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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]	[ "486" ]
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]	[ "486" ]
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) *]	[ "496", "412" ]
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 ]	[ "486" ]
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]	[ "412" ]
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]	[ "430", "486" ]
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) ] 12ADF 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	[ "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]	[ "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]	[ "496" ]
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.	[ "311" ]
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.)	[ "311" ]
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	[ "486", "412" ]
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.	[ "496" ]
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]	[ "486" ]
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]	[ "570" ]
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]	[ "496", "412", "311" ]
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]	[ "496", "412" ]
Admission Date: [2166-4-30] Discharge Date: [2166-5-9] Date Birth: [2100-7-6] Sex: F Service: MEDICINE Allergies: Amoxicillin / Bactrim / Sulfa (Sulfonamides) / Penicillins Attending:[First Name3 (LF) 613] Chief Complaint: s/p fall Major Surgical Invasive Procedure: None History Present Illness: 65 y.o. female PMHx COPD, esophageal stricture s/p dilatation [Month (only) 404] presents chief complaint falls. Patient reports long history falls, 1 fall day past 3 consecutive days. reports dizziness occasionally prior falls, otherwise denies prodrome chest pain, SOB, palpitations. reports hitting head falls, denies LOC. also recently fell right chest subsequent pain. attributes falls decreased vision (has history cataracts s/p two surgeries right, many years ago) also supposed ambulate walker, always comply. also wears 2 liters oxygen baseline noted occasionally trips oyxgen tubing trying ambulate. thus primarily comes complaint falls, noted cough productive yellow/brown sputum past 2 months subjective fevers (sweats) evaluated. reports grandchildren well gentleman building potential sick contacts, otherwise denies recent travel exposures. report getting flu shot last year receiving pneumovax 2 years ago. . ED, patient noted tachycardic 120s hypoxic 89% RA. improved 96% NRB failed attempt nasal cannula. Patient also noted lactate 3.3 leukocytosis 22.8 bandemia 9%. CXR showed right middle lower lobe infiltrates, concerning PNA given hypoxia, lactic acidosis leukocytosis, patient started Levofloxacin Ceftriaxone. Otherwise, patient noted acute renal failure 0.6 1.3 given 1 L NS. Additionally, potassium 2.4 repleted. EKG performed unremarkable, troponin x 1 elevated 0.05 setting ARF ASA given. Patient asymptomatic otherwise. Lastly, given history recent falls, CT neck head performed without evidence fracture bleed. Patient subsequently admitted ICU management probable pneumonia significant hypoxia bandemia. . Upon arrival ICU, patient NRB, speaking full sentences, acute distress. complained right sided chest pain due fall also endorsed dysuria hematuria. Otherwise, complaints. Past Medical History: #Esophageal stricture s/p dilatation [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] #Peptic ulcer disease s/p subtotal gastrectomy repair hiatal hernia fundoplication [2163-8-19] Dr. [Last Name (STitle) ] nonhealing ulcer #COPD (no PFTs OMR) #GERD #Depression #PTSD #Anemia #Hyperlipidemia #C-section x 2 ('[27], '[28]) Social History: Lives alone [Hospital3 ] [Hospital1 3494] SSI disability. Still continues smoke unquantified amount. denies alcohol illicit drugs. 3 children, estranged them. victim domestic disputes ex-husband, currently lives alone feels safe. Family History: Asthma (children), brother depression PTSD Physical Exam: Vitals: T: 99.0, BP: 141/87, P: 110 R: 24 O2: 94% 4L NC. General: Awake, alert, NAD, speaking full sentences, accessory muscle use. HEENT: NC/AT; pale conjunctiva, PERRLA, EOMI; OP clear, nonerythematous Neck: Supple, JVD Lungs: Decreased BS bilaterally, wheezes, ronchi, crackles CV: RR, normal S1 + S2, [1-24] SM 2RICs radiating, murmurs, rubs, gallops Abdomen: Soft, tender palpation RLQ, rebound guarding, + BS, old midline surgical incision Ext: Warm, well perfused, 2+ pulses, clubbing, cyanosis edema . Neuro: Alert, oriented x 2, attention impaired. Pt. unable cooperate full neurlogical exam. Proprioception appears impaired LLE, upgoing toes b/l. DTRs 3+ patella b/l. Impaired FTN [Doctor First Name ]. Pertinent Results: Labs admission discharge: . [2166-4-30] 05:10PM BLOOD WBC-23.8# RBC-3.35 Hgb-7.9* Hct-25.8* MCV-77# MCH-23.5# MCHC-30.5* RDW-16.9* Plt Ct-548* [2166-4-30] 07:35PM BLOOD Neuts-72* Bands-19* Lymphs-4* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2166-5-7] 07:05AM BLOOD WBC-11.6* RBC-3.00* Hgb-7.7* Hct-23.3* MCV-78* MCH-25.6* MCHC-32.9 RDW-18.3* Plt Ct-431 . [2166-4-30] 05:10PM BLOOD PT-15.8* PTT-33.1 INR(PT)-1.4* . [2166-5-5] 07:50AM BLOOD Ret Aut-0.3* . [2166-4-30] 05:10PM BLOOD Glucose-181* UreaN-31* Creat-1.3* Na-136 K-2.4* Cl-95* HCO3-24 AnGap-19 [2166-5-7] 07:05AM BLOOD Glucose-122* UreaN-3* Creat-0.5 Na-141 K-3.1* Cl-100 HCO3-33* AnGap-11 . [2166-4-30] 05:10PM BLOOD ALT-11 AST-25 CK(CPK)-794* AlkPhos-122* TotBili-0.5 . [2166-4-30] 05:10PM BLOOD cTropnT-0.05* [2166-5-1] 12:00AM BLOOD CK-MB-5 cTropnT-0.05* [2166-5-1] 06:15AM BLOOD CK-MB-6 cTropnT-0.03* . [2166-4-30] 05:10PM BLOOD Calcium-8.7 Phos-2.3# Mg-2.1 Iron-7 [2166-4-30] 05:10PM BLOOD calTIBC-256* Ferritn-160* TRF-197* [2166-5-1] 06:15AM BLOOD Albumin-2.4* Calcium-7.4* Phos-2.6* Mg-2.7* . [2166-4-30] 05:27PM BLOOD Lactate-3.3* [2166-5-1] 01:12AM BLOOD Lactate-1.0 [2166-5-3] 04:48AM BLOOD TSH-0.33 . [2166-4-30] 05:55PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.017 [2166-4-30] 05:55PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2166-4-30] 05:55PM URINE RBC-0-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-1 [2166-4-30] 10:49PM URINE Eos-NEGATIVE [2166-4-30] 10:49PM URINE Hours-RANDOM Na-LESS . [2166-5-6] 04:01AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.009 [2166-5-6] 04:01AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [2166-5-6] 04:01AM URINE RBC-45* WBC-2 Bacteri-NONE Yeast-NONE Epi-0 . Microbiology: . [2166-5-7] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-PENDING INPATIENT [2166-5-7] STOOL CLOSTRIDIUM DIFFICILE TOXIN & B TEST-PENDING INPATIENT [2166-5-6] STOOL CLOSTRIDIUM DIFFICILE TOXIN & B TEST-FINAL INPATIENT [2166-5-6] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2166-5-6] URINE URINE CULTURE-FINAL INPATIENT [2166-5-6] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2166-5-5] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2166-5-5] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2166-5-4] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT . [2166-5-2] URINE Legionella Urinary Antigen - negative . [2166-5-1] BLOOD CULTURE Blood Culture, Routine-no growth [2166-5-1] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-mixed flora . [2166-4-30] URINE URINE CULTURE-mixed flora [2166-4-30] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [2166-4-30] BLOOD CULTURE Blood Culture, Routine-FINAL {STREPTOCOCCUS PNEUMONIAE}; Anaerobic Bottle Gram Stain-FINAL EMERGENCY [Hospital1 ] [2166-4-30] BLOOD CULTURE Blood Culture, Routine-FINAL {STREPTOCOCCUS PNEUMONIAE}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL EMERGENCY [Hospital1 ] . Blood Culture, Routine (Final [2166-5-6]): STREPTOCOCCUS PNEUMONIAE. MEROPENEM = 0.016 MCG/ML = SENSITIVE E-TEST. Penicillin SENSITIVE 0.032 MCG/ML Sensitivity testing performed Etest. CEFTRIAXONE SENSITIVE 0.023 MCG/ML Sensitivity testing performed Etest. Note: treatment meningitis, penicillin G MIC breakpoints <=0.06 ug/ml (S) >=0.12 ug/ml (R). Note: treatment meningitis, ceftriaxone MIC breakpoints <=0.5 ug/ml (S), 1.0 ug/ml (I), >=2.0 ug/ml (R). treatment oral penicillin, MIC break points <=0.06 ug/ml (S), 0.12-1.0 (I) >=2 ug/ml (R). sensitivity testing performed [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed MCG/ML _________________________________________________________ STREPTOCOCCUS PNEUMONIAE \| ERYTHROMYCIN---------- PENICILLIN G---------- TETRACYCLINE---------- TRIMETHOPRIM/SULFA---- VANCOMYCIN------------ . Imaging/studies: . CXR admission: . FINDINGS: Portable upright AP chest radiograph obtained. patchy consolidation right mid lower lung, concerning right middle lower lobe pneumonia. left lung appears essentially clear. Cardiomediastinal silhouette appears grossly unremarkable. pneumothorax. Bony structures appear intact. . IMPRESSION: Findings concerning right middle lower lobe pneumonia. . ECG admission: Sinus tachycardia, rate 118. Low voltage standard leads. Left atrial abnormality. Compared previous tracing [2165-8-28] sinus tachycardia new borderline first degree A-V block. . CT head admission: . NON-CONTRAST HEAD CT: hemorrhage, edema, mass effect, acute large vascular territory infarction. extensive periventricular white matter hypodensity, consistent sequelae small vessel ischemic disease. mild prominence sulci ventricles, likely secondary global parenchymal atrophy. shift normally midline structures. basilar cisterns preserved. Osseous structures surrounding soft tissues, including globes orbits, unremarkable. left lens appears prosthetic. visualized paranasal sinuses mastoid air cells normally pneumatized clear. IMPRESSION: 1. Global parenchymal atrophy sequelae small vessel ischemic disease. 2. hemorrhage, edema, mass effect, acute large vascular territory infarction. . CT neck admission: . IMPRESSION: 1. fracture malalignment. 2. Mild multifocal cervical spondylosis evidence canal stenosis. 3. Biapical pleural scarring. . CT chest [5-1]: . IMPRESSION: 1. Findings consistent multifocal pneumonia without evidence cavitation. Partial right middle left lower lobe atelectasis small bilateral pleural effusions. 2. Boarderline enlarged mediastinal lymph nodes, likely reactive nature. 3. 2.6-cm benign-appearing left adrenal lesion. . CXR [5-2] - . Since yesterday, right mid lower lung opacity increased. Left upper mid lung opacity also increased, worrisome rapidly progressing multifocal pneumonia, could Legionella. Small left pleural effusion also increased. Tiny right pleural effusion unchanged. cardiomediastinal silhouette hilar contours otherwise normal . ECHO [2166-5-5]: . left atrium right atrium normal cavity size. estimated right atrial pressure 0-5 mmHg. Left ventricular wall thickness, cavity size regional/global systolic function normal (LVEF >55%). estimated cardiac index normal (>=2.5L/min/m2). Right ventricular chamber size free wall motion normal. diameters aorta sinus arch levels normal. aortic valve leaflets (?#) appear structurally normal good leaflet excursion. masses vegetations seen aortic valve, cannot fully excluded due suboptimal image quality. mitral valve appears structurally normal trivial mitral regurgitation. mitral valve prolapse. pulmonary artery systolic pressure could determined. pericardial effusion. IMPRESSION: Suboptimal image quality. valvular pathology pathologic flow identified. . CXR [5-5]: IMPRESSION: Right upper right middle lobe pneumonia, significantly changed. Small right pleural effusion. . CT chest [2166-5-6] . IMPRESSION: 1. Consolidation left lung almost completely resolved. 2. Consolidations right middle lobe right upper lobe new areas cavitation present. 3. Unchanged left adrenal lesion. 4. Persistent slight decreased small effusions, greater right side. Brief Hospital Course: 65 y.o. female PMHx significant COPD esophageal stricture, s/p dilatation [Month (only) 404] presents multifocal Streptococcal PNA, sepsis. . Brief ICU course: . diagnosed w/ PNA via CT w/ S. pneumococcal bacteremia ([2-19] BCx [4-30]). started IV CFTX Levaquine. BCx negative since starting CFTx Levofloxacin, persistent WBC count low grade fevers. treated w/ ABx above, last fever noted [5-1] 101F prior transfer floor, low grade 100 fevers since admission. oxygen requirement improved 4L NC RR decreased 18-22. Pt. also noted microcytic anemia unclear etiology, nadir HCT 18, transfused 2 U prbcs since HD stable w/ HCT mid 20s. Finally, patient tachycardic 100s - 110s, sinus rhythm. felt due sepsis. transferred medical floor management. . course complicated worsening WBC fever medical floor RML consolidation developing cavitations, multiple loose stools. Please see detailed discussion problems. . # PNA S.Pneumo Sepsis. Infiltrates felt due CAP resultant bacteremia (strep pneumo). Pt. persistent leukocytosis. aspiration noted Video swallow, however noted penetration thin liquids. continued CFTX floor. However, [5-6], developed Fever, increasing O2 requirement. pancultured CT repeated showing improved L consolidation, slight improvement right new air loculations. Due concern empyema (staph strep), ABx regimen broadened Vancomycin Zosyn treatment HAP Aspiration PNA. Patient remained HD stable. Due wheezing exam, started standing ipratropium albuterol nebulizers. treatment, WBC continued improve, O2 requirement resolved. episode fever [5-6] 101.3F. CT chest obtained showed improved infiltrate L R, newe air loculation. broadened Vanco/Zosyn one day defervesced prior ABx administered. Pulmonary team consulted regardging bronchoscopy, decided face clinical improvement likelyhood cavitation [1-20] Strep Pneumo and/or anaerobes (too short course Staph developed cavitation < 24hrs VAP). switched Cefpodoxime PO Flagyl PO 2 weeks (day 1 = [5-8], pt already received 7 days either CFTX/Levofloxacin Vanc/Zosyn) total course 3 weeks. require follow CXR end 2 weeks (last day [2166-5-22]). PCP follow arranged [5-19]. Please fax summary rehab course notes PCPs office prior discharge. require weaning nebulizers restarting home advair starting tiotropium COPD. . # Leukocytosis: Likely reactive pulmonary infection vs. C.diff. patient loose stools ABx > 5d prior onset diarrhea. Given high grade bacteremia new murmur, TTE obtained show vegetations. first C.Diff negative tx empiricaly PO Vanco given persistently loose stools Age > 65. UA/UCx negative. C.Diff retunred negative x3 PO vanco discontinued [5-8] 2 days tx. started Flagyl above. remained afebrile since [5-5] WBC 11 day discharge. persistent [Last Name (un) 940] stools, lower frequency, 5 -> 3/day. . # Anemia, microcytic. Hct baseline, 29-30. Currently HCT 23-25, admission s/p 2U PRBCs. Pt. hx iron deficiency anemia, confirmed labs [2162]. Previously iron stopped unclear reasons. colonoscopy system, patient history UGI bleed, last EGD unremarkable. Guaiac negative ED. signs hemolysis. Anemia felt multifactorial (ACD, Fe defficiency). Per discussio w/ PCP, [Last Name (NamePattern4) ]. [Doctor First Name 111639], reported colonoscopy revealed 12 cm colitis, showing acute chronic inflammation, ? chronic ischemia. HCT upon discharge 25 stable. require repeat outpatient colonoscopy endoscopy. . # Elevated Troponin: setting renal failure normal EKG asymptomatic. Troponins trended down, CK elevations. Likely due demand. signs HF, EF > 60%, WMA. continued ASA 81mg. . # PTST/Depression: Contact[Name (NI) ] patient's outpatient provider confirmed diagnoses PTSD Depression. Patient actively obtaining treatment OP prior admission. two episodes emotional lability crying spells. attention impaired (felt due delerium setting infection). Patient probably underlying dementia (global parenchymal atrophy periventricular white matter disease CT head), however could evaluated setting delirium. continued Celexa, Quetiapine Duloxetine home doses. ativan temporarily held due delerium restarted 2mg [Hospital1 ]. home dose 2mg [Hospital1 ] 4mg QHS, restarted prn pt remains stable. . # S/P Falls: Appears multifactorial - decreased vision, non-compliance walker, complicated oxygen tubing tripping likely acutely worsened setting impending infection prior admission. CT head c-spine without bleeding fractures. Per PT require acute level rehabilitation. . # Poor nutritional status. Pt. denies poor PO intake, Albumin 2.4. Noted poor PO intake nursing staff CCU. hx esophageal stricture. started Ensure supplementation TID. . # Code: FULL (confirmed patient) . # Communication: Patient currently odds children would prefer communication done SW - [First Name8 (NamePattern2) 51796] [Last Name (NamePattern1) 111640] [Street Address(2) 111641] [Location 17065]. counseling SW reports history domestic violence past. currently feels safe now. allowed staff speak son. Finally, Pt reports process evicted, states want family know. said case manager Elder Services helping deal eviction problem, consented SW calling (Anjale [First Name9 (NamePattern2) 111642] [Hospital1 8] [Hospital1 3494] Elder Services [Telephone/Fax (1) 16681]). Medications Admission: 1. Combivent 2. Citalopram 40 mg PO QD 3. Advair 250-50 mcg [Hospital1 ] 4. Lorazepam 2 mg PO QID 4mg QHS 5. Pantoprazole 40 mg PO BID 6. Quetiapine 300 mg PO QHS 200 mg QPM. 7. Duloxetine 30 mg PO QHS 8. Albuterol PRN 9. Mesalamine (in OMR, patient can't recall still taking) 10. Ondansetron 4 mg PO Q8 PRN 11. Aspirin 325 mg Discharge Medications: 1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk Device Sig: One (1) puff Inhalation [Hospital1 ] (2 times day). 3. Quetiapine 300 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO HS (at bedtime). 4. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QPM needed insomnia. 5. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO HS (at bedtime). 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) needed SOB/wheezing. 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice day. 9. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). 10. Ativan 2 mg Tablet Sig: 1-2 Tablets PO bedtime needed insomnia, anxiety: Hold sedation. 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) needed Pain. 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times day). 14. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) 2 weeks. 15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) 2 weeks. 16. Acetaminophen 500 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6 hours) needed pain. 17. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 18. Outpatient Lab Work CBC, Chem 10 within 1 week discharge hospital 19. Imaging Patient require CXR completion ABx results faxed PCP's office confirm resolution PNA. Discharge Disposition: Extended Care Facility: [Hospital 2251] Nursing Rehab Discharge Diagnosis: Primary: Streptococcal sepsis, multifocal community acquired pneumonia Secondary: COPD, PUD, Esophageal stricture, Anemia, PTSD Discharge Condition: Stable Discharge Instructions: admitted [Hospital1 18] severe pneumonia bacterial blood. treated intravenous antibiotics. treatment breathing improved. transitioned mouth antibiotics. course complicated worsening anemia (low blood cell count) require blood transfusions. transfusions, blood levels remained stable. require outpatient colonoscopy endoscopy. Several changes made medications, please refer list take medications prescribed. outpatient colonoscopy evaluate anemia. PCP GI doctor arrange you. Please call doctor return nearest emergency room for: recurrent nausea/vomiting, dehydration, blood vomit, chest pain, bloody stools, shortness breath, chest pain, abdominal pain, fainting, fevers, chills, cough, concerning symptoms. Followup Instructions: Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1982], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2166-9-22] 12:30 Provider: [Name10 (NameIs) ] [Apartment Address(1) ] (ST-3) GI ROOMS Date/Time:[2166-9-22] 12:30 Please follow psychiatrist, Dr. [First Name (STitle) ] [First Name9 (NamePattern2) 111643] [2168-5-27].30 am, please call confirm appointment, [Telephone/Fax (1) 111644]. Please follow primary care doctor, [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ]-[Doctor First Name ], [2166-5-19] 11.30 am. Please call [Telephone/Fax (1) 14315] confirm appointment. rehabilitation time PCPs appointment, please change acommodate discharge rehabilitation. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2166-5-9]	[ "496" ]
