within the L4 vertebral body, of relative lucency. This probably represents a hemangioma, but if there is any clinical concern, further evaluation with bone scan could be performed. 5. Air in the bladder, likely related to instrumentation. Please correlate with urinalysis. [**8-22**] CXR: Right lower lobe atelectasis with elevated right hemidiaphragm. [**8-24**] CXR: Comparison is made to [**2119-8-23**]. The left subclavian central venous line tip is not definitely visualized due to technique. Lung volumes are further reduced. There is unchanged pulmonary edema, allowing for the differences in volume. There is worsening right lower lobe atelectasis. Patchy left lower lobe opacity could be additional atelectasis or possible aspiration. . [**2119-8-28**] ECHO: IMPRESSION: Normal biventricular cavity size and systolic function. No structural heart disease or pathologic flow identified. Mildly dilated thoracic aorta. Brief Hospital Course: # DKA: The pt has a history of DM2 with poor medicine compliance related to difficulty with proper education, and financial troubles with buying insulin. He presented to the ED at [**Hospital **] hospital with a blood sugar of 976, and anion gap of 30. His blood gas was 7.31/26/121 at that time. His urine had glucose of 1000 and 50 ketones. He was started on an insulin drip and transferred to [**Hospital1 18**] for an ICU bed. On arrival at [**Hospital1 18**] his blood sugar was 437 and his anion gap was 15. He was admitted to the ICU on and insulin drip, and his blood sugars normalized, and the anion gap closed. He was taken off the insulin gtt, and transferred to the floor on the second hospital day. [**Last Name (un) **] Diabetes Center was consulted, and provided recommendations for an insulin regimen for him while in the hospital, and initiated teaching for home insulin use. Once he began eating, his metformin 1000 [**Hospital1 **] was restarted. . # Pancreatitis: Mr. [**Known lastname **]' pancreatitis is thought to be idiopathic, with a lipase of 1330 on admission. Gallstones were an unlikely cause as he had normal LFTS, CT and U/S. He has no significant ETOH history and triglycerides within normal limits. CT showed <[**1-16**] of the pancreas involved with a question of possible neck region necrosis, and a prominent duodenum wall. It was felt that there were no indications for antibiotic treatment. His WBC count and amylase & lipase steadily returned to normal and his hematocrit was stable. He was given percocet for pain control. After he came to the floor from the MICU, where he had been NPO, we advanced his diet as tolerated, and he was tolerating a full po diabetic diet on discharge with no problems. . # anemia:Mr. [**Known lastname **] was likely hemoconcentrated when admitted, and his hematocrit was stable throughout his hospitalization. . # trouble swallowing: Mr. [**Known lastname **] reported occasional difficulty with swallowing, and has a known history of an esophageal ring. . # hypoxemia: A CXR showed RLL atelectasis w/ pleural effusion. Mr. [**Known lastname **] was diuresed (his fluid status had been very positive since admission due to his pancreatitis), and encouraged to use an incentive spirometer. His respiratory function steadily improved, and he was stable on room air for several days prior to discharge. . # sinus tachycardia: Mr. [**Known lastname **] was tachycardic throughotu his hospitalization. In discussion with him and his PCP we found that he is tachycardic at baseline. We had extremely low suspicion for PE, and he was clinically asymptomatic and [**Last Name (un) 2677**] throughotu his stay. . # ID: Mr. [**Known lastname **] had bacteria in his UA and was treated with Cipro until his urine culture returned as no growth. He had no clinical evidence of pancreatic necrosis, and was therefore not treated for that. His blood cultures showed no growth. . # Psychiatric: Mr [**Known lastname **] has a history of depression, anxiety, and schizoaffective d/o. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 33474**] is his outside psychiatrist. We continued his quetiapine, chlorpromazine and doxepine per his home regimen. . # Prophylaxis: Mr. [**Known lastname **] was on subcutaneous heparin and a PPI. . # FULL CODE . # Contacts: Sister: [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 63333**] PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 **] [**Telephone/Fax (1) 63334**] Psych MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 33474**] ([**Telephone/Fax (1) 63335**] . DISPO: We considered that Mr. [**Known lastname **] might need a SNIF given his psychiatric history and issues with insulin teaching and compliance in the apst. He was not willing to consider this, and his PCP felt it would be reasonable for him to be at home. His sister felt she would be available for some assistance, and he was set up with the VNA. Additionally, his PCP will get him into the diabetes program at [**Hospital3 1280**] Hospital for closer follow up on his diabetic control and treatment plan. Medications on Admission: Prilosec OTC qhs Glyburide 20mg [**Hospital1 **] Metformin 1000mg [**Hospital1 **] seroquel 100 qhs thorazine 100 qhs doxepine 100 qhs lipitor 20mg daily Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Quetiapine Fumarate 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 3. Doxepin 50 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 4. Chlorpromazine 50 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 5. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 6. Insulin NPH/Reg 70-30 InnoLet 70-30 unit/mL Insulin Pen Sig: Fifty Five (55) units Subcutaneous QAM: with breakfast. Disp:*1 month supply* Refills:*2* 7. Insulin NPH/Reg 70-30 InnoLet 70-30 unit/mL Insulin Pen Sig: Thirty (30) units Subcutaneous QPM: With dinner. Disp:*1 month supply* Refills:*2* 8. BD Pen Needle Ultrafine II 30G [**5-29**]" use a fresh needle for each dose of insulin please dispense 1 month supply 2 refills 9. One Touch Ultra Test Strips use a new strip for each fingerstick dispense 1 month supply 2 refills 10. One Touch Ultra Lancets Please use a new lancet for each fingerstick dispense 1 month supply 2 refills Discharge Disposition: Home With Service Facility: [**Hospital1 **] Discharge Diagnosis: Principal: 1. Acute Pancreatitis. 2. Diabetic Ketoacidosis. 3. Congestive Heart Failure. Secondary: 1. Diabetes Mellitus Type II. 2. Schizoaffective Disorder. 3. Abnormal ECG. 4. Hyperlipidemia. 5. GERD. 6. Esophageal Ring. 7. Hepatic Steatosis. 8. S/P Cholecystectomy. Discharge Condition: Patient is fully recovered from his pancreatitis and DKA, with stable blood sugars on a twice-a-day insulin regimen. Discharge Instructions: 1. Please take your insulin as prescribed every day. 2. Please check your blood sugars by fingerstick with glucometer twice a day - in the morning and at bedtime - and record the results. 3. If you are vomiting or not eating for some reason, decrease your insulin to 37 units in the morning and 20 units at night. 4. If you ever experience symptoms of shakiness, sweating, and dizziness, check your blood sugar and if it is < 90 drink juice. 5. Don't hesitate to call your doctor with any questions regarding your medications. He is there to help you stay healthy. 6. Please follow the diet recommendations provided to you. Carbohydrates increase your blood sugar and need to be minimized. Please return to the hospital or call your doctor if you have abdominal pain, nausea/vomiting, chest pain, shortness of breath or if there are any concerns at all. Followup Instructions: Please follow up with [**Location (un) **],SHUN-HOW Tuesday [**2119-9-5**] at 10:30 AM. [**Telephone/Fax (1) 63334**]. *Dr. [**First Name (STitle) **] will get you an appointment to follow up in the diabetes clinic at [**Hospital3 1280**] hospital* Completed by:[**2119-11-15**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

