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Admission Date: [**2108-4-6**] Discharge Date: [**2081-4-7**] Date Birth: [**2059-5-7**] Sex: F Service: MED CHIEF COMPLAINT: Dyspnea. HISTORY PRESENT ILLNESS: 48 year old African American female history multiple myelomas admitted respiratory distress. patient recently discharged one week ago outside hospital ([**Hospital3 7900**]) respiratory distress. Back [**Hospital3 7362**], given nebulizer, antibiotics steroids. also elevated INR given medication lower INR although evidence bleeding. Last night, reports increased difficulty breathing. also cough. denies fever chills. patient admitted decreased p.o. intake recently sedimentary. denies swelling legs. patient noted wheezing took Albuterol inhaler without effect. Prednisone taper reports coughing thick sputum. went primary care provider today could say sentence sent Emergency Department. Emergency Department, tachypneic wheezing heart 120 blood pressure 127/82. received Solu-Medrol continued nebulizer treatment. improved, seemed tiring. ABG done showed pH 7.41; PCO2, 40; PO2, 92. speak full sentences still making wheezing. requiring continued nebulizer treatment denies chest pain, nausea, vomiting, diarrhea abdominal pain. feels weak general. PAST MEDICAL HISTORY: 1. Multiple myeloma diagnosed [**2107-12-9**], increase protein bone marrow biopsy. receive Decadron 40 mg q every week. 2. Pulmonary embolism, [**2108-1-2**]. 3. Asthma. PFTs ..................... 4. History steroid psychosis. 5. Pneumonia requiring intubation [**2107-12-9**]. MEDICATIONS UPON ADMISSION: 1. Coumadin 2.5 mg p.o. q d. 2. Serevent two puffs q.i.d. 3. Albuterol inhaler one two puffs q 6 hours prn. 4. Dexamethasone 10 mg p.o. q d. ALLERGIES: known drug allergies. SOCIAL HISTORY: Socially, lives children works home home health aid. twenty years two pack day smoking history quit [**2107-12-9**]. drinks occasional alcohol. FAMILY HISTORY: Family history shows father died myocardial infarction. Sister ovarian cancer. PHYSICAL EXAMINATION UPON ADMISSION: Temperature, 96.6; heart rate, 122; blood pressure, 127/82; respiratory rate, 24; O2 saturation, 99%. Head, eyes, ears, nose throat, pupils equal, round, reactive light accommodation extraocular movements intact. accessory muscles used. Neck supple without lymphadenopathy. Pulmonary, diffuse wheezing bibasilar crackles left greater right. Cardiac, regular rate rhythm normal S1 S2. murmurs thrills noted. Abdomen soft, nontender, nondistended normal active bowel sounds. Extremities, edema, cyanosis clubbing noted. Neurologically, patient somnolent oriented x 3. focal defects noted. LABORATORIES UPON ADMISSION: White count, 9.6; neutrophils, 66%; lymphocytes, 5%; bandemia, 21%; monocytes, 1%. Sodium, 131; potassium, 4.4; chloride, 92; bicarbonate, 24. BUN, 14; creatinine, 0.8. Glucose, 131. INR, 1.3. PTT, 29.1. ABG, 7.41; PCO2, 40; PO2, 92. HOSPITAL COURSE: 1. Pulmonary - Dyspnea secondary chronic obstructive pulmonary disease/emphysema hospital course. Briefly, patient received BIPAP, ...................., intravenous Solu-Medrol, nebulizer treatment inhaler treatment Intensive Care Unit. able weaned oxygen back room air, sating 93 94 percent. Though chest x-rays show hyperinflation signs infection, given five days worth Zithromax. echocardiogram rule cardiac wheezes showed ejection fraction greater 55%, mild right ventricular dilation mild pulmonary arterial pressure. Pulmonary function tests performed showing obstructive pattern FEC 2.56 93% predicted FEV1 0.9 43% predicted FEV1 FEC ratio 46%. patient transferred Medical Floor, CT performed showed evidence pulmonary embolism show signs emphysema. Sputum cultures sent showed growth organism. Alpha antitrypsin sent still pending. 2. Pulmonary Embolism - patient continued Coumadin INR 2 3. Since subtherapeutic, started Lovenox became therapeutic Coumadin. 3. Psychiatry - Anxiety. patient quite anxious hospital course. Psychiatry called consult recommended Risperidone 0.25 mg q hs. patient well medication. 4. Oncology - Multiple myeloma. protein electrophoresis done showing monoclonal IGG capa gammaglobulinopathy (60% total protein [**2108-1-8**], 66% total protein [**2108-4-9**], despite q weekly Dexamethasone treatment. Bone marrow biopsy done revealing 70 80 percent plasma cells. Given findings, patient transferred [**Hospital Ward Name 516**] start chemotherapy Vincristine, ................... Decadron preparation bone marrow transplant done. [**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**] Dictated By:[**First Name3 (LF) 30667**] MEDQUIST36 D: [**2108-4-17**] 15:47 T: [**2108-4-17**] 15:46 JOB#: [**Job Number 30668**]
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[
"486"
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Admission Date: [**2145-3-31**] Discharge Date: [**2145-4-7**] Date Birth: [**2071-6-4**] Sex: F Service: SURGERY Allergies: Penicillins / Dilantin Attending:[**First Name3 (LF) 301**] Chief Complaint: Severe abdominal back pain Unable take oral intake. flatus bowel movement. Abdominal distention. Major Surgical Invasive Procedure: Exploratory Laparotomy Lysis adhesions Small Bowel Resection Jejunosotomy History Present Illness: Ms [**Known lastname **] 73 year old female history multiple abdominal surgeries, pancreatitis previous SBO. presented Emergency Department [**2145-3-30**] complaints [**11-10**] abdominal pain, radiating back began morning. complains distention, inability bowel movement, inability take oral intake, fever, chills diarrhea. Past Medical History: Chronic Pancreatitis Migraines Surgical history: Pancreatic diversion, cholecystectomy, appendectomy, small bowel obstruction. Social History: Married, lives husband retired pediatric infectious disease doctor. Family History: Father: deceased, leukemia Brother: colon cancer Physical Exam: T: 97.9 HR: 79 BP: 153/60 RR: 22 Spo2 100% RA Constitutional: pain Head/Eyes: mucous membranes dry ENT/Neck: neck supple Chest/Respiratory: Clear auscultation Bilaterally GI/Abdominal: Tender light palpation. Multiple well healed scars + guarding, hypoactive bowel sounds GU: costovertebral angle tenderness Musculoskeletal: WNL Skin: Dry Neuro: alert & oriented Pertinent Results: [**2145-3-30**] 09:15PM BLOOD Glucose-116* UreaN-16 Creat-0.8 Na-139 K-3.8 Cl-103 HCO3-25 AnGap-15 [**2145-3-31**] 10:26AM BLOOD WBC-12.3*# RBC-4.01* Hgb-12.3 Hct-37.1 MCV-93 MCH-30.6 MCHC-33.0 RDW-14.2 Plt Ct-259 [**2145-3-30**] 09:15PM BLOOD ALT-12 AST-22 AlkPhos-89 Amylase-169* TotBili-0.3 [**2145-4-2**] 06:15AM BLOOD Amylase-107* [**2145-3-31**] 10:26AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.6 [**2145-3-31**] 12:44AM BLOOD Lactate-3.1* [**2145-4-2**] 02:10PM BLOOD Lactate-1.9 [**2145-3-30**] 11:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG . ABDOMEN (SUPINE & ERECT) IMPRESSION: Nonspecific bowel gas pattern without evidence obstruction. . CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST IMPRESSION: 1. High grade small-bowel obstruction. Unusual configuration loop small bowel mid abdomen concerning closed loop obstruction. moderate amount free fluid within abdomen. 2. Ill-defined opacity right middle lobe representing infection BAC evaluated PET CT. 3. Thickening first portion duodenum, uncertain clinical significance. . CHEST (PORTABLE AP) [**2145-4-2**] 1:51 PM IMPRESSION: Right lower lobe airspace opacity, could represent pneumonia appropriate clinical setting. Small bilateral pleural effusions. Followup assure resolution recommended. . CT Chest [**2145-4-2**] IMPRESSION: 1. New right lower lobe pneumonia. Small bilateral pleural effusion left basilar atelectasis. 2. Ill-defined opacity right middle lobe representing either infection BAC evaluated acute issues resolve. 3. evidence pulmonary embolus aortic dissection. 4. Small mediastinal axillary lymph nodes, meet CT criteria pathologically enlargement. CXR [**2145-4-6**] IMPRESSION: 1. Improving airspace consolidation right lower lung field consistent resolving pneumonia. 2. Small bilateral pleural effusions. Brief Hospital Course: Ms [**Known lastname **] admitted emergency room [**2145-3-31**] taken operating room. underwent uncomplicated exploratory laparatomy small bowel resection, jejunosotomy lysis adhesions, see op report details. stabilized PACU, transferred SICU POD#1. extubated, pain well controlled morphine PCA, remained NPO NGT foley catheter. initiated Cefazolin/Flagyl x 24 hours. POD#2 developed confusion decreased oxygen saturation, requiring 3L nasal cannula. Narcotics stopped, CXR CT chest obtained revealed right lower lobe pneumonia, see pertinent results details. Vanc/Levo/Flagyl initiated well ID medicine consult. transferred SICU. POD#[**4-4**] remained SICU, mental status respiratory status improved. POD#4 NGT removed transferred [**Hospital Ward Name 121**] 9, weaned room air. pain well controlled tylenol small doses oxycodone. POD#5 reported flatus followed multiple loose stools. Stool C diff negative. started sips, tolerated easily. POD#6 tolerated clear liquids longer wanted take antibiotics due frequent stools. CXR repeated showed resolving pneumonia. tolerated regular diet evening without difficulty. Infectious disease team recommended completion 7 days Levofloxacin. Clips removed POD#7, discharged home stable condition antibiotics, pain medication appropriate follow appointments. Medications Admission: Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) needed. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). 6. Trileptal Resume home dose trileptal Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 0.5-1 Tablet PO Q4-6H (every 4 6 hours) needed. Disp:*30 Tablet(s)* Refills:*0* 2. Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) needed. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 6 hours) needed. 5. 7. Levaquin 500 mg Tablet Sig: One (1) Tablet PO day. Disp:*7 Tablet(s)* Refills:*0* Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). 6. Trileptal Resume home dose trileptal Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction Internal hernia necrotic jejunum Pneumonia Discharge Condition: good Discharge Instructions: Please call surgeon develop chest pain, shortness breath, fever greater 101.5, foul smelling colorful drainage incisions, redness swelling, severe abdominal pain distention, persistent nausea vomiting, inability eat drink, symptoms concerning you. tub baths swimming. may shower. clear drainage incisions, cover dry dressing. Leave white strips incisions place, allow fall own. Activity: heavy lifting items [**11-15**] pounds follow appointment doctor. Medications: Resume home medications. problem constipation, take stool softener, Colace 100 mg twice daily needed. given pain medication may make drowsy. driving taking pain medicine. Followup Instructions: Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2145-4-20**] 2:00 appointment see Dr. [**Last Name (STitle) **] Friday, [**2145-4-23**] 3:30. Phone #: [**Telephone/Fax (1) 2723**]. Please see primary care physician regarding follow CT scan within 1 month. CT results Discharge summary faxed her. Completed by:[**2145-4-7**]
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[
"486"
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Admission Date: [**2176-8-29**] Discharge Date: [**2176-9-6**] Date Birth: [**2121-2-13**] Sex: Service: MEDICINE Allergies: Penicillins / Keflex Attending:[**First Name3 (LF) 1928**] Chief Complaint: Upper extremity weakness Major Surgical Invasive Procedure: C5-C6 anterior cervical decompression fusion, C1 tumor removal History Present Illness: 55-year-old man diabetes mellitus type 2, hypertension, severe peripheral [**First Name3 (LF) 1106**] disease s/p R SFA stent angioplasty L SFA stent placement, congenital pulmonic valve stenosis, CAD s/p BMS stents, diastolic CHF, atrial fibrillation s/p ablation warfarin, stage 3 diabetic nephropathy, intradural tumor compressing spinal cord C1/C2, admitted [**2176-8-29**] neurosurgery anterior cervical decompression C5/6 fusion ([**8-29**]) extradural tumor removal C1 intradural tumor ([**8-30**]). patient post-operatively managed ICU dexamethasone taper. developed small subdural hematoma ([**8-30**]) new neurologic symptom. Aspirin heparin SC restarted. Clopidogrel, L SFA stent, scheduled restarted POD#5, [**2176-9-4**], warfarin, atrial fibrillation, restarted [**2176-9-9**]. Patient extubated [**9-1**], coming furosemide drip dCHF. [**Month/Day (4) **] following patient mottled right foot recent [**Month/Day (4) 1106**] procedures. Patient's medical issues diabetes, HTN, CKD (Cr 1.1), atrial fibrillation (HRs 70s-80s), CAD s/p stent "chronic hyponatremia" (Na 138) stable. Transfer requested ongoing management diastolic CHF. evaluation SICU transfer, patient sleeping arousable, complaining old back pain constipation. Vital signs stable O2 saturation 98% 3L. Past Medical History: (1) Type 2 diabetes mellitus, requiring insulin, complications years poor glycemic control: -hypertension -severe peripheral [**Month/Day (4) 1106**] disease -peripheral neuropathy -pressure, venous stasis, neuropathic ulcers right left lower extremities -stage 3 diabetic nephropathy -renal insufficiency (baseline creatinine 1.5 1.7) (2) Atrial fibrillation status post ablation [**2169**] [**2174**], coumadin (3) Congenital pulmonic valve stenosis status post two childhood surgeries -history RV failure -history peripheral edema anasarca (4) Chronic hyponatremia (5) Chronic low back pain status post car accident (6) Spinal cord meningioma compressing spinal cord C1/C2 (7) COPD (8) Coronary artery disease status post stenting [**2169**] (bare metal stent Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] ([**Telephone/Fax (1) 8725**])) repeat stenting [**Hospital1 18**] [**2174**] (bare metal stent - see d/c summary [**2175-2-7**]) (9) MI [**2161**] Social History: patient married two adult sons live home. lives [**Hospital1 1474**], MA. wife works 60 hours week, left home day. bedbound several years. visiting nurse come week change dressings lower extremity ulcers. sons struggle alcoholism heroin abuse. younger son recently threatened suicide homicide (against patient's wife), source much stress home. used work "bouncer" construction, enjoyed riding motorcycle. patient says tries keep positive attitude condition. says feels depressed, says interested therapy medication depression. seen primary care physician [**Last Name (NamePattern4) **] 2 years travel ambulance PCP's office touch patient wife weekly. -[**Name2 (NI) **] 2 pack per year smoking history "several years" -He drinks alcohol occasionally, never problem alcoholism -He denies recreational IV drug use Family History: Heart disease unspecificed family members. Physical Exam: Physical exam admission: Gen: obese, deconditioned, pain movement extremities. Extrem: B LE edema Neuro: Mental status: Awake alert, cooperative exam. Language: Speech fluent good comprehension repetition. Naming intact. dysarthria paraphasic errors. Motor: Patient severe bilateral wasting muscles hand. UE's: FI's:[**2-1**] 4+/5 Grip 4+/5 Bi4+/5 Tri 4+/5. RLE: [**1-4**] PF/DF 0/5 LLE: IP3/5 PF/DF 0/5 Pertinent Results: [**2176-8-29**] 12:10PM GLUCOSE-94 UREA N-42* CREAT-1.2 SODIUM-133 POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-28 ANION GAP-14 [**2176-8-29**] 12:10PM estGFR-Using [**2176-8-29**] 12:10PM WBC-7.6 RBC-3.91* HGB-9.7* HCT-30.5* MCV-78* MCH-24.9* MCHC-31.9 RDW-13.6 [**2176-8-29**] 12:10PM PLT COUNT-206 IMAGING STUDIES: # C-spine Xray [**8-29**]: Single lateral view cervical spine obtained portably OR, labeled #1. C1 C4/5 disc space visualized. C5 vertebral body faintly seen -- bony structures lower obscured overlying soft tissues. However, surgical markers seen overlying anterior aspects C4-5 C5-6 disc spaces, anterior approach. Support tubing temperature probles noted. # C-spine CT [**2176-8-29**]: 1. New interval C5-C6 anterior fusion intervertebral disc spacer, immediate hardware complication. Post-surgical changes soft tissue subcutaneous emphysema mostly right submandibular region. 2. Mass C1 level associated cord compression consistent known meningioma better described recent MRI. 3. Soft tissue thickening right lung apex, fully characterized current CT. comparison CT neck [**2176-8-9**], increased size. CT chest recommended evaluate further, clinically warranted. # Head CT [**2176-8-30**]: 1. New interval left frontal subdural hyperdense extra-axial fluid collection new interval subdural subfalcine extra-axial hyperdense fluid collection, indicating subdural hemorrhage, likely post-surgical clinical correlation recommended. 2. Pneumocephalus distribution basilar cisterns, mostly left sylvian fissure, bifrontally falx, likely post-surgical, additionally posterior fossa near site occipital craniotomy. 3. Post-surgical changes left craniotomy occipital bone laminectomy C1 subcutaneous emphysema hyperdense products, likely post-surgical. 4. Soft tissue hyperdensity posterior parietal, occipital soft tissue region, could small post-surgical hematoma. . # C-spine MRI [**2176-8-31**]: Status post resection C1 extradural tumor, likely meningioma expectorated postoperative changes. large intraspinal hematoma seen. remains persistent narrowing spinal canal C1 level indentation posterior aspect spinal cord. Continued followup recommended. Mild spinal cord atrophy could secondary chronic myelomalacia. . # LE arterial Duplex [**2176-9-3**]: peak systolic velocity involving native right common femoral artery 104 cm/sec. Velocities within superficial femoral artery range 85 234 cm/sec within popliteal artery right, 25 cm/sec. left, peak systolic velocity within common femoral artery 132 cm/sec, SFA, velocities range 146-75 cm/sec within popliteal artery 85 cm/sec. IMPRESSION: Findings stated indicate widely patent common femoral, superficial femoral popliteal arteries bilaterally. . PATHOLOGY: # C1 tumor [**2176-8-30**]: Cervical medullary junction tumor: Meningioma, psammomatous subtype (WHO Grade I). tumor composed meningothelial cells numerous psammoma bodies collagen deposition typical features mitotic activity. Brief Hospital Course: 55-year-old man diabetes mellitus type 2, severe peripheral [**Month/Day/Year 1106**] disease, CAD, diastolic CHF, atrial fibrillation, presented planned anterior cervical decompression C5-6 removal C1 meningioma. # Cervical myelopathy meningioma: Patient underwent anterior cervical decompression C5/6 fusion [**2176-8-29**] removal C1 meningioma [**2176-8-30**]. patient post-operatively managed ICU dexamethasone taper. developed small subdural hematoma [**2176-8-30**] new neurologic symptom. Per neurosurgery recommendations, aspirin heparin SC restarted. Clopidogrel, recent left SFA stent, restarted POD#5, [**2176-9-4**], warfarin, atrial fibrillation, restarted [**2176-9-9**]. note, concern developed LE weakness procedure, re-evaluation neurosurgery team felt strength legs baseline change. continued work PT hospitalization. # Diastolic heart failure: patient experienced acute exacerbation diastolic heart failure likely secondary significant fluid administration surgery. placed furosemide gtt SICU, transitioned home dose lasix floor. discharge slightly admission weight 115kg O2 sats mid 90's room air. # Peripheral [**Date Range **] disease. patient recently underwent bilateral SFA angioplasties Left SFA stenting. preparation neurosurgery, plavix held pre-procedure subsequently re-started [**2176-9-4**]. underwent bilateral arterial ultrasound [**2176-9-3**] demonstrated patent SFA femoral arteries. # Atrial fibrillation: patient atrial fibrillation hospitalization. Given need neurosurgery coumadin held. scheduled restarted 10 days post-procedure ([**2176-9-9**]). well rate controlled time discharge. # DM II. patient's insulin regimin adjusted 50 units insulin glargine nightly humalog insulin sliding scale achieved good control blood sugars (FSBS 100-180). # Pressure ulcers. patient 2x2cm right heel full thickness ulcer without odor drainage. right dorsum small 1x1cm partial thickness ulcer. Wound care nursing consult obtained. Pressure ulcer care performed repositioning, skin cleansing conditioner application, cover ABD kerlex. # Coping. pt expressed staff members mood poor coping well surgery. never expressed suicidal ideations. expressed extremely frustrated hospitalization inability walk function independently. Discussed possibility talking psychiatrists hospital, declined. felt feeling persisted would pursue psychiatric care. number psychiatric services provided discharge. # Chronic pain syndrome: patient continued home regimen dilaudid 4mg PO Q3H:prn # Chronic hyponatremia. patient history chronic hyponatremia although sodium remained 130-140 admission. Medications Admission: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID: PRN needed constipation. 2. Furosemide 10 mg/mL Solution Sig: Sixty (60) mg Injection [**Hospital1 **] (2 times day): Hold SBP<100. 3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice day. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times day): Hold SBP<100 HR<60. 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) needed insomnia. 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) needed fever. 8. Petrolatum Ointment Sig: One (1) Appl Topical DAILY (Daily): Please apply leg wounds per wound care orders. thank you! . 9. Methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO QID (4 times day). 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation q6H: PRN needed shortness breath wheezing. 11. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) needed pain: Hold RR<12 sedation. 12. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 14. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO q6H: PRN needed itching. 15. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen (17) g PO BID: PRN needed constipation. 16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) needed constipation: hold diarrhea. 17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed anxiety. 18. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) needed dry mouth, sore throat. 19. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times day): Please apply upper forehead scalp seborrheic dermatitis (day 1 = [**2176-8-11**]). Also, please apply wound left shin overlying fungal infection(day 1 = [**2176-8-15**]). Thank you! . 20. Glycerin (Adult) Suppository Sig: One (1) Suppository Rectal PRN (as needed) needed constipation. 21. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) needed headache: Hold somnolence. 22. Heparin drip Heparin IV Sliding Scale (please see included scale): Diagnosis: DVT/A-fib, Patient Weight: 114.76 kg, Initial Bolus: 0 units IVP, Initial Infusion Rate: 1450 units/hr, Target PTT: 60 - 100 seconds, . PTT <40: 4600 units Bolus Increase infusion rate 450 units/hr, PTT 40 - 59: 2300 units Bolus Increase infusion rate 250 units/hr, PTT 60 - 100*:, PTT 101 - 120: Reduce infusion rate 250 units/hr, PTT >120: Hold 60 mins Reduce infusion rate 450 units/hr, 23. Insulin sliding scale Glargine 46 units bedtime; Humalog sliding scale per included sliding scale. Discharge Medications: 1. Hydroxyzine HCl 25 mg/mL Solution Sig: One (1) Intramuscular Q6H (every 6 hours) needed pruritis. 2. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 3. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times day). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed constipation. 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice day. 9. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO Q4H (every 4 hours). 10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-1**] Inhalation every 4-6 hours needed shortness breath wheezing. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 12. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO Q3hr:prn. 13. simvistatin 10mg Qday 14. Petrolatum Ointment Sig: One (1) Appl Topical DAILY (Daily). 15. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times day). 16. Outpatient Lab Work Chem 10 monitor electrolytes creatinine taking lasix 17. Turn reposition back prn limit sit time 1hour time using pressure redistribution cushion. Cleanse skin wound cleanser NS pat dry nad apply aquafor gluteals legs feet daily 18. heel lateral foot ulcer apply thin layer duoderm wound gel, cover dorsum lateral wound adaptic heel gauze followed ABD pad, wrap iwth kerlix change daily 19. headrest occiput frequent repositioning 20. please remove sutures posterior neck tuesday [**9-10**] [**2175**] 21. Please start warfarin [**2176-9-9**] (post op day 10) monitor INR prn 22. check weight Qday Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 701**] Discharge Diagnosis: Cervical myelopathy C1 tumor cervical myelopathy Acute chronic diastolic heart failure Discharge Condition: Stable, afebrile Discharge Instructions: admitted [**Hospital1 18**] [**2176-8-29**] worsening upper extremity weakness due spinal tumor. underwent operation remove tumor. also underwent operation decrease pressure spinal cord neck. need staples surgical site [**2176-9-10**], rehab facility. appointment made follow Dr. [**Last Name (STitle) **] 6 weeks. Please return Emergency department fever, chills, difficulty breathing, worsening upper extremity weakness, worsening symptoms. Followup Instructions: 1. [**Last Name (STitle) **] LAB [**Hospital1 18**] [**Hospital Unit Name **], [**Location (un) **] [**Location (un) **] surgery Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2176-9-26**] 3:15 2 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD LM [**Hospital Unit Name **], [**Location (un) **] [**Location (un) **] surgery Phone:[**Telephone/Fax (1) 2625**] Date/Time:[**2176-9-26**] 4:15 3. Dr. [**Last Name (STitle) 47032**] [**Name (STitle) **] address: [**Doctor First Name **] [**Hospital Unit Name **] [**Location (un) 470**] [**Hospital Unit Name **] phone: [**Telephone/Fax (1) **] appointment: [**2176-10-8**] 1:15PM 4. Psychiatry Clinic [**Hospital1 18**] Psychiatry Clinic Please call bottom number schedule appointment mood sad taking pleasure life: [**Telephone/Fax (1) **]