Admission Date: [2198-9-7] Discharge Date: [2198-9-11] Date Birth: [2117-12-20] Sex: F Service: MEDICINE Allergies: Codeine / Penicillins / Erythromycin Base / Morphine Attending:[First Name3 (LF) 800] Chief Complaint: hypotension s/p syncope Major Surgical Invasive Procedure: none History Present Illness: 80 year old woman history COPD, HTN, CRI presents syncope hypotension. reports recent past 5 days whitish phlegm turned green 1 day prior admission. denies fevers, chills night sweats. According patient awoke morning sound someone knocking door phone ringing. went get slid bed floor. denies hitting head losing consciousness. states legs gave her. report legs given 2 times past. denies dizziness, lightheadedness, palpitations. According daughter found concierge home floor vomit urine fall witnessed. denies losing urine recall vomited. EMS called. Initial vitals EMS BP 120/70 O2 sats 95% NRB. . ED, initial vs were: T97.4 HR77 BP71/31 RR20 O2sats 93 4L NC. Patient given 4L NS resuscitation. FAST scan done showing 3.8cm AAA. Given AAA hypotension, vascular surgery consult called. underwent non-contrast CT torso showed LLL infiltrate. Vascular surgery concerned AAA. given 1gm CTX, 750mg Levofloxacin 500mg Flagyl. Blood pressures improved mid-90s started trend down. R femoral CVL placed started Levophed. Lactate 2.2. found acute renal failure creatinine 2.6. Potassium 5.6. WBC 19.1 13% bands. INR noted 4.3. Blood cultures obtained. . arrival ICU complains cough without significant shortness breath. otherwise comfortable without pain. denies nausea, headache, chest pain, dysuria. Pressors weaned, patient transferred floor afebrile. . Review sytems: (+) diarrhea past week. reports diarrhea lifetime. (-) Denies fever, chills, night sweats, recent weight loss gain. Denies headache, sinus tenderness, rhinorrhea congestion. Denied chest pain tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation abdominal pain. recent change bowel bladder habits. dysuria. Denied arthralgias myalgias. Past Medical History: - Pulmonary Embolism [2-25] coumadin - Hypertension - Hypercholesterolemia - Monoclonal gammopathy - COPD - Arthritis - Gastrointestinal ulcers - Gastric esophageal reflux disease - Kidney stones 55 years ago setting pregnancy - Elevated PTH - Chronic renal insufficiency baseline 1.1 1.5 - Abdominal aortic aneurysm measuring 4.2 cm - Possible pons lacune infart noted [1-24] MR [Name13 (STitle) 2853] - Peripheral Neuropathy unclear etiology Social History: patient lives alone. divorced former husband deceased. five children. previously worked laboratory technician [Location (un) 86] State Hospital office manager. 50 pack year smoking history quit greater 25 years ago. drinks [2-17] glasses wine per day. denies use illicit drugs. Family History: patient's mother died myocardial infarction age 60. mother hyperthyroidism. patient's father myocardial infarction age [Age 90 ] benign brain tumor. sister breast cancer. daughter juvenile rheumatoid arthritis. family history gastric disorders kidney stones. Physical Exam: Vitals: T: 98.4 BP: 118/80 P: 81 R: 18 O2: 93% RA General: Alert, oriented, elderly female, acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP flat, LAD Lungs: decreased breath sounds left side, otherwise clear CV: Regular rate rhythm, normal S1 + S2, 2/6 systolic ejection murmur LUSB Abdomen: soft, non-tender, non-distended, bowel sounds present, rebound tenderness guarding, organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis, 1+ peripheral edema bilaterally, former site femoral catheter (now withdrawn) right C/D/I Neuro: A&O x 3, CNII-XII grossly intact. Pertinent Results: Labs admission: [2198-9-7] 07:31PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.015 [2198-9-7] 07:31PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [2198-9-7] 07:31PM URINE RBC-0-2 WBC-[7-26]* BACTERIA-MOD YEAST-NONE EPI-0-2 [2198-9-7] 06:30PM URINE HOURS-RANDOM CREAT-96 SODIUM-27 POTASSIUM-98 CHLORIDE-62 [2198-9-7] 06:30PM URINE OSMOLAL-440 [2198-9-7] 03:51PM K+-5.6* [2198-9-7] 12:42PM LACTATE-2.2* [2198-9-7] 12:20PM GLUCOSE-144* UREA N-49* CREAT-2.6# SODIUM-137 POTASSIUM-7.0 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14 [2198-9-7] 12:20PM estGFR-Using [2198-9-7] 12:20PM ALT(SGPT)-47* AST(SGOT)-69* ALK PHOS-65 TOT BILI-0.3 [2198-9-7] 12:20PM LIPASE-18 [2198-9-7] 12:20PM cTropnT-<0.01 [2198-9-7] 12:20PM ALBUMIN-3.4* [2198-9-7] 12:20PM WBC-19.1# RBC-3.84 HGB-10.9* HCT-33.2* MCV-87 MCH-28.5 MCHC-32.9 RDW-14.7 [2198-9-7] 12:20PM NEUTS-81* BANDS-13* LYMPHS-1* MONOS-4 EOS-0 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [2198-9-7] 12:20PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2198-9-7] 12:20PM PLT SMR-NORMAL PLT COUNT-248 [2198-9-7] 12:20PM PT-40.5* PTT-41.4* INR(PT)-4.3* Discharge: [2198-9-11] 05:15AM BLOOD WBC-9.2 RBC-3.56* Hgb-10.0* Hct-29.9* MCV-84 MCH-28.1 MCHC-33.5 RDW-14.3 Plt Ct-260 [2198-9-11] 05:15AM BLOOD Glucose-103* UreaN-18 Creat-1.0 Na-138 K-4.0 Cl-103 HCO3-29 AnGap-10 [2198-9-11] 05:15AM BLOOD ALT-31 AST-17 [2198-9-11] 05:15AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.4* Radiology: CHEST (PORTABLE AP) Study Date [2198-9-7] 12:18 PM IMPRESSION: Mild central vascular congestion without overt failure. Bibasilar atelectasis. Increased opacity retrocardiac left lower lobe may reflect underlying pneumonia aspiration. Correlate clinically. CT CHEST W/O CONTRAST Study Date [2198-9-7] 12:34 PM LUNG BASES: consolidation ground-glass opacification superior segment left lower lobe, well portions posterior basal segment right lower lobe. CT HEAD W/O CONTRAST Study Date [2198-9-7] 12:33 PM IMPRESSION: acute intracranial process. CT ABDOMEN W/O CONTRAST Study Date [2198-9-7] 12:34 PM IMPRESSION: 1. evidence rupture patient's 3.8-cm abdominal aortic aneurysm. Stability size maintained. 2. Area density within left breast lucent center, may represent intramammary lymph node, fat necrosis, oil cyst. Recommend correlation mammogram. 3. Stable appearance adrenal nodule 5 years, described above. 4. Status post cholecystectomy, stable expected dilatation common bile duct. 5. Diverticulosis evidence diverticulitis. US ABD LIMIT, SINGLE ORGAN PORT Study Date [2198-9-8] 1:54 PM IMPRESSION: Stable common bile duct approximately 9 mm. liver echotexture normal underlying suggestion cirrhosis parenchymal disease. mass lesion identified. intrahepatic biliary dilatation. interval development small right pleural effusion. Known abdominal aortic aneurysm stable size since yesterday. BILAT EXT VEINS US Study Date [2198-9-8] 1:54 PM IMPRESSION: DVT either upper extremity. Brief Hospital Course: 80 year old woman hx PE coumadin, HTN presents syncope, hypotension likely PNA concerning sepsis. . 1. Hypotension: Likely sepsis given chest CT findings PNA, elevated WBC cough. fevers. received 4L NS ED continued appear clinically dry. Volume resuscitation continued MICU along levophed weaned 24 hours. PNA treatment begun ceftriaxone levofloxacin, later switched cefpodoxime levofloaxin, total 8 day course. Patient's blood pressure floor normotensive, although continued hold home medications HCTZ, Amlodipine, Benzepril, discharged instructions follow-up PCP resume medications. . 2. Acute Renal Failure: Prior kidney function 1.2. Patient made good urine throughout hospitalization. creatinine peaked 2.6 trended nadir 1 upon discharge volume resuscitation holding nephrotoxic meds. 3. UTI: [2198-9-7], patient noted UTI urine culture E. Coli, sensitive ceftriaxone. patient treated PNA ceftriaxone levofloxacin, change antibiotic regimen, appropriately cover uncomplicated UTI. . 3. Hyperkalemia: Felt secondary acute renal failure setting taking potassium triamterene benazepril. ECG without peaked waves. Offending meds held hospitalization, held patient follow-up primary care physician. [Name10 (NameIs) ] patient's hyperkalemia improved aggressive IV fluid resusitation, discharge K 4.0. . 4. Syncope: Likely hypotension, hypovolemia. concerning patient lost urine signs seizure activity stay MICU floor. patient monitored tele without event. EEG done. . 5. Elevated INR: Likely due infection coumadin use. signs active bleeding. Would expect INR rise recent antibiotics. Coumadin initially held restarted prior discharge, INR discharge 2.7. . Code: Full (discussed patient) Medications Admission: Hydrochlorothiazide 25 mg Tab PO daily Bisoprolol Fumarate 2.5 mg Tab PO daily Omeprazole 40 mg Cap, Delayed Release 1 tab PO Daily Klor-Con 8 mEq Tab 1 tab PO BID Amlodipine 5 mg Tab 1 tab PO daily Benazepril 40 mg Tab PO daily Multivitamin Tab 1 tab PO daily Triamterene 50 mg PO daily Simvastatin 80mg PO daily Trazadone 100-150mg PO qHS PRN - taken past day perhaps monday, tuesday wednesday Coumadin alternating 1.5mg 2mg week Gabapentin 100mg PO TID Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Sepsis secondary Community Acquired Pneumonia Urinary Tract Infection . Secondary Diagnoses: Hx Pulmonary Embolism Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: admitted ICU low blood pressure setting pneumonia. treated IV fluids antibiotics symptoms improved. complete total 8 days antibiotics, follow-up PCP. . made following changes home medications: -Start Cefpodoxime - continue 6 days end [2198-9-16] -Start Levofloxacin - continue 6 days end [2198-9-16] (this every-other-day medication). -STOP Hydrochlorothiazide, Amlodipine, Benazepril, Triamterene Klor-Con see PCP [Name9 (PRE) 2974]. decide resume medications. -CHANGE Coumadin 1.5 Mg daily week - please INR drawn tomorrow, Wednesday 28th PCP's office. Followup Instructions: Please INR drawn tomorrow PCP's office. appointment see PCP [Name9 (PRE) 2974]: Name: [Last Name (LF) 7726],[First Name3 (LF) 177] A. When: FRIDAY, [2198-9-14]:30 Address: [Street Address(2) 7727],2ND FL, [Location (un) ],[Numeric Identifier 809] Phone: [Telephone/Fax (1) 7728] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 810] MD, [MD Number(3) 811]	[ "486", "496" ]
Admission Date: [2117-7-22] Discharge Date: [2117-7-31] Date Birth: [2036-6-4] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 943] Chief Complaint: nausea, vomiting, abdominal pain Major Surgical Invasive Procedure: EGD Central venous line access History Present Illness: 81 year old female presented outside hospital 3 weeks prior admission nausea, vomiting, diarrhea, abdominal pain. diagnosed cirrhosis unknown etiology; negative hepatitis, hemachromatosis, history alcoholism. symptoms improved discharged. presented [Hospital1 18] similar symptoms. CT scan abdomen demonstrated complete thrombosis SMV partial thrombosis main PV intrahepatic left right portal veins multiple abnormal loops small bowel pelvis wall thickening. Patient started heparin drip. Foley & NGT placed. received vancomycin & Zosyn ED, switched Cipro Flagyl admission ICU. Past Medical History: hypertension cirrhosis osteoarthritis dyslipidemia h/o ureteral stone seborrheic keratosis thrombocytopenia appendectomy herpes zoster GERD osteopenia depression hip replacement cellulitis Social History: denies EtOH, tobacco, illicit drug use. denies herbal over-the-counter medications. Family History: aunt ovarian ca daughter breast ca 50s family history liver disease Physical Exam: per Dr. [Last Name (STitle) ] initial presentation: 98.1 65 145/61 20 98% 4L gen: minimally response CV RRR pulm: CTAB abd: soft, nondistended, mildley tender right rectal: heme pos Pertinent Results: Admission labs: 137 105 15 -------------< 117 3.7 21 0.7 Ca: 9.4 Mg: 1.7 P: 2.6 ALT: 25 AP: 271 Tbili: 2.0 Alb: 3.2 AST: 32 LDH: Dbili: TProt: [Doctor First Name ]: 52 Lip: 54 . 12.9 9.9 >-----< 165 41 N:85.3 Band:0 L:9.7 M:3.7 E:0.9 Bas:0.4 . Trends discharge labs: [2117-7-31] 06:45AM BLOOD WBC-5.7 RBC-3.16* Hgb-10.1* Hct-30.7* MCV-97 MCH-32.0 MCHC-32.9 RDW-16.2* Plt Ct-PND [2117-7-26] 05:06AM BLOOD PT-19.5* PTT-67.8* INR(PT)-1.9* [2117-7-27] 06:00AM BLOOD PT-21.1* PTT-62.3* INR(PT)-2.0* [2117-7-28] 05:21AM BLOOD PT-21.5* PTT-93.3* INR(PT)-2.1* [2117-7-29] 05:03AM BLOOD PT-20.7* PTT-33.5 INR(PT)-2.0* [2117-7-30] 06:15AM BLOOD PT-20.6* PTT-33.0 INR(PT)-2.0* [2117-7-31] 06:45AM BLOOD Glucose-90 UreaN-13 Creat-0.8 Na-134 K-3.4 Cl-98 HCO3-33* AnGap-6* [2117-7-22] 06:05AM BLOOD ALT-25 AST-32 AlkPhos-271* Amylase-52 TotBili-2.0* [2117-7-23] 02:15AM BLOOD ALT-17 AST-26 LD(LDH)-231 AlkPhos-193* Amylase-36 TotBili-0.8 [2117-7-24] 01:57AM BLOOD ALT-17 AST-21 LD(LDH)-202 AlkPhos-171* Amylase-28 TotBili-0.6 [2117-7-25] 05:30AM BLOOD ALT-15 AST-21 LD(LDH)-191 AlkPhos-164* Amylase-27 TotBili-0.7 [2117-7-26] 05:06AM BLOOD ALT-15 AST-25 AlkPhos-159* Amylase-46 TotBili-0.8 [2117-7-27] 06:00AM BLOOD ALT-13 AST-26 LD(LDH)-213 AlkPhos-151* Amylase-45 TotBili-0.8 [2117-7-28] 05:21AM BLOOD ALT-16 AST-31 AlkPhos-156* TotBili-1.0 [2117-7-29] 05:03AM BLOOD ALT-15 AST-34 AlkPhos-179* TotBili-0.8 [2117-7-27] 06:00AM BLOOD Albumin-2.1* Calcium-7.9* Phos-2.8 Mg-2.1 [2117-7-24] 06:21AM BLOOD Lactate-1.4 . CT Abd/Pelvis ([2117-7-22]) IMPRESSION: 1. Complete thrombosis superior mesenteric vein partial thrombosis main portal vein intrahepatic left right portal veins. 2. Multiple abnormal loops small bowel within pelvis wall thickening. likely represents venous congestion thrombosis mesenteric veins. enterocolitis (inflammatory/infectious) secondary thrombosis mesenteric veins also possibility. mesenteric arteries patent; however, mesenteric ischemia venous congestion cannot excluded. 3. Shrunken, nodular liver, esophageal varices ascites, compatible cirrhosis. . CT Abd/Pelvis ([2117-7-27]) IMPRESSION: 1. Stable thrombosis portal vasculature including partial thrombosis main portal vein, complete thrombosis left portal vein, partial thrombosis right portal vein, complete thrombosis superior mesenteric vein. 2. Improving multiple small bowel loops decreased wall thickening dilatation. 3. Stable cirrhotic liver. 4. Markedly increased ascites. . EGD: Impression: Grade 1 varices lower third esophagus Portal Hypertensive Gastropathy - oozing blood causing melena. Otherwise normal EGD second part duodenum Recommendations: Requires: 1) Protonix- 40mg [Hospital1 ] 2) Carafate - 1gram qid . Micro: c diff neg stool cx neg blood cx ngtd Brief Hospital Course: 81yo woman cirrhosis SMV thrombosis. Hospital course problem: . #Complete SMV partial portal vein thrombosis. SMV portal vein thromboses demonstrated CT [7-22] repeated [7-27] showing little change. Hepatobiliary Surgery consulted urgently ED management SMV thrombosis ischemic bowel. Serial abdominal exams benign. Lactate peaked 1.5 [7-22]. episodes melena [7-17], remained otherwise asymptomatic. ICU close monitoring transferred floor [7-25]. NGT removed Coumadin started. [7-26], diet advanced transferred Hepatology management newly diagnosed cirrhosis. continued heparin coumadin INR 2.0 two consecutive days. received coumadin follows: 1mg, 1mg, 1mg, 2mg, 2mg, 2mg discharged 2mg daily. HCT remained stable. followup Dr. [Last Name (STitle) ] liver clinic. [Last Name (STitle) 18303] INR [2-20]. . #GI Bleeding Patient guaiac positive stools underwent EGD assess varices showed active bleeding portal gastropathy thought explain patient's melena. Melena may also come venous congestion small bowel result SMV thrombosis. Repeat CT scan showed resolving venous congestion. HCT dropped 5.5 points 41 34.5 HD0 HD1 30 HD4, remained stable this, without melena. Ms. [Known lastname 73649] spotting red blood pads toilet paper thought causing persistant guaiac positive stools. Exam confirmed presence hemorrhoids also raised possibility vaginal bleeding, investigated outpatient. Colonoscopy deferred given likely friable colon setting thrombosis. BRBPR, recommend checking hematocrit [Known lastname ] >28. less 28, discuss patient's PCP stopping coumadin need eval. terms possible vaginal bleeding, recommend outpt gynecology appt. continued nadolol PPI sucralfate. . #Cirrhosis/Edema/abdominal pain Etiology cirrhosis remains uncertain. Report investigations OSH ruled common viral autoimmune etiologies, genetic causes would unlikely present 81years age. NASH remains possibility, investigated outpatient hepatology follow arranged Ms. [Known lastname 73649]. experienced significant fluid retention ascites lower extremity edema, weight increasing approximately 4kgs. Lasix Aldactone, lower extremity edema improved significantly ascites persistant. Ascites caused intermittent band like upper abdominal pain mostly controlled oxycodone occassionally required 0.5mg dilaudid IV. time discharge, pain controlled oral medications alone. . # HTN: regulated nadolol, spirono, lasix. continue HCTZ . # Depression: sertraline . # Activity: seen PT. able ambulate assist. . # Code: Full . # Contact: daughter [Name (NI) ]: [Telephone/Fax (1) 100371] Medications Admission: lorazepam, Darvocet, Fosamax, HCTZ, MVI, Propoxyphene, ranitidine, sertraline, Zocor Discharge Medications: 1. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times day). Disp:120 Tablet(s) Refills:2 7. Propoxyphene 65 mg Capsule Sig: One (1) Capsule PO every six (6) hours needed pain. 8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) needed Pain 1 weeks. Disp:20 Tablet(s) Refills:0 9. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime): please adjust per recommendations PCP. [Name10 (NameIs) 18303] INR [2-20]. Disp:60 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital3 9475] Care Center - [Location (un) 3146] Discharge Diagnosis: Primary: - SMV thrombosis - Cirrhosis - Portal gastropathy Secondary: - GERD - arthritis - HTN - Hyperchol - thrombocytopenia Discharge Condition: well. Able ambulate assist Discharge Instructions: admitted abdominal pain noted SMV thrombosis. clot vein near liver. also cirrhosis fluid overload. treated ICU stabilized. continued heparin started coumadin keep blood thin. also performed EGD look bleeding stomach. remained stable. . Please take medications instructed. Please keep followup appts. important coumadin level checked Monday followed closely PCP. . Please contact PCP [Name (NI) ] experience worsening shortness breath, chest pain, abdominal pain, fevers, blood loss. . described possible vaginal bleeding. discuss PCP possibly see gynecologist. Followup Instructions: Please followup Dr. [Last Name (STitle) ] Thursday [8-5] 11:30am. office [Telephone/Fax (1) ] . Please followup Dr. [Last Name (STitle) ] [8-24] @ 12:15pm. may reach ([Telephone/Fax (1) 1582].	[ "311" ]
Admission Date: [2165-8-2] Discharge Date: [2165-8-5] Date Birth: [2098-2-18] Sex: Service: MED Allergies: Patient recorded Known Allergies Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: Dark blood G-tube Major Surgical Invasive Procedure: EGD-ulcer distal esophagus active bleeding. s/p clipping vessel good homostasis. History Present Illness: 67 yo h/o CAD, recently admitted [6-21] [7-25] presented severe headache, CT notable large intracranial bleed. Found vertebrobasilar aneurysm, s/p coiling stenting, ventriculostomy. Course complicated L sided PE treated heparin. Hospital course also complicated CHF, failure wean vent, s/p trach, PEG placment. Patient eventually weaned vent end hospitalization. discharge, patient able open eyes stimulation, spontaneous movment R side. Patient discharged [Month/Day (4) ], plavix, heparin gtt. Pt. sent [Hospital3 ]. Came ED [7-26] hypotension , sbp 80s, responded IV boluses, cleared N-[Doctor First Name ] (no change). [8-1], patient noted 50 cc dark blood G-tube rehab. ED, patient afebrile, hr-82, bp-121/64. Dark blood failed clear lavage. GI subsequently consulted. ED, hct-30, INR-2.9. Got vit K 5mg sq, IV protonix, 4 units FFP, 2 large [Last Name (un) ] IVs placed. CXR showing CHF opacities effusions. EKG showing NSR 90 bpm, nl axis, IVCD L bundle pattern, 1-[Street Address(2) 1766] depr V3-6 (old) TWI V3-6, L (old). Past Medical History: -CAD, s/p MI, CABG x 2 '[50] '[62], multiple stents -htn -s/p MV annuloplasty '[62] -s/p AICD -s/p intracranial bleed [5-28], per HPI -mult L sided PEs ([6-28]) -h/o hyponatremia -VRE pos -CHF - [6-28] echo EF 30%, moderate regional LV systolic dysfunction near AK inferior inferolateral walls, sever HK anterolat. wall. Physical Exam: 97.6 BP 121/64 P82 RR30 100% 4LNC Gen: Minimally resonsive, unable follow commands HEENT: NC/AT, PERRL 2mm bilaterally Lungs: +upper airway sounds, crackles, wheezing, good air movement CV: RRR, nl S1, S2, murmurs Abd: Soft, NTND, withdraw deep palpation. +G-tube Ext: edema, clubbing, cyanosis Neuro: responds minimally verbal stimuli, withdraws pain. Pertinent Results: [2165-8-5] 04:49AM BLOOD WBC-9.2 RBC-3.52* Hgb-10.6* Hct-32.2* MCV-92 MCH-30.1 MCHC-32.9 RDW-15.6* Plt Ct-400 [2165-8-4] 04:34PM BLOOD Hct-34.2* [2165-8-3] 11:41PM BLOOD Hct-32.5* [2165-8-3] 04:00AM BLOOD WBC-10.0 RBC-3.51* Hgb-10.6* Hct-31.5* MCV-90 MCH-30.4 MCHC-33.8 RDW-15.6* Plt Ct-379 [2165-8-2] 10:42PM BLOOD Hct-28.3* [2165-8-2] 08:13PM BLOOD Hct-29.2* [2165-8-2] 10:03AM BLOOD Hct-23.7# [2165-8-5] 04:49AM BLOOD PT-14.7 PTT-56.5* INR(PT)-1.4 [2165-8-4] 08:16PM BLOOD PTT-39.1* [2165-8-4] 04:32AM BLOOD PT-14.7* PTT-24.2 INR(PT)-1.4 [2165-8-3] 04:00AM BLOOD PT-15.2* PTT-26.1 INR(PT)-1.5 [2165-8-2] 10:40AM BLOOD PT-16.7* PTT-30.1 INR(PT)-1.8 [2165-8-2] 04:15AM BLOOD PT-20.8* PTT-37.0* INR(PT)-2.9 [2165-8-5] 04:49AM BLOOD Glucose-117* UreaN-22* Creat-0.4* Na-143 K-3.9 Cl-108 HCO3-27 AnGap-12 [2165-8-2] 04:15AM BLOOD Glucose-113* UreaN-26* Creat-0.6 Na-133 K-5.3* Cl-96 HCO3-29 AnGap-13 [2165-8-4] 04:32AM BLOOD ALT-28 AST-30 AlkPhos-124* [2165-8-3] 06:45PM BLOOD CK-MB-3 cTropnT-0.07* [2165-8-2] 10:43PM BLOOD CK-MB-4 cTropnT-0.05* [2165-8-2] 04:00PM BLOOD CK-MB-3 cTropnT-<0.01 Brief Hospital Course: 1)Upper GI bleed: Patient coumadin recent hx PE received 4 units FFP vit K EW correct INR. Coumadin held intinitally possible active bleed. GI consulted EGD done [2165-8-2] showed ulcer distal esophagus active bleeding site. Successful clipping vessel achieved using Resolution Endoclip device injected epinephrine hemostasis. Patient received total 3 units PRBC. Patient continued PPI prophylaxis serial hematocrit done remained stable (Hct>30). 2)Neuro: Patient hx intracranial bleed s/p basilar stent. Patient Plavix [Date Range ] post-stent prophylaxis. Patient remained lethargic baseline. able follow simple commands times, moving hands feet occasionally giving verbal response. Per family member, patient appears alert before. Neurosurgery following patient strongly urged hold Coumadin risk re-bleeding intracranially. discussion Dr. [Last Name (STitle) 1132] neurosurgery, decided discharge patient Lovenox. 3)A-fib: EGD proceduse, clipping bleeding vessel done epinephrine injected site. Right epinephrine injected, went rapid afib 150's ST depressions. given total 10 mg lopressor decrease HR 120's-130's. 10 mg IV diltiazem, HR came 90's-100's BP dropped 80's briefly. MI ruled serial cardiac enzymes given 25 mg lopressor. Patient remained sinus tachycardia, lopressor titrated 50 mg tid. Patient show good response IV diltiazem 10 mg. 4)PE prophylaxis: Patient initially Coumadin 12.5 mg qd Dalteparin 7500 units [Hospital1 ], held due GI bleed INR 2.9 PTT 37. Neurosurgery seen patient strongly discouraged discontinuing Coumadin due recent history intracranial bleed. However, patient PE risk another thrombotic event. discussion neurosrugery attending Dr. [Last Name (STitle) 1132], decided discharge patient Lovenox. 5)ID: [8-4] sputum gram stain showed gram positive cooci rhonchi exam. CXR intially appeared LLL opacity Vancomycin 1 g q12 started. However reviewing film team [2165-8-5], CXR consistent fluid overload effusion consolidation. Since patient afebrile normal WBC showing symptom pneumonia, Vancomycin discontinued. Medications Admission: protonix 40 qd, senna 2 [Hospital1 ], epo [2161] units q Tu/Sat, amantidine 100 [Hospital1 ], coumadin 12.5 [Last Name (LF) ], [First Name3 (LF) ] 325 qd, lopresor 25 [Hospital1 ], dalteparin 7500 units [Hospital1 ] Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once day). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once day). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times day). 4. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous Q12H (every 12 hours). 5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice day. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Esophageal bleed Atrial fib Intracranial bleed s/p stent vertebrobasilar aneurysm Hx pulmonary embolism CAD CHF Discharge Condition: Hemodynamically stable, active bleeding. Discharge Instructions: Patient needs seek medical attention (ED, PCP), bloody vomit, bloody stool, blood G-tube, dyspnea, chest pain, new neurological deficit, fever/chills. Followup Instructions: Patient needs seen PCP soon possible appointment neurosurgery following date. Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) ], MD Where: LM [Hospital Unit Name 12006] Phone:[Telephone/Fax (1) 3666] Date/Time:[2165-8-9] 2:30 [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292] Completed by:[2165-8-5]	[ "412" ]