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329, 353

11761, 11880

1791, 5776

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1437, 1455

10194, 11376

11467, 11740

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381, 1158

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20188

Discharge summary

report

Admission Date: [**2150-11-23**] Discharge Date: [**2150-12-2**] Date of Birth: [**2088-3-2**] Sex: M Service: Neurosurgery HISTORY OF PRESENT ILLNESS: Patient is a 62-year-old gentleman, who was transferred from Life Care Rehab with mental status changes with increased lethargy and urinary incontinence. He had recently been admitted under Dr.[**Name (NI) 14019**] care on [**2150-10-31**] for hydrocephalus and status post a VP shunt placement, also had a history of subarachnoid hemorrhage, who was treated conservatively at [**Hospital6 14430**]. PAST MEDICAL HISTORY: 1. Subarachnoid hemorrhage. 2. Hypertension. 3. Bell's palsy. 4. Interventricular hemorrhage on CT 1.5 years ago. 5. Status post right eye surgery. 6. Status post VP shunt on 12/[**2149**]. 7. PEG tube 12/[**2149**]. ALLERGIES: No known allergies. PHYSICAL EXAM: On physical exam, his temperature was 97.8, heart rate 64, blood pressure 148/80, respiratory rate 20, and sats 94% on 4 liters. Neurologically, patient was lethargic, responded appropriately, oriented to place, time, and person. Pupils were dysconjugate. Left fixed and dilated at 5 mm. The right was 5 mm and nonreactive to light. Can move midline to lateral gaze. Cranial nerve V decreased on the left, but cranial nerve VII has a left facial droop, which is old. Cranial nerves IX, X, and [**Doctor First Name 81**] intact and symmetric. Motor exam: His strength was [**3-24**] in his upper extremities and lower extremities. He had no pronator drift. His sensation was grossly intact. His reflexes are 2+ throughout. His toes were downgoing. He had a MRI with DWI for question of embolic stroke. He had a urinalysis, sputum culture, and chest x-ray, and tox screen. Patient is admitted to the Medical service and worked up for a possible meningitis. However, the patient had no signs or symptoms or meningitis and no LP was recommended at that time. Patient had no white count and no fever making shunt infection less likely. Patient also had a chest CT to rule out PE, which was ruled out. Chest x-ray showed retrocardiac infiltrate. EKG was in normal sinus rhythm. Head CT showed question of a left putaminal lacunar infarct, but no bleed. The patient was intubated for respiratory failure and distress on [**2150-11-23**]. On [**2150-11-24**], patient had a lumbar puncture performed with an opening pressure of 24, closing pressure of 19, CSF was sent for culture. CSF results show a glucose level of 8, 1 white cell, 210 red cells, 22 polys, 68 lymphocytes, opening pressure of 24. MRI shows restricted diffusion in the insular cortex, which is unlikely to explain his current symptoms. No evidence of any other infarcts. He continues to show communicating hydrocephalus, which has not improved since VP shunt. His opening pressure was 24 on admission on his LP. Patient had a repeat LP done on [**2150-11-25**] with an opening pressure of 36, closing pressure of 15, 25 cc of CSF was sent. The patient was preoped and went for a VP shunt revision. Postoperatively, the patient's eyes were closed. He shook his head yes and no to appropriate questions. His grasps were 3+ bilaterally. Wiggles toes on the right, minimally withdrawn on the left leg. Right pupil is trace reactive. Left is nonreactive. Remained neurologically stable, this was on [**2150-11-25**]. Patient was extubated on [**2150-11-26**], and then immediately reintubated because patient was unable to maintain a protective airway. CT showed decreased hydrocephalus and size of the ventricles. Patient on [**2150-11-28**] became unresponsive. Had a head CT, which showed enlarged ventricles. Had a LP performed, and the patient became responsive again. On [**2150-11-29**], neurologic exam: Patient would squeeze the right hand to command. Did not open his eyes. Pupils fixed. Neurology was consulted regarding question of seizure activity. CSF cultures were sent. He had an EEG, which showed slowing, but no epileptiform activity, and his mental status deteriorated on [**2150-11-29**]. His pupils were fixed and dilated. He had no corneals, no oculocephalic reflex. Absent cold caloric reflex and no response to sternal rub. CSF was sent for fungal culture, cryptococcal cytology, AFB. Infectious Disease was consulted. He recommended treating the patient with vancomycin 1.5 grams IV q.12, ceftazidime 1 gram IV q.8, and amphotericin 1 mg/kg IV q.d. to treat for a question of a nosocomial meningitis despite no pleocytosis on CSF, but there was an elevated protein and decreased glucose level. On [**2150-11-30**], the patient had no corneal reflexes. Had a positive gag reflex. No withdraw to pain in the upper or lower extremities. Head CT showed hydrocephalus again. Therefore, a vent drain was placed on [**2150-11-30**]. The protein level on CSF was 111, glucose is 53. Patient remained unresponsive. No oculocephalic response, no corneals, no gag, no response to painful stimulation in the upper or lower extremities. Continued to deteriorate, and family was approached by Dr. [**Last Name (STitle) 1132**] in discussion of his condition. The family has opted to make the patient comfort measures only, and the patient expired on [**2150-12-2**] at 6:58 p.m. Addendum: a post-mortem was performed and returned with meningeal carcinomatosis, please see pathology report. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2151-3-29**] 12:42 T: [**2151-3-30**] 07:56 JOB#: [**Job Number 54254**]

[ "518.81", "E849.7", "322.9", "482.41", "E878.1", "933.1", "434.91", "996.2", "507.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "02.42", "96.6", "96.72", "96.04", "03.31", "02.2" ]

icd9pcs

[ [ [] ] ]