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[
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"412"
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Admission Date: [**2199-12-3**] Discharge Date: [**2199-12-19**] Date Birth: Sex: Service: CHIEF COMPLAINT: Hypoxia HISTORY PRESENT ILLNESS: 33 year old male significant past medical history initially presented [**Company 191**] Outpatient Clinic [**11-27**] four days high fevers (103 degrees F), nonproductive cough, malaise, diffuse myalgias, mild resting dyspnea, exposure ill contacts. [**2199-11-27**] vital signs office temperature 99.5, blood pressure 120/85, heartrate 113 respiratory rate 20, oxygen saturation 89% room air. Weight 238 lbs. Nonspecific pulmonary examination appreciated time. prescribed Levaquin 500 mg p.o. q.d. discharged home. represented outpatient [**Hospital 191**] Clinic [**2199-12-3**] complaining persistent fever 102 degrees F, weakness, bilious emesis, worsening dyspnea, nonproductive cough. Vital signs office temperature 97.3, blood pressure 108/70, respiratory rate 20, heartrate 108, oxygen saturation 70% room air. wheezes noted examination. given 1 gm Ceftriaxone sent Emergency Department received normal saline 1 gm Vancomycin. denied pleuritic chest pain. risk factors human immunodeficiency virus. denies history seizure disorder, alcohol use, recent somnolence, symptoms gastroesophageal reflux disease. transferred Intensive Care Unit arrival. PAST MEDICAL HISTORY: significant past medical history surgical history. ALLERGIES: known drug allergies. MEDICATIONS ADMISSION: Levofloxacin 500 mg p.o. q.d. SOCIAL HISTORY: Originally [**Male First Name (un) 1056**]. bus driver, lives wife daughter, alcohol, elicit drug use. Rare alcohol use. FAMILY HISTORY: Father diabetes mellitus. PHYSICAL EXAMINATION ADMISSION: General, moderately obese, sitting bed, accessory muscle use. Vital signs, temperature 99.0, heartrate 92, blood pressure 137/74, respiratory rate 16, oxygen saturation 100% 100% nonrebreather. Head, eyes, ears, nose throat, pupils equal, round reactive light, extraocular muscles intact, anicteric, oropharynx clear, fair dentition. Neck, lymphadenopathy. Chest, rhonchi, right greater left, crackles, wheezes. Normal E ratio, egophony, fremitus, dullness percussion. Cardiac, regular rate rhythm, murmurs, rubs gallops. Abdomen, obese, normoactive bowel sounds, nontender, nondistended, masses. Neurological, cranial nerves II XII grossly intact. Alert oriented times three. Conversant appropriately. Strength 5/5 extremities. LABORATORY DATA: Laboratory findings admission revealed white blood cell count 8.4, 73% neutrophils, 0 bands, 19 lymphocytes, 6 monocytes, hematocrit 43.8, platelets 104, MCV 83, RDW 13.0, sodium 137, potassium 3.4, chloride 92, bicarbonate 29, BUN 13, creatinine 0.8, glucose 129. Arterial blood gases 100% nonrebreather, PH 7.49, carbon dioxide 39, oxygen 77. Imaging: [**2199-11-27**], chest x-ray, normal, acute cardiopulmonary process. Chest x-ray [**2199-12-3**], (on admission), patchy right upper lobe, right middle lobe infiltrate diffuse right greater left interstitial pattern, normal mediastinum, effusion. HOSPITAL COURSE: 33 year old male past medical history originally admitted Intensive Care Unit hypoxia, bilateral pneumonia, received Ceftriaxone Azithromycin, Doxycycline added since parakeet home (he also rats home). underwent bronchoscopy computed tomographic angiography thorax demonstrated right middle lobe right lower lobe pulmonary emboli question infarction. subsequently heparinized. human immunodeficiency virus test negative. received Bactrim steroids days stopped human immunodeficiency virus test came back negative. hypercoagulability workup pending arrived floor stable condition. arrival floor clinically improving heparin drip, Ceftriaxone, Azithromycin, Doxycycline. studies obtained Intensive Care Unit included [**First Name8 (NamePattern2) **] [**Doctor First Name **] negative, ANCA negative, hepatitis panel negative. LENIS demonstrated deep vein thrombosis, thrombosis right lesser saphenous vein, echocardiogram obtained well [**12-6**], demonstrated ejection fraction 50%, mildly dilated right ventricle mild tricuspid regurgitation. chest computerized tomography scan mentioned [**12-4**] demonstrated multiple small pulmonary emboli (right lower lobe right middle lobe) bilateral atypical pneumonias. Workup organism said pneumonia undertaken. negative viral culture, negative Chlamydia, negative leptospirosis, negative C. Psittaci negative mycoplasmas. Blood cultures negative well. maintained Azithromycin completed 14 day course pneumonia. Doxycycline withdrawn. completed ten day course Ceftriaxone. Regarding pulmonary emboli, remained hemodynamically stable heparin drip throughout admission. repeat computerized tomography scan thorax demonstrated bilateral expanded heterogenous soft tissue densities within rectus abdominis muscle ? hematomas, partial resolution bilateral perihilar ground-glass opacities, left SVC, however, pulmonary emboli. Given discrepancy [**12-4**] [**12-11**], computerized tomography scans, would difficult prove pulmonary emboli [**12-4**] film. decision anticoagulate three six months pursue evaluation made. Regarding anticoagulation workup, patient positive anticardiolipin IgM (46.9). intermediate range value. IgG anticardiolipin value 1.6. patient normal PTT admission. make diagnosis anticardiolipin syndrome single value, finding stands nonspecific, however, anticardiolipin panel repeated six weeks. patient subsequently continued anticoagulation pulmonary emboli. heparin drip discontinued discharge bridged Coumadin Lovenox. Regarding rectus hematomas noted computerized axial tomography scan, finding commonly seen setting anticoagulation. patient concurrently fevers maximally 101 degrees F. concern perhaps fevers may attributable hematoma local infection thereabouts. started Clindamycin conjunction Infectious Disease Consult Service's recommendations. completed ten day course Clindamycin. Finally, patient noted drop hematocrit anticoagulation. guaiac negative. source bleed identified. likely bled abdominal hematoma attributing drop hematocrit. patient also intermittently hyponatremic stay, likely secondary syndrome inappropriate antidiuretic hormone secondary thoracic processes (namely bilateral pneumonia, pulmonary embolisms) admission. DISCHARGE DIAGNOSIS: 1. Bilobar pneumonia atypical fevers 2. Pulmonary embolus 3. Rectus hematoma 4. Anticardiolipin antibody IgM positive 5. Hyponatremia 6. Anemia FOLLOW UP: patient follow primary provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] week following discharge. MEDICATIONS DISCHARGE: discharged Lovenox bridge Coumadin. also discharged Clindamycin complete ten day course. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**] Dictated By:[**Name8 (MD) 17844**] MEDQUIST36 D: [**2200-5-7**] 17:14 T: [**2200-5-7**] 19:08 JOB#: [**Job Number **]
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[
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Admission Date: [**2164-4-23**] Discharge Date: [**2164-4-27**] Date Birth: [**2096-1-7**] Sex: Service: CARDIOTHORACIC Allergies: Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest pain shortness breath Major Surgical Invasive Procedure: [**2164-4-23**] Coronary artery bypass grafting x3 left internal mammary artery left anterior descending artery reverse saphenous vein graft posterior descending artery obtuse marginal artery. History Present Illness: 68 year old male history MI 25 years ago. treated medication since then. well years 3 weeks ago started notice diaphoresis, shortness breath right sided chest discomfort occurred exertion yard work taking trash. symptoms resolve rest. also one episode chest pain, diaphoresis back pain occurred rest large meal. episode lasted little longer episodes prompted patient contact Dr. [**Last Name (STitle) 1270**]. sent stress echo abnormal referred cardiac catheterization. found three vessel disease referred cardiac surgery revascularization. Past Medical History: diabetes type II -diagnosed [**2160**]; controlled oral agents hyperlipidemia hypertension MI [**2138**] psoriasis Social History: Race:Caucasian Last Dental Exam:[**1-/2164**] Lives with:Wife Contact:[**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 90854**] Occupation:Retired FDA field investigator consultant Cigarettes: Smoked [] yes [x] Hx:smoked 2ppd 28 years quit [**2138**] Tobacco use:denies ETOH: < 1 drink/week [x] [**12-27**] drinks/week [] >8 drinks/week [] Illicit drug use:denies Family History: Premature coronary artery disease- unknown-adopted Physical Exam: Pulse:61 Resp:16 O2 sat:100/RA B/P Right:138/86 Left:135/74 Height:6'2" Weight:230 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [x] _____ Varicosities: (L)LE superficial varicosities Neuro: Grossly intact [x] Pulses: Femoral Right: Left: DP Right:2+ Left:2+ PT [**Name (NI) 167**]: Left: Radial Right: Left: Carotid Bruit -none appreciated, pulses Right:2+ Left:2+ Pertinent Results: [**2164-4-23**] Echo: PRE-BYPASS: spontaneous echo contrast seen body left atrium left atrial appendage. atrial septal defect seen 2D color Doppler. Left ventricular wall thicknesses normal. left ventricular cavity size top normal/borderline dilated. mild regional left ventricular systolic dysfunction hypokinesis basal distal inferoseptal anteroseptal walls. Overall left ventricular systolic function mildly depressed (LVEF= 50-55 %). Right ventricular chamber size free wall motion normal. simple atheroma aortic arch. simple atheroma descending thoracic aorta. aortic valve leaflets (3) appear structurally normal good leaflet excursion aortic stenosis aortic regurgitation. mitral valve leaflets mildly thickened. Mild (1+) mitral regurgitation seen. pericardial effusion. Dr. [**Last Name (STitle) **] notified person results time surgery. POST-BYPASS: patient sinus rhythm. patient inotropes. Biventricular function unchanged. Mitral regurgitation unchanged. aorta intact post-decannulation. [**2164-4-27**] 04:44AM BLOOD WBC-11.7* RBC-3.00* Hgb-9.8* Hct-28.3* MCV-94 MCH-32.5* MCHC-34.5 RDW-14.0 Plt Ct-323 [**2164-4-27**] 04:44AM BLOOD Plt Ct-323 [**2164-4-27**] 04:44AM BLOOD Glucose-121* UreaN-22* Creat-1.0 Na-139 K-3.8 Cl-102 HCO3-28 AnGap-13 [**2164-4-27**] 04:44AM BLOOD Mg-2.3 COMPARISON: [**2164-4-25**] 10:45 a.m. FINDINGS: noted previously, similar-sized left apical pneumothorax. left chest tube removed interim. Left basilar atelectasis remains. cardiac silhouette mediastinal contours unchanged. Median sternotomy wires unchanged. IMPRESSION: Unchanged small left apical pneumothorax, status post left chest tube removal. Brief Hospital Course: Mr. [**Known lastname **] 68 yr old male history MI developed worsening chest pain, underwent cath revealed significnat CAD. seen cardiac surgery service accepted CABG. day admit [**4-23**] brought directly operating room underwent coronary artery bypass graft x 3. Please see operative note surgical details. Following surgery transferred CVICU invasive monitoring stable condition. Later day weaned sedation, awoke neurologically intact extubated. weaned Neo overnight started beta-blocker POD#1. diuresed towards preoperative weight. POD#1 transferred step unit monitoring. continued progress well floor. Physical Therapy consulted evaluation strength mobility. remainder postop course essentially uneventful. cleared discharge home VNA services POD#4. Follow-up appts arranged. Medications Admission: ATENOLOL 50 mg Daily LIPITOR 20 mg Daily PLAVIX 75 mg Daily (started [**2164-4-14**]), LD [**4-17**] DILTIAZEM HCL 240 mg Daily ENALAPRIL MALEATE takes 10mg qam, 5mg qhs HYDROCHLOROTHIAZIDE 25 mg Daily METFORMIN 1,000 mg [**Hospital1 **] NITROGLYCERIN 0.4 mg Tablet PRN Aspirin 325mg Daily Centrum Silver Multivitamin 1 tablet daily Discharge Medications: 1. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO day 2 weeks. Disp:*60 Tablet Extended Release(s)* Refills:*2* 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) needed pain. Disp:*40 Tablet(s)* Refills:*0* 5. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). Disp:*1 * Refills:*2* 6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times day). Disp:*90 Tablet(s)* Refills:*2* 7. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). Disp:*120 Tablet(s)* Refills:*2* 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). Disp:*60 Capsule(s)* Refills:*2* 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO day 2 weeks. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x 3 Past medical history: diabetes type II -diagnosed [**2160**]; controlled oral agents hyperlipidemia hypertension MI [**2138**] psoriasis Discharge Condition: Alert oriented x3 nonfocal Ambulating steady gait Incisional pain managed oral analgesia Incisions: Sternal - healing well, erythema drainage Leg Right/Left - healing well, erythema drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently mild soap, baths swimming cleared surgeon. Look incisions daily redness drainage Please lotions, cream, powder, ointments incisions morning weigh evening take temperature, written chart driving approximately one month taking narcotics, discussed follow appointment surgeon able drive lifting 10 pounds 10 weeks Please call questions concerns [**Telephone/Fax (1) 170**] Females: Please wear bra reduce pulling incision, avoid rubbing lower edge **Please call cardiac surgery office questions concerns [**Telephone/Fax (1) 170**]. Answering service contact call person hours** Followup Instructions: scheduled following appointments Wound Check: [**2164-5-8**] 10:00 Surgeon: Dr. [**Last Name (STitle) **] [**2164-5-31**] @ 1pm Cardiologist/PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1270**] [**Telephone/Fax (1) 1144**] Date/Time:[**2164-5-15**] 10:30 **Please call cardiac surgery office questions concerns [**Telephone/Fax (1) 170**]. Answering service contact call person hours** Completed by:[**2164-4-27**]
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Admission Date: [**2183-3-23**] Discharge Date: [**2183-5-9**] Date Birth: [**2124-10-29**] Sex: Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 7591**] Chief Complaint: Weakness Major Surgical Invasive Procedure: Bone marrow biopsy History Present Illness: 58 y/o presented [**Hospital1 **] [**Location (un) 620**] syncopal episode today sustained facial hematoma. Pt remembers going bathroom early morning awoke floor approx 2hrs laterwith left sided facial bruising incontinence. Pt reports severe nosebleeds began 2 days prior admission. saturday, feeling lightheaded developped severe right thigh pain. Sunday, noticed decreased appetite, left thigh pain fevers/chills. review symptoms, pt noticing increased bruising general lethargy last week. Per report, wife trying get see [**Name8 (MD) **] MD months concerned generalized weakness. . Pt initially presented [**Hospital1 **] [**Location (un) **] febrile 101.2 received Vanc Ceftazidime neutropenic fever. underwent head CT revealed small foci petechial hemorrhage within left frontal lobe small subarachnoid hemorrhage. Initial VS arrival [**Hospital1 18**] ED: 100.4 P 76 BP 110/55 R 18 O2 sat 99% RA. Pt given Acyclovir possible Zoster. underwent CTA negative PE received 2L NS IVF. Pt transfused second bag plts prior arrival ICU. . arrival, pt complaining right & left proximal thigh pain approx [**8-22**]. Otherwise, denying CP, SOB, HA, abd pain, nausea, visual changes. feeling exhausted still mildly lightheaded. Past Medical History: Osteoarthritis (knees) Social History: Pt works headmaster [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1573**] school. lives wife two healthy children, three grandchildren. used marathon runner. Denies smoking illicit drug use. reports consuming approx 1 drink per day. Family History: Father died metastatic prostate cancer 80s, mother alive HTN insulin resistance. Physical Exam: Vitals: T: 98.6 BP: 137/73 P: 83 R: 20 O2: 975 RA General: alert, oriented, large ecchymosis left orbit, eye swollen shut HEENT: sclera anicteric, dry MM, oropharynx dried blood Neck: supple, JVP elevated, precervical lymphadenopathy Lungs: Clear auscultation bilaterally, wheezes, rales, ronchi CV: RRR, normal S1/S2, m/r/g Abdomen: soft, NT, ND, NABS, rebound tenderness guarding, appreciable hepatosplenomegaly Inguinal: inguinal lymphadenopathy Ext: Warm, well perfused, 2+ pulses Neuro: CN 2-12 intact (except unable assess left eye due swelling & eccyhmoses). Strength 5/5 four extremities distally. Unable assess proximal muscle strength lower extremities [**3-17**] pain. Sensation intact distally. Gait assessed. saddle anesthesia, focal spinal tenderness. Pertinent Results: [**2183-3-23**] 08:46PM GLUCOSE-116* UREA N-14 CREAT-0.8 SODIUM-138 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-24 ANION GAP-13 [**2183-3-23**] 08:46PM ALT(SGPT)-21 AST(SGOT)-20 LD(LDH)-286* CK(CPK)-126 ALK PHOS-65 TOT BILI-0.8 [**2183-3-23**] 08:46PM ALBUMIN-3.9 CALCIUM-8.5 PHOSPHATE-3.1 MAGNESIUM-2.0 URIC ACID-5.1 [**2183-3-23**] 08:46PM WBC-0.7* RBC-2.21* HGB-7.6* HCT-20.3* MCV-92 MCH-34.5* MCHC-37.5* RDW-17.5* [**2183-3-23**] 08:46PM I-HOS-AVAILABLE [**2183-3-23**] 08:46PM PLT COUNT-43* [**2183-3-23**] 08:46PM PT-17.0* PTT-29.8 INR(PT)-1.5* [**2183-3-23**] 08:46PM FDP-160-320* [**2183-3-23**] 08:46PM FIBRINOGE-303 [**2183-3-23**] 08:46PM GRAN CT-230* [**2183-3-23**] 06:55PM PLT COUNT-53*# [**2183-3-23**] 03:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]->1.050 [**2183-3-23**] 03:40PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2183-3-23**] 03:40PM URINE RBC-[**4-17**]* WBC-[**4-17**] BACTERIA-RARE YEAST-NONE EPI-0-2 [**2183-3-23**] 03:40PM URINE MUCOUS-OCC [**2183-3-23**] 03:16PM LACTATE-2.0 [**2183-3-23**] 03:10PM GLUCOSE-123* UREA N-16 CREAT-0.9 SODIUM-137 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-24 ANION GAP-15 [**2183-3-23**] 03:10PM estGFR-Using [**2183-3-23**] 03:10PM CK(CPK)-147 [**2183-3-23**] 03:10PM CK-MB-1 cTropnT-<0.01 [**2183-3-23**] 03:10PM WBC-0.7* RBC-2.63* HGB-8.9* HCT-24.2* MCV-92 MCH-34.0* MCHC-37.0* RDW-17.8* [**2183-3-23**] 03:10PM NEUTS-8* BANDS-4 LYMPHS-76* MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-4* MYELOS-2* NUC RBCS-2* OTHER-6* [**2183-3-23**] 03:10PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL [**2183-3-23**] 03:10PM PLT SMR-VERY LOW PLT COUNT-29* [**2183-3-23**] 03:10PM PT-15.9* PTT-28.2 INR(PT)-1.4* [**2183-3-23**] 03:10PM GRAN CT-290* [**2183-3-24**] CT HEAD IMPRESSION: 1. Increased size left frontal right posterior cingulate gyrus intraparenchymal hemorrhages. 2. Increased size right frontal, right temporal, interhemispheric subarachnoid hemorrhage. 3. midline shift. evidence acute infarction. [**2183-3-24**] MRI L/T-SPINE evidence acute spine injury within cervical, thoracic lumbar spine. Note made fluid level within lower lumbar spine, consistent layering subarachnoid blood. Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 40120**],[**Known firstname **] [**2124-10-29**] 58 Male [**Numeric Identifier 40121**] [**Numeric Identifier 40122**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **]. MARIAPPAN SPECIMEN SUBMITTED: Immunophenotyping, Bone Marrow Procedure date Tissue received Report Date Diagnosed [**2183-3-24**] [**2183-3-24**] [**2183-3-25**] DR. [**Last Name (STitle) **]. MARIAPPAN/ttl Previous biopsies: [**Numeric Identifier 40123**] BONE MARROW BIOPSY (1 JAR). INTERPRETATION Immunophenotypic findings consistent involvement by: immature population cells consistent acute myelogenous leukemia. Lack CD34 HLA-DR [**Last Name (STitle) 40124**] consistent diagnosis acute promyelocytic leukemia. Correlation morphologic cytogenetic findings recommended. Brief Hospital Course: 58 y/o presenting syncopal episode found multiple small ICH new pancytopenia. complicated course AMPL treatment # Leukemia: Patient found AMPL via bone marrow biopsy day admission MICU. started ATRA monitored closely symptoms DIC, TLS ATRA syndrome. transfused needed PRBC, platlets FFP. develop overt signs DIC. induced Ara-c daunurubicin. counts responded appropriatly. repeat BM biopsy showed remission continue ATRA follow Dr. [**Last Name (STitle) 410**] plans stage two treatment. . # Fevers: initially Vancomycin cefepime first starting treatment due hx fevers home, culture data negative remained afebrile antibiotics discontinued. remained afebrile [**4-14**] spiked fever. cultured blood grew strep viridans. started vanco/cefepime time. also headache day spiked CT done showing appeared brain abscesses. antibiotics eventually broadened vanco, meropenem, fluconzaole flagyl brain abscesses. continued spike, though approximately week. complained thigh pain ultrasound showing bilateral fluid collections. drained IR grew MSSA. developed pneumonia febrile period transferred ICU several days. required O2 discharged ICU. ICU, neutrophil count started drop, worried might drug effect. vanco discontinued counts began recover. Eventually meropenem, voriconazole acyclovir stopped fevers. repeat CT scan showed resolution PNA. Serial repeat head CTs showed slow decrease size abscesses. MRI thigh showed retained small fluid collections bilaterally. plan complete 6 week course antibiotics brain abscesses. reimage thighs MRI outpatient depending results, either need surgical drainage still prolonged course abx. follow ID. . # ICH: Pt multiple small ICH sustained fall acute left sided head injury setting profound thrombocytopenia. CT head revealed small foci intraparenchymal hemorrhage subarachnoid hemorrhage. (no hydrocephalus shift). [**3-24**] follow-up Head CT revealed interval increase hemorrhage without appreciable midline shift infarction. pt's neurologic exam remained stable. Neurosurgery followed closely. Platlet goal > 75K. repeat head CT one month fall showed brain abscesses discussed above. Neuro onc consulted followed along. decided biopsy. also required heparin lovenox DVTs, repeat head CTs anticoaulants remained stable without new bleeds. . # Thigh pain/weakness: Etiology unclear unable get good exam limited pain. may bone marrow pain. evidence hematoma cellulitis. bowel bladder dysfunction, saddle anesthesia, focal spinal tenderness indicate acute cord compression. MRI T/L-spine revealed evidence acute cord compression. evidence layering fluid likely SAH. Although unlikely causing pt's leg pain (nerve irritation secondary blood) Neurosurgery recommended starting Decadron [**2182-3-24**]. kept decadron chemotherapy initiated. Eventually found abscesses thighs, discussed above. . # Afib - pt went afib ICU. blood pressures remained stable started metoprolol. high rates 130s-140s; contined afib week remained NSR week prior discharge. metoprolol titrated 25 mg tid good rate control. . # [**Name (NI) 6059**] - pt one episode 16 b [**Name (NI) 6059**] v. afib aberrancy. Cards consulted agressive electrolyte repletion continued metoprolol. occurrences. . # Vasovagal bradycardia - day prior admission, patient bowel movement, noted telemetry brady 30s, felt light headed resolved 5 minutes. Appeared vaso-vagal occurrences. Again, cards consulted recommended leaving metoprolol dose 25 mg tid, bb actually helps prevent vagal episodes. . # DVTs - patient ICU, developed bilaterally pedal edema, thought initially due large amount IVFs. new afib, though, ultrasounds found DVTs R leg, R arm (because edematous pain around new PICC line). Heparin started overnight, hx ICHs, decided stop heparin place IVC filter. put place without complications. Evenutally found bilaterally leg DVTs bilateral upper extremity DVTs. point, decided anticoagulated. Heparin initially. Repeat head CT showed bleed. converted lovenox outpatient treatment DVTs. also VQ scan findings DVT showed low prob PE. . # Access - pt initially subclavian line, pulled patient febrile early [**Month (only) 958**]. PIVs transfer ICU PICC line placed. PICC line removed DVT found arm. PIVs IR guided subclavian line placed. outpatient continuation 6 week course antibiotics, hickman placed PICCs could placed due bilateraly UE DVTs. . # Pt discharged walking around, passing PT going stairs. respiratory status much improved O2 SOB. advised start work yet take easy, although, ready get back work soon possible. Medications Admission: None Discharge Medications: 1. Heparin Flush 10 unit/mL Kit Sig: One (1) flush Intravenous 6x/day. Disp:*180 flushes* Refills:*2* 2. Saline Flush 0.9 % Syringe Sig: One (1) flush Injection 10x/day. Disp:*300 flushes* Refills:*2* 3. Meropenem 1 gram Recon Soln Sig: One (1) recon soln Intravenous every eight (8) hours 22 days: make end date [**5-30**]; total 6 week course. Disp:*66 recon soln* Refills:*0* 4. Vesanoid 10 mg Capsule Sig: Five (5) Capsule PO twice day 14 days: substitutions please. Disp:*140 Capsule(s)* Refills:*0* 5. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*180 Capsule(s)* Refills:*2* 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times day). Disp:*90 Tablet(s)* Refills:*2* 7. Voriconazole 200 mg Tablet Sig: 1.5 Tablets PO Q12H (every 12 hours). Disp:*90 Tablet(s)* Refills:*2* 8. Enoxaparin 100 mg/mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). Disp:*60 syringe* Refills:*2* Discharge Disposition: Home Service Facility: Critical Care Systems Discharge Diagnosis: APML Intracranial hemorrhage Syncope Discharge Condition: vital signs stable, walking around, lovenox, normal neurological exam, afebrile Discharge Instructions: admitted hospital fell. found low blood counts bone marrow biospy showed leukemia. also small areas bleeding head stable based repeat CT scans. received chemotherapy leukemia. . here, developed infection brain around areas inital bleeds found, well thighs. treated antibiotics need continue going home. . also developed blood clots arms legs. place filter inferior vena cave (a large vein abdomen) clots would go lungs. also anticoagulated heparin. go home lovenox stay anticoagulated. . Lastly, developed heart arrhythmia called atrial fibrillation. that, continue taking medicine metoprolol. . home nurse help wife antibiotics lovenox shots. make sure start returning work slowly. probably best work work home first week see feeling starting think going back school. discuss progress Dr. [**Last Name (STitle) 410**] follow appointments. . return hospital fainting, headaches, dizziness, chest pain, shortness breath, swelling extremities, palpitiations concerns. Followup Instructions: Please follow Dr. [**Last Name (STitle) 410**] [**Hospital Ward Name 23**] 7 Tuesday [**2183-5-13**] 1:30 pm. Phone number [**Telephone/Fax (1) 3241**]. Please follow infectious disease Dr. [**Last Name (STitle) **] [**2183-5-19**] 3:00 pm. Phone number ([**Telephone/Fax (1) 4170**]. need repeat MRI prior seeing Dr. [**Last Name (STitle) **]. give date time next appointment. Completed by:[**2183-5-15**]
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[
"430",
"486"
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Admission Date: [**2140-12-8**] Discharge Date: [**2140-12-12**] Date Birth: [**2076-5-24**] Sex: Service: CT SURGERY HISTORY PRESENT ILLNESS: Mr. [**Known lastname 24524**] 64-year-old male history progressive exertional dyspnea quitting smoking approximately six months ago. Workup exertional dyspnea included exercise treadmill test ultimately positive ischemic changes well echocardiogram subsequently elective cardiac catheterization. Cardiac catheterization completed [**2140-12-5**] showed left main coronary artery disease modest calcification distal 50% taper. left anterior descending also moderate calcification proximal 70% lesion D1 R1. D2 moderate vessel 90% proximal tubular lesions, D1 R1 ectatic proximal vessel large distal vessel. left circumflex artery nondominant vessel proximal 90% lesion moderate calcification well. right coronary artery dominant vessel, total proximal occlusion bridging left-right collaterals. posterior descending artery known good target. Additional findings catheterization abdominal aorta large infrarenal aneurysm beginning 13 mm renals, bilaterally single without disease. largest extent aneurysm 4.8 cm length 11.7 cm. Proximal runoffs reveals moderate ostial left iliac lesion. common femoral artery superficial femoral artery bilaterally normal. Given patient's significant three vessel coronary artery disease symptoms occasional angina dyspnea exertion, determined would appropriate candidate coronary artery bypass grafting. Cardiothoracic Surgery service consulted catheterization procedure, following history obtained. PAST MEDICAL HISTORY: History inferior myocardial infarction electrocardiogram, mild chronic obstructive pulmonary disease, hypertension, hypercholesterolemia, 6 cm infrarenal abdominal aortic aneurysm noted previously picked incidentally examination cardiologist several months ago, benign prostatic hypertrophy, gout, greater 75 pack year smoking history recently quit last six months. hypothyroid. ALLERGIES: known drug allergies. MEDICATIONS ADMISSION: Aspirin 325 mg mouth daily, Lipitor 10 mg mouth daily, atenolol 50 mg mouth daily, allopurinol 100 mg mouth daily, Flomax .4 mg mouth daily, Tapazole 20 mg mouth daily, Mavik 1 mg mouth daily. LABORATORY DATA: Preoperative hematocrit 36. BUN creatinine 17 1.1. Catheterization data stated. Chest x-ray showed acute cardiopulmonary process. electrocardiogram significant sinus bradycardia 54, Q waves II, III AVF. abnormal ST/T wave changes. early J-point elevation. early R wave progression well. PHYSICAL EXAMINATION: Heart rate 54, blood pressure 134/70, acute distress, chest pain, carotid bruits auscultated. heart regular, prominent S2, murmur. lungs clear auscultation except decreased breath sounds throughout. abdominal examination soft, nontender, nondistended. pulsatile mass palpated xiphoid umbilicus, approximately 5 cm examination. hepatosplenomegaly, renal bruit. Flank examination negative. lower extremities palpable dorsalis pedis posterior tibial pulses distally bilaterally. HOSPITAL COURSE: Given presentation, elected bring operating room [**2140-12-8**]. first discharged elective catheterization [**2140-12-5**] ultimately readmitted [**2140-12-8**], underwent elective coronary artery bypass graft x 4 Dr. [**Last Name (STitle) **], including left internal mammary artery left anterior descending, right saphenous vein graft diagonal, well saphenous vein graft obtuse marginal saphenous vein graft right posterior descending artery. patient tolerated procedure well. Intraoperative findings transesophageal echocardiogram ejection fraction 45 50%, calcified aorta, good distal targets. pericardium left open. right radial A-line. right internal jugular cordis place, CVP, right atrial catheter. two ventricular wires two atrial wires, two mediastinal tubes one pleural tube. mean arterial pressure 77, right atrial pressure 9. found normal sinus rhythm rate 74. propofol drip 20 mcg/kg/minute sedation. transferred Cardiac Surgical Recovery Unit, first 24 hours surgery, drips weaned rapidly extubated. remained sinus rhythm 88, blood pressures 120s 130s. hematocrit 25 postoperatively, BUN creatinine 18 1. Neurologically, remained intact. started lasix, Lopressor, aspirin. Chest tubes removed, well diet advanced. subsequently transferred floor postoperative day number one. ambulating postoperative day number one, feeling well. worked Physical Therapy aggressively, continued pulmonary toilet incentive spirometry, coughing deep breathing. electrolytes repleted needed. postoperative day number two, continued feel well. low-grade temperature 100.9, otherwise remainder vitals normal, heart rate 94 sinus, blood pressure 114/60. Lopressor titrated accordingly. BUN creatinine 23 1.0, hematocrit 24. postoperative day number four, patient ambulating. wires, chest tubes Foley removed point. sinus tachycardia sinus rhythm, 90 103. blood pressure ranging 106 110 50s 60s. Oxygen saturation 95% room air. stable sternum, evidence drainage. abdominal examination unchanged admission. extremities warm well perfused, palpable pulses dorsalis pedis posterior tibial bilaterally. Subsequently patient deemed stable appropriate discharge. DISCHARGE MEDICATIONS: Lopressor 75 mg mouth twice day, Lipitor 10 mg mouth daily, lasix 20 mg mouth daily seven days, K-Dur 20 mEq mouth daily seven days, Protonix 40 mg mouth daily, aspirin 325 mg mouth daily, allopurinol 100 mg mouth daily, Tapazole 20 mg mouth daily, Flomax .4 mg mouth daily, percocet 5/325 one two tablets mouth every four six hours needed, Colace 100 mg mouth twice day. DISCHARGE STATUS: home VNA. CONDITION DISCHARGE: Stable, afebrile, normal sinus rhythm, evidence sternal drainage. DISPOSITION: home VNA instructions undergo heavy lifting greater ten pounds 30 days, driving 30 days. Wound may get wet shower. follow Dr. [**Last Name (STitle) **] four weeks, follow cardiologist primary care physician three weeks time discharge. VNA assist patient. happen dismiss day seven ten, return Wound Care Clinic, receive wound checkup. DISCHARGE DIAGNOSIS: 1. Significant three vessel coronary artery disease status post coronary artery bypass graft x 4, left internal mammary artery left anterior descending, saphenous vein graft diagonal, obtuse marginal also right posterior descending artery. 2. Hypertension 3. Hyperlipidemia 4. 6 cm abdominal aortic aneurysm 5. Benign prostatic hypertrophy 6. Mild chronic obstructive pulmonary disease 7. 50 pack year smoker 8. History inferior myocardial infarction coronary artery disease 9. Hypothyroidism 10. Questionable history osteoarthritis [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern4) 3204**] MEDQUIST36 D: [**2140-12-11**] 22:42 T: [**2140-12-12**] 00:35 JOB#: [**Job Number 24525**]
|
[
"412",
"496"
] |
Admission Date: [**2195-8-12**] Discharge Date: [**2195-9-14**] Date Birth: [**2195-8-12**] Sex: Service: Neonatology HISTORY: Baby [**Known lastname 2470**] baby boy born 35-3/7 weeks 24 year old G2, P1 mother estimated date confinement [**2195-9-13**]. Prenatal laboratories included blood type O+, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune GBS status unknown. MATERNAL HISTORY DELIVERY: maternal history notable previous primary C-section postpartum hemorrhage requiring uterine artery ligation. pregnancy reportedly unremarkable day prior delivery mother developed contractions. came hospital preterm labor, noted cervical dilation taken repeat C-section. sepsis risk factors identified, mother receive intrapartum antibiotic prophylaxis. delivery infant emerged vigorous Apgars 8 9, requiring brief blow-by O2. Increased work breathing noted persisted. Infant brought NICU. NICU moderate grunting, flaring retractions apparent room air saturations low 80s. Infant placed CPAP. PHYSICAL EXAMINATION TIME ADMISSION: Weight: 2760 grams, 75th percentile. Head circumference: 33.5 cm, 75th percentile. Length: 46 cm, 50th percentile. Vital signs: Temperature 98.4, heart rate 150s, respiratory rate 40s-50s, blood pressure 37/29 MAP 34 O2 saturations 95%- 98% 40% FIO2. general, well developed, pre- term infant, active vigorous, moderate grunting, flaring retractions rest. Skin warm, mildly pale. Sluggish capillary refill. rash. HEENT exam reveals fontanels soft flat. Positive red reflex bilaterally. Palate intact. Neck supple. lesions. Chest coarse, moderately aerated. Positive grunting, flaring retractions. Cardiac regular rate rhythm. Soft systolic murmur. Abdomen soft. hepatosplenomegaly. mass. Three-vessel cord. Quiet bowel sounds. GU: Normal male. Testes palpable bilaterally. Anus patent. Extremities: Warm. lesions. Hips/Back: Stable. Neurologic: Appropriate tone activity. SUMMARY HOSPITAL COURSE SYSTEMS: Respiratory: patient initially placed CPAP quickly, day life 1 due persist increased work breathing increased O2 requirement, intubated placed conventional ventilator. Patient also received Survanta x2, day life #4 weaned CPAP. day life #5 weaned nasal cannula day life #6, [**2195-8-18**], patient room air remained room air discharge. Two days prior discharge, infant experienced brief period duskiness associated crying. apneic time. infant monitored additional two days without recurrence. previously observed, infant remained well. thought breath holding event. Fluids, electrolytes, nutrition: Patient made NPO 1st 5 days life supplemented parenteral nutrition period. day life #6 started p.o./p.g. feeds breast milk/Enfamil 20. Patient continued advance p.o. feedings, day life #30 achieved full p.o. feeds breast milk 24/Enfamil powder. Weight time discharge 3535 g. Cardiovascular: Patient noted soft murmur time birth. EKG performed revealed normal sinus rhythm. Murmur since resolved GI: Patient noted hyperbilirubinemia day life #4. Bilirubin noted 12.7/0.5. Phototherapy discontinued day life #6 rebound bilirubin 7.7/0.3. Phototherapy never restarted. Hematology: patient known setup, transfusion ever given throughout hospital course. Infectious disease: CBC blood culture done birth. Patient started ampicillin gentamicin 48- hour rule out. length course antibiotics increased 7-day course antibiotics due persistent O2 requirement respiratory needs patient despite additional signs symptoms infection. Blood cultures negative, final [**2195-8-18**]. LP performed [**2195-8-15**], results unremarkable, CSF culture negative, final [**2195-8-18**]. Patient currently continues Nystatin treatment oral thrush. Neurologic: Patient normal physical exam noted normal suck, normal grasp, normal tone alert. Head ultrasound indicated. Sensory: Audiology: Hearing screen performed automated auditory brainstem responses. Patient passed hearing screen [**2195-8-23**]. Ophthalmology: Eye exam indicated ex-35- weeker weighing 1500 g, require prolonged O2 throughout hospital course. Psychosocial: [**Hospital1 18**] social work involved family. contact social worker [**Name (NI) 36130**] [**Name (NI) 6861**], reached [**Telephone/Fax (1) **]. CONDITION DISCHARGE: Patient currently stable condition. DISCHARGE DISPOSITION: home mother. PRIMARY CARE PEDIATRICIAN: [**Hospital 17566**] Pediatrics located [**Location (un) 5871**], MA; phone number [**Telephone/Fax (1) 37911**]; fax [**Telephone/Fax (1) 37912**]. primary care pediatrician Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) **]. CARE/RECOMMENDATIONS: time discharge patient maintained full p.o. feeds breast milk 24 ad lib. MEDICATIONS: Currently include Nystatin needed treatment oral thrush. CAR SEAT POSITIONING SCREENING: Car seat positioning screening passed [**2195-9-11**]. IMMUNIZATIONS RECEIVED: Patient receive hepatitis B vaccine [**2195-8-11**]. IMMUNIZATIONS RECOMMENDED: Synergist RSV prophylaxis considered [**Month (only) **] [**Month (only) 958**] infants meet following 3 criteria: 1) Born less 32 weeks, 2) born 32 35 weeks 2 following: 1) daycare RSV season, 2) smoker household, 3) neuromuscular disease, airway abnormalities school-age siblings, infants chronic lung disease. Influenza immunization recommended annually fall infants reach 6 months age. age 1st 24 months child's life, immunization influenza recommended household contacts out-of-home caregivers. FOLLOW-UP APPOINTMENTS RECOMMENDED PATIENT: Patient recommended follow PMD, Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) **], [**Hospital 17566**] Pediatrics [**Last Name (LF) 766**], [**2195-9-14**]. Time appointment scheduled mother. DISCHARGE DIAGNOSES: Prematurity, Respiratory Distress Syndrome, Presumed Pneumonia, Hyperbilirubinemia, Monilial Infection [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**] Dictated By:[**Last Name (NamePattern1) 62404**] MEDQUIST36 D: [**2195-9-11**] 15:05:27 T: [**2195-9-11**] 16:00:25 Job#: [**Job Number 63522**]
|
[
"769"
] |
Admission Date: [**2183-10-23**] Discharge Date: [**2183-10-28**] Date Birth: [**2117-8-8**] Sex: F Service: MEDICINE HISTORY PRESENT ILLNESS: 65-year-old woman, past medical history significant chronic alcohol abuse, history alcoholic ketoacidosis, also depression, COPD, multiple ED visits admissions intoxication, admitted ICU severe hypophosphatemia setting recurrence alcoholic ketoacidosis. patient's alcohol level 370 admission. anion gap 37 bicarbonate 11. phosphate level 0.3. PAST MEDICAL HISTORY: 1. Chronic alcohol abuse history alcoholic ketoacidosis. 2. Depression. 3. COPD. 4. Recently treated herpes zoster. 5. Benign essential tremor. 6. History adrenal mass. ALLERGIES: known drug allergies. MEDICATIONS: 1. Combivent 1-2 puffs [**Hospital1 **]. 2. Naltrexone 50 mg po qd. 3. Neurontin 40 mg po tid. 4. Desipramine 10 mg po qd. 5. Zoloft 50 mg po qd. SOCIAL HISTORY: 60-pack year tobacco history. History alcohol abuse. history IV drug abuse. patient former nurse. PHYSICAL EXAM: Vital signs - blood pressure 138/64, heart rate 104, respiratory rate 24, oxygen saturation 96% 4 liters face mask. GENERAL: Chronically ill-appearing woman visible tremor odor alcohol upon her. HEENT: Sclerae anicteric. Mucous membranes moist. PERRLA. NECK: JVD. CHEST: Clear auscultation. rhonchi, rales wheezing. CARDIOVASCULAR: Regular rate rhythm. S1, S2 normal. murmurs, rubs gallops. ABDOMEN: Obese, soft, nontender bowel sounds. EXTREMITIES: Good distal pulses. clubbing, cyanosis edema. NEURO: Nonfocal exception responding name call. PERTINENT LABS DIAGNOSTICS: CBC revealed white count 5.5, 11% bands, hematocrit 42.8, platelet count 239. Chem-7 significant sodium 140, potassium 3.8, chloride 93, bicarbonate 11, BUN 24, creatinine 1.2, glucose 186. Anion gap 36. ETOH level 370. Acetone level positive. ABG room air pH 7.40, PCO2 26, PO2 85. ASSESSMENT: 65-year-old woman, history alcohol abuse, presents hypophosphatemia alcoholic ketoacidosis. ED, also coffee ground emesis, although hematocrit remained stable. HOSPITAL COURSE - following summary [**Hospital 228**] hospital course systems: 1) HYPOPHOSPHATEMIA: patient received ample phosphate repletion in-house, day discharge longer hypophosphatemic. 2) ALCOHOLIC KETOACIDOSIS: patient aggressively treated Insulin glucose, fluids, electrolyte repletion Medical Intensive Care Unit extent anion gap acidosis resolved. 3) COFFEE GROUND EMESIS: patient seen gastrointestinal team in-house. hematocrit followed hospital drop significantly. started PPI. made NPO first, slowly advanced diet. underwent EGD prior discharge revealed [**Doctor First Name **]-[**Doctor Last Name **] tear, erythema, erosion antrum compatible gastritis, esophageal varices, otherwise normal EGD. continued PPI continued 4 weeks. Biopsy results time dictation pending. gastrointestinal team recommended follow-up appointment outpatient, well screening colonoscopy. 4) ALCOHOL INTOXICATION: patient maintained CIWA scale monitor withdrawal. received valium accordingly. patient visited substance abuse team, patient requested transfer inpatient psych facility treatment alcohol dependence. 5) ESSENTIAL TREMOR: patient treated nadolol subsequent improvement essential tremor. continued one, however, baseline. 6) DEPRESSION: patient continued Zoloft. 7) FEN: patient underwent aggressive electrolyte repletion, mentioned above. made NPO first, hematocrit remained stable abdominal complaints, advanced tolerated full diet. 8) PROPHYLAXIS: patient treated Protonix, mentioned above, well Pneumoboots bowel regimen. DISCHARGE STATUS: [**Hospital1 **] inpatient substance abuse treatment. DISCHARGE CONDITION: Fair. DISCHARGE DIAGNOSES: 1. Alcoholic ketoacidosis hypophosphatemia. 2. Essential tremor. 3. Depression. 4. Chronic obstructive pulmonary disease. 5. Gastritis. 6. Alcohol abuse. FOLLOW-UP PLANS: patient follow-up GI colonoscopy, well follow-up coffee ground emesis. patient follow-up primary care physician needed. patient receive inpatient psych care [**Hospital1 **]. DISCHARGE MEDICATIONS: 1. Diazepam 10 mg po q 6 h prn CIWA scale greater 10. 2. Calcium carbonate 500 mg po tid meals. 3. Montelukast sodium 10 mg po qd. 4. Protonix 40 mg po q 12 h. 5. Nadolol 20 mg po qd. 6. Multivitamin 1 tablet po qd. 7. Folate 1 mg po qd. 8. Thiamine 100 mg po qd. 9. Albuterol ipratropium nebs q 6 h prn. 10.Sertraline 50 mg po qd. 11.Tylenol 325-650 mg po q 6 h prn. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12*ADF Dictated By:[**Last Name (NamePattern1) 1595**] MEDQUIST36 D: [**2183-10-27**] 13:25 T: [**2183-10-27**] 13:33 JOB#: [**Job Number 47678**]