Admission Date: [2103-7-24] Discharge Date: [2103-7-26] Service: CHIEF COMPLAINT: patient 78 year old female past medical history significant obstructive sleep apnea, pulmonary hypertension, chronic hypercapnic hypoxemic respiratory failure, presented worsening shortness breath decreased oxygen saturation. HISTORY PRESENT ILLNESS: patient 78 year old woman history long-standing obstructive sleep apnea subsequent pulmonary hypertension. Two days prior admission, patient reported experiencing gradual worsening shortness breath. morning admission, patient's daughter found patient severely short breath, cyanotic called EMS. EMS arrived, patient noted room air oxygen saturation 60% range noted tachypneic respiratory rate 40s. Upon arrival [Hospital1 69] Emergency Department, patient noted cyanotic vital signs showed heart rate 85, blood pressure 175/77, respiratory rate 32, saturating 97% 100% nonrebreather face mask. denied chest pain time Emergency Department presentation. denied [Last Name (LF) ], [First Name3 (LF) 691] fever chills. denied nausea vomiting. abdominal pain. denied urinary symptoms, denied symptoms paroxysmal nocturnal dyspnea. patient placed full face mask BIPAP admitted Medical Intensive Care Unit monitoring respiratory status. PAST MEDICAL HISTORY: 1. Obstructive sleep apnea. diagnosed least five years prior time admission sleep studies performed [2098-2-17], showed 43 hypopneas oxygen saturation 70s. data records provided patient's primary pulmonologist, Dr. [Last Name (STitle) 10132], [Hospital3 ] Medical Center. home, patient wore CPAP four six hours every night received oxygen via nasal cannula rate 2 2.5 liters per minute day. 2. Chronic hypercapnic hypoxemic respiratory failure. patient room air oximetry studies performed [2102-7-21], outpatient hospital showed spent approximately 63% time oxygen saturation 90s, 24% time oxygen saturation 80s 5% time oxygen saturation 70s. 3. Restrictive lung disease. 4. Pulmonary hypertension. 5. Hypertension. 6. Coronary artery disease, status post coronary artery catheterization [2097-10-18], showed clean coronary arteries. 7. Status post inferior myocardial infarction approximately fifteen years ago. 8. Inguinal hernia. 9. Chronic anemia thought due Vitamin B12 deficiency. MEDICATIONS ADMISSION: 1. Lasix 40 mg q.d. 2. Atenolol 25 mg day. 3. Nitroglycerin patch 0.4 mg transdermal patch applied day. 4. Carvedilol 3.125 mg day. 5. Allopurinol. ALLERGIES: Reported allergies Penicillin Streptomycin. FAMILY HISTORY: assessed. SOCIAL HISTORY: patient Russian speaking woman come United States [Country 532] eight years ago. lives alone [Location (un) 86] area two daughters lived nearby. history tobacco use history exposure asbestos known industrial agents. PHYSICAL EXAMINATION: examined patient, vital signs revealed heart rate 48, blood pressure 89/48, respiratory rate 26, oxygen saturation 92% BIPAP face mask pressure support 15, PEEP 5 FIO2 40%. noted awake, alert able respond questions help translation. skin examination notable pallor cyanosis. Examination jugular venous distention revealed jugular venous pulse 9.0 centimeters. chest examination showed diffusely decreased breath sounds, decreased left side right side, however, wheezes crackles noted. cardiac examination revealed bradycardic heart rate regular rhythm harsh IV/VI systolic murmur heard across precordium, occasional S3 rubs. abdominal examination revealed normoactive bowel sounds, obese soft abdomen, nontender. costovertebral angle tenderness. Examination extremities showed dorsalis pedis pulses 1+ bilaterally. extremities warm. 1+ bilateral lower extremity edema. also noted bilateral calf tenderness. LABORATORY DATA: admission, sodium 142, initial potassium 7.0 hemolyzed specimen repeat potassium 4.9, chloride 96, bicarbonate 37, blood urea nitrogen 23, creatinine 0.8, glucose 151. complete blood count revealed white blood cell count 6.9, hematocrit 37.5, platelet count 357,000. white blood cell count differential included 72% polys, 20 lymphocytes 7 monocytes. coagulation panel showed prothrombin time 13.0, partial thromboplastin time 29.1 INR 1.2. Initial CK level 65. Electrocardiogram showed normal sinus rhythm rate 78 beats per minute right axis deviation right bundle branch block unchanged previous electrocardiogram provided outside hospital. chest x-ray showed opacification right mediastinal border prominent pulmonary vasculature focal consolidation. HOSPITAL COURSE: Emergency Department, initial arterial blood gas performed patient 100% nonrebreather face mask. blood gas revealed pH 7.19, pCO2 122, pO2 150. patient placed face mask 50% FIO2, repeat blood gas showed pH 7.13, pCO2 137, pO2 132. patient given single dose Levofloxacin Emergency Department treat community acquired pneumonia. also given intravenous Solu-Medrol treat underlying bronchospastic component contributing pulmonary decompensation. given 1 mg Morphine Sulfate also Nitroglycerin paste Emergency Department. time Emergency Department presentation, patient reported DNR/DNI code status. Therefore, intubation attempted patient. Instead, full face mask preferred method oxygen delivery admitted Medical Intensive Care Unit monitoring oxygenation ventilatory status. evening admission, ultrasound studies lower extremities performed revealed evidence deep vein thrombosis. patient also diuresed Lasix, received total 100 mg intravenous Lasix Emergency Department additional 40 mg Lasix admission Intensive Care Unit. produced net diuresis negative two liters evening admission. antibiotics held time patient afebrile elevated white blood cell count low clinical suspicion pneumonia. steroids also held. Overnight, patient's oxygenation ventilatory status improved somewhat based repeat arterial blood gas analysis. placed nasal CPAP overnight. subsequently ruled myocardial infarction via cardiac enzymes. [2103-7-25], hospital day two, echocardiogram obtained order assess possible role diastolic congestive heart failure contributing pulmonary edema patient's shortness breath. Following echocardiogram performed bedside, patient experienced desaturation oxygen saturation noted 30 40% range. patient noted profoundly cyanotic also began report left sided chest pain. electrocardiogram obtained showed changes suggestive acute ischemia. Stat portable chest x-ray also showed acute change prior chest x-rays. time desaturation event, patient nasal CPAP ultimately placed full face mask BIPAP, patient's oxygen saturation returned 80% range. echocardiogram ultimately showed ejection fraction greater 55%, mild symmetric left ventricular hypertrophy. left atrium right atrium noted dilated. overall decrease right heart function severe pulmonary artery systolic hypertension. Although previously obtained lower extremity ultrasounds revealed deep vein thrombosis, continued entertain diagnosis pulmonary embolism. time Emergency Department presentation, patient unable lie flat without becoming profoundly short breath. Therefore, unable send patient CT angiogram study prove presence pulmonary embolism. However, desaturation event, decision made empirically anticoagulate patient Heparin. Levofloxacin also restarted treat presumptive pneumonia. day initial blood culture taken Emergency Department returned positive gram positive cocci pairs clusters one two bottles patient begun Vancomycin. patient subsequently remained stable respiratory standpoint noted intermittent bradycardia heart rates 30 40s transient associated hypotension. Atropine placed patient's bedside. morning [2103-7-26], patient restarted Solu-Medrol treat possible underlying component bronchospastic disease decision made obtain bedside abdominal ultrasound evaluate question pleural effusion right lung base seen serial chest x-rays. However, ultrasound could obtained, patient experienced another desaturation event early afternoon [2103-7-26]. accompanied bradycardia eventually cardiopulmonary arrest patient ultimately succumbed declared deceased afternoon [2103-7-26]. DR.[Last Name (STitle) ],[First Name3 (LF) ] R. 12-207 Dictated By:[Doctor Last Name 35468] MEDQUIST36 D: [2103-7-27] 14:50 T: [2103-7-30] 17:13 JOB#: [Job Number 35469]	[ "486", "496" ]
Admission Date: [2109-7-21] Discharge Date: [2109-8-13] Date Birth: [2053-6-5] Sex: F Service: [Doctor Last Name 1181] MEDICINE HISTORY PRESENT ILLNESS: 56-year-old white female history right frontal craniotomy [2109-7-1], dysembryoplastic angioneural epithelial lesion features oligodendroglioma started Dilantin postoperatively seizure prophylaxis subsequently developed eye discharge seen optometrist treated sulfate ophthalmic drops. patient developed oral sores rash chest night admission rapidly spread face, trunk, upper extremities within last 24 hours. patient unable eat secondary mouth pain. fevers, weakness, diarrhea. genital morning [7-20]. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Benign right frontal cystic tumor status post right frontal craniotomy [2109-7-1]. ALLERGIES: KNOWN DRUG ALLERGIES. MEDICATIONS: Lipitor, Tylenol Codeine, Dilantin, previously Decadron q.i.d. tapered one week discontinued week ago. SOCIAL HISTORY: patient lives husband, daughter, son. [Name (NI) ] smoking ethanol use history. PHYSICAL EXAMINATION: Vital signs: T-max 104.3??????, currently 100.8??????, heart rate 107-110, blood pressure 110/27, respirations 15-20, oxygen saturation 98% room air. General: patient alert, ill-appearing woman postsurgical occiput. Head neck: Injected conjunctivae, greenish ocular discharge, ulcerative oral lesions. Cardiovascular: Regular rhythm. Rapid rate. murmurs. Pulmonary: Clear auscultation bilaterally. Abdomen: Normoactive bowel sounds. Soft, nontender, nondistended. Extremities: edema. Skin: Diffuse erythema pustules face. Patulous pustules chest, back, proximal upper extremities. GU: genital lesions. LABORATORY DATA: Hematocrit 34.1, WBC 10.3, platelet count 291,000, differential 87 neutrophils, 0 bands; sodium 133, potassium 3.8, chloride 93, CO2 21, BUN 17, creatinine 0.9, glucose 121; ALT 39, AST 42, LDH 434, amylase 63, albumin 3.4, total bilirubin 0.3; urinalysis positive ketones, negative nitrites; urine culture pending; blood cultures times two pending; conjunctival culture pending. HOSPITAL COURSE: Given patient's severe exfoliative skin involvement rapid progression extensive involvement body, admitted Medical Intensive Care Unit close monitoring. started prophylactic Oxacillin cover skin flora, Dermatology consulted along Neurology Ophthalmology ophthalmic involvement. patient's course Intensive Care Unit uneventful, discharged floor close monitoring included q.1 hour Pred Forte application eye close consultation Ophthalmology. regard skin lesions, continued exfoliate next couple days, skin care included frequent Vaseline hydrated petroleum application decrease insensible losses. patient's intake output closely monitored replaced appropriately; however, intensive nursing care requirement made difficult patient receive adequate floor, therefore, transferred Medical Intensive Care Unit frequent ophthalmic applications skin care. MICU, patient continued meticulous skin care eye care. skin lesions continued desquamate exfoliate natural progression disease. began involvement genital area continued desquamation exfoliative lesions. course Intensive Care Unit within next 8-10 days slow gradual improvement dermatologic ophthalmologic standpoint. cardiovascular standpoint, sinus tachycardia felt secondary [Doctor Last Name ]-[Location (un) ] syndrome leading dehydration insensible fluid losses. Intensive Care Unit, also found mildly hypoxic likely secondary atelectasis patient's immobility. Lower extremity Dopplers also done, deep venous thromboses found. Infectious Disease standpoint, patient started intravenous Oxacillin empirically. Blood cultures 5th growth times two; however, one bottle PICC line grew gram-positive cocci [7-27]. started course Vancomycin. Subsequently organism found CNS Corynebacterium, Vancomycin discontinued prior transfer floor [8-5]. patient's course floor uncomplicated continued improvement. Dermatology: patient, indicated, improved dramatically presentation time discharge. exfoliative lesions healed course admission. skin care requirements decreased Petroleum jelly twice day time discharge. able take oral foot without problems. Ophthalmology: patient's eye care requirement improved markedly. able open eyes use vision without significant problems time discharge. Pred Forte discontinued day discharge, follow-up Ophthalmology couple days discharge. Fluid, electrolytes, nutrition: admission patient begun TPN nutritional support. patient improved medical perspective, TPN weaned, time discharge, patient taking adequate p.o. supplementation Boost. Infectious Disease: time admission, started empiric antibiotics placed contact precautions secondary extensive skin lesions; however, patient improved throughout course admission, contact precautions discontinued, patient discharged home services. Cardiology/Pulmonology: patient tachycardiac throughout admission attributed fluid losses secondary [Doctor Last Name ]-[Location (un) ] syndrome; however, given patient's immobility throughout course admission, CT angiogram performed evaluate possible pulmonary embolism, none found. Neurology: patient history cystic tumor status post resection [Month (only) 205] year started prophylactic Dilantin leading presumed [Doctor Last Name ]-[Location (un) ] syndrome. time admission, patient's Dilantin discontinued, anticonvulsants started, given patient's risk seizures several weeks surgery unlikely. decision made support neurosurgeon, Dr. [Last Name (STitle) ] [Last Name (NamePattern4) 1338]. Five days discharge, patient syncopal event bathroom showering help nursing aide. likely etiology orthostatic hypotension fluid losses; however, given patient's neurologic history, Neurology consulted evaluate possible seizure. Neurology's recommendations obtain repeat CT scan unchanged previous showing right frontal lobe extra-axial hypodensity stable. also recommended repeat MR imaging unremarkable except stable extra-axial lesion noted CT scan. Neurology therefore agrees primary team syncopal event likely secondary vasovagal reaction. follow-up MR scan would recommended gadolinium evaluate presence residual tumor. done outpatient Dr. [Last Name (STitle) 1338]. Rehabilitation: patient throughout admission worked physical therapy people continued improve regard range motion strength upper lower extremities, time discharge, ambulating throughout [Doctor Last Name ] around hospital without problems. therefore discharged home without need Physical Therapy Services. time discharge, patient markedly improved initial presentation discharged home nursing assistance. DISCHARGE STATUS: Markedly improved. DISCHARGE DIAGNOSIS: 1. [Doctor Last Name ]-[Location (un) ] syndrome secondary Dilantin. 2. Status post craniotomy [2109-7-1], cystic cranial lesion, likely dysembryoplastic angioneural epithelial lesion features consistent oligodendroglioma. DISCHARGE MEDICATIONS: Polysporin ophthalmology O.U. q.i.d., hydrated Petroleum needed, Lipitor 10 mg p.o. q.d., Nystatin, Boost t.i.d. FOLLOW-UP: 1. Ophthalmology [2109-8-20], 12:45 p.m. 2. Primary care physician two weeks. 3. Dermatology needed. DISCHARGE NOTE: PLEASE NOTE PATIENT ALLERGIC DILANTIN TEGRETOL GIVEN [Doctor Last Name ]-[Location (un) ] SECONDARY DILANTIN. patient recommended wear alert bracelet indicates reaction. [Name6 (MD) 2415] [Last Name (NamePattern4) 3474], M.D. [MD Number(1) 3475] Dictated By:[Last Name (NamePattern4) 40425] MEDQUIST36 D: [2109-9-3] 12:59 T: [2109-9-3] 12:58 JOB#: [Job Number 99931] [Name6 (MD) ] [Name8 (MD) ], M.D.(cclist)	[ "311" ]
Admission Date: [2144-3-7] Discharge Date: [2144-3-16] Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 2145] Chief Complaint: transfer OSH [State 108] R hip fx. Major Surgical Invasive Procedure: R hip ORIF History Present Illness: HPI: [Age 90 ]F hx dementia, CAD, CHF EF 40%, chronic afib, lives 24 hour caretaker. brought OSH neck pain inability hold head well confusion, found transverse C2 dens fracture, immobilized [Location (un) 5622] collar. Pt fell 3 weeks prior admission, home aide stated injuries fall. Noted CHF exacerbation --> resolving diuresis reportedly stable [3-20] liters NC (uses O2 home). In-house OSH, fall unfortunately suffered right intertrochanteric fracture. Pt family [Hospital1 1559] pt med flighted [State 108] [Hospital1 18]. Family connection [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. Reportedly, C2 fracture stable surgeons wanted immobilize hip could addressed. . Pt cardiology consult [State 108], CHF exacerbation BNP 15,000. Toprol XL increased 37.5 50 mg PO qd plan increase 100 mg po QD. started digoixin. lasix increased. . note, transfer paperwork notes pt seen PCP [Name9 (PRE) 108] exertional CP SOB relieved NTG [Month (only) 1096] [2143]. time Imdur increased 30 60 mg PO qd. . hospitalization increasingly agitated started Risperdal, recently d/c'd became increasingly confused. . Labs OSH: [3-6]: INR 1.1, Na 146, K 3.8, Cl 106, HCO3 33, BUN 29, Cr 1.0, Ca 8.7 Dig 1.0, [3-2] Blood Cx: NGTD . Studies: [3-2] EKG: afib 98bpm RAD, LVH, QTc 526, bad baseline [3-4] CT Head mod-severe atrophy, bleed [3-5] R hip/pelvis, comminuted fx R hip [3-5] CT cervical spine: transverse fx base dens. displacement. Transverse lucency spinous process C3 (chronic) Transverse lucency spinous process C3 (chronic). [3-3] CXR: Mild CHF, patchy infiltrate base right lung, small bilateral pleural effusions. . Past Medical History: PMH: CHF EF 40%, [2-20] echo: inf hypokinesis CAD, hx MI, s/p PCI LAD, LCx RCA stents [2136] [Hospital1 ] afib hypercholesterolemia COPD HTN severe ([2-20] echo 59 mmHg peak gradient, valve area 0.6 cmsq) mod-severe MR mild MS [First Name (Titles) ] [Last Name (Titles) ] Dementia (Mild Alzheimer's vs vascular) per transfer paperwork, however pt's family states hospitalization pt living independently live help. Hiatal hernia s/p repair hx GIB AVM associated elevated INR [4-18] s/p ccy s/p TAH macular degeneration kyphoscoliosis DJD/OA Social History: Social Hx: widowed, 4 children. Lived independently 24 hour aides. EtOH tob. Transferring physician: [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) 24606] [Last Name (NamePattern1) 79] cell [Telephone/Fax (1) 65356] (is on-call weekend) [Hospital 32303] Medical Center [Hospital 65357], [State 108] [Telephone/Fax (1) 65358]. [Name (NI) ] son: [Name (NI) ] [Name (NI) 122] [Telephone/Fax (1) 65359] HCP, lives [Name (NI) 108] coming [3-7]. Pts daughter ([Name (NI) 19948] [Last Name (NamePattern1) ]) lives [Name (NI) 1559] phone number [Telephone/Fax (1) 65360]. . [Hospital1 1559] PCP: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1683] ([Hospital1 ]) [Hospital1 1559] Cardiologist: Dr. [Last Name (STitle) 65361] ([Hospital1 ]) Physical Exam: PE: VS: 98.6 HR 64 R 20 BP 88/54 95%2L Gen: NAD, laying bed Aspen collar HEENT: slight droop L eyelid, PERRL, MMM, O/P clear Neck: Aspen collar Chest: crackles bases, clear apices CV: [Last Name (un) 3526] [Last Name (un) 3526] rate rhythm, 3/6 SEM RUSB rad carotids, 3/6 systolic murmur apex Abd: soft, NT, ND +BS Ext: pain palpation R hip, lim ROM. edema, 2+ DP pulses bilaterally Neuro: alert, oriented person only, moves 4. Brief Hospital Course: [Age 90 ] yo F h/o dementia, CAD, diastolic CHF (EF 55%), severe AS, chronic afib, transferred OSH R hip fracture possible C2 fracture operative management hip. stable floor initial arrival. Given CHF AS, high risk surgical candidate, family decided go ahead operation. Postoperatively MICU briefly hypotension extubated without difficulty, weaned pressors rehydration transferred back floor. Perioperatively, developed UTI LIJ clot, treated. Postoperatively, also developed delirium, less verbal previously. failed speech swallow evaluation, medical team optomistic would improve. meantime, multiple attempts NGT placement unsuccessful. floor, [3-14]-30, patient showed signs inability clear secretions. [3-15], episode hypoxia. CXR time revealed fluid overload, seemed improve lasix. Overnight night, 1/2 blood culture bottles positive S.aureus Vancomycin started. [3-16], continued poorly, hypoxic. CXR time revealed dry lungs, likely aspiriation PNA LUL. Despite aggressive suctioning broadening antibiotic coverage, Mrs. [Known lastname 65362] continued deteriorate ultimately died approx 4:25 PM [3-16]. . # COde - DNR/DNI verified son HCP. . # Communication: son [Name (NI) ] [Name (NI) 122] [Telephone/Fax (1) 65359] (HCP; daughter ([Name (NI) 19948] [Name (NI) ] [Telephone/Fax (1) 65360]). [Hospital1 1559] PCP: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1683] ([Hospital1 ]); [Hospital1 1559] Cardiologist: Dr. [Last Name (STitle) 65361] ([Hospital1 ]). Previously [Hospital 32303] Medical Center [Last Name (LF) 65357], [First Name3 (LF) 108] [Telephone/Fax (1) 65358]. . Medications Admission: Meds transfer: Lipitor 40 mg PO qd Digoxin 0.125 mg qD Lasix 80 mg IV BID Atrovent neb QID Imdur 30 mg PO qd Levalbuterol neb QID Losartan 12.5 mg PO BID Toprol XL 50 mg PO qd coumadin 2 mg PO alternating 3 mg PO qd (held) Tylenol prn Discharge Disposition: Expired Discharge Diagnosis: Hip fracture s/p ORIF LIJ clot UTI Aspiration PNA Perioperative delirium Discharge Condition: Death Discharge Instructions: None. Followup Instructions: None. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2158]	[ "496" ]