860, 3754

169, 571

3772, 5633

593, 844

61,667

174,217

27132

Discharge summary

report

Admission Date: [**2160-6-9**] Discharge Date: [**2160-6-13**] Service: MEDICINE Allergies: Amoxicillin Attending:[**First Name3 (LF) 10682**] Chief Complaint: Anemia, Hct 18 Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] year old male with a history of hemolytic anemia (autoimmune) and recurrent GI bleeding without known source, status post multiple EGDs and capsule endoscopy in the past, presenting from [**Hospital 100**] Rehab with Hct 18 seen on routine labs. Patient reports somewhat worsened fatigue over the last week or so, but otherwise has been asymptomatic. He reports no diarrhea or abdominal pain. There has been no report of hematemesis, melena or hematochezia. He has experienced no dyspnea on exertion or chest pain. Patient states that he would not like an EGD or colonoscopy during this admission, but he will accept blood transfusions. He has received numerous work-ups for his anemia and GI bleeding in the past (EGD x4, [**Last Name (un) **] x2, capsule x3, CT abd/pelvis, bleeding scan). Patient is typically transfused at [**Hospital 100**] Rehab every two weeks. On past admission, more conservative measures including transfusions and iron supplementation were decided on. Patient has had no recent changes in medications. Patient has an AVR with goal INR 2-2.5. In the ED, initial vs were: 97.8 82 118/62 16 95% RA. Patient was noted to have heme positive melena on exam. INR on admission was 4.2. GI was consulted and recommended no NG lavage and likely no colonoscopy since patient has had multiple negative work-ups in the past. Patient's heme/onc doctor recommended holding warfarin, but not to reverse INR, and admit to the [**Hospital Unit Name 153**]. Patient was ordered for two units of blood in the ED, but did not receive any while down there. Vitals in ED prior to transfer are as follows: afebrile 82 109/53 16 99%RA. On the floor, patient has no current complaints. He reports no chest pain, shortness of breath, or abdominal pain. Patient endorses left arm pain that is chronic. He has had no recent falls. Past Medical History: # Anemia, multifactorial as below, baseline HCT 28 # Autoimmune hemolytic anemia (Coomb's +, warm autoantibody), on prednisone 10mg Po daily # Listeria Endocarditis s/p AVR, suppressive amoxicillin stopped due to hemolytic anemia # Aortic mechanical valve, recently Coumadin resistant so intermittently on Lovenox bridge, followed by Dr. [**Last Name (STitle) **] # hx recent GI bleeds: colonoscopy [**1-10**]: noted normal colon with melanotic stool in terminal ileum # GERD: EGD [**12/2159**] Polyp in the area of the papilla; found on the wall opposite the ampulla. Small hiatal hernia. Otherwise normal EGD to third part of the duodenum. # H/o presyncope # CKD Cr 1.6-2.0 Stage III # CAD s/p NSTEMI [**7-10**] # Chronic CHF, likely diastolic, ([**9-9**] EF=50%) # Hyperlipidemia # Hypertension # Depression vs adjustment disorder after death of brother # Prostate cancer- s/p radiation # Bladder/bowel incontinence # Right lateral malleolus stage 1 pressure ulcer # Dementia Social History: Never smoked, no EtOH or other drugs. Currently living at [**Hospital 100**] Rehab. Uses wheelchair typically. Requires a significant degree of assistance in all his ADLs and IADLs. Has 2 sons and 4 grandchildren. Family History: No bleeding diatheses. Father had stomach cancer. No other cancers including colon. Physical Exam: At admission: Vitals: T: 96.9 BP: 78 P: 109/59 R: 19 O2: 97%RA General: Alert, oriented x 3, appropriate, no acute distress, pleasant and cooperative HEENT: Sclera anicteric, conjunctivae pale, MM dry, oropharynx clear with no lesions noted Neck: supple, JVP not elevated, no cervical or supraclavicular LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate, mechanical heart sounds best heard at LUSB, no rubs or gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, trace peripheral edema, no clubbing, cyanosis or edema Neuro: AAOx3, sensation intact in all extremities Pertinent Results: Admission labs: [**2160-6-9**] 02:45PM BLOOD WBC-5.0 RBC-1.76*# Hgb-6.4*# Hct-18.4*# MCV-105* MCH-36.5* MCHC-34.9 RDW-22.7* Plt Ct-166 [**2160-6-9**] 02:45PM BLOOD Neuts-80* Bands-0 Lymphs-16.0* Monos-4 Eos-0 Baso-0 [**2160-6-9**] 02:45PM BLOOD PT-40.5* PTT-30.9 INR(PT)-4.2* [**2160-6-9**] 02:45PM BLOOD Ret Man-4.9* [**2160-6-9**] 02:45PM BLOOD Glucose-179* UreaN-42* Creat-1.6* Na-140 K-4.6 Cl-109* HCO3-24 AnGap-12 [**2160-6-10**] 01:58AM BLOOD Calcium-7.8* Phos-3.6 Mg-2.4 Discharge labs: [**2160-6-13**] 10:15AM BLOOD WBC-4.9 RBC-2.54* Hgb-8.7* Hct-26.3* MCV-104* MCH-34.1* MCHC-32.9 RDW-22.0* Plt Ct-115* [**2160-6-13**] 01:13AM BLOOD PT-17.3* PTT-150* INR(PT)-1.5* [**2160-6-12**] 06:35AM BLOOD Glucose-78 UreaN-24* Creat-1.3* Na-141 