|
[
"496",
"311"
] |
Admission Date: [**2124-7-14**] Discharge Date: [**2124-7-19**] Date Birth: [**2067-12-2**] Sex: Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 2297**] Chief Complaint: Hypotension Major Surgical Invasive Procedure: None History Present Illness: 56 year old alcoholic cirrhosis end-stage liver disease "in out" [**Location 24355**] past months repeated episodes LE cellulitis including ? nec fascitis one occasion. rehab hospital today (was sent VA) feeling well per report, wanting D/C'd got labs concerning (hct, cr) sent [**Hospital 6451**] Hospital. found Hct 27, SBP 60's, Melena. started levophed NS "wide open" one 20 Ga IV. transferred here. arrival ED here, afebrile, HR 91, BP 72/36 RR 20 Sat 96% 2L. given 2 18 Ga PIV, Rt. femoral TLC, Vitamin K, litre NS, FFP (3 U), 1 U PRBC IV protonix. GI renal consulted. Cr. 3.6, K 5.8, noted ECG changes 12-lead; given kayexelate. . MICU admission requested. Past Medical History: Alcoholic cirrhosis end-stage liver disease - transplant list anywhere per pt. (was evaluated this). CRI (? baseline Cr.) Mult. recent episodes cellulitis DM2 Social History: etoh, last drink per pt. 10 yy ago; IVDU, Army, also worked delivery man Family History: DM - mother, denies hx. CHD family Physical Exam: VS: BP 60's 40's HR 115, AF, R 25, 96% NC HEENT EOMI, sclerae icteric COR: Tachy, regular, [**12-27**] hsm PULM: CTA ant ABD: Distended tense ascites EXT: 4+ LE edema NEURO: Alert, oriented place, time, event Brief Hospital Course: Patient admitted MICU. condition continued deteriorate despite measures made DNR/DNI consensus family [**2124-7-18**]. continued decline morning [**2124-7-19**], verbal discussion three children, patient made COMFORT MEASURES ONLY. treated morphine respiratory distress pressors withdrawn. Patient passed away shortly thereafter pronounced deceased [**7-19**] 00:20 [**First Name8 (NamePattern2) 11556**] [**Last Name (NamePattern1) 18721**] MD [**First Name8 (NamePattern2) 2894**] [**Last Name (NamePattern1) **] MD. . . . IMP:56 y/o ETOH cirrosis end-stage liver disease presented OSH rehab hypotension, melena . #Hypotension: Likely cause GIB/hypovolemia. Place line, cont. bolus Map less 65. Add vasopressin responding levophed IVF. Monitor UOP. Serial Hct. Transfuse hct less 25. FFP correct coagulopathy. Discuss GI. . #Melena - above, call GI. [**Month (only) 116**] need NGL. Serial Hct. PPI IV BID. Octreotide gtt. . #Cirrhosis/liver disease: obstructive picture. Patient pericentesis x 2 order relieve abdominal ascites. first removed 4.5 liters clear yellow ascites fluid second removed 2 liters. Consult liver. Continue lactulose. Follow INR. Check albumin. Hold diuretics hypotense. . #Renal failure: ? baseline Cr. Possible HRS vs. pre-renal volume depletion [**12-23**] GIB. Consult liver renal, continue volume repletion, maintain SBP above. Consider albumin post tap, Consider adding midodrine. Patient started CVVH. . #Hyperkalemia: Resolved. . # FEN: IVF above, lytes prn, NPO given GIB. . # PPX: PPI [**Hospital1 **], coagulopathic. . # Access: 2 PIV, TLC lt. groin. . # Code: COMFORT MEASURES . # Communication: Daughter - [**Name (NI) **], [**First Name3 (LF) **], daughter [**Name (NI) **] . # Disposition: MICU Medications Admission: Aldactone Calcium Lasix Insulin Lactulose Nepro Ocycodone Discharge Medications: deceased Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased
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[
"570"
] |
Admission Date: [**2139-9-8**] Discharge Date: [**2139-9-26**] Date Birth: [**2082-11-16**] Sex: F Service: Newurosurgery HISTORY PRESENT ILLNESS: patient 57 year old female past medical history sudden onset midback pain severe headache. said felt like bomb giving speech [**Country 2784**]. finished speech vomited once. [**2139-9-4**]. headache persisted. returned United States following day increased fatigue, headache backache. went [**Hospital3 **] Emergency Department [**2139-9-7**], CTA revealed large bilobed 1.2 2.0 centimeter ACA aneurysm, transferred [**Hospital 4415**] [**2139-9-7**], workup. CTA repeated confirming previously mentioned aneurysm. transferred [**Hospital1 69**] embolization aneurysm. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. ALLERGIES: known drug allergies. MEDICATIONS ADMISSION: None. SOCIAL HISTORY: ETOH thirty pack year smoker. PHYSICAL EXAMINATION: Neurologically completely intact. Speech clear. pupils reactive light accommodation, 3.0 millimeters brisk. facial asymmetry. drift. Speech clear fluent, awake, alert oriented times three. Vital signs revealed blood pressure 92 106 60 70s, respiratory rate 14 18. HOSPITAL COURSE: patient admitted went directly angiography suite bilobed ACA aneurysm coiled. coiling partially done time. actual angiogram coiling, patient complain chest pain. seen cardiology angiography suite chest pain resolved own. felt anxiety produced. Postoperatively, vital signs temperature 96.0, blood pressure 103/60, pulse 69, respiratory rate 18, oxygen saturation 99%. patient awake, alert oriented times three. unsure hospital recently transferred. know month day. Negative drift, symmetric smile. pupils equal reactive times light accommodation, 2.5 2.0. left conjunctival hematoma. Positive pedal pulse. Groin intact sheath. upper lower extremities revealed motor strength [**3-23**]. followed commands. headache. white blood cell count 9.4, hematocrit 32.9. preoperative hematocrit 37.7. prothrombin time 15.4, partial thromboplastin time 150. INR 1.6. first postoperative day, patient's vital signs 99 100 range. awake alert oriented times three. complained seven ten headache, diplopia. Extraocular movements full. Visual fields intact. Negative drift. Grip [**3-23**]. Positive femoral right pulse. remained neurologic Intensive Care Unit received Nimodipine 30 mg q2hours, normal saline 150 per hour. Central line placed. blood pressure kept less 140. Heparin continued 600 per hour. [**2139-9-9**], patient brought back complete coiling. Postoperatively, awake, alert oriented times three. speech fluent. Naming intact. followed commands. right groin sheath remained intact. blood pressure kept 100 130 range. needed remain Heparin apparent vessel possibly thrombosed want wean off. Heparin kept 600 per hour. want area thrombose quickly. coiling went well successful. remained Heparin postoperatively. patient remained Intensive Care Unit Heparin partial thromboplastin time kept 60 80. sheaths remained place. [**2139-9-14**], patient awake, alert oriented complaints grips [**3-23**], drift. patient's Heparin drip reduced [**2139-9-14**], started Aspirin 325 mg daily. However, patient start complain blurry vision peripheral type tunneling left eye lasting thirty forty-five minutes. retinal fellow consulted found evidence vascular occlusion. decreased vision left eye, however, patient claimed lasting greater 1.5 years. felt ocular migraine left eye. patient continue stay Heparin. [**2139-9-15**], partial thromboplastin time 50. seen retinal specialist still felt ocular migraine sign wanted follow-up outpatient. Heparin stopped [**2139-9-16**]. Aspirin 81 mg continued. sodium 136, dropped 134. monitored twice day. [**2139-9-16**], patient underwent cerebral angiogram check progressive thrombus coiled left internal carotid artery. Stable appearance coils noted day. start Plavix 75 mg daily Aspirin 325 mg daily. longer needed Heparin. Postoperative check, awake, alert. Extraocular movements full, drift. [**2139-9-18**], remained awake alert headaches time. Extraocular movements full. face symmetric. sodium 134. Again, angiogram previous day showed spasm. Intravenous fluids kept 150 per hour. continue Nimodipine. [**2139-9-18**], ask retinal specialist reexamine patient complained decreased vision left eye last one two days. ophthalmic examination within normal limits. decreased acuity left eye unclear. Possibilities included mass effect, compression aneurysm. recommended considering intravenous steroids, also recommended getting ESR, CRP neurologic ophthalmology consultation. Neurophthalmology seen patient felt compression optic neuropathy felt related ACA aneurysm mass effect. request steroids. patient started Decadron 4 mg p.o. q6hours. [**2139-9-19**], vision improved. [**2139-9-21**], patient underwent status post neuroform stent mediated coiling right internal carotid artery aneurysm. Postoperatively, well intraoperative complications. Postoperatively, stay Plavix Aspirin. sheaths remained place overnight remained Heparin overnight. Postoperatively, alert without complaints, denied headaches double vision. left groin oozing around sheath. Dressing replaced. pupils equal, round, reactive light accommodation. Extraocular movements full. Visual fields full confrontation. recommended one unit packed red blood cells. blood pressure kept 120 range continued Aspirin Plavix. Postoperatively, hematocrit 28.5 [**2139-9-22**], receive one unit packed red blood cells. Sheath removed. [**2139-9-23**], vital signs temperature 98.2, blood pressure 97/49. White blood cell count 10.0, hematocrit 32.1, platelet count 364,000. patient neurologically intact. sign hematomas. [**2139-9-24**], patient transferred Neurologic Intensive Care Unit. given physical therapy consultation. intravenous fluids decreased 100 per hour. diet increased tolerated. given intravenous boluses systolic blood pressure less 100. remained surgical floor. patient discharged [**2139-9-26**]. DISCHARGE INSTRUCTIONS: 1. strenuous exercise, driving cleared Dr. [**Last Name (STitle) 1132**]. 2. follow-up Dr. [**Last Name (STitle) 1132**] one week neurophthalmology, given telephone number call. MEDICATIONS DISCHARGE: 1. Protonix 40 mg p.o. daily. 2. Percocet 5/325 one two tablets p.o. q3-4hours needed. 3. Plavix 75 mg p.o. daily. 4. Aspirin 325 mg p.o. daily. 5. Decadron wean week. CONDITION DISCHARGE: patient discharged neurologically stable [**2139-9-26**]. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern4) 26792**] MEDQUIST36 D: [**2139-10-28**] 13:00 T: [**2139-10-31**] 10:17 JOB#: [**Job Number 50244**]
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[
"430"
] |
Admission Date: [**2178-12-25**] Discharge Date: [**2178-12-27**] Date Birth: [**2116-2-19**] Sex: F Service: MEDICINE Allergies: Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7055**] Chief Complaint: Transfer [**Hospital3 **] admitted atypical chest pain SOB Major Surgical Invasive Procedure: -Central venous line insertion R IJ -Multiple attempts securing arterial access History Present Illness: 62F hx severe pulm HTN, CAD s/p DES Lcx/LAD [**10/2177**], prior CVA s/p b/l CEA's, PVD, COPD admitted OSH [**12-23**] atypical chest pain SOB. ruled ACS enzymes (MB 8 -> 7 -> 5; Trop 0.06 -> 0.07 -> 0.06) EKG without acute ischemic changes found BNP 11K admission. assessed severe decompensated R-sided CHF diuresed 40mg IV lasix ED later day experienced [**9-9**] back pain desat 50's transferred CCU close monitoring HR 60's BP's 90's. ECHO [**12-24**] showed severe pulmonary hypertension, RV pressure overload, modestly depressed RV function, LVEF 55-65%. . CCU describes feeling gradually short breath past 2 months become acutely worse past 1-2 weeks. Interestingly, 1 month ago started sildenafil treatment pulm htn felt became short breath taking medication stopped taking 2 weeks ago started feeling acutely short breath. states gained 2-3lbs past two weeks noticed increased ankle swelling, increasing need oxygen (she usually 88-92 3LNC home prior past 2 weeks used oxygen night). 2 pillow orthopnea, denies PND. denies dietary indiscretion, recent illnesses, fevers, chills, cough, sputum production, symptoms. According family never low back pain problem patient states back pain gets better positional changes rubbing. Also, baseline daily function decreased normally able move around rooms house able walk 10 feet due shortness breath addition basleine vascular claudication. . review systems, s/he denies prior history stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding time surgery, myalgias, joint pains, cough, hemoptysis, black stools red stools. S/he denies recent fevers, chills rigors. review systems negative. . Cardiac review systems notable absence chest pain, paroxysmal nocturnal dyspnea, palpitations, syncope presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: CAD s/p LAD cypher stenting - CABG: n/a - PERCUTANEOUS CORONARY INTERVENTIONS: - PACING/ICD: n/a 3. PAST MEDICAL HISTORY: -Occult SBE aortic valve vegetation -Severe pHTN -Severe PVD s/p multiple vascular surgeries -Rt Fem-[**Doctor Last Name **] bypass -Rt CEA following CVA prior [**2173**] -Lt CEA following TIA [**2173**] -Stenting LCx DPromus [**Name Prefix (Prefixes) **] -[**Last Name (Prefixes) **] Prox/Mid LAD Promus Stent Social History: Pt livers two daughters home. Tob: 0.5ppd x40years (since age 17) EtOH: social - 2 beers every 2 weeks Illicit drug use: denies Family History: Father MI 50's stroke 60's. Siblings DM. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T=96.7 BP=103/66 HR=72 RR=10 O2 sat= 93% non-rebreather GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, pallor cyanosis oral mucosa. xanthalesma. NECK: Supple JVP earlobes CARDIAC: PMI located 5th intercostal space, midclavicular line. RR, normal S1, loud S2. m/r/g. S3 apex. thrills, lifts. LUNGS: Rales halfway bases ABDOMEN: Soft, obese, NTND. HSM tenderness. Abd aorta enlarged palpation. abdominial bruits. EXTREMITIES: 2+ pitting mid shin, several old scars prior vascular surgery procedures. femoral bruits. SKIN: Mild stasis dermatitis changes. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP dopplerable, PT dopplerable . DISCHARGE PHYSICAL EXAM: Patient expired. Pertinent Results: ADMISSION LABS: . [**2178-12-25**] 06:24PM BLOOD WBC-12.5* RBC-4.46 Hgb-11.4* Hct-35.8* MCV-80* MCH-25.5* MCHC-31.7 RDW-17.5* Plt Ct-348 [**2178-12-25**] 06:24PM BLOOD Neuts-77* Bands-0 Lymphs-18 Monos-4 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 NRBC-1* [**2178-12-25**] 06:24PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-2+ Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Ovalocy-OCCASIONAL Target-OCCASIONAL Burr-2+ [**2178-12-25**] 06:24PM BLOOD PT-17.0* PTT-34.3 INR(PT)-1.5* [**2178-12-25**] 06:24PM BLOOD Glucose-40* UreaN-45* Creat-1.8* Na-131* K-3.6 Cl-93* HCO3-22 AnGap-20 [**2178-12-25**] 06:24PM BLOOD CK(CPK)-180 [**2178-12-26**] 05:17AM BLOOD ALT-81* AST-65* LD(LDH)-365* CK(CPK)-149 AlkPhos-88 TotBili-1.2 [**2178-12-25**] 06:24PM BLOOD CK-MB-13* MB Indx-7.2 cTropnT-0.37* [**2178-12-25**] 06:24PM BLOOD Calcium-8.7 Phos-5.6* Mg-1.4* . PERTINENT LABS: . [**2178-12-25**] 06:24PM BLOOD CK-MB-13* MB Indx-7.2 cTropnT-0.37* [**2178-12-26**] 05:17AM BLOOD CK-MB-11* MB Indx-7.4* cTropnT-0.31* [**2178-12-26**] 08:54PM BLOOD CK-MB-9 cTropnT-0.35* [**2178-12-27**] 04:23AM BLOOD CK-MB-29* MB Indx-10.1* cTropnT-1.00* [**2178-12-27**] 04:23AM BLOOD Cortsol-32.8* [**2178-12-27**] 04:23AM BLOOD TSH-2.1 [**2178-12-26**] 05:41AM BLOOD Lactate-1.7 [**2178-12-26**] 03:52PM BLOOD Lactate-2.5* [**2178-12-26**] 11:26PM BLOOD Lactate-7.5* [**2178-12-27**] 01:50AM BLOOD Lactate-8.7* [**2178-12-27**] 04:24AM BLOOD Lactate-11.1* [**2178-12-27**] 05:05AM BLOOD Lactate-10.3* [**2178-12-27**] 11:38AM BLOOD Lactate-5.1* [**2178-12-26**] 03:52PM BLOOD Type-ART pO2-52* pCO2-35 pH-7.42 calTCO2-23 Base XS [**2178-12-27**] 01:50AM BLOOD Type-[**Last Name (un) **] pO2-40* pCO2-69* pH-7.02* calTCO2-19* Base XS--15 [**2178-12-27**] 04:24AM BLOOD Type-CENTRAL pO2-53* pCO2-60* pH-7.10* calTCO2-20* Base XS--11 [**2178-12-27**] 05:05AM BLOOD Type-CENTRAL pO2-52* pCO2-58* pH-7.16* calTCO2-22 Base XS--8 [**2178-12-27**] 11:38AM BLOOD Type-[**Last Name (un) **] pO2-42* pCO2-73* pH-7.20* calTCO2-30 Base XS--1 . DISCHARGE LABS: . [**2178-12-27**] 11:16AM BLOOD WBC-26.6*# RBC-4.37 Hgb-11.3* Hct-36.8 MCV-84 MCH-25.8* MCHC-30.6* RDW-16.9* Plt Ct-335 [**2178-12-27**] 04:23AM BLOOD Glucose-506* UreaN-41* Creat-1.8* Na-131* K-4.2 Cl-89* HCO3-19* AnGap-27* [**2178-12-27**] 04:23AM BLOOD ALT-226* AST-262* LD(LDH)-905* CK(CPK)-288* AlkPhos-89 TotBili-1.7* [**2178-12-27**] 04:23AM BLOOD CK-MB-29* MB Indx-10.1* cTropnT-1.00* [**2178-12-27**] 04:23AM BLOOD Albumin-3.4* Calcium-8.1* Phos-7.3*# Mg-2.5 [**2178-12-27**] 11:38AM BLOOD Type-[**Last Name (un) **] pO2-42* pCO2-73* pH-7.20* calTCO2-30 Base XS--1 [**2178-12-27**] 11:38AM BLOOD Lactate-5.1* . MICRO/PATH: . Blood Cultures x 2: Pending MRSA Screen: Pending . IMAGING/STUDIES: . CXR Portable [**12-25**]: IMPRESSION: Mild interstitial pulmonary edema present, along small right pleural effusion, decreased since [**9-5**]. Heart size top normal, main pulmonary artery substantially dilated, indicating persistent pulmonary arterial hypertension. Previous mediastinal adenopathy documented chest CT [**Month (only) 216**] difficult assess probably worsened. pneumothorax. . Aorta/Branches U/S [**12-25**]: IMPRESSION: evidence abdominal aortic aneurysm. Atherosclerosis. . CXR Portable [**12-25**]: Tip new right internal jugular line ends region superior cavoatrial junction. pneumothorax increase small right pleural effusion. Interval increase mediastinal caliber due vascular engorgement, due elevated central venous pressure, probably function biventricular heart failure, reflected mild increase heart size, moderate increase pulmonary edema. Severe pulmonary atrial enlargement, indication marked pulmonary arterial hypertension, aortic valvular calcification, could hemodynamically significant (particularly setting decreased LV filling), severe, global coronary calcification shown Chest CT [**Month (only) 216**] [**2178**], discussed Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 30814**] time dictation. . R LENI [**12-26**]: IMPRESSION: Limited assessment right lower extremity due early termination examination. DVT seen examined veins. . CXR Portable [**12-27**]: FINDINGS: comparison study [**12-25**], placement endotracheal tube tip upper clavicular level, approximately 6.5 cm carina. Nasogastric tube extends upper stomach, though side hole within lower portion esophagus. Continued enlargement cardiac silhouette substantial pulmonary arterial enlargement consistent pulmonary artery hypertension. moderate pulmonary edema well. . TTE [**12-27**]:The left atrium mildly dilated. estimated right atrial pressure least 15 mmHg. Left ventricular wall thicknesses cavity size normal. severe global left ventricular hypokinesis. basal inferolateral wall contracts best (LVEF = 25%). right ventricular cavity moderately dilated severe global free wall hypokinesis. [Intrinisic right ventricular systolic function depressed given severity tricuspid regurgitation.] abnormal septal motion/position consistent right ventricular pressure/volume overload. aortic valve leaflets mildly thickened (?#). aortic regurgitation seen. mitral valve leaflets mildly thickened. mitral valve prolapse. Mild (1+) mitral regurgitation seen. Moderate severe [3+] tricuspid regurgitation seen. pericardial effusion. IMPRESSION: Suboptimal image quality. Normal left ventricular cavity size extensive systolic dysfunction c/w diffuse process (multivessel CAD, toxin, metabolic, etc.). Marked right ventricular cavity dilation free wall hypokinesis abnormal septal motion c/w marked pulmonary artery hypertension (not quantified). Moderate severe tricuspid regurgitation. Mild mitral regurgitation. Compared prior study (images reviewed) [**2178-10-16**], biventricular systolic function deteriorated heart rate much higher. Biventricular cavity size similar. Brief Hospital Course: 62F hx severe pulm HTN, CAD s/p DES Lcx/LAD [**10/2177**], prior CVA s/p b/l CEA's, PVD, [**Hospital 2182**] transferred OSH evaluation management right-sided diastolic CHF exacerbation background severe pulmonary hypertension rapidly decompensated passed away despite maximal medical therapy. . ACTIVE DIAGNOSES: . # Right-sided Diastolic CHF Exacerbation: Pt clinical evidence rales halfway lung fields, JVD, peripheral edema admission CXR evidence pulmonary edema BNP 11,000 OSH, ECHO demonstrating fluid overloaded RV S3 gallop exam. ruled ACS OSH negative enzymes non-ischemic EKG's transferred dopamine drip pressure support max O2 venturi mask moderate respiratory distress satting low 90's. arrival CCU, R IJ placed without complications started sildenafil 20mg QID hope pressor support vasodilatation pulmonary vasculature would increase cardiac output allow gentle diuresis. Unfortunately found anuric despite measures Cr 1.8 transfer 0.8-0.9 days prior OSH. late morning day following transfer, dobutamine added attempt improve ionotropy medication started BP began drop next hours norepinephrine added maintain MAPs >65. medications titrated try achieve stable blood pressure kept ranging 70/40-140/50. stability could reached. time HR 100-130's. CCU team (including CCU attending) attempted place arterial line better BP monitoring given severe peripheral vascular disease unsuccesful via radial aproach. Anesthesia contact[**Name (NI) **] attempt axial arterial line deemed feasible. anesthesia attending attempted obtain L femoral arterial line without success. right side attempted given previous Fem-[**Doctor Last Name **] bypass. oxygenation worsening switched 100% non-rebreather. around 1600 dobutamine stopped felt contributing persistently low BP's. remained stable around 2100 BP began decrease. 