Admission Date: [2179-3-5] Discharge Date: [2179-3-24] Date Birth: [2105-3-13] Sex: F Service: MEDICINE Allergies: Benzodiazepines Attending:[First Name3 (LF) 3984] Chief Complaint: shortness breath, red hands feet Major Surgical Invasive Procedure: endotracheal intubation, mechanical ventilation, right IJ central line placed, tracheostomy tube placed History Present Illness: Ms. [Known lastname 94714] 73yo woman h/o ALS presents 3 weeks redness hands feet well recent difficulty breathing. patient complained dyspnea husband noted tachypnea respiratory distress per husband went doctor today, noted "not breathing well" sent ER hypoxic 80s, responding well O2 NC. found ABG 7.19/126/525/51 started Bipap. tolerate non-invasive mask ventilation despite sedateion (versed 2mg, fentanyl 100mg). experienced reduction blood pressure 66/30, subsequently intubated. Per husband, patient ALS three years. performs ADLs trouble speech well keeping mouth closed baseline. respiratory complaints. previously lost 40 pounds last year given Gtube since gained back 14 pounds. [Name (NI) 1094] husband states prior last 3 weeks USOH, denies new symptoms including cough, sputum, sick contacts. entirely NPO year. CXR ER showed acute CP process UA negative signs infection. Per pt's husband never sort conversation regarding code status. patinet try bipap past unable tolerate it, outpatient neurologist never mentioned intubation tracheostomy. Mr. [Known lastname 94714] states new thoughts he's entirely certain wife would want point. transferred [Hospital Unit Name 153], started AC 450x16, 100% FiO2, PEEP 5. ABG setting 7.40/57/426/37 FiO2 turned 50%. Past Medical History: - ALS diagnosed 3y ago - Gtube tube feeds, difficulty speech - hypercholesterolemia -?depression Social History: lives home husband, three children two live west coast one lives [Location ]. never used tobacco, drink alcohol, drugs. Works writer. baseline performs ADLs, writes, uses internet chat grandchildren. Family History: father MI age 52, mother deceased age [Age 90 ] Physical Exam: 96.7, 78, 112/64, 16, 100% AC settings Gen: sedated, unresponsive, intubated HEENT: PERRL, NCAT Cor: s1s2, RRR, r/g/m Pulm: CTAB Abd: soft, NT, ND, +BS, Gtube c/d/i Ext; c/c/e, bilateral toes skin changes c/w venous stasis, bilateral fingers erythematous dry excoriated skin Neuro: babinski upgoing bilaterally, myoclonus BLE, hyperreflexic B patellar, biceps Pertinent Results: arrival Na 126, CK 273-->115, MB 14-->10, trop <0.01--> <0.01, bicarb 40, UA negative [2179-3-23] 02:44AM BLOOD WBC-10.0 RBC-2.88* Hgb-9.4* Hct-27.6* MCV-96 MCH-32.7* MCHC-34.1 RDW-13.5 Plt Ct-316 [2179-3-23] 02:44AM BLOOD Neuts-78.7* Bands-0 Lymphs-15.8* Monos-3.6 Eos-1.6 Baso-0.3 [2179-3-22] 04:15AM BLOOD PT-11.7 PTT-22.6 INR(PT)-1.0 [2179-3-23] 02:44AM BLOOD Glucose-127* UreaN-24* Creat-1.3* Na-145 K-4.5 Cl-107 HCO3-31 AnGap-12 [2179-3-19] 05:54AM BLOOD ALT-49* AST-44* LD(LDH)-267* AlkPhos-142* Amylase-41 TotBili-0.3 [2179-3-19] 05:54AM BLOOD Lipase-30 [2179-3-5] 02:50PM BLOOD CK-MB-14* MB Indx-5.1 cTropnT-<0.01 [2179-3-5] 10:15PM BLOOD CK-MB-10 MB Indx-8.7* cTropnT-0.01 [2179-3-23] 02:44AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.4 [2179-3-19] 05:54AM BLOOD TSH-3.0 [2179-3-18] 11:55AM BLOOD Cortsol-23.9* [2179-3-18] 12:51PM BLOOD Cortsol-43.3* [2179-3-18] 01:48PM BLOOD Cortsol-51.1* [2179-3-22] 04:11PM BLOOD Type-ART pO2-136* pCO2-50* pH-7.45 calHCO3-36* Base XS-9 [2179-3-22] 04:11PM BLOOD Lactate-1.2 . [2179-3-12] 10:57 pm BLOOD CULTURE LT PIV. FINAL REPORT [2179-3-18] AEROBIC BOTTLE (Final [2179-3-15]): REPORTED PHONE [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [2179-3-13] @ 2:35 PM. STAPH AUREUS COAG +. FINAL SENSITIVITIES. Oxacillin RESISTANT Staphylococci MUST reported also RESISTANT penicillins, cephalosporins, carbacephems, carbapenems, beta-lactamase inhibitor combinations. Rifampin used alone therapy. SENSITIVITIES: MIC expressed MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 TETRACYCLINE---------- <=1 VANCOMYCIN------------ <=1 ANAEROBIC BOTTLE (Final [2179-3-18]): GROWTH. . [2179-3-13] 12:20 SPUTUM Source: Endotracheal. FINAL REPORT [2179-3-15] GRAM STAIN (Final [2179-3-13]): >25 PMNs <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. PAIRS CLUSTERS. RESPIRATORY CULTURE (Final [2179-3-15]): SPARSE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST reported also RESISTANT penicillins, cephalosporins, carbacephems, carbapenems, beta-lactamase inhibitor combinations Rifampin used alone therapy. SENSITIVITIES: MIC expressed MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 TETRACYCLINE---------- <=1 VANCOMYCIN------------ <=1 . [3-15] ECHO: 1.The left atrium normal size. 2.There mild symmetric left ventricular hypertrophy. left ventricular cavity size normal. Regional left ventricular wall motion normal. Overall left ventricular systolic function normal (LVEF>55%). 3. Right ventricular chamber size normal. 4.The aortic valve leaflets (3) appear structurally normal good leaflet excursion. aortic regurgitation seen. 5.The mitral valve leaflets mildly thickened. mitral regurgitation seen. 6.There pericardial effusion. . [2179-3-5] EKG: Sinus rhythm. Slight ST segment elevation leads II, III aVF may represent active inferior ischemic process. Followup clinical correlation suggested. previous tracing available comparison . [2179-3-12] EKG: Atrial fibrillation rapid ventricular response, rate 160. Non-specific repolarization changes. Compared previous tracing [2179-3-5] normal sinus rhythm abbreviated P-R interval given way atrial fibrillation rapid ventricular response . [3-21] CXR: continues dense opacification retrocardiac region consistent left lower lobe collapse small left effusion. patchy areas increased opacity right lower lung left mid lung may represent early infiltrate volume loss. significant change compared film two days ago. right subclavian line unchanged. . [2179-3-22] Renal US: Mildly echogenic otherwise normal-appearing kidneys may secondary medical renal disease. 1.1 x 0.9 cm echogenic focus left kidney may represent cholesterol deposit versus nonobstructing kidney stone. Brief Hospital Course: # hypercarbic resp failure: felt likely ALS induced muscular weakness combined possible acute PNA given LLL consolidation CXR. intubated repiratory failure, treated possible pneumonia. able tolerate weaning ventilator, therefore required tracheostomy longer term ventilator support. awaiting trach placement, Ms. [Known lastname 94714] also developed ventilator associated pneumonia. grew MRSA sputum blood, treated course vancomycin. Zosyn added 5 days vancomycin repeated L lung collapse thick mucous plugging, wanted cover pneumonia well. Subsequent surveillance cultures clean. Zosyn later switched Cefepime [1-7] worsening renal failure attributed Zosyn. completed 8 day course antibiotics. tracheostomy went well, started in/exsufflator well aid clearing secretions/mucous prevent recurrent lung colapse. . # fib: Ms. [Known lastname 94714] several episodes atrial fibrillation RVR, setting L lung collapse. initially started beta blocker good response. multiple episodes started amiodarone anticoagulation heparin. cases converted sinus rhythm own. Shortly starting heparin, episode guaiac positive stool, small amount melena. heparin stopped, restarted remained sinus rhythm, concern risk GI bleeding higher risk stroke. PEG lavaged, OB negative. also need colonoscopy outpatient evaluate cause melena. subtle ST changes inital EKG, ruled MI enzymes. . # hypotension: Ms [Known lastname 94714] hypotensive intial presentation, responding well fluid boluses. cortisol stimulation test normal response. became clear responds sedation benzodiazepines prolonged hypotension (as well increased delerium agitation), therefore stopped, put allergy list. cessation benzodiazepines, blood pressure much stable, require bolusing. never required pressors. . # ALS: felt likely progression ALS, diaphragmatic weakness CO2 retention. respiratory mechanics repeatedly asessed, showed would able come vent. Therefore trach placed thoracic surgery (IP unable place due anatomy). . # hyponatremia: Mrs [Known lastname 94714] hyponatremic admission. Tis resolved hydration, indicating likely hypovolemic total body sodium depleted. problems duration stay. . #Diarrhea: New [2179-3-24]/ Slight increase WBC 15. Afebrile. abdominal pain. course antibiotics vent associated PNA. antibiotics stopped today. ALso tube feeds. C. Diff possibility given recent abx may also related tube feeds. C.Diff pending. point reasonable follow fever curve stool output. C.Diff lab followed up. [Month (only) 116] consider empiric treatment c. diff flagyl febrile diarrhea persists. . #Hypernatremia - Likely releated low volume. increase free water tube feeds 100cc q4hr 150cc q4h. chenistry panel checked [2179-3-26] make sure Na remains stable. . # conjunctivitis: Ms. [Known lastname 94714] bilateral conjunctivitis admission. resolved 7 day course erythromycin eye cream. . # skin changes: Ms [Known lastname 94715] intitial presenting chief complaint erythema hands feet. Dermatology consulted, said likely erythromyalgia. treatment sarna lotion aspirin, improvement occur less month. treated sarna ASA throughout stay. Additionally burns inside thighs hot tea spill home prior admission. Per dermatology recs, areas treated antibiotic cream xeroform dressings, healed cleanly without infection. . # FEN: Ms. [Known lastname 94714] PEG admission able take PO intake time secondary progression ALS. continued NPO, tubefeeds per nutrition. monitored & repleted electrolytes lytes. kept euvolemic. #Renal Failure: Pt's Creatinine increased admission 0.7 1.3. BUN remained around 20 .Urine lytes consistent ATN>Reanla failure attributed ATN d/2 Zosyn.Although chenged Cefepime, improvement. Renal US showed obstruction. Pt's creatinitne remained near 1.3.Plan keep pt hydrated , avoid nephrotoxins follow creatinine outpatient. . # PPX: Ms. [Known lastname 94714] treated SC heparin, protonix, bowel regimen. constipation, bowel regimen increased good results. . # access: maintained PIVs throughout hospitalization. Shortly discharge PICC line placed losing peripheral access. . # code status: Per discussion Ms [Known lastname 94714] husband full code throughout stay. Medications Admission: Elavil (stopped weeks ago) Discharge Medications: 1. Docusate Sodium 150 mg/15 mL Liquid Sig: [12-7] PO BID (2 times day). 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times day). 3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times day). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times day). 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times day). 6. Bisacodyl 10 mg Suppository Sig: [12-7] Suppositorys Rectal DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times day). 9. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed. Disp:60 Tablet(s) Refills:0 10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 6 hours) needed. Discharge Disposition: Extended Care Facility: [Hospital3 672] Hospital Discharge Diagnosis: Amiotrophic Lateral Sclerosis Hypercarbic Respiratory Failure Atrial Fibrillation Recurrent Pneumonia-Ventilator Associated Pneumonia Renal Failure Discharge Condition: good , afebrile , cough , fever, tracheostomy good condition. Discharge Instructions: Please continue using exsuflator needed.PLease come back ED new episode worsening cough, fever productive sputum. . Pleae take medications prescribed. . noted diarrhea morning prior discharge, please call [Hospital1 18] check results c. diff stool culture [2179-3-25], consider c. diff study diarrhea continues. Followup Instructions: PCP: [Name10 (NameIs) ],[First Name3 (LF) 2946] S. [Telephone/Fax (1) 2936] . Recent onset diarrhea. Please call [Hospital1 18] microbiology lab ([Telephone/Fax (1) 94716] follow results c. diff toxin assay. . Please check cbc chem 7 [2179-3-26]. New onset hypernatremia [2179-3-24]. Free water increased tube feeds [2179-3-24]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] Completed by:[2179-3-24]	[ "486" ]
Admission Date: [2151-6-14] Discharge Date: [2151-9-18] Date Birth: [2151-6-14] Sex: F Service: Neonatology HISTORY: 1320 g female, twin A, born via c-section 37-year-old G4, P [1-27] mother 32 1/7 weeks IUGR twin B. history decreased Doppler flow twin B. Maternal labs include blood type O+, antibody negative, RPR nonreactive, hepatitis B surface antigen negative, rubella immune, GBS unknown. infant emerged vigorous Apgars 8 8. received blow-by O2 routine stimulation suctioning. ADMISSION PHYSICAL EXAMINATION: Vital Signs: Weight 1320 g (25th percentile); length 41.5 (25th 50th percentile); head circumference 29.25 (25th percentile); temperature 97; heart rate 170; respiratory rate 36; blood pressure 43/34 (34); O2 saturation 89% blow-by O2. General: Alert; pink; crying. HEENT: Anterior fontanelle open flat; mucous membranes moist; palate intact. Lungs: Decreased air movement throughout, prolonged expiratory phase. Cardiovascular: Regular rate rhythm; murmur; 2+ femoral pulses. GI: Soft; masses. GU: Normal premature female external genitalia. Musculoskeletal: Hips clavicles intact. Neurologic: Moved extremities. DISCHARGE PHYSICAL EXAMINATION: Weight 3835 g; head circumference 36.0 cm; length 52 cm. SUMMARY HOSPITAL COURSE SYSTEM: 1. Respiratory. Upon admission, baby started nasal CPAP. needed intubated day life 1 remained intubated day life 3 transitioned back nasal CPAP. day life 4, transitioned room air room air since time. apnea prematurity treated caffeine. discontinued day life 14. issues since time. 2. Cardiovascular. birth, normal blood pressure never required pressors fluid boluses. murmur stable. 3. Fluids, Electrolytes, Nutrition. baby started n.p.o. IV fluids. UVC several days received several days parenteral nutrition. day life 3, started feeds, advanced tolerated. many problems p.o. feeds. Secondary difficulty p.o. feeds taking enough, received jejunostomy tube. Currently, p.o. ad. lib. feeds day night, starting 10 p.m. going till 6 a.m., receives J tube continuous feeds 100 mL/kg 8 hours. 4. GI. baby found hyperbilirubinemia day life 2 peak 6.8/0.2. received several days phototherapy, phototherapy stopped day life 5 bilirubin issues. day life 12, started iron 2 mg/kg/day, continued today. baby found severe reflux worked GI [Hospital3 1810], [Location (un) 86]. started multiple medications, continues today Prilosec, Reglan, Zantac, Maalox. Secondary this, endoscopy [2151-9-10]. negative esophagitis although pathology biopsies still pending. NJ tube placed see would improve feeding also improve irritability, arching, reflux-related behaviors did. So, jejunostomy tube placed [2151-9-14]. need follow Dr. [Last Name (STitle) 79] [Hospital ] clinic [Hospital3 1810], [Location (un) 86]. 5. Hematology. birth, CBC done baby hematocrit 41.2 283 platelets. latest hematocrit 31.1 day life 91. 6. Infectious Diseases. birth, rule-out sepsis workup done. baby white count 7 51 neutrophils 2 bands. 48 hours ampicillin gentamicin, discontinued. postop day #1, [2151-9-15], spiked fever 101.3 sepsis workup done again. reassuring negative. received 48 hours ampicillin gentamicin issues. 7. Neurology. baby always normal neurologic exam 2 normal head ultrasounds - latest [2151-7-20]. 8. Sensory. a. Audiology. hearing screen performed automated auditory brain stem responses, baby passed. b. Ophthalmology. baby 2 ophthalmologic exams. eyes recently examined [2151-7-26], revealing mature retinal vessels. follow-up exam 6 months recommended. CONDITION DISCHARGE: Good. DISCHARGE DISPOSITION: Home. PRIMARY CARE PEDIATRICIAN: [Last Name (un) ]-[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 437] Pediatric Associates [Location (un) 3786] (phone number [Telephone/Fax (1) 45614]). CARE RECOMMENDATIONS: 1. Feeds discharge - Please continue Neocate 24 feeds p.o. ad. lib. day J tube feeds 100 mL/kg 8 hours night. 2. Medications - Prilosec 1 mg/kg/dose b.i.d.; Reglan 0.1 mg/kg q.i.d.; Zantac 10 mg p.o. b.i.d.; Maalox 2.5 mL q p.o. feed; iron sulfate 2 mg/kg/day. 3. Iron vitamin supplementation. a. Iron supplementation recommended preterm low birth weight infants 12 months corrected age. b. infants fed predominantly breast milk receive vitamin supplementation 200 IU (may provided multivitamin preparation) daily 12 months corrected age. 4. Car seat position screening test passed prior discharge. 5. State newborn screening status - baby 3 state newborn screens - [2151-6-17]; [2151-6-28]; [2151-7-26] - normal. 6. Immunizations received - baby received immunizations prior discharge. 7. Immunization recommendations: a. Synagis RSV prophylaxis considered [Month (only) ] [Month (only) 958] infants meet following 4 criteria: 1) born less 32 weeks; 2) born 32 35 weeks 2 following: daycare RSV season, smoker household, neuromuscular disease, airway abnormalities, school- age siblings; 3) chronic lung disease; 4) hemodynamically significant congenital heart disease. b. Influenza immunization recommended annually fall infants reach 6 months age. age (and first 24 months child's life), immunization influenza recommended household contact out-of-home caregivers. c. infant received rotavirus vaccine. American Academy Pediatrics recommends initial vaccination preterm infants following discharge hospital clinically stable least 6 weeks, fewer 12 weeks age. FOLLOW-UP APPOINTMENT SCHEDULE RECOMMENDED: 1. baby follow-up appointment primary care pediatrician [Last Name (LF) 766], [2151-9-20]. 2. follow-up appointment needs made [Hospital1 62374] GI, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 79], 2 weeks discharge. DISCHARGE DIAGNOSES: 1. Prematurity 32 1/7 weeks' gestation. 2. Twin gestation. 3. Rule sepsis. 4. Respiratory distress syndrome. 5. Severe gastroesophageal reflux. 6. Status post J tube placement. Reviewed By: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 53043], [MD Number(1) 53044] Dictated By:[First Name3 (LF) 72788] MEDQUIST36 D: [2151-9-20] 14:06:19 T: [2151-9-20] 15:21:09 Job#: [Job Number 72789]	[ "769" ]
Admission Date: [2150-12-24] Discharge Date: [2150-12-26] Date Birth: [2092-10-10] Sex: F Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 898] Chief Complaint: Dyspnea Major Surgical Invasive Procedure: None History Present Illness: 58f breast cancer, HTN, CHF, PAF s/p PVI presents shortness breath, increasing past day. notes symptoms became gradually, increasing dyspnea exertion productive cough developed palpitations, increased dyspnea related this. pulse fast irregular. came emergency department found rapid atrial fibrillation; chest x-ray revealed pneumonia. recieved levofloxacin IV diltiazem ED admitted. Past Medical History: 1. PAF s/p pulm vein isolation, w/ recurrence s/p radiation, amiodarone. 2. CHF diastolic EF 62% MRI [3-6] 3. Breast cancer Stage II status post right mastectomy status post six months tamoxifen therapy, s/p XRT 4. Hypertension. 5. Hyperlipidemia. Social History: Patient married lives husband. denied smoking alcohol use. Family History: NC Physical Exam: 99.4, bp 134/86, hr 122, rr 18, spo2 96% 2L nc gen- pleasant f, looks age, mild distress, non-toxic heent- anicteric, op clear mmm neck- jvd/lad/thyromegaly cv- tachy, irreg irreg, m/r/g pul- moves air well, slight bibasilar rales r>l abd- soft, nt, nd, nabs extrm- cyanosis/edema, warm/dry nails- clubbing, pitting/color changes/indentations neuro- a&ox3, focal cn/motor deficits Pertinent Results: [2150-12-24] 10:00PM BLOOD WBC-6.5 RBC-4.33 Hgb-13.0 Hct-36.7 MCV-85# MCH-29.9 MCHC-35.4# RDW-14.7 Plt Ct-150 [2150-12-26] 06:00AM BLOOD Glucose-91 UreaN-11 Creat-0.8 Na-139 K-4.3 Cl-105 HCO3-25 AnGap-13 [2150-12-24] 10:00PM BLOOD CK(CPK)-54 TotBili-0.6 [2150-12-24] 10:00PM BLOOD CK-MB-NotDone cTropnT-<0.01 [2150-12-26] 06:00AM BLOOD CK(CPK)-81 [2150-12-26] 06:00AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2150-12-25] 06:40AM BLOOD ALT-31 AST-18 AlkPhos-76 TotBili-0.5 [2150-12-25] 06:40AM BLOOD TSH-4.6 Brief Hospital Course: 58f breast cancer, htn, chf, paf s/p pvi admitted pneumonia afib rapid ventricular response . Afib -- Mrs. [Known lastname ] maintained amiodarone home sinus rhythm. felt pneumonia likely culprit exacerbation back fibrillation. seen EP staff felt would well loading dose amiodarone 400mg twice daily three days; would return usual dose 200mg daily. begun good response. Sinus rhythm quickly re-instated. symptoms dyspnea palpitations seems improved reversion sinus. discharged one day loading-dose amidodarone left sinus rhythm, rates generally 70's. . Pneumonia -- Although clinically mild, felt sufficient cause loss sinus rhythm. O2 requirement treated course levofloxacin. time discharged, afebrile decreased cough sputum production. Micro data unrevealing. Medications Admission: Pantoprazole 40mg daily Amiodarone 200mg daily Metoprolol 25mf twice daily Warfarin 2mg mon-fri 1mg sat-sun ASA 325mg daily Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times day). 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) 4 days. Disp:4 Tablet(s) Refills:0 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Warfarin 1 mg Tablet Sig: One (1) Tablet PO SAT-SUN (). 6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO MON-FRI (). 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times day) 1 days: Take 2 pills twice day Saturday Sunday, return 200mg day. Disp:4 Tablet(s) Refills:0 Discharge Disposition: Home Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Atrial fibrillation rapid ventricular response Pneumonia Secondary: 1. PAF s/p pulm vv isolation, w/ recurrence s/p radiation, amiodarone. 2. CHF, one episode post cardioversion, diastolic EF 55% 2/04 3. Breast cancer Stage II status post right mastectomy status post six months tamoxifen therapy, s/p XRT 4. Hypertension 5. Hyperlipidemia Discharge Condition: Good, sinus rhythm, improved symptoms Discharge Instructions: admitted pneumonia rapid heart rate; heart rate controlled temporarily increased dose amiodarone, given antibiotics pneumonia. . Call PCP return ED fevers/chills, chest pain, shortness breath, lightheadedness, loss conciousness, concerning symptoms. . Take 400mg amiodarone twice day Saturday Sunday, return usual dose 200mg day Monday. Followup Instructions: Please see primary care doctor next 1-2 weeks; call [Telephone/Fax (1) 2740] make appointment. . Provider: [Last Name (NamePattern4) 105871] NP/DR [Last Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2151-3-4] 8:00 . Provider: [Name10 (NameIs) 326] [Name11 (NameIs) ] DX RM2 RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2151-3-9] 11:00 . Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 677], M.D. Phone:[Telephone/Fax (1) 2934] Date/Time:[2151-3-19] 3:15	[ "486" ]