K-4.0 Cl-108 HCO3-28 AnGap-9 CHEST PORT. LINE PLACEMENT Study Date of [**2160-6-11**] Left PICC tip is in the upper SVC. There are no other acute interval changes from the prior study performed 6 hours earlier. There are persistent low lung volume, cardiomegaly, and bibasilar atelectasis. The sternal wires are aligned. The patient is status post aortic valve replacement. Surgical clips are noted in the right upper hemithorax. Right PICC has been removed. There is no pneumothorax or large pleural effusions. Brief Hospital Course: [**Age over 90 **] year old male with a history of autoimmune hemolytic anemia, AVR with goal INR of [**3-5**].5, and recurrent GI bleeding without known source, status post multiple EGDs and capsule endoscopy in the past, who presented from [**Hospital 100**] Rehab on [**2160-6-9**] with routine Hct 18, asymptomatic, initially admitted to MICU. # Chronic blood loss anemia/Hemolytic anemia: Patient had a hematocrit of 18 on admission, baseline 28, likely multifactorial, related to hemolysis (for which he is on prednisone, low haptoglobin but nl LDH) and chronic bleed. He was asymptomatic. Per patient, patient is intermittently transfused at [**Hospital 100**] Rehab and the facility has a difficult time finding matched blood. Melena was noted on admission in the ED. No further episodes while hospitalized. Patient declined colonoscopy, EGD, but accepted transfusions. He received 2 U PRBC on [**6-9**] with appropriate increase, 1 U PRBC on [**6-11**], and 1 U PRBCs on [**6-13**]. He was initially on IV PPI, changed to PO PPI and started on carafate. He was continued on his home prednisone and bactrim prophylaxis, vitamin B12, folic acid. His Coumadin was initially held, and heparin gtt was started to complete bridge back to therapeutic INR. *****Patient should have HCT/HGB checked every 3-4 days. When the HCT is <25, please call Dr.[**Name (NI) 3930**] clinic ([**Telephone/Fax (1) 3241**]) to arrange for outpatient blood transfusion. IF the patient is symptomatic (chest pain, shortness of breath), then it is reasonable to send patient to the Emergency Room. # s/p Aortic mechanical valve: Patient is on coumadin with INR goal 2-2.5. He was noted to have INR of 4.2 on admission. His coumadin was initially held and restarted with heparin bridge when his HCT stabilized. # Hypertension: He was continued on his carvedilol. # Hyperlipidemia: He was continued on his simvastatin. # Chronic kidney disease, stage III: His Cr remained stable throughout the hospitalization. # Hypothyroidism: He was continued on levothyroxine. Code: Patient would like DNR but may be intubated HCP: [**Name (NI) **] [**Name (NI) 43131**] [**Name (NI) 66590**] ([**Telephone/Fax (1) 66592**] home, [**Telephone/Fax (1) 66591**] cell) Medications on Admission: Warfarin 2 mg PO daily Carvedilol 3.125 mg PO BID Bactrim SS 1 tab PO daily Levothyroxine 75 mcg PO daily Prednisone 10 mg PO daily Omeprazole 40 mg PO BID Simvastatin 40 g PO daily Cyanocobalamin [**2149**] mcg PO daily Folic acid 4 mg PO daily Acetaminophen 325 mg PO Q6h PRN pain Oxycodone 2.5 mg PO TID PRN pain Senna 8.6 mg PO daily Allergies: Amoxicillin Discharge Medications: 1. heparin (porcine) in NS 10,000 unit/1,000 mL Parenteral Solution Intravenous 2. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 3. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. cyanocobalamin (vitamin B-12) 2,000 mcg Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day. 10. folic acid 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 11. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Chronic blood loss anemia Hemolytic anemia Aortic mechanical valve Hypertension Hyperlipidemia Chronic kidney disease, stage III Hypothyroidism 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 66590**], It was a pleasure taking care of you. You were admitted for anemia, likely from bleeding in the gastrointestinal tract like before. You were given blood transfusions and your blood counts improved. You declined further endoscopies as these have not been revealing in the past. You were started on carafate to protect the stomach. No other changes were made to your medications. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2160-6-26**] at 11:30 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13863**], RN [**Telephone/Fax (1) 3241**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/BMT When: THURSDAY [**2160-6-26**] at 12:00 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], RNC [**Telephone/Fax (1) 3241**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "578.1", "272.4", "V15.3", "V43.3", "V58.65", "428.0", "244.9", "585.3", "403.90", "294.8", "729.5", "428.32", "280.0", "412", "414.01", "707.21", "283.0", "707.06", "V10.46", "V58.61" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9189, 9255