250 mL NS bolus given without response phenylephrine started point. Also around time oxygen saturation began drop BiPAP started. point patient dopamine, norepinephrine phenylephrine BP support BiPAP respiratory support BP 79/55-101/57 O2 sat 90%. 2300 (after ~3 hrs BiPAP) given tenious state persistently low BP, persistnently low O2 sat tachypnea discussion held patient family regarding endotracheal intubation. Given worseining cardiopulmonary status CCU team recommended intubation try achieve better oxygenation, prevent respiratory colapse allow us manage worsening heart failure maintaing patent airway adequate oxygenation. Anesthesia called 0000 non-emergent intubation. performed succesfully patient tolerated well. ~0030, milrinone added attempt improve ionotropy. point anesthesia attending asked assistance placing arterial line given need better blood pressure oxygenation parameters. Right radial attempted well left femoral without success. around 0100-0130 BP began drop, milrinone stopped vasopressin added. Despite 4 pressors BP continued drop. point given 4 amps bicarb, 1 mg epinephrine 1 amp calcium carbonate. family updated condition. Despite additions BP continued drop point bicarb drip epinephrine drip started. stabilized around 0200 remained HR 120-130's SBP 80-100's next several hours. around 0500 ventilator began alarming due high peak/plateau pressures. thought due pulmonary edema repeated succitioning brought frothy fluid. continued max doses 5 pressors throughout day maximal respiratory settings sake oxygenation. condition continued deteriorate despite maximal medical support. family made aware grave circumstances started carefully consider code status. coded later morning 2 days following transfer pulseless electrical activity coded briefly resuscitative efforts halted per family request. cause rapid decline unclear hypothesis team included possibly PE (with suboptimal LENI negative). abdominal ultrasound look possible ruptured AAA given report acute onset low back pain OSH negative. . # Anuric Acute Kidney Injury: Cr 1.8 admission oliguria/near anuria, 0.6-0.7 baseline. 0.9 yesterday OSH making urine. Thought due brief hypotensive episode receiving bolus 40mg IV lasix OSH. # Severe Chronic Pulmonary Hypertension/Cor Pulmonale: Unclear etiology. Perhaps related mild-moderate COPD CT (although re-assuring spirometry records) possibly recurrent embolic phenomena. treated aggressively unfortunately poor outcome. . CHRONIC DIAGNOSES: . # COPD/Hypoxia: PT mild-moderate COPD changes recent CT chest essentially normal PFT's. requires 3LNC home often worn sleep recently day even rest. 20-40 pack-year smoking history. home COPD medications. ended ventilated respiratory support above. . # CAD: Pt severe 3VD prior [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 LCx LAD 8/[**2177**]. Non-ischemic EKG admission OSH. Enzymes unimpressive x 3. chest pain discomfort. continued aspirin, plavix, statin. . # HLD: Stable. Continued statin. . # Severe PVD: Stable. Continued statin. . # NIDDM Complicated Neuropathy: Stable. Managed HISS in-house well lyrica gabapentin prior hemodynamic compromise. . TRANSITIONAL ISSUES: -To deep regret CCU team, Mrs. [**Known lastname **] poorly hospital course. team took solace fact surrounded large, loving family hopefully felt little pain suffering final hours. Medications Admission: - Plavix 75mg PO daily - Gabapentin 200mg PO QHS - Aspirin 81mg PO daily - Metoprolol succinate 100mg PO daily - Ativan 1mg PO TID PRN - Metformin 100mg PO BID - Glyburide 2.5mg PO daily - Lisinopril 2.5mg PO daily - Torsemide 40mg PO daily - Lyrica 100mg PO BID - Tylenol PM 1 tab QHS - Simvastatin 40mg PO daily - Prilosec 20mg PO daily - Niacin 500mg PO BID Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: -Severe Pulmonary Hypertension/Cor Pulmonale -Biventricular diastolic congestive heart failure -Severe peripheral vascular disease -Chronic obstructive pulmonary disease Discharge Condition: Deceased Discharge Instructions: Patient transferred OSH acute decompensated biventricular heart failure complicated severe pulmonary hypertension. managed aggressively pressors (5 max doses) goal optimize cardiac function hope inducing diuresis. Unfortunately hemodynamics declined rapidly. Code called PEA initiation chest compressions epi x 1 time code called per family preference. Followup Instructions: N/A Completed by:[**2178-12-28**]
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Admission Date: [**2181-4-20**] Discharge Date: [**2181-4-22**] Date Birth: [**2135-4-5**] Sex: Service: MEDICINE Allergies: Drug Allergy Information File Attending:[**First Name3 (LF) 23197**] Chief Complaint: intoxication / seizure Major Surgical Invasive Procedure: Intubation History Present Illness: 46 y/o hx etoh abuse (per ED signout) possible depression presented emergency room around 6pm evening. obviously intoxicated. found EMS front liquor store brought eval. Initial vitals 98.1, p 100, bp 112/94, r 20, 95% RA. ED, climbed side rails bed fell. transferred Red Zone fall found mostly non-responsive despite noxious stimuli. CT scan head C-spine time negative. EJ femoral line place. almost intubated became arousable. . next hours, alert interactive. speech slurred appeared drunk. interview exam, patient complaining abdominal pain, bloody vomit stool (was guiac negative), suicidal ideation. fight brother-in-law feeling depressed that. also claimed wanted hurt brother-in-law, too. Psych consulted SI/HI waiting interview sober. . yellow zone waiting evaluation, abrupt onset fall went ground unresponsive minute two. witnessed tonic-clonic seizure. received 2 mg ativan time. Several minutes later another tonic-clonic seizure, given 2 mg ativan. intubated time airway protection. initially started midazolam gtt aggitated. switched propofol gtt. another CT head C-spine preliminarily read normal. . arrival floor, intubated sedated. moving 4 extremities would follow commands appropriately. . Past Medical History: ETOH abuse Hx pancreatitis Depression Social History: smokes occasionally, drinks heavily daily basis, also history ?heroin v. cocaine use [**Male First Name (un) 1056**] (moved 2 months ago), unmarried Family History: per brother-in-law, HTN Physical Exam: Vitals - afebrile, 141/96, 81, 18, 100% cmv 18 x 550, 100% x5 Gen - thin man, intubated, sedated, intermittently aggitated trying pull restraints HEENT - PERRLA, ET tube place CV - RRR, m,r,g Lungs - CTA B, referred vent sounds Abd - soft, NT, ND, hsm masses Ext - warm, well perfused, palp pulses, track marks; LE scarring Neuro - could obtain secondary infection Pertinent Results: [**2181-4-20**] 07:30PM ASA-NEG ETHANOL-295* ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2181-4-20**] 07:30PM LIPASE-78* [**2181-4-20**] 07:30PM cTropnT-<0.01 [**2181-4-20**] 07:30PM ALT(SGPT)-17 AST(SGOT)-20 CK(CPK)-182 ALK PHOS-64 TOT BILI-0.1 [**2181-4-20**] 07:30PM WBC-6.3 RBC-5.35 HGB-15.1 HCT-46.1 MCV-86 MCH-28.1 MCHC-32.7 RDW-14.4 CT C-SPINE W/O CONTRAST Study Date [**2181-4-21**] 1:05 IMPRESSION: evidence acute injury cervical spine. Head CT NON-CONTRAST HEAD CT: intracranial hemorrhage, mass effect, [**Doctor Last Name 352**]-white matter differentiation, abnormality. ventricles extra-axial spaces within normal limits. evidence fracture. Mucosal thickening within bilateral maxillary sinuses ethmoid sinus air cells sphenoid sinuses mild. aerosolized secretions nasopharynx. IMPRESSION: acute intracranial abnormality. Brief Hospital Course: 46 y/o hx etoh abuse (per ED reports), coming intoxicated complaining abdominal pain, n/v/diarrhea, suicidal ideation. seizure intubated airway protection. . # Seizure: seizure activity initial one ED. [**Month (only) 116**] due EtOH intoxication. CT head, labs unremarkable. . # Abdominal Pain: Resolved pt extubated. . # Respiratory Failure: pt intubated altered mental status airway protection setting seizure. successfully extubated morning following admission, respiratory problems. . # EtOH/SI: pt seen psychiatry found capacity make medical decisions. declined rehab/detox reported psychiatric follow [**Hospital1 **] CHC Tuesday. pt discharged care girlfriend planned take church stay overnight. Medications Admission: 1. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice day. 2. Seroquel 25 mg Tablet Sig: One (1) Tablet PO bedtime. Discharge Medications: 1. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice day. 2. Seroquel 25 mg Tablet Sig: One (1) Tablet PO bedtime. 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Intoxication Discharge Condition: Mental Status: Clear coherent, fluent Spanish Level Consciousness: Alert interactive Activity Status: Ambulatory - Independent Discharge Instructions: admitted intoxication. intubated (a breathing tube placed) protect airway. evaluated psychiatry, felt safe return home family, close psychiatric follow up. . Please continue take seroquel wellbutrin. added folate thiamine nutritional status. Followup Instructions: Please follow psychiatrist [**Hospital1 **] St. Community Health Center planned Tuesday.
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Admission Date: [**2186-2-1**] Discharge Date: [**2186-2-10**] Date Birth: [**2163-2-7**] Sex: Service: NEUROLOGY Allergies: Codeine / Depakote Attending:[**First Name3 (LF) 7567**] Chief Complaint: Elective admission depth electrode placement invasive EEG monitoring possible temporal lobectomy Major Surgical Invasive Procedure: Craniotomy depth electrode placement History Present Illness: patient 22 year old right handed man history refractory complex partial epilepsy admitted invasive electroencephalographic monitoring. transferred Neurosurgery service placement depth electrodes strips. history seizures began age 16. history febrile seizures, meningo-encephalitic infection early childhood, head trauma. Preceding first witnessed seizure months, noted intermittent stairing spells unknown duration significance noted retrospect. unwitnessed event driving car, leading motor vehicle accident possibly head concussion. hospitalized injury, witnessed generalized convulsions hospital one day later. initially started Phenytoin left temporal slowing found routine EEG. medication compliance poor, resulting generalized convulsions approximately every six months. seizures multiple semiologies. generalized convulsions (secondary generalized tonic-clonic) usually nocturnal, included loss consciousness tongue biting, preceded auras. sometimes showed appearance experiencing ictal fear. different type episode (complex partial) would pupillary dilation, staring, behavioral arrest. sometimes preceded feelings [**Last Name (un) 5083**] vu. events typically last seconds minutes (per OMR 5 seconds 3.5 minutes). also third type episode (simple partial) includes feeling [**Last Name (un) 5083**] vu. reports feelings jamais vu well along [**Last Name (un) 5083**] vu prior staring spells. auras, sometimes feels things appear unreal strange, almost though body. denies micropsia/macropsia, tableau visual distortion, strange tastes smells, epigastric rising sensation. approximately three work-reated minor head injuries initial onset seizures. tried Dilantin/phenytoin (ineffective vs noncompliance), Depakote/valproic acid (weight gain, tremor), Trileptal/oxcarbazepine (headaches). subsequently switched Keppra/levetiracetam Lamictal/lamotrigine Epilepsy service diminishment seizure frequency per patient mother. Past Medical History: 1. Epilepsy including generalized tonic-clonic "absence seizures" likely complex partial seizures 2. Headache d/o related (pre/post) seizures 3. h/o right hand fracture punching wall 4. h/o right UE trauma-related thrombosis MVC [**11/2179**] placed Lovenox two months (unrevealing hypercoagulable workup). Social History: +Tobacco (occasional cigar, cigarettes). +ETOH (weekend, social). illicit drug use. Born full-term without perinatal complications. Reportedly achieved developmental milestones early. Completed college level education, complete due concentration difficulties. Currently unemployed. currently driving. Family History: Seizures (maternal aunt, possibly drug use). seizure history. Mother - hypothyroidism. Father - died PE (@bed rest sciatic pain). Physical Exam: ADMISSION EXAM: General: NAD, lying bed comfortably. / Head: NC/AT, conjunctival icterus, oropharyngeal lesions / Neck: Supple, nuchal rigidity / Cardiovascular: RRR, M/R/G / Pulmonary: Equal air entry bilaterally, crackles wheezes / Abdomen: Soft, NT, ND, +BS, guarding / Extremities: Warm, edema, palpable radial/dorsalis pedis pulses / Skin: rashes lesions Neurologic Examination: - Mental Status - Awake, alert, oriented x 3. Recalls coherent history. Registration [**3-18**] recall [**3-18**]. Concentration maintained recalling months backwards. Follows two step commands, midline appendicular. Language fluent intact repetition verbal comprehension. Normal prosody. paraphasic errors. High low frequency naming intact. dysarthria. apraxia neglect. - Cranial Nerves - [II] PERRL 3->2 brisk. VF full number counting. Funduscopy shows crisp disc margins, papilledema. [III, IV, VI] EOMI, nystagmus, slightly droopy eyelids left slightly lower right notably tired/exhausted, hold eyelids volitionally. [V] V1-V3 without deficits light touch bilaterally. [VII] facial asymmetry. [VIII] Hearing intact finger rub bilaterally. [IX, X] Palate elevation symmetric. [[**Doctor First Name 81**]] SCM/Trapezius strength 5/5 bilaterally. [XII] Tongue midline. - Motor - Normal bulk tone. pronation, drift. tremor asterixis. =[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas] [[**Last Name (un) 938**]] [C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5] L 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 - Sensory - deficits light touch bilaterally. - Reflexes =[Bic] [Tri] [[**Last Name (un) 1035**]] [Quad] [Gastroc] L 2 2 2 2 2 R 2 2 2 2 2 Plantar response flexor bilaterally. - Coordination - dysmetria finger nose testing. Slight change cadence right hand [**Doctor First Name **], less impaired left hand [**Doctor First Name **]. - Gait - Unable assess time examination, restraints s/p electrode placement. ---- Pertinent Results: WBC 14.7, Hgb 14.1, Plt 297, Na 145, Cr 1, Glu 158 NCHCT [**2-1**] - hemorhage, depth electrodes place, pneumocephalus MRI Head [**2-2**] FINDINGS: interval placement electrodes, posterior parietal approach, one side. right-sided electrode, courses parietal temporal lobes, hippocampus, tip extending slightly beyond margins hippocampus antral medially inferiorly right temporal lobe. left-sided lead tip within left hippocampus. focus slow diffusion suggest acute infarction. ventricles extra-axial CSF spaces normal. focal areas altered signal intensity noted brain parenchyma non-contrast images. major intracranial arterial flow voids noted. imaged portions paranasal sinuses mastoid air cells clear. Post-procedural changes noted soft tissues scalp bone adjacent soft tissues posterior temporal regions. NCHCT `[**2-9**] FINDINGS: Previously visualized bitemporal depth electrodes well bilateral temporal grids since removed. Five burr holes noted temporal lobes, posterior aspect parietal lobes, right lateral aspect frontal bone. Mild right frontal bitemporal pneumocephalus noted, well focus gas subgaleal tissues overlying right temporal bone. is, however, evidence hemorrhage, edema, large vessel territorial infarction, shift normally midline structures. ventricles sulci remain normal size configuration. visualized paranasal sinuses mastoid air cells clear. IMPRESSION: Interval removal previously placed depth electrodes grids. evidence post-procedural complications. EEG [**2-2**] IMPRESSION: abnormal video intracranial EEG monitoring session left temporal clinical focal seizure, described above. arose regionally antero-mesial temporal region (subdural strip anterior temporal strip hippocampus), exact ictal onset zone recorded. clinical manifestation brief eye opening. ictal activity briefly spread right subtemporal strip, repetitive spikes spike-wave activity 20 seconds, spread right temporal electrodes. abundant bilateral hippocampal depth electrode spikes, described above. Spikes frequent right anterior hippocampus also seen frequently left anterior hippocampus. EEG [**2-3**] IMPRESSION: abnormal video intracranial EEG monitoring session two left temporal complex partial seizures described above. appear arise regionally antero-mesial temporal region (subdural strip anterior temporal strip hippocampus), exact ictal onset zone recorded. ictal activity spread briefly right subdural strip electrodes, repetitive spikes RST2-3 RST3-4, involve right temporal electrodes. abundant bilateral hippocampal depth electrode spikes, described above. Spikes frequent right anterior hippocampus also seen frequently left anterior hippocampus. Compared prior day's recording, significant change interictal activity, two complex partial seizures recorded. EEG [**2-4**] IMPRESSION: abnormal video intracranial EEG monitoring session abundant bilateral hippocampal depth electrode spikes described above. Spikes frequent right anterior hippocampus also seen frequently left anterior hippocampus. electrographic seizures present. Compared prior day's recording, significant change interictal activity, seizures recorded. EEG [**2-5**] IMPRESSION: abnormal video intracranial EEG monitoring session abundant bilateral hippocampal depth electrode spikes described above. Spikes frequent right anterior hippocampus also seen frequently left anterior hippocampus. electrographic seizures present. Compared prior day's recording, significant change interictal activity, seizures recorded. Brief Hospital Course: 22yoW h/o epilepsy, depression electively admitted depth electrode placement, continuous EEG, localization temporal lobe seizure focus anticipation surgical resection. [] Depth Electrodes Placement Invasive EEG Monitoring - depth electrodes placed Dr. [**Last Name (STitle) **]/Neurosurgery without major perioperative complications, removed similarly without major complications. persistent new neurologic deficits either procedure. covered antibiotics including 7 days cephalexin discharge (vancomycin gentamicin in-house). [] Epilepsy - patient monitored invasive EEG monitoring medications downtitrated revealed bilateral temporal lobe seizures. medications restarted lamotrigine uptitrated 200 qAM 300 qPM. [] Depression - Sertraline increased 100 mg daily. display signs worsening depression, new findings bilateral temporal seizures inability get temporal lobectomy could major trigger worsening depression. PENDING STUDIES: EEG final reports TRANSITIONAL CARE ISSUES: [ ] Please assess seizure frequency new dose lamotrigine. [ ] Please follow emotional state/depression higher dose Sertraline. Medications Admission: Keppra 1500mg [**Hospital1 **], Lamictal 200mg [**Hospital1 **], Sertraline 50mg Daily Discharge Medications: 1. lamotrigine 200 mg Tablet Sig: One (1) Tablet PO QAM. Disp:*30 Tablet(s)* Refills:*2* 2. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO twice day. 3. sumatriptan succinate 50 mg Tablet Sig: One (1) Tablet PO PRN needed headache. 4. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times day 7 days: prevention infection operation. Disp:*28 Capsule(s)* Refills:*0* 5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO three times day needed pain 3 days: take prescribed amount. drive operate heavy machinery make drowsy. Disp:*18 Tablet(s)* Refills:*0* 6. lamotrigine 200 mg Tablet Sig: 1.5 Tablets PO QPM. Disp:*45 Tablet(s)* Refills:*2* 7. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice day 7 days. Disp:*14 Tablet(s)* Refills:*0* 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice day 7 days. Disp:*14 Tablet(s)* Refills:*0* 9. sertraline 100 mg Tablet Sig: One (1) Tablet PO day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Epilepsy/Seizures Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Neurologic: deficits. Discharge Instructions: [ NEUROLOGY DISCHARGE INSTRUCTIONS ] Mr. [**Known lastname 88790**], admitted hospital invasive electroencephalographic monitoring seizure disorder (temporal lobe epilepsy). depth electrodes strips placed Neurosurgical team without major complications. monitored Epilepsy Monitoring Unit able record several seizures. electrodes subsequently removed. Dr. [**First Name (STitle) **] using data continue guiding management epilepsy. time, making changes medication regimen. Please take anticonvulsants previously prescribed. changingthe following medications: 1. Please increased evening dose LAMICTAL/lamotrigine 300 MG per night. take LAMICTAL 200 MG morning 300 MG evening. 2. Please take KEFLEX/cephalexin 500 MG four times per day (every 6 hours) 7 days prevention infection surgery. 3. Sertraline increased 100 MG per day. prescribing new tablet. 4. Please take Docusate Sodium Senna prescribed prevent constipation whiel taking Oxycodone pain. 5. take Oxycodone 5 mg every 8 hours needed pain next days. operate heavy machinery using medication make drowsy. also take Acetaminophen 650 MG three four times daily needed headache days (do take frequently long term). Please continue take scheduled medications. would like followup Dr. [**First Name (STitle) **] listed below. following symptoms, please seek medical attention. pleasure providing medical care hospitalization. [ NEUROSURGERY DISCHARGE INSTRUCTIONS ] ?????? friend/family member check incision daily signs infection. ?????? Take pain medicine prescribed. ?????? Exercise limited walking; lifting, straining, excessive bending. ?????? Dressing may removed Day 2 surgery. ?????? dissolvable sutures may wash hair get incision wet day 3 surgery. may shower time using shower cap cover head. ?????? wound closed staples non-dissolvable sutures must wait removed wash hair. may shower time using shower cap cover head. ?????? Increase intake fluids fiber, narcotic pain medicine cause constipation. generally recommend taking counter stool softener, Docusate (Colace) taking narcotic pain medication. ?????? Unless directed doctor, take anti-inflammatory medicines Motrin, Aspirin, Advil, Ibuprofen etc. CALL SURGEON IMMEDIATELY EXPERIENCE FOLLOWING ?????? New onset tremors seizures. ?????? confusion change mental status. ?????? numbness, tingling, weakness extremities. ?????? Pain headache continually increasing, relieved pain medication. ?????? signs infection wound site: redness, swelling, tenderness, drainage. ?????? Fever greater equal 101?????? F. Followup Instructions: NEUROLOGY Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7025**], MD Phone: [**Telephone/Fax (1) 3294**] Date/Time: [**2186-3-3**] 1:00 NEUROSURGERY: Please call [**Telephone/Fax (1) 1669**] set time staples removed. occur 1 week. (The Neurosurgeons provided information instructions.)