Admission Date: [2115-1-11] Discharge Date: [2115-1-19] Date Birth: [2033-12-10] Sex: Service: MEDICINE Allergies: Iodine Attending:[First Name3 (LF) 7881] Chief Complaint: chest pain Major Surgical Invasive Procedure: Cardiac Catheterization History Present Illness: 81 year old man CAD s/p CABG [2103] LIMA LAD, SVG PDA, SVG OM, HTN, IDDM, PVD s/p bilateral LE bypass, CRI, admitted [Hospital3 417] Hospital [1-7] shortness breath chest pain x one week. Initially thought rest angina. Ruled MI, EKG changes. Transferred cath. holding area pt chest pain, EKG changes. Underwent difficult catheterization today(received large amount radiation)which demonstrated severe native three vessel disease. left main heavily calcified 80% distal stenosis. left anterior descending received blood LIMA graft. left circumflex demonstrated 90% ostial lesion. RCA diffusely diseased. LIMA-LAD graft patent. SVG-OM patent; SVG-RPDA patent 85% mid RCA lesion. attempt PCI today due excessive radiation dose dye dose. Pt scheduled planned PCI SVG-rPDA possible LMCA intervention Monday. Past Medical History: HTN IDDM CAD s/p CABG [2103] LIMA LAD, SVG PDA, SVG OM ([2103]) PVD s/p bilateral LE bypass COPD carotid disease CRI BPH s/p TURP nephrolithiasis history thrombocytopenia Social History: Social history significant 50 pack year smoking history; quit '[03], ETOh drug use. Lives home wife, independent ADLs. Family History: NC Physical Exam: GEN: elderly male, NAD HEENT: NC/AT, EOMI, PERRL, O/P clear, MMM Neck: JVP+9, supple CV: RRR, m/r/g Lungs: CTA bilaterally Abd: Obese, soft, NT, ND Ext: WWP, edema Neuro: A&O x3 Pertinent Results: [2115-1-11] 09:15PM GLUCOSE-208* UREA N-45* CREAT-1.9* SODIUM-136 POTASSIUM-5.1 CHLORIDE-107 TOTAL CO2-21* ANION GAP-13 [2115-1-11] 09:15PM CALCIUM-8.8 PHOSPHATE-2.8 MAGNESIUM-2.2 [2115-1-11] 09:15PM WBC-4.1 RBC-3.07* HGB-10.1* HCT-29.7* MCV-97 MCH-32.9# MCHC-34.0 RDW-15.7 [2115-1-11] 09:15PM PLT COUNT-96* [2115-1-11] 06:16PM GLUCOSE-369* UREA N-45* CREAT-1.8* SODIUM-134 POTASSIUM-5.3* CHLORIDE-105 TOTAL CO2-20* ANION GAP-14 [2115-1-11] 06:16PM estGFR-Using C.CATH [1-11] COMMENTS: 1. Selective cornary angiography right dominant system revealed diffuse three vessel coronary artery disease. LMCA unable engaged selectively despite using 4 french JL4, JL4.5, JL5. five french JL5, JL4.5, AL1, AL2, AL3 also unsucessful. LMCA heavily calcified ostial plaque. 80% distal LMCA lesion involved origins LAD, ramus, [Month/Day (4) ]. LAD functional ostial stenosis (extended distal LMCA); signficiant proximal stenosis; minimal flow mid LAD. Overall, LAD able well visualized difficulty engaging LMCA. [Month/Day (4) ] 90% stenosis origin extended distal LMCA. AV groove [Month/Day (4) ] supplied diffusely disease OM1 (up 70% stenosis) LPL. ramus well seen ostial 80% stenosis. heavily calcified plaque aorta origin RCA. RCA heavy calcification proximally 70% 90% stenoses. mid vessel 50% stenosis. distal RCA tortuous vessel supplied long lower acute marginal lateral branches supplied inferior septum. native AV groove RCA heavily calcified subtotally occluded take-off large lower AM. 2. Venous conduit angiography revealed SVG OM (engaged 5 french AL2) patent thoughout touched onto lower pole OM communicate native AV groove [Name (NI) ]. SVG-rPDA (engaged 5 french MPA) ostial 30% mid 85% stenosis; graft retrogradely filled severely diffusely diseased distal AV groove RCA gave septal collaterals LAD. 3. Nonselective arterial conduit angiography revealed patent LIMA 30% ostial stenosis touches small calibur, heavily calcifed LAD (not well imaged). 4. Left subclavian angiography revealed heavily calcifed vessel proximal 50% stenosis. left subclavian stenosis prevented advancement 4 french [Female First Name (un) 899] catheter despite use angled glide wire, slip catheter, Amplatz stiff wire. 4 french Berenstein ultimately advance subclavian distal LIMA angled glide wire. 5. Left ventriculography perfomed secondary renal insufficency. 6. Limited hemodynamics demonstrated systemic systolic hypertension central aortic pressure 167/68 (systolic/diastolic mmHg). severe diastolic dysfunction LVEDP 32 mmHg. gradient across aortic valve pullback. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Severe diastolic ventricular dysfunction. . [1-14] Cardiac cath: 1. Planned intervention 90% body SVG-PDA lesion direct stenting Vision 3.5x18mm stent. 2. Limited hemodynamics BP 142/59 HR 55 significant ventricular ectopy. 3. Access via 6F long sheath RFA. FINAL DIAGNOSIS: 1. Succesful direct stenting SVG-PDA graft bare metal stent. Brief Hospital Course: . #. CAD: patient presented OSH [1-7] shortness breath chest pain. transferred [Hospital1 18] cardiac cathterization. diagnostic procedure [2115-1-11] complicated requiring signficant amount dye radiation, therefore, intervention planned another day. demonstrated severe native 3vd, patent LIMA-LAD, SVG-OM, 90% [Date Range ] ostial lesion, diffusely diseased RCA 85% lesion patent SVG-RPDA. received Reopro post cathterization developed hematoma requiring pressure dressing. patient developed refractory chest pain without ECG changes intervention could performed, transferred CCU monitoring management. CCU, given Argatroban ACS (reported concern re: HIT). cardiac cathterization [2115-1-14] intervention stenting SVG-RCA. sheath pulled Argatroban patient developed significant hematoma requiring 2 units pRBC transfusion. next day, patient developed stuttering chest pain plans made take back cath lab possible intervention left main RCA. transitioned nitro gtt isosorbide chest pain. started argatroban prior procedure. underwent third catheterization [1-17] stenting L. Subclavian. subsequently remained chest pain free. continued aspirin, Plavix, statin, Toprol. events occured, chest pain resolved sent home medications. . #. Systolic Heart Failure: echo performed showed EF 60%. Patient continued Lasix beta blocker increased. . #. Rhythm: Patient normal sinus rhythm hospital stay, however CCU episodes bradycardia beta blocker held. subsequently resumed prior discharge. . #. Diabetes-Patient placed insulin sliding scale placed back home glyburide prior discharge. . #CRI-Baseline 2.2 OSH. initially increased first catheterization subsequently improved post-cath hydration IVF. creatinine monitored remained stable throughout rest hospitalization. medications renally dosed received pre- post-cath hydration procedures. . #Hematuria-Pt gross blood foley thought related traumatic insertion. foley subsequently flushed clots. evidence hematuria intervention taken. . #BPH-Patient continued home hytrin . #Thrombocytopenia-Patient known chronic thrombocytopenia. unclear baseline is, OSH platelets low 100s. HIT Ab sent negative. Heparin held throughout stay platelets remained stable 80s low 100s. intervention taken. . #Chronic Anemia-Pt Procrit q week (tues). received 2 units prbcs CCU hematoma HCt subsequently remained stable. receive Procrit hospitalization resumed per regular schedule upon discharge. . #Sciatica-Patient continued home Neurontin. Medications Admission: ASA 325mg daily Nexium 40mg daily Toprol XL 25mg daily MVI Neurontin 300nmg daily Hytrin 2mg PO QHS Lasix 40mg daily Glyburide 5mg daily Iron 325mg daily Procrot q week (tues) Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 6. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO day. 10. Glyburide 5 mg Tablet Sig: One (1) Tablet PO day. 11. Procrit Injection 12. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO day. 13. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual every 5 minutes three times needed pain: Tkae every 5 minutes three doses; working call doctor go ER. Discharge Disposition: Extended Care Facility: Baypointe - [Hospital1 1474] Discharge Diagnosis: Primary CAD s/p 3 PCIs . Secondary HTN IDDM COPD PVD CRI BPH Thrombocytopenia Discharge Condition: Improved Discharge Instructions: admitted hospital chest pain. underwent 3 cardiac catheterizations stents placed blocked vessels heart. complication one procedures bruising swelling groin resolved. . changes made medications. started Lipitor, Plavix. medications kept same. . chest pain, shortness breath, nausea,vomiting, palpitations, lightheadednes, bleeding groin, concerning symptoms, please call doctor return ER. . Please follow Followup Instructions: Please follow cardiologist Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] 2 weeks. Please call make appt PCP [Last Name (NamePattern4) ] [4-8] weeks.	[ "496" ]
Admission Date: [2111-9-29] Discharge Date: [2111-10-5] Date Birth: [2050-1-9] Sex: Service: CARDIOTHORACIC Allergies: Ampicillin / Amoxicillin / Ativan Attending:[First Name3 (LF) 165] Chief Complaint: fatigue Major Surgical Invasive Procedure: OP CABGx2(LIMA-LAD,SVG-OM)[10-1] History Present Illness: 61 yo 2 month decline energy malaise walking home, unable sleep tripped/lost balance fell bath tub developed SOB. OSH, found R ptx rib fx. also found pulmonary edema elevated trops.Had known CAD, uncerwent repeat cath showed significant CAD. Tansferred [Hospital1 18] eval. Past Medical History: Acute Chronic systolic heart failure DM HTN [Hospital1 18048] ESRD - HD (MWF) - last dialysis [11-8]; [11-11] Thrombectomy L arm fistula [12-22] Hypercholesterolemia GIB [10-20] prepyloric area EGD (? [12-19] NSAIDS) Gastritis [12-22] (EGD) Anemia Hip surgery [6-21] - coumadin Prostate adenocarcinoma Chronic low back pain Social History: Occasional EtOH, tobacco, drugs Family History: Mother: [Name (NI) 18048] Physical Exam: Obese NAD Neuro A&O, forgetful train though, wanders, grip strenth L [3-21], R [2-19] PERRL CV RRR 2/6 SEM Resp crackles thoughout Right, Left clear GI obese, soft/NT Right groin macerated/fungal infection Pertinent Results: [2111-10-4] 08:20AM BLOOD WBC-8.0 RBC-2.74* Hgb-8.4* Hct-24.9* MCV-91 MCH-30.5 MCHC-33.6 RDW-16.4* Plt Ct-130* [2111-10-3] 08:35AM BLOOD WBC-7.9 RBC-3.03* Hgb-9.4* Hct-27.5* MCV-91 MCH-31.1 MCHC-34.2 RDW-16.9* Plt Ct-127* [2111-10-4] 08:20AM BLOOD Plt Ct-130* [2111-10-3] 08:35AM BLOOD Plt Ct-127* [2111-10-1] 01:33PM BLOOD PT-19.9* PTT-39.1* INR(PT)-1.9* [2111-10-4] 08:20AM BLOOD Glucose-155* UreaN-38* Creat-6.8# Na-129 K-4.4 Cl-89* HCO3-30 AnGap-14 [2111-10-3] 08:35AM BLOOD Glucose-123* UreaN-22* Creat-5.2* Na-135 K-4.2 Cl-92* HCO3-31 AnGap-16 [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 21518] (Complete) Done [2111-10-1] 10:54:10 FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] Division Cardiothoracic [Doctor First Name ] [First Name (Titles) ] [Last Name (Titles) ] [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2050-1-9] Age (years): 61 Hgt (in): 70 BP (mm Hg): 137/74 Wgt (lb): 235 HR (bpm): 68 BSA (m2): 2.24 m2 Indication: Intraoperative TEE CABG ICD-9 Codes: 410.91, 440.0 Test Information Date/Time: [2111-10-1] 10:54 Interpret MD: [Name6 (MD) 3892] [Name8 (MD) 3893], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 5740], MD Doppler: Full Doppler color Doppler Test Location: Anesthesia West cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW2-: Machine: 2 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.3 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.9 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 40% >= 55% Left Ventricle - Peak Resting LVOT gradient: 3 mm Hg <= 10 mm Hg Aorta - Annulus: 2.3 cm <= 3.0 cm Aorta - Sinus Level: 3.4 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.4 cm <= 3.0 cm Aorta - Ascending: 3.6 cm <= 3.4 cm Aorta - Descending Thoracic: 2.9 cm <= 2.5 cm Aortic Valve - Peak Velocity: 1.7 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 11 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 7 mm Hg Aortic Valve - LVOT pk vel: 0.[Age 90 ] m/sec Aortic Valve - LVOT diam: 2.1 cm Aortic Valve - Valve Area: 2.0 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Mild LA enlargement. spontaneous echo contrast thrombus LA/LAA RA/RAA. four pulmonary veins identified enter left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Dynamic interatrial septum. ASD 2D color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity. Moderate regional LV systolic dysfunction. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size free wall motion. AORTA: Normal aortic diameter sinus level. Focal calcifications aortic root. Mildly dilated ascending aorta. Simple atheroma aortic arch. Mildly dilated descending aorta. Simple atheroma descending aorta. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve well seen. PERICARDIUM: pericardial effusion. GENERAL COMMENTS: TEE performed location listed above. certify present compliance HCFA regulations. patient general anesthesia throughout procedure. TEE related complications. patient appears sinus rhythm. Results personally reviewed MD caring patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, = Akinetic, = Dyskinetic Conclusions PRE-revascularization: 1. left atrium mildly dilated. atrial septal defect seen 2D color Doppler. 2. mild symmetric left ventricular hypertrophy. left ventricular cavity mildly dilated. moderate severe regional left ventricular systolic dysfunction inferior, septal anterior walls. Overall left ventricular systolic function mildly depressed (LVEF= 40 %). 3. Right ventricular chamber size free wall motion normal. 4. simple atheroma aortic arch. descending thoracic aorta mildly dilated. simple atheroma descending thoracic aorta. 5. three aortic valve leaflets. aortic valve leaflets moderately thickened focal calcification left coronary cusp causing aorto sclerosis. aortic valve stenosis. Trace aortic regurgitation seen. 6. mitral valve leaflets mildly thickened. Trivial mitral regurgitation seen. 7. pericardial effusion. Post revascularization: Pt phenylephrine infusion intrinsic sinus rhythm: 1. Normal Rv function. LVEF 40% 2. new regional wall motion abnormalites, valves listed pre-revascularization. 3. Thoracic aortic contour intact CHEST (PORTABLE AP) [2111-10-2] 4:28 PM CHEST (PORTABLE AP) Reason: r/o ptx [Hospital 93] MEDICAL CONDITION: 61 year old man s/p cabg ct removal REASON EXAMINATION: r/o ptx HISTORY: Status post CABG chest tube removal; assess pneumothorax. FINDINGS: comparison study [9-21], endotracheal tube, Swan-Ganz catheter, nasogastric tube removed. Left chest tube also removed evidence pneumothorax. probably residual atelectatic change left base well right upper zone, decreasing. Brief Hospital Course: admitted cardiac surgery. seen renal continue HD. taken operating room [10-1] underwent OPCABG x 2. transferred ICU critical stable condition. given vancomycin perioperative prophylaxis house preoperatively. extubated morning POD #1. continued HD postop. transferred floor POD #1. started renagel per renal. well postoperatively ready discharge rehab POD #4. Medications Admission: crestor 40', colace 150", zoloft 100', lisinopril 40', norvasc 10', asprin 81', thiamin 100', plavix 75', protonix 40', toprol xl 200', ambien 10', folate 1", sensipar 180', lovaza 1"" Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) needed pain. 4. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES DAY MEALS). 5. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Cinacalcet 30 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily). 12. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO day. Discharge Disposition: Extended Care Facility: [Hospital 38] Rehab [Location (un) 1110] Discharge Diagnosis: CAD s/p CABG Acute Chronic systolic heart failure ESRD HD(L AV fist), CAD s/p MI, HTN, ^lipids, DM2 , s/p L THR, prostate CA s/p cryo/lupron, h/o gastric ulcer Discharge Condition: Good. Discharge Instructions: Call fever, redness drainage incision weight gain 2 pounds one day five one week. Shower, baths, lotions,creams powders incisions. lifting 10 pounds driving follow surgeon. Followup Instructions: Dr. [Last Name (STitle) 20764] 2 weeks Dr. [First Name (STitle) ] 4 weeks [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2111-10-5]	[ "412" ]
Admission Date: [2118-12-2] Discharge Date: [2118-12-16] Date Birth: [2039-1-27] Sex: Service: SURGERY Allergies: Ativan / Morphine Attending:[First Name3 (LF) 2836] Chief Complaint: weakness, abdominal pain Major Surgical Invasive Procedure: None Attempted IV Port placement History Present Illness: patient 79y man end ileostomy, well-known surgery service recently discharged [11-30], returns ED 24h peristomal abdominal pain weakness. pain began day following discharge, describes constant dull pain, non-radiating. also complains weakness. ostomy out-put within normal limits patient. out-put liquid visible blood. denies dizziness, fever, chills. one episode emesis morning presentation. SBP admission ED 70s. PMH: 1. Gout 2. Hypertension 3. atrial fibrillation 4. h/o spontaneous pneumothorax 5. ? pulmonary fibrosis 6. h/o rheumatic fever 7. h/o multiple small bowel obstructions 8. carotid artery stenosis 9. brain infarct asymptomatic 10. h/o recent c.diff 11. GERD 12. Chronic renal insufficiency 13. h/o Port-a-cath 14. Colonic stricture chronic small bowel obstruction, partial. PSH: 1. Colectomy, ileostomy "gangrene"/diverticulitis/"toxic megacolon" 2. Ileostomy reversal 2 years ago 3. Lysis adhesions [2118-7-5] 4. Appendectomy 5. Removal cyst neck 6. Left hip replacement 7. Removal 2 burs elbows 8. s/p talc pleurodesis ([Hospital1 112]) 9. s/p port removal staph sepsis 10. Resection ileocolic anastomosis creation end-ileostomy ([11-2]) Past Medical History: PSH: 1. Colectomy, ileostomy "gangrene"/diverticulitis/"toxic megacolon" 2. Ileostomy reversal 2 years ago 3. Lysis adhesions [2118-7-5] 4. Appendectomy 5. Removal cyst neck 6. Left hip replacement 7. Removal 2 burs elbows 8. s/p talc pleurodesis ([Hospital1 112]) 9. s/p port removal staph sepsis 10. Resection ileocolic anastomosis creation end-ileostomy ([11-2]) Social History: Social History: Quit smoking 35 years ago. ETOH. Family History: Family History: Noncontributory Physical Exam: VS: 97.5 85 122/56 17 1003L Gen: acute distress CV: RRR S1 S2 Lungs: coarse breath sounds bilaterally, rales wheeze Abd: soft, non-distended, moderate tympany, tender palpation diffusely primarily around ileostomy site. rebound guarding. Ostomy pink healthy appearing. Brown liquid out-put bag. Ext: Warm, well perfused Pertinent Results: Admit Labs CBC: 26/35.9\539 Chem: 128/98/42 ---------<239 5.8\13\2.0 Lactate:7.4 Tbil:0.5 AST:26 ALT:57 AP:96 . [2118-12-2] 01:10PM BLOOD WBC-26.3# RBC-3.66 Hgb-11.8* Hct-35.9* MCV-98 MCH-32.1* MCHC-32.8 RDW-15.1 Plt Ct-539* [2118-12-3] 04:48AM BLOOD WBC-23.5* RBC-3.47* Hgb-11.1* Hct-32.4* MCV-94 MCH-32.0 MCHC-34.2 RDW-15.5 Plt Ct-454* [2118-12-13] 05:45AM BLOOD WBC-12.6* RBC-2.92* Hgb-9.4* Hct-27.7* MCV-95 MCH-32.2* MCHC-34.0 RDW-16.4* Plt Ct-422 [2118-12-11] 04:25AM BLOOD PT-27.8* INR(PT)-2.8* [2118-12-2] 01:10PM BLOOD Glucose-239* UreaN-42* Creat-2.0* Na-128* K-5.8* Cl-98 HCO3-13* AnGap-23* [2118-12-3] 04:48AM BLOOD Glucose-132* UreaN-37* Creat-1.5* Na-132* K-5.5* Cl-102 HCO3-18* AnGap-18 [2118-12-13] 05:45AM BLOOD Glucose-106* UreaN-18 Creat-1.1 Na-131* K-4.8 Cl-101 HCO3-22 AnGap-13 [2118-12-5] 03:54AM BLOOD ALT-27 AST-18 LD(LDH)-151 AlkPhos-54 Amylase-36 TotBili-0.5 [2118-12-13] 05:45AM BLOOD Calcium-7.9* Phos-3.8 Mg-1.9 [2118-12-7] 04:30AM BLOOD TSH-13* [2118-12-7] 04:30AM BLOOD Free T4-0.91* [2118-12-6] 06:15AM BLOOD Digoxin-0.7* [2118-12-2] 01:28PM BLOOD Lactate-7.4* [2118-12-3] 05:04AM BLOOD Lactate-3.0* [2118-12-5] 04:17AM BLOOD Lactate-0.6 . [2118-12-5] 11:08 MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Final [2118-12-6]): POSITIVE METHICILLIN RESISTANT STAPH AUREUS. . Radiology Report CT PELVIS W/CONTRAST Study Date [2118-12-2] 2:10 PM IMPRESSION: 1. Significant small bowel dilation fecalization proximal right mid abdominal anastomosis concerning massive impaction. Stricture stoma cannot excluded. Small amount free intra- abdominal air pneumatosis several loops ileum deep within pelvis concerning ischemic process. 2. Unchanged aneurysm (x2) infrarenal abdominal aorta. . Brief Hospital Course: patient 79yM w/ end ileostomy presenting w/ abdominal pain weakness, found small foci free air pneumatosis ileum proximal ostomy. admitted surgery started IVF resuscitation dehydration, weakness elevated Lactate. CT scan done showed fecal impaction disimpacted emergency room. also demonstrated small foci free air possible pneuomotosis proximal illeum. Currently reports significant improvement abdominal pain since disimpaction. Vascular consulted due history superior mesenteric artery stent mesenteric ishemia resection ileocolic anastomosis creation end-ileostomy. presented increased watery ostomy output parastomal abdominal pain. Review CT scan shows stent patent unlikely mesenteric ischemia. Leukocytosis: started Zosyn 1 week course WBC defervesced. C.diffs negative. Hyponatremia/Hyperkalemia: Improved hydration Hypotension/Hemodynamic Instability: Dehydrated improved hydration. diet advanced eating well. ostomy output 1-liter/day. ordered Opium Tincture Psyllium 1.7 g Wafer. abdomen soft nontender nondistended. IV Port attempted, successful. needs continued close monitoring I&O's. Medications Admission: protonix 40', amiodarone 200'', digoxin 0.125', lopressor 12.5''', Tylenol prn, Imodium 2mg tab''', coumadin (for afib, 3mg/d), levothyroxine 50mcg PO daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times day). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Monitor INR. 5. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO QID (4 times day). 6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Opium Tincture 10 mg/mL Tincture Sig: Three (3) Drop PO TID (3 times day): 0.3mL. Titrate according stool consistency. Avoid constipation. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO day. Discharge Disposition: Extended Care Facility: [Hospital3 672] Hospital Discharge Diagnosis: Abdominal pain Weakness Leukocytosis Elevated Lactate 7.4 Hyponatremia/Hyperkalemia Hypotension Hemodynamic Instability Dilated loops small bowel fecalization distal ileum Acute Renal Failure Discharge Condition: Good Discharge Instructions: admitted dehydration, weakness hemodynamic instability. Please call doctor return ER following: * experience new chest pain, pressure, squeezing tightness. * New worsening cough wheezing. * vomiting cannot keep fluids medications. * getting dehydrated due continued vomiting, diarrhea reasons. * Signs dehydration include dry mouth, rapid heartbeat feeling dizzy faint standing. * see blood dark/black material vomit bowel movement. * skin, whites eyes become yellow. * pain improving within 8-12 hours gone within 24 hours. Call return immediately pain getting worse changing location moving chest back. * shaking chills, fever greater 101.5 (F) degrees 38(C) degrees. * serious change symptoms, new symptoms concern you. . * Take new meds ordered. * drive operate heavy machinery taking narcotic pain medication. may constipation taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); continue drinking fluids, may take stool softeners, eat foods high fiber. * Continue increase activity daily * Continue Ostomy care Followup Instructions: Please follow-up Dr. [First Name (STitle) ] [2-27] weeks. Call [Telephone/Fax (1) 2998] schedule appointment. Completed by:[2118-12-15]	[ "515" ]