5522, 7779

234, 240

9443, 9443

4241, 4241

10064, 10715

3395, 3483

8191, 9166

9276, 9422

7805, 8168

9619, 10041

4736, 5499

3498, 4222

180, 196

268, 2140

4257, 4720

9458, 9595

2162, 3144

3160, 3379

5,343

181,404

3527

Discharge summary

report

Admission Date: [**2185-8-8**] Discharge Date: [**2185-8-10**] Date of Birth: [**2124-7-12**] Sex: F Service: MEDICINE Allergies: Univasc / Amlodipine / Norvasc Attending:[**First Name3 (LF) 425**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: Permanent pacemaker History of Present Illness: Ms. [**Known lastname 14738**] is a 61 y/o F with hx of mild dHF, HTN, bicuspid AV, s/p mechanical AVR on coumadin (INR 2.4 on admission), severe asthma (on prednisone) who was transferred to [**Hospital1 18**] for [**Hospital 16186**] after presenting there for syncope. She has a hx of severe asthma and has been on prednisone for the last 6-7 years with inability to wean due to increased wheezing and SOB. She states that over the last 6 months she has had more frequent episodes of "blacking out" that seem to occur after using her asthma inhalers. During each episode she denies CP, SOB, but has some nausea. Yesterday, while at her daughter's house she was sitting on the couch and blacked out on two separate occasions lasting a few seconds and then she came two. She was hospitalized [**2184-7-5**] year ago for similar c/o and was monitored continuously on Tele, with no events detected. At OSH, VS 98.8, 121/48, 48, 21 98%RA. EKG obtained at OSH was c/w CHB with infranodal escape with RB at 43BPM. She was transferred to [**Hospital1 18**] for further evaluation. Upon transfer in the ED she had another syncopal episode and was apparently in Sinus tachy to 110 at this point. EKG at this time showed sinus tachycardia with RBBB. EP was called and was told to give Metop, but it was not given. They repleted his K and sent admitted him to the CCU. Upon admission to the CCU, initial EKG showed sinus tachycardic with 1st degree AVB with a LBBB pattern. During initial evaluation, the patient had a 9 second pause on tele during which time the patient reported "blacking out". Her rhythm returned spontaneously and repeat EKG at this time showed CHB with RBBB pattern. After which, emergent temporary pacer was placed in the right ventricle via a right IJ Cordis. The wires are situated in the posterior RV, placement confirmed by CXR post-procedure. She is currently being paced at 50bpm, MA 5mV. Past Medical History: PAST CARDIAC HISTORY: . 1. CARDIAC RISK FACTORS: (+)Diabetes (borderline), (-)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: - Aortic valve replacement for critical AS/bicuspid aortic valve, #21 Carbomedics mechanical valve c/b pericardial tamponade and cardiac arrest ([**2175**]) . OTHER PAST MEDICAL HISTORY: - chronic anticoagulation w/ warfarin - Hypertension, well controlled on meds - Severe asthma, on multiple meds - Allergic rhinitis - Right lower quadrant hernia - Osteoarthritis - Chronically elevated CPK and bilateral calf pain - Acid reflux - Obesity - DM2 (borderline, not on meds) - Gout - Gallstones - H/o colonic ulcer [**2183**] Social History: SOCIAL HISTORY: - Tobacco history: denies - EtOH: social, very rare - Illicit drugs: denies . Family History: FAMILY HISTORY: Daughter died of AML @ age 38 in [**2184-6-4**]. Older sister with breast cancer age 65. Strong family history of DM2 & HTN. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. - Sister x 2 --> Breast Ca - Sister --> Heart Block - Brother --> CAD - Brother --> Thyroid Ca Physical Exam: ADMISSION: VS: T=98.8 BP=133/65 HR=104 RR= 21 O2 sat= 97%RA GENERAL: Overweight 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: No JVD, right Cordis in place. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 3/6 systolic ejection murmur with loud S2. No thrills, lifts. No S3 or S4. LUNGS: Bilateral expiratory wheezes over anterior chest. ABDOMEN: Obese abdomen, soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. RLQ hernia. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ DISCHARGE: Pertinent Results: ADMISSION: [**2185-8-8**] 11:30AM BLOOD WBC-17.5*# RBC-4.26 Hgb-12.1 Hct-36.2 MCV-85 MCH-28.4 MCHC-33.4 RDW-16.0* Plt Ct-291 [**2185-8-8**] 11:30AM BLOOD Neuts-71.8* Lymphs-23.3 Monos-3.7 Eos-0.6 Baso-0.5 [**2185-8-8**] 11:30AM BLOOD PT-24.7* PTT-35.2 INR(PT)-2.4* [**2185-8-8**] 11:30AM BLOOD Glucose-138* UreaN-20 Creat-0.8 Na-140 K-3.5 Cl-101 HCO3-28 AnGap-15 [**2185-8-8**] 11:30AM BLOOD ALT-75* AST-53* AlkPhos-105 TotBili-0.6 [**2185-8-8**] 11:30AM BLOOD Lipase-20 [**2185-8-8**] 11:30AM BLOOD cTropnT-0.01 [**2185-8-8**] 11:30AM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.3 Mg-1.8 STUDIES: CXR: Status post sternotomy and aortic valve replacement, newly implanted permanent pacer, unremarkable position of electrode termination and no pneumothorax. Brief Hospital