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Admission Date: [**2126-11-1**] Discharge Date: [**2126-11-6**] Date Birth: [**2069-11-6**] Sex: Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[**First Name3 (LF) 7333**] Chief Complaint: s/p PEA arrest Major Surgical Invasive Procedure: None History Present Illness: 58 year old male history atrial fibrillation, DM2, prior MI presents s/p PEA arrest OSH VATS. . Patient intubated unresponsive arrival, history obtained outside records. . early [**Month (only) 359**], sore throat felt poorly. went PCP treated 10 days ammoxicillin. treated penicillin dental extraction. Shortly this, became progressively short breath. saw PCP referred Cardiology (Dr. [**Last Name (STitle) 77919**]. time CXR performed showed opacification right lower [**12-9**] [**12-8**] hemithorax, interpreted infiltrate + pleural effusion. also stress echocardiogram cardiac catheterization planned. chest X-ray repeated [**2126-10-28**], unchanged. cath deferred scheduled undergo VATS possible pleural decortication. . admitted [**Hospital3 26615**] [**2126-10-30**] VATS bronchoscopy. 2600 cc straw colored pleural fluid removed, pleural biopsy taken. end procedure, prior extubation, patient drop blood pressure suffered PEA arrest. Patient received defibrillation, epinephrine, chest compresions 17 minutes. returned [**Location 213**] sinus rhythm, transferred ICU. put lasix drip. echo demonstrated pericardial effusion, CT PA demonstrated PE. labs significant WBC 12. Cardiac enzymes flat. treated levaquin unasyn presumed PNA. weaned sedation responded noxious stimuli. evaluated neurology recommended MRI EEG. transferred [**Hospital1 18**] cardiology neurology evaluation. transfer, heparin drip, midazolam/fentanyl sedation mechanical ventilation (AC). Past Medical History: - Atrial Fibrillation - Diabetes Type II - H/O MI Social History: -Tobacco history: Quit smoking three years ago, 1 ppd x 20 years previously -ETOH: 12 pack weekends -Illicit drugs: Family History: NC Physical Exam: VS: T= 99.7 BP= 126/81 HR= 78 RR= 16 O2 sat= 100/ AC FiO2 100, Tv 550, RR 16, PEEP 5 GENERAL: Intubated, sedated, responsive commands. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, pallor cyanosis oral mucosa. xanthalesma. NECK: Supple JVP 10 cm. CARDIAC: PMI located 5th intercostal space, midclavicular line. RR, normal S1, S2. m/r/g. thrills, lifts. S3 S4. LUNGS: chest wall deformities, scoliosis kyphosis. Resp unlabored, accessory muscle use. CTAB, crackles, wheezes rhonchi. ABDOMEN: Soft, NTND. HSM tenderness. Abd aorta enlarged palpation. abdominial bruits. EXTREMITIES: c/c/e. femoral bruits. SKIN: stasis dermatitis, ulcers, scars, xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ NEURO: Unresponsive commands. Pupils reactive light, corneal relfex intact. Babinski going. spontaneous movement observed. . time death: extubated Pertinent Results: [**2126-11-1**] 06:22PM BLOOD WBC-9.1 RBC-4.64 Hgb-14.7 Hct-41.6 MCV-90 MCH-31.8 MCHC-35.4* RDW-13.5 Plt Ct-222 [**2126-11-1**] 06:22PM BLOOD Neuts-74.9* Lymphs-17.0* Monos-5.7 Eos-0.7 Baso-1.8 [**2126-11-1**] 06:22PM BLOOD PT-15.6* PTT-32.2 INR(PT)-1.4* [**2126-11-2**] 04:11AM BLOOD ESR-30* [**2126-11-1**] 06:22PM BLOOD Glucose-143* UreaN-16 Creat-1.0 Na-136 K-3.7 Cl-98 HCO3-29 AnGap-13 [**2126-11-1**] 06:22PM BLOOD ALT-24 AST-51* CK(CPK)-100 AlkPhos-75 TotBili-2.1* [**2126-11-2**] 04:11AM BLOOD ALT-22 AST-50* AlkPhos-69 TotBili-2.0* [**2126-11-3**] 04:26AM BLOOD ALT-22 AST-54* AlkPhos-69 TotBili-2.4* [**2126-11-1**] 06:22PM BLOOD CK-MB-1 cTropnT-<0.01 [**2126-11-1**] 06:22PM BLOOD Calcium-8.6 Phos-2.9 Mg-2.1 [**2126-11-2**] 04:11AM BLOOD CRP-41.7* [**2126-11-2**] 04:11AM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE [**2126-11-1**] 06:27PM BLOOD Type-ART pO2-386* pCO2-39 pH-7.48* calTCO2-30 Base XS-6 [**2126-11-3**] 05:12AM BLOOD Type-ART pO2-143* pCO2-39 pH-7.47* calTCO2-29 Base XS-5 [**2126-11-1**] 06:27PM BLOOD Lactate-1.6 . EEG: abnormal routine EEG due presence low-voltage background invariant nonreactive external stimulation. finding suggests diffuse severe encephalopathy, caused hypoxic-ischemic injury, toxic-metabolic changes, medication effect, among things. focal abnormalities epileptiform features noted. . PCXR: ET tube tip 5.2 cm carina. NG tube tip passes diaphragm tip stomach. Diffuse pericardial calcification noted, circumferential. Mediastinum minimally widened might related portable technique study. minimal vascular congestion overt edema. Left retrocardiac opacity might represent area atelectasis, aspiration infectious process closely monitored. . TTE: left atrium elongated. right atrium moderately dilated. estimated right atrial pressure 10-20mmHg. mild moderate regional left ventricular systolic dysfunction basal mid inferior, inferolateral, anterolateral hypokinesis. Due suboptimal technical quality, additional focal wall motion abnormality cannot fully excluded. Overall left ventricular systolic function mildly depressed (LVEF= 40%). Unable assess left ventricular diastolic function. Right ventricular chamber size free wall motion normal. abnormal septal motion/position. ascending aorta mildly dilated. aortic valve leaflets mildly thickened (?#). aortic valve stenosis. Trace aortic regurgitation seen. mitral valve leaflets mildly thickened. mitral regurgitation seen. pericardial effusion. anterior space likely represents prominent fat pad. . MR HEAD W/ W/O CON: 1. Extensive confluent areas decreased diffusion bilateral parietal occipital [**Month/Day/Year 3630**] parts frontal lobes likely related cortical infarction degree cortical swelling. Spreading temporal lobes, basal ganglia right cerebellar hemisphere probably left cerebellar hemisphere. Correlate clinically consider followup/correlation brain scan. 2. Area increased signal intensity T2 FLAIR sequences right frontal [**Last Name (LF) 3630**], [**First Name3 (LF) **] relate changes parenchyma surrounding small developmental venous anomaly. However, given lack prior studies extent FLAIR hyperintense area, measures 2.1 x 2.6 cm, consider followup assess stability/progression exclude associated low-grade neoplasm. 3. Mucosal thickening mastoid air cells sides, right left. . Brief Hospital Course: #. s/p PEA arrest. Post-op/peri anesthesia hypotension likely precipitant PEA. Possible contribution hypoxia given lung collapse seen CT. CT PA negative PE, echo negative tamponade. Labs essentially normal, cardiac enzymes negative. Neurology consulted EEG MRI head done, consistent poor neurologic prognosis. Neurology team explained prognosis patient's family agreed would within wishes exist without meaningful interaction. NEOB initially contact[**Name (NI) **] pt. longer possible donor extubated. . # Respiratory Failure/Pleural Effusion: Patient never extubated post-thoracentesis. Continued levaquin unasyn given concern aspiration/oral flora given unilateral PNA, recent tooth extraction alcohol history. Pleural fluid analysis empyema, suggestive exudate. Fluid cytology negative. Patient overbreathing vent excellent RSBI prior extubation. made DNR/DNI prior extubation. successfully extubated [**11-4**] morphine drip given scopolamine patch comfort measures. expired morning [**11-6**]. Autopsy requested family. Medications Admission: HOME MEDICATIONS: Metformin 1000mg PO bid ASA 325mg PO daily Glyburide 5mg PO bid Imdur 30mg PO daily . MEDICATIONS TRANSFER: Combivent Heparin gtt 900 U/hr Unasyn 3gm IV q6 Levaquin 750 mg q24 Lasix 40mg IV q daily Discharge Disposition: Expired Discharge Diagnosis: s/p PEA arrest Death Discharge Condition: Expired
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[
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Admission Date: [**2162-6-3**] Discharge Date: [**2162-6-9**] Service: MEDICINE Allergies: Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 1402**] Chief Complaint: lethargy, bradycardia, fever Major Surgical Invasive Procedure: None History Present Illness: 89M w/ COPD, Afib coumadin, moderate dementia urinary retention indwelling foley, admitted altered mental status, admitted MICU fever, new complete heart block question sepsis. morning admission, patient noted fatigued unable walk. baseline, lives [**Hospital1 100**] generally oriented self answer basic questions, walk walker. exam rehab, bradycardia 40s, BP 154/64, O2 sat 94% RA, temp 99.3. EKG showed complete heart block. transferred ED evaluation. ED, initial VS were: 101.3 44 155/37 32 87% RA. Hypoxia improved 2L nasal cannula. UA sig UTI (>182 WBC, lrg leuks, pos nitrates, many bacteria). CXR concerning ? infiltrate. Pressures stable SBPs 120s-130s. Got 2L IVF, ceftriaxone azithro. Confirmed 3rd degree heartblock EKG. Labs showed acute renal failure (Cr 1.6, baseline 1.0), lactate 2.7, concern mild sepsis. 18G 20G placed. A&O&1. Patient confirmed DNR, would consider PPM. foley catheter replaced. arrival MICU, patient resting comfortably. questioning daughter denies pain. felt appeared better morning. discussion, would like temporary pacing necessary. would like father DNR/DNI, would okay reversing status pacemaker placement. Past Medical History: - Bacteremia [**11/2161**] VRE [**Female First Name (un) **] - COPD (unclear history, always nonsmoker) - HTN meds - AF coumadin - colon cancer [**2152**] - dementia (recognizes children oriented place able converse normally oriented place time), significant behavioral component - History TB, found 10mm PPD [**2153**], negative CXR treated [**2153**] 9 months latent TB. CXR repeat [**2156**] looked increased density bases - BPH chronic indwelling foley, h/o [**Year (4 digits) 40097**] E.Coli urine infection - GERD - anemia - intermittent complete heart block. Asymptomatic, discussion family, PPM clear benefit. Social History: Lives [**Hospital 100**] Rehab. Never smoker. Able walk walker assist. Diet pureed/nectar thickened several months, recently switched back thin liquids. Family History: Daughter know significant family history. Physical Exam: Admission Exam: VS: 101.3 44 155/37 32 87% RA General: Alert, oriented self, acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP mildly elevated 8-10cm, LAD CV: Distant heart sounds, marked bradycardia, normal S1 + S2, audible murmurs, rubs, gallops Lungs: Clear auscultation anteriorly, wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, organomegaly GU: foley place Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis edema Neuro: CNII-XII intact, moving four extremities, unable cooperate. Discharge Exam: Vitals: afebrile x2.5days, Tc 98.5, 150/85, 51, 18, 99%RA General: resting comfortably bed, acute distress, interactive, smiling HEENT: Sclera anicteric, dryMM Neck: supple, JVP elevated, LAD CV: bradycardiain 50s, normal S1 + S2, audible murmurs, rubs, gallops Lungs: + mild rales bilaterally bases, rhonchi/wheezes. Abdomen: soft, non-tender, non-distended, bowel sounds present, organomegaly GU: indwelling foley place Ext: room temperature, improved cap refill, 2+ pulses, clubbing, cyanosis edema Dementia: speaking sensical Russian currently, oriented self. baseline. Pertinent Results: Admission Labs: [**2162-6-3**] 02:20PM BLOOD WBC-14.0*# RBC-5.66# Hgb-13.2*# Hct-44.6# MCV-79* MCH-23.3* MCHC-29.6* RDW-15.8* Plt Ct-221 [**2162-6-3**] 02:20PM BLOOD Neuts-89.0* Lymphs-6.7* Monos-3.7 Eos-0.6 Baso-0.2 [**2162-6-3**] 02:20PM BLOOD PT-32.5* PTT-39.6* INR(PT)-3.2* [**2162-6-3**] 02:20PM BLOOD Glucose-145* UreaN-27* Creat-1.6* Na-138 K-7.4* Cl-106 HCO3-21* AnGap-18 [**2162-6-3**] 02:20PM BLOOD ALT-49* AST-76* AlkPhos-81 TotBili-0.5 [**2162-6-3**] 02:20PM BLOOD Lipase-40 [**2162-6-3**] 02:20PM BLOOD cTropnT-0.06* [**2162-6-3**] 02:20PM BLOOD Albumin-3.8 Calcium-8.8 Phos-2.6* Mg-2.4 [**2162-6-3**] 02:28PM BLOOD Lactate-2.7* K-5.7* Admission UA: [**2162-6-3**] 02:30PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.020 [**2162-6-3**] 02:30PM URINE Blood-MOD Nitrite-POS Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [**2162-6-3**] 02:30PM URINE RBC-9* WBC->182* Bacteri-MANY Yeast-NONE Epi-0 Repeat UA: [**2162-6-5**] 09:00PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.019 [**2162-6-5**] 09:00PM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR [**2162-6-5**] 09:00PM URINE RBC-7* WBC-5 Bacteri-NONE Yeast-NONE Epi-0 Lactate trend: [**2162-6-3**] 02:28PM BLOOD Lactate-2.7* K-5.7* [**2162-6-4**] 12:33AM BLOOD Lactate-1.4 [**2162-6-5**] 07:51PM BLOOD Lactate-3.4* [**2162-6-5**] 08:14PM BLOOD Lactate-1.4 Troponin Trend: [**2162-6-3**] 02:20PM BLOOD cTropnT-0.06* [**2162-6-3**] 10:10PM BLOOD CK-MB-3 cTropnT-0.06* [**2162-6-5**] 04:06AM BLOOD CK-MB-3 cTropnT-0.05* WBC trend: 14.0->11.7->10.1->9.2->7.9->8.2->7.8->6.9 Discharge Labs: [**2162-6-9**] 06:49AM BLOOD WBC-6.9 RBC-5.05 Hgb-11.9* Hct-39.7* MCV-79* MCH-23.6* MCHC-30.0* RDW-16.1* Plt Ct-257 [**2162-6-9**] 06:49AM BLOOD PT-22.8* PTT-32.0 INR(PT)-2.2* [**2162-6-9**] 06:49AM BLOOD Glucose-77 UreaN-22* Creat-0.9 Na-146* K-4.4 Cl-114* HCO3-24 AnGap-12 [**2162-6-9**] 06:49AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.2 MICRO: [**2162-6-3**] MRSA SCREEN MRSA SCREEN-negative [**2162-6-3**] URINE URINE CULTURE- Mixed Flora [**2162-6-3**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2162-6-3**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2162-6-8**] STOOL C. difficile DNA amplification assay-negative [**2162-6-5**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2162-6-5**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2162-6-5**] URINE URINE CULTURE-mixed flora IMAGING: [**2162-6-3**] EKG: Sinus rhythm high grade A-V block. Baseline artifact obscures interpretation appears complete heart block present junctional escape approximately 40 beats per minute. Compared previous tracing [**2161-5-29**] heart block new. High grade A-V block new. TRACING #1 [**2162-6-4**] EKG: High grade A-V dissociation junctional escape approximately 34 beats per minute. appear conducted P waves likely isorhythmic dissociation. variation P-P interval may due ventriculophasic affect. Compared previous tracing [**2161-5-29**] heart block persists. TRACING #2 [**2162-6-3**] CXR: Low lung volumes. Probable bibasilar atelectasis aspiration difficult exclude. Possible trace bilateral pleural effusions. [**2162-6-4**] Echo: left atrium mildly dilated. atrial septal defect seen 2D color Doppler. mild symmetric left ventricular hypertrophy normal cavity size regional/global systolic function (LVEF>55%). ventricular septal defect. Right ventricular chamber size free wall motion normal. diameters aorta sinus, ascending arch levels normal. aortic valve leaflets (3) mildly thickened aortic stenosis present. Mild (1+) aortic regurgitation seen. aortic regurgitation jet eccentric, directed toward anterior mitral leaflet. mitral valve leaflets mildly thickened. mitral valve prolapse. Mild (1+) mitral regurgitation seen. tricuspid valve leaflets mildly thickened. mild pulmonary artery systolic hypertension. pericardial effusion. Compared prior study (images reviewed) [**2161-11-18**], clear change. [**2162-6-5**] CXR: heart moderately enlarged. moderate-sized left effusion increased compared prior. pulmonary vascular redistribution alveolar infiltrate suggesting element fluid overload; however, addition, dense alveolar infiltrate involving left lower lobe. unclear due infectious process. Chronic right upper lobe lower lobe lung changes visualized. IMPRESSION: 1. New infiltrate left lower lobe. 2. Increased fluid overload. Brief Hospital Course: 89M w/ COPD, Afib coumadin, moderate dementia urinary retention indwelling foley, admitted altered mental status, new complete heart block infection unclear source. Acute Issues: # Complete heart block: Patient previously PR interval 218, suggesting progressive nodal disease. narrow QRS, slow escape rhythm. Trial atropine suggestive infranodal disease, telemetry also shows multiple foci disease. course hospital stay, heart block resolved intermittently heart rate time discharge persistently 50-60s. result family discussion risks benefits PPM elderly patient end stage dementia intermittent asymptomatic complete heart block coumadin afib, potential (not guaranteed) benefits PPM placement would outweight potential risks. # Fever/UTI/Infection unclear source: Patient presented fever 101.3F grossly positive UA. likely source urinary, given positive UA. Indwelling foley replaced ED. CXR similar prior. history resistant bacteria (VRE [**Month/Day/Year 40097**] e.coli), iniatially covered broadly Meropenem Linezolid [**Last Name (un) **] Daptomycin. Urine culture finalized mixed flora evidence VRE [**Last Name (LF) 40097**], [**First Name3 (LF) **] pt narrowed ceftriaxone. 10 hours last dose meropenem, became febrile 102.9F, venous lactate 2.4. UTI cause high fevers, ddx included prostatitis, pyelonephritis, PNA. Repeat UA without bacteria repeat urine culture mixed flora. CXR showed fluid overload possible infiltrate/PNA, sypmtoms. C. diff PCR negative. Blood cultures NGTD. rebroadened Meropenem (Daptomycin restarted, suspicion gram positive infection) WBC continued trend without subsequent fevers. Patient lost IV access (pulling IVs EKG leads) replacement IVs successfully placed. Given source infection unknown, failed trial narrowing antibiotics, continued [**First Name3 (LF) **] 1gm IM daily remainder antibiotic course. continued [**First Name3 (LF) 49799**] 2 days inhouse afebrile normal WBC, continue course [**2162-6-12**]. # Respiratory Alkalosis/Hypoxia/dCHF: transfer MICU, noted tachypneic decreased O2 saturation. ABG showed respiratory alkalosis, likely due hyperventilation 2/2 hypoxia: pH 7.53, pCO2 23, pO2 62. Placed O2 repeat ABG showed pH 7.40, pCO2 40, pO2 68. CXR showed acute congestive heart failure posible infiltrate LLL. Echo showed mild pulmonary hypertension (increased TR gradient) nml EF. CHB likely decreased CO caused mild CHF. Given 10mg IV lasix gentle diuresis good urine output improvement O2 sats. Patient without symptoms cough. WBC continued trend current meropenem/[**Last Name (LF) 49799**], [**First Name3 (LF) **] pneumonia treatment initiated. # Hypertension (Occult Hypoperfusion): Patient carries diagnosis HTN, though noted antihypertensives outpatient. Since CHB, patient noted higher BPs (SBPs 150s-180s). low HRs (30-40s), patient dry cool, suggesting vascularly constricted, likely effort maintain perfusion tissues CHB. Venous lactate 3.4, arterial lactate 1.4, supporting likely occult hypoperfusion [**2-4**] CHB. Several days admission, heart rates improved 50-60s, rarely complete heart block. elevated blood pressure never rose SBP 200, tolerated effort maintain perfusion tissues. Chronic Issues: # Dementia: Patient end stage dementia, oriented self able communicate sensically. Initially found fatigued able walk around. Family concerned baseline terms mental status time, however treatment infection returned baseline MS. may element decreased MS heart rates 30s, however infection improved, heart rate improved, difficult assess. Patient continued home mirtazipine zyprexa rare doses zydis agitation (which family reports baseline). # [**Last Name (un) **]: Patient presented [**Last Name (un) **] (Cr 1.6, baseline noted 1.0). Likely due hypoperfusion infection compounded complete heart block. Cr trended since admission, discharge 0.9. # Afib: CHADS score 2, coumadin goal [**2-5**]. Presented INR 3.2. Coumadin initially held, restarted remained therapeutic home dose 3mg daily except Mondays takes 3.5mg daily. # COPD: Written albuterol ipratropium nebs needed wheezing. # BPH: Continued finasteride chronic foley, exchanged ED [**2162-6-3**]. Transitional Issues: DNR/DNI Given patient intermittently complete heart block, anticoagulated end stage dementia, given appears baseline mental status currently, decided risks outweight benefits pacemaker placement. long blood pressure <200, elevated blood pressures tolerated patient bradycardic. higher blood pressures natural compensation maintain blood perfusion body cardiac output decreased slower heart rate. Medications Admission: - mirtazapine 30mg QHS - trazodone 50mg QHS PRN insomnia - Senna 17.2mg QHS - Miralax 17gm daily - Bacitracin 1 application [**Hospital1 **] - finasteride 5mg daily - tylenol 650mg Q6hrs PRN - olanzapine 2.5mg daily - warfarin 3mg daily TuWeThFrSaSu - warfarin 3.5mg daily Mo Discharge Medications: 1. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO bedtime. 2. trazodone 50 mg Tablet Sig: One (1) Tablet PO bedtime needed insomnia. 3. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. polyethylene glycol 3350 17 gram Powder Packet Sig: One (1) Powder Packet PO DAILY (Daily). 5. bacitracin Topical 6. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours needed pain. 8. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. warfarin 3 mg Tablet Sig: One (1) Tablet PO daily except 3.5mg Mondays. 10. warfarin 1 mg Tablet Sig: 3.5 Tablets PO 1X/WEEK (MO): 3mg daily, except 3.5mg Mondays. 11. [**Hospital1 49799**] 1 gram Recon Soln Sig: One (1) gram Injection day 4 days: Give 2pm daily 4 doses, last dose [**2162-6-12**] 2pm. Mix injection lidocaine lessen pain injection. Disp:*4 gram* Refills:*0* 12. miconazole nitrate 2 % Aerosol Powder Sig: One (1) application Topical four times day: fungal rash buttocks. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] Aged - MACU Discharge Diagnosis: Primary Diagnosis: Complete Heart Block, Urinary Tract Infection Secondary Diagnosis: Hypertension Dementia Acute Kidney Injury Atrial Fibrillation COPD BPH Discharge Condition: Mental Status: Confused - always. Level Consciousness: Alert interactive. Activity Status: Ambulatory - requires assistance aid (walker cane). Discharge Instructions: Dear Mr. [**Known lastname 55195**], pleasure taking care fo [**Hospital1 827**]. admitted extreme fatigue irregular heart beat. admission found urinary tract infection, treated for. Additionally, noted irregularly slow heart rhythm called Complete Heart Block, however improved admission. decided risks outweight possible benefit placing pacemaker problem. [**Name (NI) **] improved treatment infection safe discharge. Please make following changes outpatient medication regimen: START [**Name (NI) **] 1mg intramuscular injection daily 4 days. START miconazole powder applied 4 times daily fungal rash buttocks. Keep area dry clean. changes made outpatient medications. Continue medications previously prescribed. Weigh every morning, [**Name8 (MD) 138**] MD weight goes 3 lbs. Followup Instructions: followed doctors [**First Name (Titles) **] [**Last Name (Titles) 100**] Rehab.