Admission Date: [2120-11-9] Discharge Date: [2121-1-9] Service: [Hospital1 ] HISTORY PRESENT ILLNESS: patient 83 year-old female history rectal cancer admitted [Hospital1 69] [2120-11-9] low anterior resection rectal cancer ileostomy omental flap placement stump. initially course complicated necrosis omental pouch prolonged postoperative ileus. Multiple CT scans abdomen revealed evidence obstruction ileus thought secondary inflammation irritation necrotic omentum. [12-18], patient found less responsive increasing respiratory effort. arterial blood gas revealed pH 7.22, CO2 100 PA2 84 3 liters oxygen. point patient intubated hypercarbic respiratory failure transferred Medical Intensive Care Unit. respiratory standpoint, patient extubated following day, required reintubation three days secondary increasing secretions need constant pulmonary toilet. patient remained difficult wean. attributed volume overload secondary diastolic dysfunction well component chronic obstructive pulmonary disease. sputum culture [12-18] subsequently grew MRSA patient treated ten day course Vancomycin. patient finally extubated [1-5] extensive diuresis. gastrointestinal standpoint CT abdomen [12-16] revealed communication Hartmann's pouch peritoneal cavity abdominal fluid collection. Per Surgery Service collection noted draining rectal stump recommended surgical management. infectious disease standpoint four four blood culture bottles [12-5] [12-6] grew coag negative staphylococcus, treated Vancomycin. Surveillance cultures [12-28] revealed growth date. mentioned previously, patient sputum [12-18], grew MRSA. Blood cultures [12-18] subsequently grew [Female First Name (un) ] [Female First Name (un) 29361], patient completed fourteen day course Fluconazole [1-4]. Lastly, sputum [1-4] grew Pseudomonas. Infectious Disease Service consulted believed patient colonized, particularly since currently evidence pneumonia. cardiac standpoint concern volume overload secondary diastolic dysfunction. patient echocardiogram [12-19], revealed left ventricular ejection fraction 55% unremarkable chamber sizes thicknesses. also concern coronary artery disease. patient reportedly cardiac catheterization outside hospital 30% left anterior descending coronary artery 50% right coronary artery. several episodes atypical chest pain stay ruled myocardial infarction multiple times. MICU stay patient frequent episodes paroxysmal atrial fibrillation. treated Amiodarone Lopressor good effects. nutrition standpoint patient initially total parenteral nutrition, discontinued [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 29361] fungemia. patient since tube feeds via nasogastric tube goal. psychiatric standpoint patient profoundly depressed followed Psychiatry Service. episode self extubation attempt. point feel suicide risk. tried Celexa Ritalin without benefit. currently Wellbutrin. PAST MEDICAL HISTORY: 1. Rectal carcinoma status post radiation therapy chemosensitization low anterior resection [2120-11-15]. 2. Hypertension question diastolic dysfunction. 3. Coronary artery disease 30% left anterior descending coronary artery, 50% right coronary artery. 4. Status post cholecystectomy. ALLERGIES: Penicillin, Erythromycin intravenous contrast (but tolerate contrast). MEDICATIONS TRANSFER: Lopressor 50 mg po b.i.d., Wellbutrin 100 mg po t.i.d., Lasix 80 mg po b.i.d., Prevacid 30 mg po q.d., Amiodarone 400 mg po q.d., Atrovent, Colace 100 mg po b.i.d., Reglan 10 mg po q.i.d., heparin subQ, Tylenol prn. SOCIAL HISTORY: lives husband. positive tobacco history. PHYSICAL EXAMINATION: patient temperature 99.9. blood pressure 129/34. Heart rate 78. Respiratory rate 30. sating 100% 4 liters oxygen nasal cannula. general, patient sad, conversant older female acute distress. Neck examination jugulovenous pressure approximately 8 cm water. neck supple without lymphadenopathy. Cardiovascular examination regular rate rhythm. murmurs, rubs gallops. Respiratory examination, patient decreased breath sounds bilaterally well soft bibasilar rales. Abdomen examination patient positive bowel sounds. abdomen soft, nontender, nondistended. colostomy site clean intact. extremities warm without clubbing, cyanosis edema. 2+ dorsalis pedis pulses bilaterally. LABORATORY: patient white blood cell count 11.6, hematocrit 32.2, platelet count 376, sodium 137, potassium 4.8, chloride 88, CO2 41, BUN 15, creatinine 0.4, calcium 9.1, mag 1.8, phosphate 4.3. Studies, patient chest x-ray [1-6], revealed interval improvement upper zone redistribution small left pleural effusion residual left lower lobe collapse questionable consolidation retrocardiac region thought secondary atelectasis. CT abdomen [12-25], revealed collection fluid air within abdomen consistent abdominal abscess. CT adomen [12-16], revealed collection fluid air within abdomen identifiable Hartmann's pouch. TTE [12-19]. found ejection fraction 60%. left atrium mildly dilated. left ventricular thickness cavity size normal. right ventricular thickness size normal. found moderate mitral annular calcification 1+ mitral regurgitation. Microbiologic data, sputum culture [1-4] grew Pseudomanas. [12-28] MRSA, [12-22] MRSA [12-18] MRSA. Blood cultures [12-28] growth times two sets. [12-18] one four [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 29361], [12-6] two two coag negative staph. [12-5] two two coag negative staph. [11-27] growth times two. HOSPITAL COURSE: patient transferred General Medicine Service [1-6] management. 1. Pulmonary: patient daily chest physical therapy aggressive pulmonary toilet. encouraged use incentive spirometer. decided treat patient course Ciprofloxacin Pseudomonas sputum. discussed treatment infectious disease fellow think needed double covered pan sensitive Pseudomonas sputum. patient's respiratory status continued improve daily basis. oxygen saturations improved dramatically point required 3 4 liters nasal cannula maintain appropriate oxygen saturation. 2. Infectious disease: mentioned previously treated patient empirically Pseudomonas pneumonia Ciprofloxacin. clear evidence pneumonia, given history tenuous status opted treat empirically single [Doctor Last Name 360]. infectious disease standpoint patient well. overt signs infection. followed blood cultures carefully additional growth date surveillance cultures. white blood cell count fever curve remained within normal limits. 3. Gastrointestinal: patient noted abdominal collection draining rectal stump. followed Surgery Service stay believe needed surgical management. abdominal examination remained benign. 4. Cardiovascular: cardiovascular standpoint evidence acute ischemia, however, stay Medical Intensive Care Unit patient several episodes paroxysmal atrial fibrillation. continued Amiodarone Lopressor. Despite several episodes stay general medicine floor. time remained hemodynamically stable ventricular response rate 150s. responded quite well low dose intravenous Lopressor converting sinus rhythm almost instantaneous. think atrial fibrillation secondary patient's general medical problems. Toward end hospital stay patient remained normal sinus rhythm. Despite opted continue Amiodarone Lopresor. stay Medical Intensive Care Unit, patient felt diastolic dysfunction, noted fluid sensitive responsive Lasix. time arrived medical floor felt euvolemic. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 1211], M.D. [MD Number(1) 1212] Dictated By:[Last Name (NamePattern1) 11732] MEDQUIST36 D: [2121-3-18] 17:00 T: [2121-3-19] 05:41 JOB#: [Job Number 36073]	[ "496" ]
Admission Date: [2153-2-3] Discharge Date: [2153-2-7] Date Birth: [2074-10-16] Sex: Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 30] Chief Complaint: hypotension, fever 101 Major Surgical Invasive Procedure: femoral central line History Present Illness: 78 yo man c PMH Chronic Liver disease, Hepatoma s/p [First Name3 (LF) 54267] x 2, COPD, Afib coumadin, USOH [2153-2-3] began chills, rigors febrile home 101, per pt. went [Location (un) ] ED found hypotensive BP low 70 s. Pt denies having: cough, SOB, dysuria, urinary frequency, diarrhea, abdominal pain, n/v, night sweats, anorexia. Last BM yesterday. [Location (un) ]: Levaquin, 3 L NS, dopamine 5 mcg/min. Pt arrived [Hospital1 18] ED c BP near 120/48 HR 80-90s. Dopamine drip stopped. However pt noticed refractory hypotension started Levophed again. [Hospital1 ] ED, received IV Vanco, Levoflox, FFP NS IVF 100cc/hour. . MICU course: pt vanc, levo, flagyl unit. Panculture negative date. CXR without infiltrates. Abd u/s negative cholecystitis. Abdominal CT r/o new liver abscess considering pt's PMH negative. Vancomycin tapered [2-6] (received 4 days). IV levoflox flagyl continued. Pt also steroids bronchospasm, COPD MICU, received prednisone 60mg po qd unit, bronchodilators. satting 99-100% 2L NC (his baseline oxygen requirement). Initially, INR supratherapeutic 4.9, coumadin held initially. Coumadin restarted goal INR [1-12]. foley d/c'd continues urinate well. tolerating regular diet, taking meds orally. Past Medical History: -Afib many years coumadin -HTN -COPD -Hepatocellular carcinoma cirrhosis s/p [Month/Day (3) 54267] surgery x 2, dx'd 2 years ago, folloed Dr. [First Name (STitle) ] [Hospital1 18] . Pt hx liver abscess s/p second [First Name9 (NamePattern2) 54267] [5-13]. -Prosthetic rigtht eye s/p HSV subsequent enucleation -Stent pancreas mass h/o obstructive jaundice -Sarcoidosis s/p lung biopsy right -h/o Right temporal infarct [1-11] subtherapeutic INR, Afib MRI, [6-13] -h/o splenic infarct thought [1-11] subtherapeutic INR, Afib [6-13] -last echo [2152-6-13]: EF 55%, mod-markedly dil atria b/l. dil RV free wall hypokinesis, RV pressure overload, 1+MR, 4+TR, severe pulm artery HTN, Cardiologist [Location (un) ] Dr. [Last Name (STitle) 3503], dry weight 162 lbs. Social History: patient lives home wife, independent ADLs, 2 daughters, originally [Name (NI) 4754] since [2103], smoked 2ppd x 20 years quit 40 yrs ago, etoh, drugs. Former construction worker [Location (un) ] gas co. Family History: patient one 11 children. 2 brothers 1 sister strokes, brothers ages 38 50. One brother [Name2 (NI) 499] cancer. seizures run family. Physical Exam: Physical Exam admission: VITALS: 99.7 HR 90-110 afib, 88-96/58-70, 18, 95% 2 Lt GEN: acute distress, pleasant elderly man SKIN: rash , jaundiced [Name2 (NI) 4459]: NC/AT, anicteric sclera, mmm NECK: supple, meningismus , + JVP CHEST: normal respiratory pattern, CTA bilat anteriorly , decreased breath sounds bases CV: irregular irregular rate, murmurs ABD: soft, nontender, nondistended, +BS, liver edge palpable , ascites. EXTREM: edema, 1+ dorsalis pedis pulses, 2+ radial pulses . Phys Exam call MICU: Vitals: Tm: 96.8 Tc: 96.6 BP: 111/64 (99-120/49-69) P: 81 RR: 19-25 O2sat: 98-100% 2L NC. 24 hour I/O 3090/1310 +1780. 8 hour I/O: 1250/2365 -1115. General: Well appearing CM NAD. Pleasant cooperative. Sitting upright chair talking daughter. [Name (NI) 4459]: right eye prosthetic, left eye PERRL, left eye EOMI. nasal discharge. MM slightly dry, OP clear. Poor dentition. JVD mid neck. cervical LAD. Lungs: CTAB CV: Irregularly irregular rhythm. S1 S2 audible. Abd: Soft, NT, ND, Positive BS, ascites. HSM. Ext: peripheral edema. cyanosis/clubbing. Ext warm well perfused. 2+ DP pulses b/l. Pertinent Results: [2153-2-3] 08:00PM WBC-12.2# RBC-2.92 HGB-10.3* HCT-29.8* MCV-102* MCH-35.1* MCHC-34.5 RDW-16.8* [2153-2-3] 08:00PM NEUTS-73* BANDS-11* LYMPHS-11* MONOS-3 EOS-1 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [2153-2-3] 08:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [2153-2-3] 08:00PM PLT COUNT-163 [2153-2-3] 07:45PM LACTATE-1.3 [2153-2-3] 08:00PM PT-43.3* PTT-39.9* INR(PT)-4.9* . [2153-2-3]: CXR IMPRESSION: Cardiomegaly congestive heart failure.Bibasilar atelectasis small bilateral pleural effusions. . [2153-2-4]: Abdominal Ultrasound IMPRESSION: evidence acute cholecystitis cholelithiasis. Patchy areas increased echogenicity right lobe liver likely representing changes associated prior RF ablation. . [2153-2-5] CT TORSO IMPRESSION: 1. Bilateral predominantly peripheral ground glass opacities, new prior study. etiology uncertain, differential diagnosis includes includes infectious inflammatory process, cryptogenic organizing pneumonia, eosinophilic hypersensitivity pneumonia pulmonary edema superimposed severe emphysema. Clinical correlation follow indicated recommended. 2. Stable renal cysts. 3. Stable appearance radiofrequency ablations site. evidence abdominal abscess pseudocyst. 4. Peripheral high attenuation area transiently seen ?perfusion anomaly, described. . CULTURE DATA: [2153-2-3] Blood cx X 4 neg [2153-2-4] Blood cx X 4 neg [2153-2-3] Urine cx growth [2153-2-3]: UA neg nitr, neg leuks, 0-2 WBC, [2-11] RBC, rare bact, 0-2 epi. . Brief Hospital Course: 78 yo man Chronic Liver disease, Hepatoma s/p [Month/Day (1) 54267] x 2, h/o liver abscess, COPD, Atrial fibrillation coumadin admitted fever hypotension, thought septic secondary unclear etiology-- CXR negative infiltrate bilateral pleural effusions (effusions small diagnostic thoracentesis), Urinalysis negative, urine cx negative, blood cx X 4 negative. Pt covered empirically X 4 days Vanco/Levo/Flagyl, d/c Vanco [2153-2-6], continued Levo/Flagyl complete 7 day course given history liver abscess past. . 1. Hypotension, Fever admission thought [1-11] Septic-picture: clear source. However low BP, documented fever OSH, hx chills makes infection likely. Pt started Levofloxacin + Vanc ED Levophed trough peripheral IV. vanc, levo, flagyl MICU. Panculture negative date. CXR without infiltrates. Abd u/s negative cholecystitis. CT torso showing ground glass opacities lungs inflamm vs. infectious, bilateral effusions small tap. intraabd abscess. - Plan continue Levo/Flagyl 2 days complete 7 day course given h/o liver abscess past. . 2. Cardiovascular: A. Coronaries: signs ischemia EKG, enzymes negative. Aspirin held beta blocker continued. B. Pump: signs ischemia EKG enzymes. Getting 20mg IV lasix diuresis, transitioned 40mg po lasix transfer medical floor. note, usually gets 80mg po qd lasix home. Last echo [6-13] showing EF 55%, severe pulm HTN, dil atria b/l, dilated right ventricle pressure overload. discharge, monitor daily weight call PCP weight increases 3 lbs more, may indicate heart failure. C. Rhythm: Atrial fibrillation. continue beta blocker, atenolol, rate control, coumadin anticoagulation. Goal INR [1-12]. pt goal INR 1mg coumadin po qday. . 3. COPD: Started prednisone 60mg qday total 5 days, completed hospitalization. continue bronchodilators. Pt satting well 2L NC, baseline oxygen requirement. satting well ambulating physical therapy. . 4. GI: Pt hx liver disease, hepatocellular carcinoma status post [Month/Day (3) 54267]. LFTs elevated, AFP high, however stable trending downward. abd pain, nausea, vomiting, diarrhea, constipation. intraabdominal abscess seen CT abdomen. Stable appearance radiofrequency ablations site CT Abdomen. . 5. HTN: Pt's blood pressure remained stable, required pressors 48 hours, fluids needed past 24 hours. Taking well po. Restarted Beta blocker [Last Name (un) ] tight hold parameters. . 6. Code: Pt full code. Medications Admission: 1. Aspirin 81 mg Tablet 2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol 3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk Device Sig: 4. Atenolol 25 mg Tablet Sig 5. Losartan Potassium 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO day. 7. LT4 25 ug QD 8. Lasix 20 QD Discharge Medications: 1. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:15 Tablet(s) Refills:3 2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) 2 days. Disp:2 Tablet(s) Refills:0 4. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): need see Dr. [Last Name (STitle) 8521] refills monitor INR lab values/adjust dose. . Disp:30 Tablet(s) Refills:0 5. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): need follow Dr. [Last Name (STitle) 8521] refills, check electrolytes. Disp:60 Tablet(s) Refills:0 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times day) 2 days. Disp:6 Tablet(s) Refills:0 8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every 4-6 hours needed wheezing. Disp:1 MDI Refills:2 9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times day). Disp:1 MDI Refills:2 Discharge Disposition: Home Service Facility: [Hospital ] Home Health Care Discharge Diagnosis: 1. Hypotension 2. Atrial fibrillation 3. Hypertension 4. Chronic Obstructive Pulmonary Disease 5. Hepatocellular carcinoma 6. history right temporal infarct 7. history splenic infarct 8. history sarcoidosis status post lung biopsy right 9. history prosthetic right eye Discharge Condition: Stable, Good Discharge Instructions: experience fever, chills, chest pain, shortness breath, abdominal pain, nausea, vomiting, please report emergency room immediately. Please take medications prescribed. Please follow physician. [Name10 (NameIs) ] information below. Followup Instructions: appointment Dr. [Last Name (STitle) 31446] [Name (STitle) 8521], 11:00am, [2-14], [2152]. Please call office [Telephone/Fax (1) 54268] need reschedule appointment. Completed by:[2153-2-7]	[ "496" ]
Admission Date: [2151-10-1] Discharge Date: [2151-10-5] Date Birth: [2091-12-3] Sex: F Service: MEDICINE Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 13256] Chief Complaint: Altered mental status Major Surgical Invasive Procedure: n/a History Present Illness: 59 yo F w/ PMH alcohol hepatitis C cirrhosis history varices upper GI bleed presents loss consciousnes Guiac positive HCT drop 44-->33 setting intoxicated alcohol developed hematemesis ED. Per ED report, patietn alert oriented x3 admission, intoxicated, hypotensive systolic 70s. given multiple listers fluid developed hematemesis vomiting bright red blood clots. NG tube placed continued vomit blood. started octerotid PPI drip boluses, given dose ceftriaxone vancomycin transffused 2u PRBC. pressures continued low received 4th L fluid prior transfer MICU. arrival MICU, intubated sedated. Review systems: unable obatin patient sedated Past Medical History: - Alcoholic cirrhosis- low grade varices- banded, bleeding past. Peripheral edema (on lasix 20mg daily). 1 pint brandy per day year. tried detox once. Denies withdrawal seizures. - Chronic Back pain - Hepatitis C, diagnosed ~ 8 years ago, never treated. Unknown got it, denies IVDU, transfusions. Never liver bx. - Hypertension - Alcoholic cirrhosis- low grade varices- banded, bleeding past. Peripheral edema (on lasix 20mg daily). 1 pint brandy per day year. tried detox once. Denies withdrawal seizures. - Chronic Back pain - Hepatitis C, diagnosed ~ 8 years ago, never treated. Unknown got it, denies IVDU, transfusions. Never liver bx. - Hypertension Social History: Lives [Location 686] 16yo son. [Name (NI) ] history alcohol abuse, 10 years. Current smoker. Denies drug use. alcohol detox - relaped shortly thereafter. Drinks [2-8] 1 pint brandy per day though actively trying quit. Family History: Mother MI Sister diabetes. Many family members alcohol abuse Physical Exam: Exam Admission: General: sedateed intubated, NAD HEENT: Sclera anicteric. Intubated blood ETT , unable assess JVP CV: RRR, MRG appreciated Lungs: Rhonchrousou breath sounds bilaterally Abdomen: soft, protuberant nondistended. Hypoactive bowel sounds. GU: foley Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis edema Neuro: sedated inutbated DISCHARGE: O: AF 120s/70s 83-97 18 97%RA Gen: NAD, sitting chair comfortable HEENT: MMM, hallitosis. CV: RRR, normal S1/S2, m/r/g. Pulm: CTAB, wheezes, rhonchi rales. Abd: Soft, non-tender, obese. Neuro: AAO person, place, time, president Pertinent Results: Labs Admission: [2151-10-1] 02:15AM BLOOD WBC-7.2# RBC-3.03* Hgb-11.1# Hct-33.1 MCV-109* MCH-36.7* MCHC-33.5 RDW-16.4* Plt Ct-78* [2151-10-1] 02:15AM BLOOD Neuts-37.2* Lymphs-54.5* Monos-5.9 Eos-1.8 Baso-0.7 [2151-10-1] 09:03AM BLOOD PT-22.6* PTT-34.9 INR(PT)-2.2* [2151-10-1] 02:15AM BLOOD Glucose-129* UreaN-18 Creat-1.0 Na-138 K-5.1 Cl-104 HCO3-22 AnGap-17 [2151-10-1] 07:40PM BLOOD ALT-28 AST-61* LD(LDH)-161 AlkPhos-97 TotBili-2.5* [2151-10-1] 02:15AM BLOOD Calcium-8.1* Phos-2.4* Mg-1.5* [2151-10-1] 02:15AM BLOOD ASA-NEG Ethanol-292* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2151-10-1] 09:13AM BLOOD Type-[Last Name (un) ] pH-7.20* [2151-10-1] 02:36AM BLOOD Lactate-4.8* K-4.6 [2151-10-1] 09:13AM BLOOD freeCa-0.86* Labs Discharge: [2151-10-5] 05:01AM BLOOD WBC-4.5 RBC-2.56* Hgb-8.7* Hct-26.2* MCV-102* MCH-34.0* MCHC-33.2 RDW-21.8* Plt Ct-57* [2151-10-5] 05:01AM BLOOD Glucose-122* UreaN-4* Creat-0.4 Na-136 K-3.5 Cl-107 HCO3-27 AnGap-6* [2151-10-5] 05:01AM BLOOD ALT-27 AST-55* AlkPhos-117* TotBili-1.9* [2151-10-5] 05:01AM BLOOD Calcium-7.8* Phos-3.3 Mg-1.9 Imaging: EGD ([2151-10-1]): "Source bleeding identified [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] tear GE junction, bleeding time endoscopy. interventions done. Otherwise grade varices lower third esophagus stigmata bleeding. Moderate amount old blood clots stomach, sources bleeding identified stomach; Normal mucosa duodenum otherwise normal EGD third part duodenum." Portable Chest ([2151-10-1]): "Single frontal view chest obtained. Cardiac mediastinal hilar contours unremarkable. lungs clear focal consolidation, pleural effusion pneumothorax." Portable Abdomen ([2151-10-1]): "Gaseous distention loop small bowel lower abdomen, paucity gas remaining throughout abdomen. findings nonspecific, cannot exclude partial small-bowel obstruction. evidence free intraperitoneal air, though image quality limits assessment. Nasogastric tube place. Right-sided pelvic catheter consistent central venous access line." Brief Hospital Course: 59 year old female history hepatitis C alcoholic cirrhosis known Grade varices presented UGIB secondary [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] tear. #UGIB- patient history esophageal varices followed Dr. [Last Name (STitle) ] cirrhosis. nadalal one home medications. developed hematemesis ED, received 3L crystalloid 2 units PRBC. trasnferred MICU, EGD performed GI revealed [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] tears esophagus. monitored MICU HCT remained stable throughout MICU stay. started sucralfate received 48 hours protonix drip. transfer floor, continued remain hemodynamically stable, although continue melanic stools. HCT continued remain stable discharge. sent home sucralfate pantoprazole daily, along iron supplementation setting acute blood loss. #Hypovolemic shock- Patient presented hypotension elevated lactate resolved fluid resusciation blood products. Since EGD, remained hemodynamically stable, lactate trended down, required additional blood products. #Altered mental status- Patient found altered home intoxicated. positive flapping tremor started lactulose time transfer MICU. patient continued CIWA scale floor, required minimal diazepam symptoms. #Cirrhosis- Patient alcoholic/HepC cirrhosis. followed liver clinic Dr. [Last Name (STitle) ]. still actively drinking per postiive blood alcohol today ED. MELD score 15. thormbocytopenia known esophageal varices. history ascites hepatic encephalopathy, however flapping tremor somnolent time d/c MICU, persistent floor. treated 4d course ceftriaxone setting GI Bleed. #Alcohol abuse- Patient came MICU intoxicated >200 BAL. Social work consulted. patient demonstrated interest attending AA discharge. #Hypertension- Patient normotensive MICU admission, nadolol restarted transfer MICU continued floor. home lasix lisinopril held setting GI bleeding, signs fluid overload day discharge restarted. #hypokalemia - K around 3.3-3.5. Unknown etiology. repleted PO K. #Depression- Patient restarted citalopram able tolerate PO #Migraines- Fiorecet held hospital. patient full code throughout admission. TRANSITIONAL ISSUES: Pt need weekly labs follow hypokalemia hematocrit several weeks, f/u appt primary care [10-14]. f/u appointment GI need repeat EGD roughly 3 weeks per GI recommendations. Medications Admission: Preadmission medications listed correct complete. Information obtained webOMR. 1. Furosemide 20 mg PO DAILY Hold SBP<90 2. Spironolactone 50 mg PO DAILY Hold SBP<90 3. Nadolol 20 mg PO DAILY Hold SBP<90, HR<60 4. Acetaminophen-Caff-Butalbital [2-8] TAB PO Q8H:PRN headache 5. Citalopram 10 mg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Thiamine 100 mg PO DAILY Discharge Medications: 1. Nadolol 20 mg PO DAILY Hold SBP<90, HR<60 2. Acetaminophen-Caff-Butalbital [2-8] TAB PO Q8H:PRN headache 3. Citalopram 10 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Thiamine 100 mg PO DAILY 7. Pantoprazole 40 mg PO Q24H RX pantoprazole 40 mg 1 tablet(s) mouth daily Disp #31 Tablet Refills:3 8. Sucralfate 1 gm PO BID RX sucralfate 1 gram 1 tablet(s) mouth twice day Disp #31 Tablet Refills:4 9. Lactulose 30 mL PO TID RX lactulose [Constulose] 10 gram/15 mL 15-30 mL mouth use 4 times day Disp #1000 Milliliter Refills:3 10. Ferrous Sulfate 325 mg PO BID RX ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) mouth twice day Disp #62 Tablet Refills:3 Discharge Disposition: Home Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: [Doctor First Name ]-[Doctor Last Name ] Tears Alcoholic intoxication Secondary: Hepatitis C Virus Cirrhosis Migraines Hypertension Chronic low back pain Lower extremity edema Depression Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [Known lastname ], recently admitted [Hospital1 18] found altered mental status. here, EGD vomitting blood showed change varices, evidence tearing likely caused bleeding. changes home medications. imperitive discontinue drinking, likely cause hospital admission. pleasure take care patient here. Please hesitate contact us questions, comments concerns. Warm Regards, Inpatient Medicine Team Followup Instructions: Department: [Hospital3 249] When: THURSDAY [2151-10-14] 2:10 PM With: Dr. [Last Name (STitle) ] [Name (STitle) ] Location: [Company 191] POST [Hospital 894] CLINIC [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] South [Hospital ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage appointment hospital-based doctor part transition hospital back primary care provider. [Name10 (NameIs) 616] visit, see regular primary care doctor follow up. Department: LIVER CENTER When: FRIDAY [2151-10-22] 11:00 With: [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) ], MD [Telephone/Fax (1) 2422] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: RADIOLOGY When: FRIDAY [2151-10-22] 9:00 With: ULTRASOUND [Telephone/Fax (1) 590] Building: CC [Location (un) 591] [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage	[ "311" ]