Course: 61 y/o F with hx of mild dHF, HTN, bicuspid AV, s/p mechanical AVR on coumadin (INR 2.4 on admission), severe asthma (on standing prednisone) who was transferred to [**Hospital1 18**] from OSH after presenting with syncope found to be in CHB and 9-sec pause on tele. . # SYNCOPE - likely due to arrhythmia septal disease in the area involving the bundle of His, potentially exacerbated by increased albuterol use (increased heart rate inducing prolonged pausing at AV node). Initially had temporary pacer placed on admission. Permanent pacermaker placed by EP on [**8-9**]. We started metoprolol 25mg PO Q8H. Post op we started Vancomycin and then switched to PO Clindamycing 450 q8 x 48 hours for prophylaxis. Pt set up with EP follow up. . ------- CHRONIC ------- # HTN - pt normotensive during admission. We continued losartan 50mg po daily, added metop 25mg PO Q8H for control of arrhythmia. . # AV Replacement: Mechanical AVR in [**2175**] for bicuspid AV, recent Echo ([**6-/2185**]) showed that valve with well seated with no evidence of dehiscence. We continued Warfarin at home dose (4mg PO daily) . # ASTHMA: Patient has severe asthma in setting of possible mold contamination in her home. She has been on prednisone for last 6-7 years with inability to wean. We continued prednisone 10mg PO daily, Ipratroprium/Budesonide nebs, Albuterol PRN . # DM Type 2 vs Steroid Induced: Last A1C (7%, [**2185-7-28**]) not currently on any home DM medications. We treated with Insulin SC . ## TRANSITIONAL - Follow up with EP Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Furosemide 60 mg PO DAILY 2. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB or Wheezing 3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB or wheezing 4. Losartan Potassium 50 mg PO DAILY 5. Meclizine 25 mg PO BID:PRN Dizziness 6. Metoprolol Tartrate 25 mg PO BID 7. Montelukast Sodium 10 mg PO DAILY 8. Nystatin Cream 1 Appl TP [**Hospital1 **] 9. omalizumab *NF* 300 mg Subcutaneous Q2 weeks 10. Omeprazole 20 mg PO TID 11. PredniSONE 5 mg PO DAILY Taper Tapered dose - DOWN 12. TraMADOL (Ultram) 50 mg PO TID:PRN pain 13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP [**Hospital1 **] 14. Colchicine 0.6 mg PO QOD 15. Fluticasone Propionate NASAL 2 SPRY NU DAILY 16. Artificial Tears 1-2 DROP BOTH EYES [**Hospital1 **] 17. Fish Oil (Omega 3) 1000 mg PO BID 18. Terbinafine 1% Cream 1 Appl TP [**Hospital1 **] 19. Verapamil SR 240 mg PO Q24H 20. Warfarin 4 mg PO DAILY16 Discharge Medications: 1. Clindamycin 450 mg PO Q8H Duration: 2 Days RX *clindamycin HCl 150 mg three capsule(s) by mouth three times a day Disp #*27 Capsule Refills:*0 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB or wheezing 3. Artificial Tears 1-2 DROP BOTH EYES [**Hospital1 **] 4. Colchicine 0.6 mg PO QOD 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY 6. Furosemide 60 mg PO DAILY 7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB or Wheezing 8. Losartan Potassium 50 mg PO DAILY 9. Montelukast Sodium 10 mg PO DAILY 10. Omeprazole 20 mg PO TID 11. Fish Oil (Omega 3) 1000 mg PO BID 12. Meclizine 25 mg PO BID:PRN Dizziness 13. Nystatin Cream 1 Appl TP [**Hospital1 **] 14. omalizumab *NF* 300 mg Subcutaneous Q2 weeks 15. Terbinafine 1% Cream 1 Appl TP [**Hospital1 **] 16. TraMADOL (Ultram) 50 mg PO TID:PRN pain 17. Triamcinolone Acetonide 0.1% Cream 1 Appl TP [**Hospital1 **] 18. Warfarin 4 mg PO DAILY16 Please take 2 mg today, [**8-10**], then resume 4mg daily 19. PredniSONE 10 mg PO DAILY Tapered dose - DOWN 20. budesonide *NF* 0.5 mg/2 mL Inhalation every 4-5 hours take with ipratroprium/albuterol 21. Metoprolol Tartrate 25 mg PO TID 22. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 Discharge Disposition: Home With Service Facility: [**Location (un) 8930**] Discharge Diagnosis: Cardiogenic Syncope Mechanical aortic valve Dyslipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 14738**], You were admitted for episodes of losing consciousness. Based on multiple EKGs, we determined that the cause of these episodes is due to problem with the rhythm of your heart. You were evaluated by cardiology doctors who recommended a permanent pacemaker, which was placed on [**2185-8-9**]. We also changed your metoprolol to three times daily. We have made an appointment for you with cardiology, please see details below. Please check your INR on [**2185-8-15**] when you are here for your follow up visit. Call the [**Hospital3 **] if you have any questions. Followup Instructions: Department: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**] When: MONDAY [**2185-8-15**] at 3:20 PM With: Dr [**Last Name (STitle) 16187**] [**Name (STitle) **] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Central [**Hospital **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: TUESDAY [**2185-8-16**] 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