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Admission Date: [**2108-9-26**] Discharge Date: [**2108-10-5**] Service: MEDICINE Allergies: Aspirin / Sulfa (Sulfonamides) / Codeine Attending:[**First Name3 (LF) 2297**] Chief Complaint: transfer MWH cardiac catheterization CP trops elevation 0.79, likely NSTEMI (non ST elevation myocardial infarction) Major Surgical Invasive Procedure: cardiac catheterization History Present Illness: 84yo male CAD - CABG x5 [**2094**] (LIM LAD, SVG DA, SVG [**Female First Name (un) **], SVG PDA, SVG lt ventr branches), MI [**2070**], s/p AAA repair, s/p fem-[**Doctor Last Name **] bypass, CRF HD transferred MWH cath ?dx MI. Patient initially presented MWH ED [**2108-9-24**] c/o continuous 7 10 shoulder shoulder chest pain radiation. denied SOB diaphoresis. Took nitro home x2 relief. ED, +Trop 0.79, EKG 100% paced, received iv nitro morphine, plavix heparin. aspirin given (as per GI) h/o severe GI bleed aspitrin. Pt 2 subsequent episodes CP overnight relieved Morphine. [**9-26**], pt transferred [**Hospital1 18**] cath. Past Medical History: CAD - MI [**2070**], CABG x5 [**2094**] [**Hospital1 336**] s/p AAA repair [**2082**] PPM [**2105**] Bilateral Fem-[**Doctor Last Name **] Bypass CRF-HD T-Th-Sat (last dialysis [**9-25**], tolerated well) severe duodenal ulcer bleed [**2105**] - received 11 PRBC Chrone's Dx diverticulosis Social History: past tobacco Family History: . Physical Exam: PE: pt bed, looks comfortable, acute distress 98.7 BP 130/72, HR 60, RR 18, 96% R/A HEENT: symm neck, mouth clear, LN, flat JBP CHest: limited exam, clear, GAEB CVS: rrr, N S1S2, syst gr II-III/VI murm precordium [**Last Name (un) **]: soft, N BS, NT Extrem: edema, varicose veins Pulses: normal carotid, radial, doplerable pedal Neuro: alert, oriented x3, grossly N Lt Groin: hematoma (4pm) Pertinent Results: [**2108-9-26**] 06:55PM CK-MB-30* MB INDX-13.8* cTropnT-0.89* [**2108-9-27**] 03:00AM CK-MB-129* MB Indx-20.4* [**2108-9-27**] 06:40AM CK-MB-155* MB Indx-20.9* cTropnT-2.54* [**2108-9-26**] 06:55PM WBC-7.1 RBC-3.25* HGB-11.4* HCT-33.7* MCV-104* MCH-35.0* MCHC-33.7 RDW-15.8* [**2108-9-26**] 06:55PM PLT SMR-NORMAL PLT COUNT-178 [**2108-9-26**] 06:55PM GLUCOSE-74 UREA N-52* CREAT-6.4* SODIUM-135 POTASSIUM-5.3* CHLORIDE-92* TOTAL CO2-21* ANION GAP-27* Cardiac cath:1. Coronary grft angiography showed previous right dominant system. LMCA diffusely disesed focal critical lesions. LAD tapered mid segment large S2 totally occluded. D1 D2 small vessels diffusely diseased. D3 recived SVG seen LMCA injection. Mid distal LAD receives LIMA. Cx vessel self lesions. gives lengthy collateral. OM1 arises close LMCA small. OM2 arises close LMCA large. proximal lesion 80%. OM3 recives SVG seen LMCA injection. OM4/postero latateral branch arises distally small vessel. RCA occluded proximally. distal RCA including PDA PLV collateralised left system. PDA poorly filled mid 60% lesion. LIMA , LIMA-LAD anastomosis distal LAD free disease. LIMA fills LAD retrogradely supply proximal LAD D3. D3 ostial 70% lesion TIMI III flow. SV grafts RCA PLB occluded completely seen stumps aorta. graft Diagonal could located, likely occluded given angiogaphic findings. SVG OM3 shows diffuse disease mid lengthy lesion 99 % whole vessel showed TIMI II flow. collaterals OM. 2. Left ventriculography performed. 3. Predilation using 1.5 X 15 Maverick balloon, stenting using 3.0 X 28 3.0 X 33 OTW Cypher stents thrombus extraction using export catheter gradual deterioration flow SVG OM3. flow deteriorated TIMI TIMI 0. FINAL DIAGNOSIS: 1. Three vessel native coronary artery disease functioning LIMA LAD. 2. Acute occlusion SVG OM chronically occluded SV grafts PDA, PLB Diagonal. 3. Unable restore flow SVG OM despite stenting, pharmacotherapy thrombus aspiration. . Echo: . left atrium mildly dilated. 2. left ventricular cavity size normal. Overall left ventricular systolic function mildly depressed. Basal inferior hypokinesis present. 3. aortic valve leaflets severely thickened/deformed. moderate aortic valve stenosis. 4. mitral valve leaflets mildly thickened. 5. mild pulmonary artery systolic hypertension. . ct scan: 1. evidence intrahepatic gas suggested prior ultrasound. Repeat ultrasound suggested given change appearance. 2. Bibasilar dependent atelectatic changes/consolidation associated effusions. 3. Gas distended loops bowel air-fluid levels without transition suggesting ileus. Stool distended rectum. 4. Small infrarenal abdominal aortic aneurysm. Brief Hospital Course: admitted unstable angina, total occlusion svg grafts patent LIMA LAD, received 2 cypher stents. catheterization compicted failed thrombus extractuib abd TIMI 0. catherization persistent CP evidence NSTEMI. Initially treated ASA past GI bleed, persistent ischemia, added plavix. required significant morphine controll pain. discussions MICU team family pain control determined option him. code status changed DNR/DNI/. Due ongoing ischemia, persistent hypotension required multiple pressors. HD changed CVVH low blood presssure. also intermittent NSVT. transferred [**Hospital Unit Name 196**] team MICU team due hypotension HD cardiac catheterization concern possible sepsis. concern acute abdomen appeared impacted stool. disimpacted received aggresive bowel regimen. distension pain improved. low grade temperatures initially treated pneumonia hypoxic. source infection identified. likely cardiogenic shock fluid overload. repeat bedside echo reveal worsening ventricular function. required blood transfusions persistently dropping HCT setting frequent blood draws. also coagulopathy appear DIC. required vitamin K supplementation. expired 6:45am [**2108-10-5**] episode severe chest pain. Medications Admission: Plavix 300mg x2 [**2078-9-24**] mg [**Hospital1 **] starting [**2108-9-26**] Lopressor 12.5mg [**Hospital1 **] Foslo 667mg x4 TID Quinine 324mg daily Pentasa 250mg x4 QID MVI Mirtazapine 15mg qhs Colace 100mg [**Hospital1 **] Protonix 40mg daily Morphine prn Nitro prn Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: sinus tachycardia nsvt cardiogenic shock coagulopathy obstipation nstemi esrd Discharge Condition: expired Discharge Instructions: . Followup Instructions: . Completed by:[**2108-12-21**]
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[
"486"
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Admission Date: [**2108-4-4**] Discharge Date: [**2108-5-8**] Date Birth: [**2036-9-21**] Sex: F Service: SURGERY Allergies: Sulfa(Sulfonamide Antibiotics) / Heparin Agents Attending:[**First Name3 (LF) 32612**] Chief Complaint: Painless jaundice. Major Surgical Invasive Procedure: [**2108-4-4**]: -Diagnostic laparoscopy. -Peritoneal washings cytology -Exploratory laparotomy. -Cholecystectomy. -Harvest pedicled omental flap protection anastomoses. -Pancreaticoduodenectomy standard gastrojejunostomy, antecolic. - Right hepatic artery reconstruction using right gonadal vein interposition graft (performed Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]). History Present Illness: 71F presented painless jaundice, dark urine, bloating, anorexia. first noticed onset symptoms [**Month (only) **] [**Month (only) 1096**] alerted friend increasing jaundice, prompted medical evaluation. [**Hospital3 3583**], labs follows: total bilirubin 28, Alk phos 338, ALT 128 prior arrival. underwent ultrasound CT contrast found 2.4 x 1.8 cm mass cystic structre head pancreas, distended thickened gallbladder, intrahepatic (1.9 cm)and pancreatic duct (1.2 cm). time consultation clinically well denies nausea, vomiting, changes bowel habits. underwent ERCP revealed single irregular stricture malignant appearance 2 cm long lower third common bile duct. severe post-obstructive dilation. limited pancreatogram revealed stricture main duct head. Cannulation biliary duct successful. Contrast medium injected resulting complete opacification. sphincterotomy performed. 7cm 10FR biliary stent placed. Cytology samples obtained histology returned positive adenocarcinoma. patient offered Whipple operation, following explained: 1-2% risk death, 30-40% risk complication. OSH scan report, involvement mesenteric vessels evidence metastatic disease, although periportal lymphadenopathy. understood risks/benefits surgery, decided proceed operation. Past Medical History: PMH: None PSH: Tonsillectomy/adenoidectomy, teeth extracted Social History: Retired high school teacher, children, lives female HCP. [**Name (NI) 4084**] [**Name2 (NI) 1818**], drank [**2-17**] glasses wine per night symptoms started [**Month (only) **]/[**Month (only) **], drug use. Family History: Sister died leukemia age 65, mother died cervical cancer. history benign malignant pancreatic disease. Physical Exam: Physical Exam Admission: 97.3 91 173/94 20 100%RA Gen: Alert oriented, pleasant Skin: Pronounced scleral dermal jaundice CV: RRR Resp: Clear auscultation Abd: Soft, non-tender, non-distended. Negative [**Doctor Last Name 515**] sign, palpable masses Ext: 1+ edema, palp DP/PT pulses. Pertinent Results: [**2108-4-12**] 07:24AM BLOOD Vanco-31.4* [**2108-5-8**] 06:05AM BLOOD Vanco-12.4 [**2108-4-4**] 07:54PM BLOOD Albumin-2.1* Calcium-8.9 Phos-5.7*# Mg-1.9 [**2108-5-8**] 01:56AM BLOOD Calcium-10.9* Phos-2.1* Mg-2.7* [**2108-4-4**] 07:54PM BLOOD CK-MB-2 cTropnT-<0.01 [**2108-4-15**] 12:58PM BLOOD CK-MB-2 cTropnT-0.03* [**2108-4-5**] 03:30AM BLOOD Lipase-13 [**2108-5-7**] 01:23AM BLOOD Lipase-7 [**2108-4-4**] 07:54PM BLOOD ALT-303* AST-827* CK(CPK)-57 AlkPhos-56 TotBili-5.7* [**2108-4-18**] 01:45AM BLOOD ALT-38 AST-80* AlkPhos-59 TotBili-32.4* DirBili-23.7* IndBili-8.7 [**2108-5-2**] 01:18AM BLOOD ALT-49* AST-82* AlkPhos-65 TotBili-36.9* [**2108-5-8**] 01:56AM BLOOD ALT-59* AST-94* LD(LDH)-202 AlkPhos-77 TotBili-33.6* [**2108-4-4**] 07:54PM BLOOD Glucose-104* UreaN-11 Creat-0.6 Na-134 K-4.8 Cl-100 HCO3-15* AnGap-24* [**2108-5-8**] 01:56AM BLOOD Glucose-143* UreaN-4* Creat-0.5 Na-142 K-4.7 Cl-101 HCO3-9* AnGap-37* [**2108-4-4**] 08:12AM BLOOD Fibrino-515* [**2108-4-5**] 07:50PM BLOOD Fibrino-156*# [**2108-4-4**] 08:12AM BLOOD PT-12.3 PTT-27.8 INR(PT)-1.1 [**2108-4-6**] 03:48AM BLOOD Plt Ct-139* [**2108-4-7**] 11:55PM BLOOD Plt Smr-VERY LOW Plt Ct-62* [**2108-4-12**] 02:57AM BLOOD Plt Ct-56*# [**2108-5-7**] 08:15PM BLOOD Plt Ct-<5 [**2108-5-8**] 01:56AM BLOOD PT-49.9* PTT-122.1* INR(PT)-4.9* [**2108-4-7**] 11:55PM BLOOD Neuts-86* Bands-3 Lymphs-4* Monos-3 Eos-2 Baso-0 Atyps-0 Metas-1* Myelos-1* NRBC-1* [**2108-5-6**] 02:16AM BLOOD Neuts-90* Bands-1 Lymphs-2* Monos-4 Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-0 Promyel-1* [**2108-4-4**] 07:54PM BLOOD WBC-14.6*# RBC-2.58* Hgb-8.2* Hct-24.1* MCV-93# MCH-31.7# MCHC-34.0 RDW-16.5* Plt Ct-88* [**2108-4-5**] 07:50PM BLOOD WBC-26.4*# RBC-3.07* Hgb-9.7* Hct-28.4* MCV-93 MCH-31.7 MCHC-34.2 RDW-16.3* Plt Ct-102* [**2108-4-7**] 05:41AM BLOOD WBC-28.5* RBC-3.23* Hgb-9.7* Hct-29.7* MCV-92 MCH-30.0 MCHC-32.6 RDW-16.0* Plt Ct-93* [**2108-4-9**] 12:49PM BLOOD WBC-16.4* RBC-3.05* Hgb-9.5* Hct-28.8* MCV-95 MCH-31.3 MCHC-33.0 RDW-18.0* Plt Ct-43* [**2108-5-7**] 08:15PM BLOOD WBC-41.4* RBC-2.19* Hgb-7.5* Hct-23.7* MCV-108* MCH-34.3* MCHC-31.7 RDW-22.5* Plt Ct-<5 [**2108-5-7**] 10:15PM BLOOD WBC-48.1* RBC-2.26* Hgb-7.7* Hct-24.9* MCV-110* MCH-34.1* MCHC-31.0 RDW-22.8* Plt Ct-88* [**2108-5-8**] 01:56AM BLOOD WBC-47.3* RBC-2.21* Hgb-7.7* Hct-24.5* MCV-115* MCH-34.7* MCHC-30.2* RDW-23.0* Plt Ct-72* . [**2108-4-9**] 11:46 SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2108-4-9**]): >25 PMNs <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2108-4-12**]): Commensal Respiratory Flora Absent. HAFNIA ALVEI. SPARSE GROWTH. Piperacillin/tazobactam sensitivity testing available request. SENSITIVITIES: MIC expressed MCG/ML _________________________________________________________ HAFNIA ALVEI | AMPICILLIN------------ 16 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 CEFTAZIDIME----------- <=1 CEFTRIAXONE----------- <=1 CIPROFLOXACIN---------<=0.25 GENTAMICIN------------ <=1 MEROPENEM-------------<=0.25 TOBRAMYCIN------------ <=1 TRIMETHOPRIM/SULFA---- <=1 . [**2108-5-1**] 5:55 PERITONEAL FLUID DAS ACU VERIFIED [**First Name9 (NamePattern2) 92514**] [**Location (un) **] [**5-1**] @0950. GRAM STAIN (Final [**2108-5-1**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. MICROORGANISMS SEEN. concentrated smear made cytospin method, please refer hematology quantitative white blood cell count.. FLUID CULTURE (Final [**2108-5-5**]): Reported read back [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2108-5-2**] 2:45PM 4-3130. culture contains mixed bacterial types (>=3) abbreviated workup performed. growth P.aeruginosa, S.aureus beta hemolytic streptococci reported. BACTERIA REPORTED BELOW, PRESENT culture.. Work-up organism(s) listed discontinued (excepted screened organisms) due presence mixed bacterial flora detected incubation. ENTEROCOCCUS SP.. RARE GROWTH. SENSITIVITIES: MIC expressed MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R PENICILLIN G---------- =>64 R VANCOMYCIN------------ <=0.5 ANAEROBIC CULTURE (Final [**2108-5-5**]): ANAEROBES ISOLATED. FUNGAL CULTURE (Preliminary): FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2108-5-2**]): ACID FAST BACILLI SEEN DIRECT SMEAR. ACID FAST CULTURE (Preliminary): MYCOBACTERIA ISOLATED. . [**2108-5-6**]: [**2108-5-6**] 10:54 URINE Source: Catheter. **FINAL REPORT [**2108-5-7**]** URINE CULTURE (Final [**2108-5-7**]): YEAST. >100,000 ORGANISMS/ML.. . [**2108-4-12**]: IMPRESSION: Non-occlusive deep vein thrombosis seen within one two left brachial veins . [**2108-4-16**]: IMPRESSION: 1. Status post Whipple serpiginous hypodensity seen left lobe consistent retraction injury. drainable collection. 2. radiologically evident cause leukocytosis observed. 3. Extensive anasarca, likely secondary volume overload. . Final Pathology Report: MACROSCOPIC Specimen Type: Pancreaticoduodenectomy, partial pancreatectomy. Tumor Site: Pancreatic head, uncinate process. Tumor Size: Greatest dimension: 2.9 cm. Additional dimensions: 2.5 cm x 2.5 cm. organs/Tissues Received: Gallbladder, Stomach. MICROSCOPIC Histologic Type: Ductal adenocarcinoma. Histologic Grade: G2: Moderately differentiated. EXTENT INVASION Primary Tumor: pT3: Tumor extends beyond pancreas without involvement celiac axis superior mesenteric artery. Regional Lymph Nodes: pN1: Regional lymph node metastasis. Lymph Nodes Number examined: 11. Number involved: 1. Distant metastasis: pMX: Cannot assessed. Margins: Margins uninvolved invasive carcinoma: Distance closest margin: 1 mm peri-uncinate-process adipose tissue margin. Venous/Lymphatic vessel invasion: Absent. Perineural invasion: Present. Additional Pathologic Findings: Pancreatic intraepithelial neoplasia -- highest grade: PanIN: III; chronic pancreatitis. . Brief Hospital Course: patient brought operating room [**2108-4-4**] Whipple procedure, necessitating right hepatic artery reconstruction gonadal vein vascular surgery service consulted intraoperatively. Reader referred operative notes full details. received 6 u pRBC, 2 FFP, 500 albumin OR, left intubated pressors, taken surgical ICU post operatively. course thereafter ICU complicated. brief: required frequent blood transfusions pRBCs, FFP, albumin, persistent pressor requirement; developed acute renal failure requiring CVVH, persistent elevations LFTs, persistent leukocytosis total cardiology, infectious disease, renal, hepatology services consulted. Significant events post-operative day included: POD2 renal service consulted given persistent renal failure postoperatively, begun CVVH. Given down-trending platelets, HIT panel sent returned positive POD5, patient begun bivalirudin drip per hematology recommendations. POD6 TF initiated via NGT, foley removed, sputum cultures revealed GNR begun vancomycin/ciprofloxacin/flagyl. Antibiotics thereafter tailored appropriately consultation infectious disease service. POD8 left brachial vein clot found non-invasives initiated fondaparinux, subsequently discontinued. POD11 patient noted QTC prolongation, cardiology service consulted, recommendations followed regarding medication adjustments. [**2108-4-17**] patient extubated, briefly pressors. found SBP, begun meropenem consultation hepatology ID services. Lactulose initiated given poor mental status (AOx1 initially), seemed initially improve. POD20 patient failed speech swallow evaluation, continued tube feedings. pressor requirement remained persistent, WBC continued trend upwards. [**2108-5-4**], discussion patient's HCP, made DNR/DNI. evening [**2108-5-7**] noted hypothermic 89, DIC per labarotory values passed away [**2108-5-8**], post-operative day 34. Discharge Disposition: Expired Discharge Diagnosis: -Pancreatic cancer -Spontaneous bacterial peritonitis -Heparin Induced Thrombocytopenia -Renal failure Discharge Condition: Expired. Discharge Instructions: N/A. Followup Instructions: N/A. Completed by:[**2108-5-9**]
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Admission Date: [**2118-5-7**] Discharge Date: [**2118-5-19**] Date Birth: [**2047-9-30**] Sex: Service: MEDICINE Allergies: Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2698**] Chief Complaint: Chest pain anemia Major Surgical Invasive Procedure: Colonoscopy Upper Endoscopy History Present Illness: 70 year old man afib coumadin, insulin dependent DM, obseity, systolic diastolic heart failure LVEF 40-45%, CAD s/p CABG '[**93**], PTCA'[**15**], STEMI BMS SVG-OM graft [**2118-4-8**], presents fatigue dyspnea exertion past week. initially feeling well discharge [**3-/2117**] began exercising losing weight. However, past week dyspnea increased exertional capacity decreased. called cardiologist thought might overdiuresed, therefore lasix spironolactone reduced half prior doses. Dyspnea worsened despite change. day admission 2 bowel movements, second dark black. bowel movement preceeded crampy abdominal pain. attempted walk bathroom kitchen acutely dyspneic. sat developed chest pain, took nitro relief. Tried walk chest pain returned, thus called EMS brought OSH. chest pain relieved repeated nitroglycerin eventually started nitroglycerin drip. Labs OSH notable HCT 25, INR 3.7, K 7. Enroute [**Hospital1 18**], SBP dropped increasing nitro drip doses. Upon arrival [**Hospital1 18**], chest pain free VS 97.6 99/56, 74 16 97% 2L. ECG showed new LBBB, trop negative. Labs notable K 7.2 (not hemolyzed) thus received calcium, D50/insulin, kayexalate. INR 4.9. GI called given HCT drop 31 25 made plans scope morning. Rectal exam notable brown stool guaiac positive specks black stool. Nitroglycerin drip stopped pain controlled morphine PRN. received 1L NS. Vitals prior transfer 98.1 69 109/41 16 99% RA pain 0. arrival MICU, initially comfortable, developed chest pain prompting morphine 2mg x3 without relief. SL nitro given improvement pain. ECG showed narrow complex sinus rhythm ST depressions I, V4-V6. later another episode pain relieved SL nitroglycerin. Past Medical History: CAD s/p CABG [**2093**], s/p cath [**2103**] wiuth BMS Lcx, [**2113**] revealing severe stenosis SVG OM s/p BMS x 3, [**2115**] [**Hospital1 112**] (patient says stent unknown location) IDDM morbid obesity COPD sleep apnea BiPAP CHF, diastolic, EF 71% per OSH reports afib HTN CVA right sided numbness history rheumatic fever Social History: Lives wife four children. Worked carpenter. tob/ETOH/IVDA. Family History: Adopted, unknown Physical Exam: Admission exam: Vitals: 98F 108/44 71 9 99% RA General: Alert, oriented, acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP elevated, LAD CV: Regular rate rhythm, normal S1 + S2, murmurs, rubs, gallops Lungs: Clear auscultation bilaterally, wheezes, rales, ronchi Abdomen: soft, obese, non-tender, non-distended, bowel sounds present, organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation Discharge exam: VS - 98.0, 98.6, 96/49 (94-145/48-71), 71 (52-81), 20, 100RA GENERAL - Obese late-middle aged man NAD. Oriented x3. HEENT - NCAT. Oropharynx clear NECK - Supple, unable assess JVD due habitus CARDIAC - RRR, normal S1, S2. m/r/g. S3 S4. LUNGS - CTAB, crackles, wheezes rhonchi. ABDOMEN - Soft, obese NTND. HSM tenderness. EXTREMITIES - WWP, LE edema, clubbing SKIN - Multiple scars across lower extremities vein harvesting, chronic stasis changes Pertinent Results: Admission Labs: =============== [**2118-5-6**] 11:55PM BLOOD WBC-11.2* RBC-2.82* Hgb-8.0* Hct-24.7* MCV-87 MCH-28.3 MCHC-32.3 RDW-19.2* Plt Ct-178 [**2118-5-6**] 11:55PM BLOOD Neuts-85.1* Lymphs-10.4* Monos-3.0 Eos-1.3 Baso-0.2 [**2118-5-6**] 11:55PM BLOOD PT-49.3* PTT-56.2* INR(PT)-4.9* [**2118-5-6**] 11:55PM BLOOD Glucose-187* UreaN-78* Creat-1.9* Na-131* K-7.2* Cl-99 HCO3-22 AnGap-17 [**2118-5-7**] 03:20AM BLOOD Calcium-9.6 Phos-4.1 Mg-2.6 Pertinent Labs: =============== [**2118-5-6**] 11:55PM BLOOD cTropnT-<0.01 [**2118-5-7**] 03:20AM BLOOD CK-MB-4 cTropnT-0.02* [**2118-5-7**] 08:55AM BLOOD CK-MB-5 cTropnT-0.04* [**2118-5-7**] 10:58PM BLOOD CK-MB-4 cTropnT-0.05* [**2118-5-12**] 10:50AM BLOOD Hapto-164 [**2118-5-12**] 10:50AM BLOOD LD(LDH)-195 TotBili-2.0* DirBili-0.5* IndBili-1.5 HELICOBACTER PYLORI ANTIBODY TEST: POSITIVE EIA. Urine culture [**5-9**]- growth Discharge Labs: =============== [**2118-5-19**] 06:35AM BLOOD Hct-29.5* [**2118-5-17**] 11:00AM BLOOD PT-11.9 PTT-33.3 INR(PT)-1.1 [**2118-5-18**] 11:10AM BLOOD Glucose-108* UreaN-21* Creat-1.1 Na-136 K-4.6 Cl-100 HCO3-28 AnGap-13 [**2118-5-18**] 11:10AM BLOOD Calcium-8.0* Phos-3.5 Mg-3.2* Micro/Path: =========== URINE CULTURE (Final [**2118-5-10**]): GROWTH. HELICOBACTER PYLORI ANTIBODY TEST (Final [**2118-5-9**]): POSITIVE EIA. MRSA SCREEN (Final [**2118-5-9**]): MRSA isolated. Imaging/Studies: ================ CXR [**5-9**]- Status post sternotomy, mild prominence cardiomediastinal silhouette. upper zone re-distribution without overt CHF. minimal atelectasis bases. frank consolidation effusion. EKG [**5-9**]- LBBB -> sinus rhythm narrow complex, ST depressions V4-V6 I, avL EGD [**5-9**]- Nodularity whole stomach compatible nodular gastritis. Normal EGD third part duodenum. CT abd/pelvis [**5-12**]- 1. evidence retroperitoneal bleed acute intra-abdominal process. 