Admission Date: [2103-5-19] Discharge Date: [2103-5-27] Date Birth: [2080-7-19] Sex: F Service: MEDICINE Allergies: Morphine / Dilaudid Attending:[First Name3 (LF) 1055] Chief Complaint: Back pain one day Major Surgical Invasive Procedure: None History Present Illness: Ms. [Known lastname 14164] 22 year-old African-American woman known [Known lastname 14165] cell disease, presents 1-day history right-sided posterior chest pain. notes well 4-days prior admission developed URI symptoms, including headache, rhinorrea, generalized fatigue. subsequently developed cough, productive small amounts dark yellow sputum. Yesterday, developed right-sided posterior chest pain, pleuritic nature, worse coughing, deep breathing lying culprit side. reports mild SOB. felt warm past days, measure temperature. denies chills. unsure whether received Pneumovax Influenza vaccines. ROS otherwise negative joint pain. GI urinary complaints. lightheadedness, dizziness. ED, vitals initially 99.4, HR 80, BP 119/58, RR 16, oxygen saturation 95% 3L, 88% room air. CXR revealed RLL infiltrate. given Ceftriaxone 1 gm IV X1 Azithromycin 500 mg PO QD. also given Morphine 1 mg IV X1, Benadryl 25 mg X1, Dilaudid pain control. Past Medical History: 1. [Known lastname ] cell disease, 1 admission per year since [2100] acute pain crisis. 2. History gonorrhea 3. Prior pneumonia versus acute chest syndrome [2100] 4. History pre-eclampsia first pregnancy 5. Known multiple RBC allo-antibodies difficult cross-match Social History: lives 2 children aged 4 2 years-old. active smoker, smokes 5 cigarettes per day. quit 3 years, restarted last year. EtOH consumption. also denies illicit drug use. Family History: lived [Doctor Last Name ] home age 5 onwards. Per OMR records, mother father [Name2 (NI) 14165] cell trait. children [Name2 (NI) 14165] cell trait. Physical Exam: Physical examination admission: VITALS: 99.4, HR 100, BP 110/55, RR 20, Sat 99% 3 liters via NC. GEN: Sleepy. Scratching over. Uncomfortable motion. HEENT: Anicteric. EOMI. PERRL. Frontal bossing. LN: cervical lymphadenopathy. RESP: Dullness percussion right base. Decreased air entry right base, basilar crackles. bronchial breathing. + egophony, + whispered pectoriloquy. CVS: PMI displaced. Normal S1, physiologic splitting S2. S3, S4. Soft, late systolic murmur apex, non-radiating. GI: BS NA. Abdomen soft non-tender. EXT: Strong pedal pulses. pedal edema. Pertinent Results: Relevant laboratory data admission: CBC: WBC 11.1, Hb 6.9, Hct 19.9, Platelet 552 NEUTS-54 BANDS-1 LYMPHS-35 MONOS-7 EOS-2 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1 HYPOCHROM-2+ ANISOCYT-3+ POIKILOCY-3+ MACROCYT-2+ MICROCYT-1+ POLYCHROM-NORMAL SPHEROCYT-1+ OVALOCYT-1+ TARGET-2+ [Name2 (NI) ]-2+ Chemistry: Na 138, K 4.7, Cl 106, HCO3 24, BUN 8, Creat 0.7, Glucose 0.7 Relevant imagind studies: [2103-5-19] CXR: Stable cardiac contours. Interval development patchy opacity right lower lobe, pleural effusion. [2103-5-20] CXR: Heart size within normal limits evidence CHF. consolidation right middle right lower lobes associated small right pleural effusion, increased compared prior film [5-19], 05. atelectasis left lung base previously demonstrated. probably associated collapse right lobe. IMPRESSION: Increase extent right middle lobe right lower lobe consolidation small right pleural effusion. Left basilar atelectasis. [2103-5-21] CXR: cardiac silhouette upper limits normal size slight increase pulmonary vascularity, consistent patient's known [Year/Month/Day 14165] cell status. multifocal areas consolidation involving right middle lower lobes, progressed interval. also bilateral probable small pleural effusions. IMPRESSION: Worsening multifocal consolidation suggesting multifocal pneumonia. [Year/Month/Day ] cell lung differential diagnosis infectious symptoms present. [2103-5-22] CXR: significant interval change. [2103-5-23] CXR: Increased mild moderate left pleural effusion. Persistent right middle lower lobe infiltrate right pleural effusion, stable. [2103-5-24] CXR: Slight interval improvement right middle lobe aeration. Slight improvement right pleural effusion. Stable left pleural effusion left lower lobe retrocardiac atelectasis. [2103-5-26] CXR: Improving right middle lobe left lower lobe opacities. small left-sided pleural effusion unchanged. ****** [2103-5-22] ECHO: left atrium mildly elongated. Left ventricular wall thickness, cavity size, systolic function normal (LVEF>55%). Regional left ventricular wall motion normal. Right ventricular chamber size free wall motion normal. aortic valve leaflets (3) appear structurally normal good leaflet excursion aortic regurgitation. mitral valve leaflets mildly thickened. mitral valve prolapse. trivial mitral regurgitatino. borderline pulmonary artery systolic hypertension. pericardial effusion. Brief Hospital Course: 22 year-old African-American woman [Year/Month/Day 14165] cell disease admitted respiratory symptoms right-sided back pain, found RLL infiltrate + hypoxemia. 1) Pneumonia +/- acute chest syndrome: CXR admission revealed RLL infiltrate suspicious pneumonia, although acute chest syndrome ruled out. Examination also remarkable hypoxemia, saturation low 80s. empirically started Ceftriaxone Azithromycin coverage Mycoplasma, Chlamydia, Hemophilus pneumococcus, hydrated. afebrile admission, subsequently developed fever hospital rising WBC 34.6 [5-21]. also developed worsening hypoxemia [5-21] increasing SOB setting decreasing hematocrit 15.5, 14.3. ABG revealed pH 7.41/38/70. repeat CXR performed remarkable worsening RML/RLL pneumonia. Given well inability transfuse PRBCs [3-21] available cross-matched blood (multiple allo-antibodies), Ms. [Known lastname 14164] transferred ICU [5-20]. ICU, supportive care provided. continued Ceftriaxone Azithromycin. Sputum cultures returned OP flora, without predominance organisms (can rule Chlamydia Mycoplasma). Blood urine cultures returned negative. Serial CXRs initially revealed worsening picture, interval development LLL infiltrate consistent multilobar process, bilateral pleural effusions. echo performed showed normal EF>60%. effusions ultimately felt likely [3-21] fluid overload setting aggressive IVF administration, diuresed Lasix [5-23] [5-24]. eventually improved defervesced, decreasing oxygen requirements improved radiographic picture. Antibiotics changed PO Levofloxacin [5-24], Ceftriaxone D/C'd [5-24] (received 6 days), Azithromycin D/C'd [5-25] (received 7 days). complete 14-day course (total) Levofloxacin (last dose [2103-6-1]). note, effusions persist discharge, stable size. also persistent leukocytosis WBC 16.2 discharge. improve time. need follow-up imaging completion antibiotic course document complete resolution infiltrate/effusion, well repeat WBC. effusions persist, thoracentesis would indicated rule parapneumonic effusion. given Pneumococcal, Meningococcal Hib vaccines prior discharge. follow-up PCP [Name Initial (PRE) 176] 1 week discharge. 2) [Name Initial (PRE) ] cell disease: Hematocrit admission 19.9 (around baseline), 15.3 [5-20] 2+ [Month/Year (2) 14165] cells peripheral smear, nadir 14.3 [5-21]. hematology service consulted. Ms. [Known lastname 14164] multiple allo-antibodies HRB absent rare except African-Americans. blood bank unable provide matched blood. transfused 1 unmatched unit [5-22] pre-medication Prednisone 60 mg PO QD, without response. transfusion therefore held. Per hematology, folate increased 5 mg PO QD. hematocrit slowly trended 22 discharge. note, ferritin sent rule concomitant iron deficiency, returned elevated 791. appropriate reticulocytosis 22% setting anemia. follow-up Dr. [Last Name (STitle) ] Hematology within 1 week discharge. Treatment hydroxyurea addressed. 3) Pain control: Pain control achieved Dilaudid IV prn pre-medication Benadryl. switched PO OxyContin 10 mg PO BID oxycodone breakthrough [5-26], fair pain control. Tylenol around clock Naproxen also added. discharged OxyContin/Oxycodone/Naproxen/Tylenol + bowel regimen. 4) Bacterial vaginosis: Ms. [Known lastname 14164] diagnosed bacterial vaginosis prior admission, treated Flagyl. completed 5-day course Flagyl hospital, resolution symptoms ([5-22] --> [5-26]). 5) Oral lesions: hospital, developed oral lesions suspicious oral HSV. started Valtrex 1 gm PO TID plan complete 3 days. complete course out-patient (last doses [2103-5-28*]). Medications Admission: Folate 2 mg PO QD Metronidazole (has taking intermittently bacterial vaginosis) Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily). Disp:150 Tablet(s)* Refills:1 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice day: Please take Oxycontin. Disp:60 Capsule(s) Refills:0 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) 5 days: Start [5-28], last dose [6-1]. Disp:5 Tablet(s) Refills:0 4. Valacyclovir HCl 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times day) needed HSV 3 doses: Please take 1 pill tonight, 1 pill tomorrow morning 1 pill tomorrow night. . Disp:6 Tablet(s) Refills:0 5. Oxycodone HCl 10 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO Q12H (every 12 hours). Disp:25 Tablet Sustained Release 12HR(s) Refills:0 6. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 6 hours) needed pain. Disp:40 Tablet(s) Refills:0 7. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) 7 days. Disp:28 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: [Month/Year (2) ] cell disease Anemia Pneumonia RBC antibodies Secondary diagnoses: Bacterial vaginosis Probable oral herpes simplex Discharge Condition: Patient discharged home stable condition. Saturation 94-96% room air. Hematocrit 22.5. Discharge Instructions: Please return hospital call PCP develop worsening respiratory symptoms, including increasing shortness breath, increasing cough. also return develop fever. Please continue take Levofloxacin daily, last dose [6-1]. treat pneumonia. Start [5-28]. Please note also increased folate 5 mg daily. Please take Oxycontin 10 mg twice daily pain control. also take oxycodone 5 mg needed every 4 6 hours breakthrough pain. Note given 3 vaccines (Haemophilus influenza, Pneumococcal, Meningococcal vaccines) Followup Instructions: Please call PCP (Dr. [Last Name (STitle) 14166] [Telephone/Fax (1) 14167] schedule appointment see within 1 week discharge. need repeat CXR next 2 weeks. Please call Dr.[Name (NI) 220] office (Hematology) [Telephone/Fax (1) 9645], schedule appointment see within 1-2 weeks discharge. Completed by:[2103-5-27]	[ "486" ]
Admission Date: [2151-1-31] Discharge Date: [2151-2-16] Date Birth: [2096-2-11] Sex: Service: MICU HISTORY PRESENT ILLNESS: patient 54 year old man admitted Intensive Care Unit [2151-1-31], [Hospital3 6265] evaluation hematemesis, melena abdominal mass. patient well Tuesday prior admission developed headache point took Vicodin developed nausea vomiting abdominal pain. Thursday evening prior admission, states passed floor bathroom fall secondary severe pain. states loss consciousness fifteen minutes. denies head trauma. Saturday prior admission, patient states retching blood. presented Emergency Department [Hospital3 3583] admitted found hematocrit 26.3, potassium 6.2, also acute renal failure. Abdominal CT indicated large peripancreatic mass. patient transferred [Hospital1 69] evaluation. transfer, white blood cell count 28, creatinine 3.4. PAST MEDICAL HISTORY: 1. History spontaneous pneumothorax. 2. History immune complex mediated glomerulonephritis. 3. History peptic ulcer disease, status post surgery. 4. Acute renal failure. MEDICATIONS ADMISSION: Vicodin p.r.n. ALLERGIES: patient states allergic Sulfa, Aspirin Naprosyn. SOCIAL HISTORY: patient works sales. twenty pack year history smoking. denies alcohol street drug use. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: admission, patient's temperature 97.0, heart rate 107, respiratory rate 15, blood pressure 135/42, oxygen saturation 98% two liters. general, patient alert, acute distress. neck supple. Pulmonary examination indicated scant crackles bilaterally. Cardiovascular examination indicated regular rhythm, normal S1 S2, II/VI systolic murmur. abdomen distended decreased bowel sounds mild diffuse tenderness percussion. extremity examination, patient 2+ peripheral pulses edema. stool guaiac negative. LABORATORY DATA: Initial laboratory studies indicated white count 28.6, hematocrit 25.6, platelet count 404,000. Chem7 indicated blood urea nitrogen 43 creatinine 3.4. INR elevated 1.9. Liver function tests within normal limits. Electrocardiogram indicated normal sinus rhythm, rate 99 beats per minute, normal axis, normal intervals ischemic changes. HOSPITAL COURSE: patient admitted Intensive Care Unit. Nasogastric lavage performed indicated presence coffee ground emesis. evaluated gastroenterology service emergent endoscopy performed indicated presence hiatal hernia well compression second third part duodenum. biopsy taken compression site indicated chronic inactive duodenitis focal Brunner gland hyperplasia. also gastric mucocele metaplasia. CT abdomen indicated 10 6.0 centimeter soft tissue mass within mesentery pelvic rim well 10 16 centimeter mesenteric retroperitoneal hematoma displaying duodenum anteriorly compressing inferior vena cava. Significant mesenteric lymphadenopathy also noted. Renal surgery services consulted. recommendation surgery service, follow-up abdominal CT p.o. contrast completed indicated persistent intra-abdominal hematoma intra-abdominal mass. patient also noted increased liver function tests ALT 622, AST 649, normal total bilirubin alkaline phosphatase. patient's hematocrit continued drop, bleeding scan conducted indicated active bleeding abdomen clear source. patient therefore received angiogram indicated presence superior mesenteric artery aneurysm well active bleeding gastroduodenal artery embolized. patient also developed shortness breath following administration total fourteen units packed red blood cells Intensive Care Unit. Chest x-ray indicated presence congestive heart failure possible left sided infiltrate. patient started Lasix well Levaquin Flagyl. hepatitis panel sent negative. ANCA sent concern possible polyarteritis nodosa, however, study negative. patient also started total parenteral nutrition secondary expected ileus following embolization. Intensive Care Unit following embolization, transaminases trended downward, creatinine improved, hematocrit remained stable. patient develop transient episodic hypertension systolic pressure 200 requiring Labetalol drip, however, successfully weaned patient transitioned Labetalol tablets. unit, also developed bipedal scrotal edema, thought secondary volume overload setting multiple transfusions. Echocardiogram conducted hospital day number four indicated ejection fraction greater 55% 1+ tricuspid regurgitation. hospital day number six, patient transferred floor additional workup questionable abdominal mass. repeat [Location (un) 1131] patient's existing CAT scans, determined initially read mass first CT likely extension hematoma. Follow-up imaging four weeks recommended. first day floor, patient spiked temperature 101.3 degrees Fahrenheit. Repeat chest x-ray indicated worsening pulmonary infiltrates bilaterally. point, patient switched Ceftazidime Clindamycin treat possible nosocomial pneumonia. Sputum blood cultures sent negative. patient's pulmonary status improved significantly intravenous antibiotics. patient able tolerate p.o. intake, total parenteral nutrition discontinued. However, patient noted pain eating found small lesion site denture insertion site. patient able tolerate food pretreatment Viscous Lidocaine solution. Although patient's initial abdominal pain subsided, maintained Oxycontin control residual abdominal pain floor. patient's lower extremity edema decreased administration intravenous subsequently p.o. Lasix. hospital day number ten, patient noted increasing jaundice altered mental status. Liver function tests time indicated alkaline phosphatase 1091 total bilirubin 11.4. transaminases slightly elevated. right upper quadrant ultrasound performed indicated dilatation common bile duct well presence biliary sludge. intrahepatic biliary duct dilatation gallstones. Endoscopic retrograde cholangiopancreatography performed consultation gastroenterology service. study indicated fifteen millimeter common bile duct stented well stenosis distal bulb. patient's liver function tests, jaundice mental status improved following endoscopic retrograde cholangiopancreatography. patient follow-up endoscopic retrograde cholangiopancreatography three months stent removal. Although patient's mental status improve following endoscopic retrograde cholangiopancreatography, residual symptoms agitation paranoia prompted psychiatry consultation recommended low dose Haldol p.r.n. worsening symptoms. However, patient's mental status slowly returned baseline. patient evaluated physical therapy service found would benefit acute rehabilitation. time discharge summary, patient screened placement acute rehabilitation facility. DISCHARGE DIAGNOSES: 1. Superior mesenteric artery aneurysm. 2. Status post embolization gastroduodenal artery. 3. Biliary sludge. 4. Pneumonia. 5. Glomerulonephritis. 6. History peptic ulcer disease. 7. History pneumothorax. MEDICATIONS DISCHARGE: 1. Lasix 80 mg p.o. q.d. 2. Viscous Lidocaine 2% solution 15 ccs swish spit meals p.r.n. 3. Senna two tablets p.o. q.h.s. p.r.n. 4. Colace 100 mg p.o. b.i.d. 5. Boost t.i.d. meals. 6. Protonix 40 mg p.o. b.i.d. 7. Labetalol 200 mg p.o. q12hours. 8. Albuterol Atrovent MDI two puffs q4hours p.r.n. 9. Lipitor 10 mg p.o. q.d. 10. Nephrocaps 1 mg p.o. q.d. DISPOSITION: time dictation, patient screened placement acute rehabilitation facility. follow-up endoscopic retrograde cholangiopancreatography stent removal three months following discharge well follow-up abdominal CT scan three weeks following discharge. follow-up [Hospital ] Clinic. DISCHARGE DISPOSITION: Improved. [Doctor Last Name ] [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 5712] Dictated By:[Last Name (NamePattern1) 194] MEDQUIST36 D: [2151-2-15] 19:22 T: [2151-2-15] 19:42 JOB#: [Job Number 96120]	[ "486" ]