[ "272.4", "401.9", "426.4", "V58.61", "428.0", "V43.3", "790.29", "V58.65", "780.2", "426.0", "493.90", "428.32" ]

icd9cm

[ [ [] ] ]

[ "37.83", "37.78", "37.72" ]

icd9pcs

[ [ [] ] ]

8950, 9005

5103, 6634

297, 318

9106, 9106

4327, 5080

9883, 10506

3093, 3428

7661, 8927

9026, 9085

6660, 7638

9257, 9860

3443, 4308

2424, 2589

250, 259

346, 2274

9121, 9233

2611, 2949

2981, 3061

13,330

169,590

1789

Discharge summary

report

Admission Date: [**2104-6-5**] Discharge Date: [**2104-6-11**] Date of Birth: [**2048-10-2**] Sex: M Service: CARDIOTHORACIC Allergies: Bacitracin Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: High pitched cough, PNA d/t severe TBM Major Surgical or Invasive Procedure: 1. Right thoracotomy with posterior membranous wall tracheoplasty with mesh. 2. Right mainstem and bronchus intermedius plasty with mesh. 3. Left mainstem bronchoplasty with mesh. 4. Flexible bronchoscopy with aspiration tracheobronchial tree. History of Present Illness: The patient is a delightful 55- year-old gentleman with a long history of high-pitched cough who recently presented with a severe pneumonia and was found, on imaging, to have severe tracheobronchomalacia. Past Medical History: IDDM - last HgA1c=5.9, on insulin pump Hypothyroidism Hyperlipidemia Diabetic neuropathy Gastroparesis CAD s/p stent in [**2097**] Mood d/o OSA - on CPAP at home Social History: No tobacco, EtOH, drug use, teaches 9th grade, married. Family History: Non-contributory Physical Exam: General: well appearing young male in NAD at rest. Resp: lungs CTA Cor: RRR S1, S2 Abd: Soft, NT, ND,+BS Extrem: no C/C/E Pertinent Results: PA AND LATERAL VIEWS OF THE CHEST. REASON FOR EXAMINATION: SP tracheoplasty. COMPARISON: Comparison is made to prior study dated [**2104-6-8**]. FINDINGS: There is mild interval decrease in the pulmonary vascular markings. There are no new focal consolidations. There is no pneumothorax. Unchanged mild right pleural effusion. There is no cardiomegaly, the mediastinal contour is unremarkable. The oseous structures are unremarkable. IMPRESSION: 1. Mild interval improvement in the pulmonary vascular markings. 2. Unchanged small right pleural effusion. Brief Hospital Course: Pt was admitted and taken to the OR on [**2104-6-5**] for tracheoplasty w/ mesh via right thoracotomy. Post op remained intubated and transferred to the ICU for continued resp management and monitoring. Maintained on vanco, levo for mesh prophylaxis, and lopressor for afib prophylaxis post op. POD#1 bronchoscopy done and clean w/ residual edema. Vent weaned and pt extubated. On insulin gtt for diabetes management; [**Last Name (un) **] consulted (pt on insulin pump as out pt). Chest tube to sxn w/ minimal drainage. epidural for pain control. gently diuresed. POD#2 bronch w/ minimal white secretions and persistant but decreased posterior wall edema. [**Last Name (un) 1815**] reg diet. OOB to chair. Chest tubes to water seal w/ minimal drainage. POD#3 transferred from ICU to floor for continued pulmonary hygiene, Diabetes management w/ Lantus and SSRI while waiting insulin pump from home. POD #4 chest tube d/c'd. Epidural d/c'd and [**Last Name (un) 1815**] po pain med. POD#5 Insulin pump started w/ pt self management [**First Name8 (NamePattern2) **] [**Last Name (un) **] guidelines. Bronch clean-no secretions, minimal posterior wall edema. POD#6 d/c'd to home. vanco/levo d/c'd and started on po augmentin for 2 weeks. Will follow up w/IP for bronch in 2 weeks. Medications on Admission: insulin pump, lipitor 40', lasix 80', synthroid 200', reglan 10q6, neurontin 800"', nortriptyline 100qhs, prozac 40', relafen 500" prn, abilify 15", zelnorm 6', hydromet prn, lamictal 200", miralax, modafinil 200', prevacid 30", trazodone prn, valium5prn Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol [**Last Name (un) **]: 1-2 Puffs Inhalation Q6H (every 6 hours). 2. Modafinil 100 mg Tablet [**Last Name (un) **]: Two (2) Tablet PO qd (). 3. Nortriptyline 25 mg Capsule [**Last Name (un) **]: Four (4) Capsule PO HS (at bedtime). 4. Gabapentin 400 mg Capsule [**Last Name (un) **]: Two (2) Capsule PO Q8H (every 8 hours). 5. Lamotrigine 100 mg Tablet [**Last Name (un) **]: Two (2) Tablet PO BID (2 times a day). 6. Guaifenesin 100 mg/5 mL Syrup [**Last Name (un) **]: 5-10 MLs PO Q6H (every 6 hours) as needed. 7. Albuterol Sulfate 0.083 % Solution [**Last Name (un) **]: One (1) Inhalation Q4H (every 4 hours) as needed. 8. Ipratropium Bromide 0.02 % Solution [**Last Name (un) **]: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Metoprolol Tartrate 25 mg Tablet [**Last Name (un) **]: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*0* 10. Levothyroxine 100 mcg Tablet [**Last Name (un) **]: Two (2) Tablet PO DAILY (Daily). 11. Furosemide 80 mg Tablet [**Last Name (un) **]: One (1) Tablet PO DAILY (Daily). 12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 13. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 14. Atorvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 15. Fluoxetine 20 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO DAILY (Daily). 16. Aripiprazole 15 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 17. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times a day). 18. Oxycodone-Acetaminophen 5-325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*80 Tablet(s)* Refills:*0* 19. Ibuprofen 600 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*1* 20. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 21. insulin pump pt to self regulate insulin pump 22. Augmentin 875-125 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: tracheoplasty Discharge Condition: good Discharge Instructions: Call Dr.[**Name (NI) 1816**] office [**Telephone/Fax (1) 170**] if you experience chest pain, shortness of breath, productive cough, fever, chills. Do not drive while taking pain medication. Followup Instructions: Call Interventional pulmonology [**Telephone/Fax (1) 10082**] to arrange a bronchcoscopy in 2 weeks. Call Dr.[**Name (NI) 1816**] office for a follow up appointment. Completed by:[**2104-6-12**]

[ "244.9", "357.2", "V45.82", "519.1", "414.00", "250.61" ]

icd9cm

[ [ [] ] ]

[ "33.48", "33.23", "31.79", "96.05" ]

icd9pcs

[ [ [] ] ]

5736, 5742

1845, 3128

323, 580

5800, 5807

1266, 1822

6047, 6243

1090, 1108

3435, 5713

5763, 5779

3154, 3412

5831, 6024

1123, 1247

245, 285

608, 814

836, 1000

1016, 1074