2. Fatty infiltration liver. 3. Cholelithiasis. 4. Right renal cyst. Colonoscopy [**2118-5-18**]: Impression: Grade 1 internal hemorrhoids Diverticulosis sigmoid colon Otherwise normal colonoscopy cecum Brief Hospital Course: 70 year old man afib coumadin, insulin dependent DM, obseity, systolic diastolic heart failure LVEF 40-45%, CAD s/p CABG '[**93**], PTCA'[**15**], STEMI BMS SVG-OM graft [**2118-4-8**], presents fatigue dyspnea exertion, found hematocrit drop secondary GI bleed. ACTIVE DIAGNOSES: ================= # Chest Pain: Demand ischemia setting GI bleed. known coronary vascular disease refractory angina amenable intervention per cardiology team. evidence consolidation PTX CXR suggest pulmonary cause. Patient transfused total 8 units pRBCs; hematocrit initially stabilized heparin gtt coumadin re-started, hematocrit dropped chest pain returned without EKG changes. continued aspirin, plavix, ranolazine. Imdur started lower dose home dose given concern hypotension setting bleeding, BP remained stable imdur titrated home dose. return chest pain, dynamic ST changes V3-V5 I/avL, consistent known non-intervenable areas disease. imdur increased 240mg metoprolol increased tartrate 150mg PO BID without episodes chest pain. # UGIB/H.Pylori + Nodular Gastritis: EGD, patient evidence nodular gastritis superficial erosions. H.pylori returned positive patient began triple therapy amoxicillin (not candidate clarithromycin given interaction ranolazine), metronidazole pantoprazole. Coumadin held INR reversed vitamin K. Patient ongoing hematocrit drop without obvious bleeding heparin drip restarted, coumadin heparin stopped. Patient complete 2 weeks triple therapy, continue [**Hospital1 **] pantoprazole. require GI follow-up test cure. also underwent colonoscopy reveal additional alternative source bleeding. continues bleed, next step would capsule endoscopy. [**Hospital1 **] check prior PCP appointment assess hematocrit. # Acute blood loss anemia: Source suspected gastritis above. Coumadin held admission ICU reversed vitamin K FFP. transfused total 8 units admission; initially 4 units ICU inappropriate response blood, floor initiation coumadin bridge heparin drip, patient's hematocrit drifted down. Haptoglobin LDH normal, indirect bilirubin slightly elevated (and post transfusion) low suspicion hemolysis. discontinuation heparin drip coumadin, hematocrit stabilized patient require transfusion >72 hours prior discharge. # Constipation: Significantly constipated admission. Required 2 days prep prior colonoscopy. Patient discharged senna/colace/miralax prevent constipation. # Acute chronic systolic heart failure: admission, patient mild pulmonary edema secondary decreased lasix spironolactone dose past week prior admission. Patient diuresed ICU, euvolemic transfer floor. continued home lasix 40mg daily, extra doses transfusions. episodes orthostatic hypotension prompting decrease lasix dose 20mg PO daily. Patient euvolemic time discharge, weight stable 120 kg. # Hyperkalemia: 7.2 admission likely secondary ARF, spironolactone, lisinopril. ECG improved narrow complex potassium normalized. Potassium remained stable remainder admission. Spironolactone restarted, lisinopril restarted lower dose 5mg PO daily. # LBBB: Suspect metabolic etiology given improved K correction. Trop negative suggesting acute coronary syndrome. LBBB resolved correction K. # Acute renal failure: Likely secondary systolic CHF poor forward flow second hit poor perfusion due acute GIB. Patient's creatinine trended 1.1 day discharge. # Leukocytosis: Unclear etiology, may due stress GIB. evidence infectious colitis, UA without evidence infection consolidation seen CXR. White count resolved remained normal remainder admission. CHRONIC DIAGNOSES: ================== # HLD: continued atorvastatin # Depression: continued venlafaxine # DMII: Blood sugar well controlled admission. Transitional issues: # Spironolactone held discharge given hyperkalemia 7.2 admission. # Coumadin held discharge -> anticipate holding medication month gastritis heals protection stroke aspirin 325mg plavix 75mg interim. # Lisinopril decreased 5mg daily prevent hyperkalemia increase pressure room uptitrate Imdur 240mg PO daily metoprolol 150mg tartrate [**Hospital1 **] # H.pylori triple therapy treatment continue [**2118-5-23**] # Hematocrit electrolytes rechecked PCP [**Name9 (PRE) 702**] appointment, script this. # Insulin decreased 70/30 mix 80 units daily given in-house hypoglycemia. suggest setting [**Last Name (un) **] diabetes management wanted discuss PCP [**Name Initial (PRE) **]. # Weight discharge 120kg, discharged furosemide 20mg daily. Medications Admission: 1. aspirin 325 mg DAILY 2. nitroglycerin 0.4 mg q5min PRN 3. furosemide 40 mg PO daily 4. lisinopril 10 mg PO DAILY 5. atorvastatin 80 mg PO DAILY 6. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: One Hundred (100) units Subcutaneous twice day. 7. metformin 500 mg PO daily 8. venlafaxine 75 mg PO DAILY 9. warfarin 5 mg PO day. 10. pantoprazole 40 mg PO day. 12. ranolazine 1,000 mg PO twice day. 13. clopidogrel 75 mg PO daily 14. isosorbide mononitrate 60 mg PO day. 15. metoprolol succinate 200 mg PO day. 16. spironolactone 25 mg PO day. Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. ranolazine 500 mg Tablet Extended Release 12 hr Sig: Two (2) Tablet Extended Release 12 hr PO BID (2 times day). 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). [**Name Initial (PRE) **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) needed chest pain. 7. metformin 500 mg Tablet Sig: One (1) Tablet PO day. 8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) 4 days. [**Name Initial (PRE) **]:*12 Tablet(s)* Refills:*0* 9. amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice day 4 days. [**Name Initial (PRE) **]:*16 Tablet(s)* Refills:*0* 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed Constipation. [**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*0* 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). [**Name Initial (PRE) **]:*30 Capsule(s)* Refills:*2* 12. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO day. 13. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO twice day. [**Name Initial (PRE) **]:*180 Tablet(s)* Refills:*2* 14. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: Eighty (80) units Subcutaneous twice day. 15. Imdur 60 mg Tablet Extended Release 24 hr Sig: Four (4) Tablet Extended Release 24 hr PO day. 16. Miralax 17 gram Powder Packet Sig: One (1) PO day. [**Name Initial (PRE) **]:*30 packets* Refills:*2* 17. lisinopril 5 mg Tablet Sig: One (1) Tablet PO day. [**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*0* 18. furosemide 20 mg Tablet Sig: One (1) Tablet PO day. [**Name Initial (PRE) **]:*30 Tablet(s)* Refills:*0* 19. Outpatient [**Name Initial (PRE) **] Work Please obtain CBC, Chem 7 prior appointment. results communicated PCP: [**Name Initial (NameIs) 7274**]: [**Name Initial (NameIs) **],[**Name Initial (NameIs) **] Address: [**Hospital1 29147**], [**Location (un) **],[**Numeric Identifier 29160**] Phone: [**Telephone/Fax (1) 29149**] Fax: [**Telephone/Fax (1) 29155**] Discharge Disposition: Home Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: # Unstable Angina # H. pylori + nodular gastritis erosions # Blood loss anemia Secondary diagnosis: # Coronary artery disease # Atrial Fibrillation Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - requires assistance aid (rolling walker) Discharge Instructions: Dear Mr. [**Known lastname **], pleasure taking care you! admitted [**Hospital1 18**] evaluation treatment chest pain, shortness breath, GI bleeding. found low blood count likely due slow bleed GI tract related blood thinners gastritis erosions H. pylori (a bacteria pre-disposes gastritis ulcers). started medication protect GI tract, treatment infection, given blood transfusions improve blood counts. underwent upper endoscopy showed inflammation stomach erosions colonoscopy without source bleeding. also elevation potassium level, spironolactone discontinued. attempted re-starting anticoagulation began bleed again. result, coumadin held resolution gastritis. suggesting waiting month resuming coumadin would like re-assure recieving protection stroke afib aspirin plavix. following changes made medication regimen: - START Metronidazole three times day Monday [**2118-5-23**] treat infection stomach - START Amoxicillin twice day Monday [**2118-5-23**] treat infection stomach - INCREASE pantoprazole twice day protect stomach lining - INCREASE Imdur 240mg mouth daily - CHANGE Metoprolol Tartrate 150mg mouth twice daily - DECREASE Lisinopril 5mg daily - DECREASE Lasix 20mg daily - DECREASE Insulin 70/30 80 units twice daily - STOP Spironolactone - STOP Coumadin -> discuss primary care doctor restarting medication month gastritis healed - START Senna Colace twice day needed constipation - START Miralax daily needed constipation Please follow suggested below. Followup Instructions: Name:[**Name6 (MD) **] [**Name8 (MD) **],MD Specialty: Primary Care Address: [**Hospital1 29147**], [**Location (un) **],[**Numeric Identifier 29160**] Phone: [**Telephone/Fax (1) 29149**] When: Tuesday, [**5-24**] 3:15pm -Please labs checked prior appointment, discharge hematocrit 29.5 Department: CARDIAC SERVICES When: THURSDAY [**2118-5-26**] 9:40 With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2118-5-20**]
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[
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Admission Date: [**2146-5-11**] Discharge Date: [**2146-5-14**] Date Birth: [**2068-2-6**] Sex: Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[**First Name3 (LF) 458**] Chief Complaint: Shortness breath Major Surgical Invasive Procedure: Cardiac catheterization Drug eluting stent Right coronary Artery History Present Illness: 78 year-old male patient Dr. [**First Name (STitle) 28622**] Attar Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] history includes CAD, s/p MI X 2, s/p CABG [**2139**], s/p prior stent LAD s/p prior PTCA diagonal admitted [**Hospital6 17032**] [**2146-5-7**] shortness breath. diagnosed acute chronic CHF initial BNP 482. diuresed IV Lasix ruled MI negative cardiac enzymes. nuclear stress performed [**5-9**] showed several areas questionable reversible inferolateral anteroapical ischemic changes EKG changes chest pain. believed heart rate response blunted [**2-14**] high dose BBlocker deconditioning. overall duration treadmill time 5 minutes heart rate max 81 bpm. discharged home returned [**Location (un) **] ED continued complaints shortness breath. Cardiac enzymes negative transferred cardiac cathterization evaluation symptoms. cath lab, pt unable lie flat secondary history PTSD, claustrophia, anxiety therefore required intubation. 90% distal lesion, beyond PDA stented [**Location (un) **]. end procedure, NGT placed dose plavix. Pt already started integrelin heparin. Subsequently, patient developed significant nose bleed. Heparin integrelin held, ENT called, pressure held patient given intranasal afrin. Right heart cath also notable elevated RVEDP (16 mm Hg) PCWP (28 mm Hg mean). Past Medical History: Coronary Artery Disease s/p CABG [**2139**] (LIMA->diag, SVG->OM1, SVG->LAD) s/p Myocardial Infarction X 2 s/p prior LAD stent PTCA diag Chronic systolic heart failure [**2-14**] ischemic cardiomyopathy, last known EF 20% Ischemic cardiomyopathy, s/p ICD implantation [**2141-7-14**] Type 2 Diabetes Mellitus, insulin-dependent Chronic Obstructive Pulmonary Disease, home O2 requirement Hypertension Hyperlipidemia Diabetic Nephropathy/Chronic Renal Insufficiency Diabetic Neuropathy s/p right renal artery stent Severe Peripheral Vascular Disease, s/p left fem-[**Doctor Last Name **] bypass [**2137**] GERD Anxiety Depression Post Traumatic Stress Disorder Paroxysmal Atrial Fibrillation Nonsustained Ventricular Tachycardia Social History: Married lives wife. Retired Army. recently worked cook [**Hospital **] [**Hospital6 28623**]. used drink alcohol heavily, none 40 years. 40+ pack year h/o smoking, quit 40 years ago. Family History: Father died MI age 48. Brother died MI age 64. Physical Exam: Vitals: 129/48 - 67 - 17 - 100% room air Neuro: Alert, oriented person, place, time. Hard hearing. Cardiac: Regular rate rhythm. Normal S1,S2. murmurs/rubs/gallops. Resp: Lungs fine crackles bases bilaterally. Breathing regular unlabored rest. Periph vasc: Bilateral femoral pulses palpable. Bilateral DP PT pulses palpable. 1+ pedal edema bilaterally. ECG: SR 73 PVC's Pertinent Results: Admission labs: [**2146-5-11**] 09:52PM BLOOD WBC-9.5# RBC-4.34* Hgb-13.3* Hct-39.0* MCV-90 MCH-30.7 MCHC-34.2 RDW-14.6 Plt Ct-280 [**2146-5-11**] 09:52PM BLOOD Neuts-76.0* Lymphs-13.9* Monos-6.5 Eos-3.2 Baso-0.4 [**2146-5-11**] 09:52PM BLOOD PT-13.7* PTT-24.9 INR(PT)-1.2* [**2146-5-11**] 09:52PM BLOOD Glucose-264* UreaN-29* Creat-1.6* Na-134 K-4.6 Cl-99 HCO3-27 AnGap-13 [**2146-5-11**] 09:52PM BLOOD Calcium-9.0 Phos-3.4 Mg-2.4 . Cardiac cath ([**5-13**]): 1. Coronary angiography right dominant system revealed native three vessel coronary artery disease. LMCA distal 50% stenosis. LAD occluded mid-vessel. major diagonal branch ostial 60% stenosis. LCx long 60% lesion OM1. RCA 90% stenosis beyond origin PDA. 2. Arterial conduit angiography demonstrated patent LIMA-D1 SVG-OM grafts. SVG-OM occluded proximally. 3. Resting hemodynamics revealed elevated right left sided filling pressures (RVEDP 16 mm Hg, PCWP mean 28 mm Hg). moderate severe pulmonary arterial hypertension (PASP 61 mm Hg). systemic arterial blood pressure normal (SBP 122 mm Hg). cardiac index normal 2.7 l/min/m2. systemic vascular resistance normal (911 dynes-sec/cm5). pulmonary vascular resistance normal (PVR 135 dynes-sec/cm5). 4. Successful PTCA stenting distal RCA jailing right PDA Xience (3x18mm) drug eluting stent postdilated 3.25mm balloon. Final angiography demonstrated angiographically apparent dissection, residual stenosis TIMI III flow throughout vessel (See PTCA comments). 5. Successful closure right femoral arteriotomy site Mynx closure device. FINAL DIAGNOSIS: 1. Native three vessel coronary artery disease. 2. Patent LIMA-D1 SVG-LAD grafts. 3. Occluded SVG-OM graft. 4. Moderate biventricular diastolic dysfunction. 5. Moderate pulmonary hypertension. 6. Successful PTCA stenting distal RCA Xience drug eluting stent. 7. Successful closure right femoral arteriotomy site Mynx closure device. . Discharge labs: [**2146-5-14**] 07:41AM BLOOD WBC-8.8 RBC-4.17* Hgb-12.7* Hct-36.9* MCV-89 MCH-30.4 MCHC-34.3 RDW-14.6 Plt Ct-275 [**2146-5-14**] 07:41AM BLOOD Glucose-206* UreaN-31* Creat-1.6* Na-137 K-4.1 Cl-99 HCO3-25 AnGap-17 [**2146-5-14**] 07:41AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.4 Brief Hospital Course: 78 year-old man referred OSH cardiac catheterization secondary persistent shortness breath. # Coronary Artery Disease - Patient known hx CAD, prior CABG, prior stent/PTCA referred cardiac ctah persistent shortness breath. Patient tolerate lying flat procedure due significant history claustrophobia, PTSD anxiety intubated procedure. started heparin, integrillin plavix loaded pre-procedure however developed severe epistaxis intubation integrilin stopped. Cardiac cath showed distal 90% RCA lesion [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] placed. continued aspirin, plavix statin. cath, remained intubated airway protection epistaxis nad admitted CCU closer management. extubated hospital day #2 without complication. . # Chronic systolic heart failure - Ischemic cardiomyopathy, EF 20%. RHC notable elevated RVEDP (16 mm Hg) PCWP (28 mm Hg mean). catheterization diuresed bolus lasix home dose lasix increased 100mg [**Hospital1 **]. continued Inspra, Diovan Toprol. time discharge exam notable lower extremity edema, patient evidence pulmonary edema oxygen requirement instructed continue higher dose lasix could discuss lasix titration cardiologist outpatient. . # Epistaxis - Developed cardiac catheterization ENT consulted. managed Afrin. Estimated blood loss 200cc stabilized without tranfusion. resolved within 24 hours recurrent events. . # Hypertension: continued home [**Hospital1 4319**] Lasix, Diovan, Norvasc, Inspra Toprol good control . # Hyperlipidemia: recent lipid panel. admission tricor statin added regimen. . # Type II Diabetes, Insulin-Dependent: continued home regimen basal-bolus insulin good control. changed amde insulin regimen admission. . # Stage 3 chronic renal failure - Baseline Cr 1.8, received pre-cath hydration mucomyst creatinine remained stable contrast load procedure. . # Depression: Mood stable admission . Patient currently pharmacological treatment depression. Medications Admission: Flonase 50 mcg one spray nostril daily Proventil inhaler two puffs four times daily prn shortness breath wheezing Tricor 145 mg one tab daily Lasix 80 mg twice day (reduced time d/c NVMC prior dose 120 mg [**Hospital1 **]) Aspirin 325 mg one tab daily Imdur 30 mg one tab daily Insulin 70/30 60 units subcutaneous injection breakfast Insulin 50/50 60 unit subcutaneous injection dinnertime Levemir 37 units subcutaneous injection bedtime Diovan 40 mg one tab daily (recently added Dr. [**Last Name (STitle) 11493**] Inspra 25 mg one tab daily Norvasc 2.5 mg one tab daily Toprol XL 200 mg one tab daily (added NVMC) Plavix 75 mg one tab daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every four (4) hours needed shortness breath wheezing. 5. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO day. 7. Insulin NPH & Regular Human 100 unit/mL (50-50) Suspension Sig: Sixty (60) units Subcutaneous twice day. 8. Levemir 100 unit/mL Solution Sig: Thirty Seven (37) units Subcutaneous bedtime. 9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Diovan 40 mg Tablet Sig: One (1) Tablet PO day. Disp:*30 Tablet(s)* Refills:*2* 11. Tricor 145 mg Tablet Sig: One (1) Tablet PO day. 12. Eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times day). Disp:*150 Tablet(s)* Refills:*2* 14. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Coronary Artery Disease Epistaxis Post Traumatic Stress Syndrome Discharge Condition: stable. Discharge Instructions: cardiac catheterization drug eluting stent placed right coronary artery. need take Plavix every day one year. miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] stop taking Plavix unless Dr. [**Last Name (STitle) 11493**] tells to. lifting 10 pounds 1 week. baths pools one week. may shower take dressing groin. procedure intubated breathing machine. nose bleed caused blood thinners needed Afrin sprayed nose stop bleeding. fever antibiotics short time. chest X-ray show pneumonia antibiotics discontinued. Weigh every morning, [**Name8 (MD) 138**] MD weight > 3 lbs 1 day 6 pounds 3 days. Adhere 2 gm sodium diet . Please call Dr. [**Last Name (STitle) 11493**] notice increased trouble breathing, chest pain, nausea, light headedness, increased bruising bleeding groin region, increasing coughs, fevers concerning symptoms. Followup Instructions: Primary Care: ATTAR,[**Female First Name (un) **] Phone: [**Telephone/Fax (1) 24306**] Date/time: please call get home appt [**1-14**] weeks. Cardiology: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:Friday [**6-10**] 1:00pm Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2146-8-5**] 11:20 Completed by:[**2146-5-16**]
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[
"496",
"412"
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