Admission Date: [2135-12-26] Discharge Date: [2136-1-3] Date Birth: [2080-2-9] Sex: Service: HISTORY PRESENT ILLNESS: Patient 55-year-old man multiple medical problems including insulin dependent diabetes secondary severe pancreatitis [2123], remote history Hodgkin's disease [2113] treated among things, radiation therapy left patient severe osteoporosis resulting compression fractures, history alcohol abuse, chronic opioids residual pain secondary pancreatitis, presented [12-26] delta MS. Per patient's lifetime partner, patient self increased dose opiate using approximately four patches Fentanyl increasing Seroquel dose 150 300 mg. presented ED [2135-12-26] increased weakness, tremor, disorientation x2 months, worse prior three days. ED, patient's temperature 98.4, blood pressure 136-145/60-70. heart rate 71-130. treated Ativan 7 mg thought alcohol withdrawal, increased patient's sedation subsequently systolic blood pressure decreased 88-97. Patient negative head CT. lumbar puncture attempted, successful. Patient started acyclovir, Vancomycin empiric meningitis coverage. patient's Chem-7 time significant glucose 354, anion gap 13, 15 ketones urine. results, ED started patient insulin drip. blood gas initially 7.23/55/46, decreased 7.16/56/260. patient minimally alert time. progressive somnolence. Patient started BiPAP 10 5, admitted MICU. PAST MEDICAL HISTORY: 1. COPD. 2. Diabetes mellitus insulin dependent secondary chronic pancreatitis. 3. Chronic alcohol induced pancreatitis status post debridement. 4. History alcohol abuse. 5. Osteoporosis. 6. CHF ejection fraction 40%. 7. Hodgkin's disease status post XRT, chemotherapy, splenectomy. 8. Hypothyroidism. 9. GERD. 10. Vocal cord paralysis. 11. Chronic pain multiple narcotics. 12. Anxiety depression. ALLERGIES: known drug allergies. SOCIAL HISTORY: Patient 40 pack year history tobacco. recent ethanol use. PHYSICAL EXAM: Temperature 98.5, blood pressure 104/64, heart rate 107. Cardiovascular: Patient 3/6 systolic murmur heard best left lower sternal border apex. Abdomen soft, nontender, nondistended, multiple surgical scars. Extremities: cyanosis, clubbing, edema. Pulses [12-30]+ bilaterally. Neurologic: patient responds commands, moving four extremities. HOSPITAL COURSE: patient admitted MICU management. [2135-12-27], intubated due increased somnolence hypoxia. [2135-12-28], EEG performed, read possibly consistent encephalitis. Patient seen Neuro team, recommended MRI LP. [2135-12-28], patient's temperature spiked 101.6. continued ampicillin, ceftriaxone, acyclovir possible meningitis. also started bicarb drip metabolic acidosis. patient initially treated Ativan narcotic withdrawal, D/C'd later started lower dose Fentanyl. [2135-12-29], patient transferred VICU. Analysis CSF fluid revealed 2 monocytes, 15 lymphocytes, 1 band. Gram stain negative PMNs, macrophages, bacteria. Culture negative. PCR Listeria HSV negative. Results patient's MRI [2135-12-28] revealed normal brain parenchyma. blood breakdown edema present. Overall impression MRI grossly normal, however, study limited patient motion. MICU, patient extubated. mental status continued improve. continued antibiotics treatment presumed community acquired pneumonia. noted eosinophilia, improved course hospitalization. transfused 1 unit blood transiently went pulmonary edema setting transfusion. resolved Lasix nebulizers. Acyclovir D/C'd patient's MRI lumbar puncture negative. patient transferred medical floor, alert oriented, able ambulate cane, tolerating good p.o. intake. seen Physical Therapy, felt would benefit rehabilitation stay. CONDITION DISCHARGE: Stable. DISCHARGE STATUS: [Hospital3 2558] [Hospital ] Hospital. DISCHARGE DIAGNOSES: 1. Chronic obstructive pulmonary disease. 2. Insulin dependent diabetes. 3. History chronic alcoholic-induced pancreatitis. 4. Remote history alcohol abuse. 5. Severe osteoporosis. 6. Congestive heart failure ejection fraction 40%. 7. Hodgkin's disease. 8. Hypothyroidism. 9. Gastroesophageal reflux disease. 10. Vocal cord paralysis exacerbated recent intubation. 11. Chronic pain multiple narcotics. 12. Anxiety depression. MEDICATIONS DISCHARGE: 1. Lasix 20 mg p.o. q.d. 2. Pantoprazole 40 mg p.o. q.d. 3. Lisinopril 5 mg p.o. q.d. 4. Morphine sulfate 15 mg p.o. q.6h. prn. 5. Clindamycin 600 mg IV q.8h. 6. Ceftriaxone 1 gram IV q.24h. 7. Docusate 100 mg b.i.d. 8. Fentanyl patch 150 mcg/hour transdermal patch q.72h. 9. Quetiapine fumarate 100 mg p.o. q.h.s. 10. Insulin-sliding scale 7 units glargine bedtime. 11. Lorazepam 1-2 mg IV q.3-4h. prn. 12. Levothyroxine 125 mcg p.o. q.d. 13. Folic acid 1 mg p.o. q.d. 14. Multivitamin. 15. Pancrease four capsules p.o. t.i.d. meals. 16. Tylenol prn. 17. Vitamin D. 18. Citalopram 40 mg p.o. q.d. 19. Calcium 500 mg p.o. t.i.d. 20. Antibiotic therapy completed [2136-1-10]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8184], M.D. [MD Number(1) 8185] Dictated By:[Last Name (NamePattern1) 9725] MEDQUIST36 D: [2136-1-3] 10:42 T: [2136-1-3] 11:00 JOB#: [Job Number 108105]	[ "486", "496" ]
Admission Date: [2165-4-29] Discharge Date: [2165-5-15] Service: MEDICINE Allergies: Atorvastatin / Tylenol / Ibuprofen / Rosuvastatin Attending:[Last Name (NamePattern1) 1171] Chief Complaint: Chest pain, total body pain Major Surgical Invasive Procedure: None History Present Illness: [Age 90 ] y/o F PMHx CAD, CHF EF 40%, recent admission respiratory failure requiring intubation presents total body pain chest pain. patient's current symptoms began Saturday nausea. following day (one day prior admission), patient experienced aching throughout body, including back, chest, back head. morning, patient awoke sleep 6am due right index finger pain, erythema, swelling, calor spread rest body (back, chest, back head). Finger pain described stiff, sore, achy associated calor. Total body pain described sharp body aches generalized, lasted received Morphine ED. patient describes chest pain along total body pain, received SL Nitro x3 without relief. pain similar features prior anginal equivalent, experienced chest pain, shortness breath, upper back pain, current pain consists nausea without dyspnea lightheadedness. . ER, vitals T99.9 BP 156/61 P76 R18 PO2 100% 2L. Chest pain [7-18] arrival started nitro gtt without significant relief symptoms. However, symptoms resolved morphine, currently 0/10. EKG revealed sinus rhythm baseline LBBB acute EKG changes. received Morphine 500cc bolus en route EMS, received additional Morphine ED. . evaluation floor, pt asymptomatic complaining thirst. denies PND, reports 2 pillow orthopnea remained unchanged years. . . REVIEW SYSTEMS: denies prior history stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding time surgery, myalgias, joint pains, cough, hemoptysis, black stools red stools. denies recent fevers, chills rigors. denies exertional buttock calf pain. Denies fevers/chills, night-sweats, abdominal pain, diarrhea, dysuria, rash. report (+) congestion/cough white sputum since hospitalization, helped albuterol. review systems negative. . Cardiac review systems notable absence chest pain, dyspnea exertion, paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope presyncope. Past Medical History: # Diabetes # Dyslipidemia # Hypertension # Coronary Disease - s/p NSTEMI [9-16] medically managed Cath s/p stent [3-20]. # Chronic systolic/diastolic congestive heart failure, recent EF>60% # Chronic renal failure, stage III CKD - Dr [Last Name (STitle) ] # Hypertension # Hyperlipidemia, intolerant statins # Type 2 diabetes, diet-controlled # GERD # Breast Cancer - diagnosed [2145], s/p lumpectomy [State 108] # s/p total abdominal hysterectomy [2094] fibroids # Cataracts Social History: lives home alone, family area. Social history significant absence current tobacco use, remote social tobacco use college. history alcohol abuse. home [Year (4 digits) 269] w tele reports daily PT. Presents rehab following multiple admissions. Family History: family history premature coronary artery disease sudden death. father hypertension. sister alive healthy 93. Physical Exam: admission VS: T=98.6 BP=146/70 HR=75 R=20 PO2 sat= 100% 2L GENERAL: WDWN NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, pallor cyanosis oral mucosa. xanthalesma. NECK: Supple JVP <9 cm. CARDIAC: RRR, normal S1, S2. GII systolic murmer LSB, gallops, rubs. S4 present LSB apex. thrills, lifts. LUNGS: chest wall deformities, scoliosis kyphosis. Resp unlabored, accessory muscle use. Crackles bases b/l; egophany. wheezes rhonchi. ABDOMEN: Soft, NTND. HSM tenderness. Abd aorta enlarged palpation. abdominial bruits. NABS. EXTREMITIES: c/c/e. SKIN: stasis dermatitis, ulcers, scars, xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ discharge VS: 97.3, 120/47, 52, 18, 100%RA I/O: 120/350 today, [Telephone/Fax (1) 93520] yesterday GENERAL: AAOx3, pleasant elderly female NAD. Fatigued, interactive. HEENT: NCAT. Sclera anicteric. NECK: Supple JVP <9 cm sitting 90 degrees CARDIAC: RRR, normal S1, S2. S4 present LSB apex. LUNGS: mild kyphosis. Resp unlabored, accessory muscle use. soft crackles bibasilarly, breath sounds bases decreased ABDOMEN: Soft, NTND. HSM tenderness. NABS. EXTREMITIES: c/c/e. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: CXR ([4-29]): Two views compared bedside examination obtained 10 hours earlier, well previous examinations [4-16] [2165-4-19]. clearing findings CHF bilateral pleural effusions, residual rounded LV enlargement atherosclerotic change involving thoracic aorta. lungs appear hyperinflated, suggestive underlying obstructive disease; however, focal airspace opacity. diffuse osteopenia slight anterior wedging several thoracic vertebrae resultant slight kyphosis. acute abnormality thoracic skeleton. . CXR ([5-5]): 1. Worsening pulmonary edema increasing small pleural effusions. 2. Bilateral lower lobe airspace opacities, may due dependent areas pulmonary edema superimposed secondary process aspiration infectious pneumonia. Followup radiographs diuresis may helpful regard. . CXR ([5-6]) CHEST, AP: Mild interstitial edema slightly worsened. Mild cardiomegaly small bilateral pleural effusions unchanged. Bibasilar consolidation stable. cardiac silhouette normal. aorta calcified tortuous. IMPRESSION: Slightly increased vascular congestion. . SUPINE ABDOMEN ([5-6]) Limited study partially imaged left abdomen. Bowel gas pattern present nonobstructive air seen non-dilated loops small large bowel. free intraperitoneal air pneumatosis. cardiac silhouette moderately enlarged. questionable deep sulcus sign right hemithorax, right clinical setting, may represent pneumothorax. small opacification left lower lung. . CBC [2165-5-13] 05:15AM BLOOD WBC-8.3 RBC-3.41* Hgb-10.1* Hct-30.1* MCV-88 MCH-29.7 MCHC-33.7 RDW-15.2 Plt Ct-402 [2165-5-12] 04:35AM BLOOD WBC-8.4 RBC-3.45* Hgb-10.5* Hct-30.3* MCV-88 MCH-30.5 MCHC-34.7 RDW-14.9 Plt Ct-355 [2165-5-11] 06:10AM BLOOD WBC-7.8 RBC-3.28* Hgb-9.7* Hct-28.7* MCV-88 MCH-29.5 MCHC-33.7 RDW-15.0 Plt Ct-369 [2165-5-10] 05:20AM BLOOD WBC-6.0 RBC-3.09* Hgb-9.1* Hct-27.1* MCV-88 MCH-29.5 MCHC-33.7 RDW-14.9 Plt Ct-389 [2165-5-9] 05:30AM BLOOD WBC-5.6 RBC-3.16* Hgb-9.1* Hct-27.2* MCV-86 MCH-28.9 MCHC-33.5 RDW-14.7 Plt Ct-341 [2165-5-8] 05:15AM BLOOD WBC-6.9 RBC-3.07* Hgb-9.1* Hct-26.5* MCV-87 MCH-29.7 MCHC-34.4 RDW-14.7 Plt Ct-286 [2165-5-7] 06:02AM BLOOD WBC-6.6 RBC-3.02* Hgb-9.0* Hct-26.2* MCV-87 MCH-29.9 MCHC-34.5 RDW-14.8 Plt Ct-305 [2165-5-6] 12:48AM BLOOD WBC-7.4# RBC-3.03* Hgb-8.9* Hct-25.7* MCV-85 MCH-29.4 MCHC-34.7 RDW-14.8 Plt Ct-239 [2165-5-5] 04:10AM BLOOD WBC-4.5 RBC-2.71* Hgb-8.3* Hct-23.8* MCV-88 MCH-30.6 MCHC-35.0 RDW-14.9 Plt Ct-248 [2165-5-4] 07:30AM BLOOD WBC-4.9 RBC-3.01* Hgb-9.1* Hct-26.6* MCV-88 MCH-30.3 MCHC-34.3 RDW-15.0 Plt Ct-239 [2165-5-3] 05:05AM BLOOD WBC-5.7 RBC-3.06* Hgb-9.4* Hct-27.2* MCV-89 MCH-30.6 MCHC-34.4 RDW-15.3 Plt Ct-242 [2165-5-2] 05:25AM BLOOD WBC-5.8 RBC-3.36* Hgb-10.1* Hct-29.2* MCV-87 MCH-30.0 MCHC-34.6 RDW-15.0 Plt Ct-225 [2165-5-1] 07:30AM BLOOD WBC-8.6 RBC-3.31* Hgb-9.9* Hct-29.5* MCV-89 MCH-30.1 MCHC-33.7 RDW-15.4 Plt Ct-245 [2165-4-30] 10:50AM BLOOD WBC-7.8 RBC-3.29* Hgb-9.8* Hct-28.6* MCV-87 MCH-29.7 MCHC-34.1 RDW-15.2 Plt Ct-215 [2165-4-30] 07:25AM BLOOD WBC-9.9 RBC-3.36* Hgb-10.3* Hct-29.9* MCV-89 MCH-30.7 MCHC-34.5 RDW-15.5 Plt Ct-245 [2165-4-29] 07:55AM BLOOD WBC-16.0# RBC-3.75 Hgb-11.3* Hct-32.3* MCV-86 MCH-30.0 MCHC-34.9 RDW-15.6* Plt Ct-269 Coags [2165-5-11] 06:10AM BLOOD PT-12.7 PTT-30.2 INR(PT)-1.1 [2165-5-10] 05:20AM BLOOD PT-12.1 PTT-27.4 INR(PT)-1.0 [2165-5-9] 05:30AM BLOOD PT-12.0 PTT-28.0 INR(PT)-1.0 [2165-5-8] 05:15AM BLOOD PT-12.8 PTT-28.9 INR(PT)-1.1 [2165-5-7] 06:02AM BLOOD PT-12.6 PTT-31.4 INR(PT)-1.1 [2165-5-6] 01:01AM BLOOD PT-13.1 PTT-26.5 INR(PT)-1.1 [2165-4-30] 07:25AM BLOOD PT-13.2 PTT-28.4 INR(PT)-1.1 Chemistry [2165-5-13] 05:15AM BLOOD Glucose-117* UreaN-116* Creat-3.7* Na-131* K-3.5 Cl-78* HCO3-40* AnGap-17 [2165-5-12] 04:35AM BLOOD Glucose-121* UreaN-117* Creat-3.5* Na-131* K-3.7 Cl-78* HCO3-39* AnGap-18 [2165-5-11] 06:10AM BLOOD Glucose-131* UreaN-117* Creat-3.7* Na-130* K-3.8 Cl-79* HCO3-38* AnGap-17 [2165-5-10] 05:20AM BLOOD Glucose-118* UreaN-119* Creat-3.7* Na-130* K-4.0 Cl-79* HCO3-37* AnGap-18 [2165-5-9] 05:30AM BLOOD Glucose-109* UreaN-119* Creat-3.7* Na-129* K-3.2* Cl-79* HCO3-35* AnGap-18 [2165-5-8] 05:15AM BLOOD Glucose-111* UreaN-118* Creat-3.9* Na-128* K-3.4 Cl-77* HCO3-34* AnGap-20 [2165-5-7] 06:02AM BLOOD Glucose-115* UreaN-116* Creat-4.1* Na-125* K-3.3 Cl-76* HCO3-34* AnGap-18 [2165-5-6] 04:08PM BLOOD UreaN-112* Creat-4.2* Na-129* K-3.7 Cl-81* HCO3-32 AnGap-20 [2165-5-6] 12:48AM BLOOD Glucose-137* UreaN-108* Creat-4.4* Na-123* K-3.8 Cl-75* HCO3-29 AnGap-23* [2165-5-5] 04:10AM BLOOD Glucose-107* UreaN-105* Creat-4.3* Na-125* K-3.9 Cl-80* HCO3-30 AnGap-19 [2165-5-4] 07:30AM BLOOD Glucose-127* UreaN-95* Creat-3.9* Na-126* K-3.9 Cl-80* HCO3-29 AnGap-21* [2165-5-3] 05:10PM BLOOD Glucose-202* UreaN-93* Creat-3.8* Na-125* K-4.2 Cl-81* HCO3-28 AnGap-20 [2165-5-5] 04:10AM BLOOD Glucose-107* UreaN-105* Creat-4.3* Na-125* K-3.9 Cl-80* HCO3-30 AnGap-19 [2165-5-4] 07:30AM BLOOD Glucose-127* UreaN-95* Creat-3.9* Na-126* K-3.9 Cl-80* HCO3-29 AnGap-21* [2165-5-3] 05:10PM BLOOD Glucose-202* UreaN-93* Creat-3.8* Na-125* K-4.2 Cl-81* HCO3-28 AnGap-20 [2165-5-3] 05:05AM BLOOD Glucose-136* UreaN-91* Creat-3.6* Na-127* K-4.1 Cl-85* HCO3-29 AnGap-17 [2165-5-2] 05:25AM BLOOD Glucose-135* UreaN-84* Creat-3.1* Na-135 K-4.0 Cl-92* HCO3-28 AnGap-19 [2165-5-1] 07:30AM BLOOD Glucose-110* UreaN-82* Creat-3.0* Na-136 K-4.3 Cl-94* HCO3-32 AnGap-14 [2165-4-30] 10:50AM BLOOD Glucose-186* UreaN-81* Creat-2.9* Na-135 K-3.4 Cl-92* HCO3-32 AnGap-14 [2165-4-30] 07:25AM BLOOD Glucose-109* UreaN-81* Creat-2.9* Na-136 K-3.4 Cl-92* HCO3-32 AnGap-15 [2165-4-29] 07:55AM BLOOD Glucose-163* UreaN-84* Creat-2.9* Na-138 K-3.5 Cl-94* HCO3-30 AnGap-18 [2165-5-13] 05:15AM BLOOD Calcium-9.0 Phos-5.1* Mg-3.8* [2165-5-12] 04:35AM BLOOD Calcium-9.0 Phos-4.7* Mg-4.0* [2165-5-11] 06:10AM BLOOD Calcium-8.7 Phos-4.2 Mg-4.0* [2165-5-10] 05:20AM BLOOD Calcium-8.5 Phos-4.1 Mg-4.0* [2165-5-9] 05:30AM BLOOD Calcium-8.8 Phos-5.3* Mg-3.8* [2165-5-8] 05:15AM BLOOD Calcium-8.6 Phos-5.4* Mg-4.0* [2165-5-7] 06:02AM BLOOD Calcium-9.2 Phos-6.5* Mg-4.1* [2165-5-6] 12:48AM BLOOD Albumin-3.6 Calcium-9.2 Phos-5.8* Mg-3.6* [2165-5-5] 04:10AM BLOOD Calcium-8.9 Phos-6.1* Mg-3.3* [2165-5-4] 07:30AM BLOOD Calcium-9.1 Phos-5.1* Mg-3.0* [2165-5-3] 05:05AM BLOOD Calcium-9.1 Phos-4.2 Mg-3.0* [2165-5-2] 05:25AM BLOOD Calcium-9.6 Phos-4.8* Mg-2.7* [2165-5-1] 07:30AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.9* [2165-4-30] 10:50AM BLOOD Calcium-9.2 Phos-4.1 Mg-2.6 [2165-4-30] 07:25AM BLOOD Calcium-9.5 Phos-4.8* Mg-2.5 [2165-4-29] 07:55AM BLOOD Calcium-9.9 Phos-4.2 Mg-2.5 Cardiac Enzymes [2165-5-6] 12:48AM BLOOD CK(CPK)-17* [2165-5-5] 04:10AM BLOOD CK(CPK)-11* [2165-5-2] 05:25AM BLOOD CK(CPK)-16* [2165-5-1] 09:14PM BLOOD CK(CPK)-20* [2165-4-30] 07:25AM BLOOD CK(CPK)-17* [2165-4-30] 03:40AM BLOOD CK(CPK)-15* [2165-4-29] 03:05PM BLOOD CK(CPK)-19* [2165-4-29] 07:55AM BLOOD CK(CPK)-20* [2165-5-6] 12:48AM BLOOD CK-MB-NotDone cTropnT-0.20* [2165-5-5] 04:10AM BLOOD CK-MB-1 cTropnT-0.19* [2165-5-2] 05:25AM BLOOD CK-MB-NotDone cTropnT-0.09* [2165-5-1] 09:14PM BLOOD CK-MB-NotDone cTropnT-0.07* [2165-4-30] 07:25AM BLOOD CK-MB-NotDone cTropnT-0.07* [2165-4-30] 03:40AM BLOOD CK-MB-NotDone cTropnT-0.06* [2165-4-29] 03:05PM BLOOD CK-MB-NotDone cTropnT-0.03* proBNP-[Numeric Identifier 93521]* [2165-4-29] 07:55AM BLOOD cTropnT-0.03* Brief Hospital Course: [Age 90 ]yoF CAD s/p stent mid-[Name (NI) ], PTCA jailed OM1, IVUS LMCA MLA presenting body pain chest pain. . # CORONARIES: Patient h/o prior stent [Name (NI) ] PTCA jailed OM1 presenting atypical chest pain concerning ACS. significant EKG changes light LBBB (by Sgarbossa criteria), CE's negative. patient continued Aspirin 162mg daily Clopidogrel 75 mg daily per outpatient regimen. . # PUMP/CHF: Patient history chronic systolic diastolic heart failure EF 40% [3-/2165], moderate (2+) MR, small secundum ASD left-to-right shunt across interatrial septum rest. appeared clinically fluid overloaded without hypoxia, BNP >45,000. Pt complex course medicine floor multiple episodes worsening resp status thought due flash pulm edema. Initially, symptoms responded lasix additional BP control. However, renal function slowly worsened decreasing response diuresis. Pt became progressively uremic confused [5-5] mild respiratory distress. transferred CCU [5-6] received 240mg Lasix IV bolus followed gtt. aggressively diuresed, per renal recs, started Lasix 80mg PO BID. good volume output lasix. Patient good volume status since, episodes flash pulmonary edema. fluctuating O2 requirements, times saturating well room air times requiring 2L O2. . # Chronic renal failure: Stage III CKD, followed Dr [Last Name (STitle) ]. Patient baseline Cr 1.5 [Month (only) 956] baseline increased 2.4. admission patient worsening renal function creatinine rising 2.9 4.3. unclear whether patient's increasing creatinine due dehydration vs volume overload - particularly given recurrent episodes flash pulmonary edema CXR showing evidence fluid overload. aggressively diuresed CCU volume status stable 80 mg PO lasix [Hospital1 ]. Patient family decided decline hemodialysis focus comfort measures. # Renal Artery Stenosis: Patient atrophic right kidney, left renal artery stenosis. likely reason difficult diurese reason flashes easily. originally planned renal artery stenting, procedure held unstable, requiring CCU transfer. Goals care discussed patient renal stenting tabled patient decided aggressive management focus comfort. . # Body Pain: Patient describes body pain since waking morning admission. Unclear etiology, likely viral symptoms vs non-specific findings [3-12] CHF exacerbation. Infectious workup negative. Leukocytosis resolved discharge. Patient 2 transient episodes chest pain admission reproducible palpation worse movement, likely musculoskeletal etiology, relieved 0.5 mg PO morphine. . # Right Finger Pain: Pt initially presented right index finger erythema, swelling, calor consistent gout; septic arthritis osteomyelitis less likely given fevers, effusion, nidus infection. Resolved without intervention. . # Hypertension: Patient's home antihypertensives initially continued, following CCU transfer recurrent flash pulmonary edema, changed amlodipine, carvedilol, furosemide, imdur. Following CCU admission stable SBP ranging 110s-130s. . # Hyperlipidemia: Pt intolerant statins, given statins discussion PCP [Last Name (NamePattern4) ]: goals patient's care. . # Type 2 diabetes: diet-controlled. Covered SSI in-house. . # GERD: Continued Famotidine 20 mg Tablet per outpatient regimen . # Goals care: patient made DNR/DNI CCU. Patient family decided starting hemodialysis, preference comfort directed care. prior discharge hospital, patient asked sign DNR/DNI form would continue DNR/DNI status transport nursing facility, refused sign. Patient repeatedly stated want resuscitated, however refused sign form. amenable daughter (HCP) signing DNR/DNI forms her, however daughter available prior discharge sign papers. daughter understands would able sign DNR/DNI papers nursing facility. nursing facility, patient's care focused comfort care. Medications Admission: 1. Senna 8.6 mg [Hospital1 ] 2. Famotidine 20 mg Tablet 3. Calcitriol 0.25 mcg Capsule PO QMOWEFR 4. Aspirin 162mg daily 5. Clopidogrel 75 mg daily 6. Cyanocobalamin 500 mcg daily 7. Hydralazine 10 mg q6hr 8. Isosorbide Mononitrate 20 mg [Hospital1 ] 9. Docusate Sodium 100 mg [Hospital1 ] 10. Felodipine 10 mg daily 11. Carvedilol 12.5 mg [Hospital1 ] 12. Furosemide 40 mg Tablet [Hospital1 ] 13. Iron (Ferrous Sulfate) 325 mg daily 14. Nitrostat 0.4 mg Tablet, Sublingual prn Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) needed chest pain: 3 tablets needed chest pain 5 minutes apart. 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 6. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) needed shortness breath, wheezing. 9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES DAY MEALS). 11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: Two (2) Adhesive Patch, Medicated Topical 12 HOURS ON, 12 HOURS (). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO day needed constipation. 16. Miralax 17 gram Powder Packet Sig: Seventeen (17) grams PO day needed constipation. 17. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times day). 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) needed constipation. 19. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) needed constipation. 20. Morphine Concentrate 20 mg/mL Solution Sig: 0.5 mg PO every six (6) hours needed pain. Discharge Disposition: Extended Care Facility: [Hospital3 2732] & Retirement Home - [Location (un) 55] Discharge Diagnosis: Primary Diagnosis: Acute Chronic Systolic Diastolic Heart Failure Pulmonary Edema Left Renal Artery Stenosis Secondary Diagnosis: Hypertension Diabetes Coronary Artery Disease Discharge Condition: Mental Status: Confused - sometimes Level Consciousness: Lethargic arousable Activity Status: Ambulatory - requires assistance aid (walker cane) Discharge Instructions: presented hospital body pain chest pain. EKG blood tests show evidence heart attack, found heart failure. hospital, frequent episodes shortness breath improved starting Lasix help remove fluid. admission, many discussions whether start dialysis. final decision dialysis started, instead pursue hospice care instead. discharged nursing facility help treating symptoms making comfortable. . medications changed, please take medications listed below: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) needed chest pain: 3 tablets needed chest pain 5 minutes apart. 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 6. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) needed shortness breath, wheezing. 9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES DAY MEALS). 11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: Two (2) Adhesive Patch, Medicated Topical 12 HOURS ON, 12 HOURS (). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours). 13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 14. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO day needed constipation. 16. Miralax 17 gram Powder Packet Sig: Seventeen (17) grams PO day needed constipation. 17. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times day). 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) needed constipation. 19. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) needed constipation. 20. Morphine Concentrate 20 mg/mL Solution Sig: 0.5 mg PO every six (6) hours needed pain. Weigh every morning, [Name8 (MD) 138] MD weight goes 3 lbs. Followup Instructions: Please call schedule appointment see primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3029] ([Telephone/Fax (1) 250**]), needed.	[ "496", "412" ]
Admission Date: [2191-11-28] Discharge Date: [2191-12-21] Date Birth: [2114-4-22] Sex: F Service: CARDIOTHORACIC Allergies: Morphine / Heparin Agents Attending:[First Name3 (LF) 1283] Chief Complaint: Mrs. [Known lastname ] s/p CABG [2187], increasing SOB/DOE. underwent cardiac catheterization [11-24] showed patent LIMA-LAD, totally occluded SVG-OM ectatic SVG-PDA, aortic valve area 0.59cm2. admitted [Hospital 24356] hospital diuresis due elevated wedge pressure transferred [Hospital1 18] surgery Major Surgical Invasive Procedure: s/p redo sternotomy/CABGx1 SVG-PDA/AVR 21mm pericardial [12-7] History Present Illness: Mrs. [Known lastname ] s/p CABG [2187], increasing SOB/DOE. underwent cardiac catheterization [11-24] showed patent LIMA-LAD, totally occluded SVG-OM ectatic SVG-PDA, aortic valve area 0.59cm2. admitted [Hospital 24356] hospital diuresis due elevated wedge pressure transferred [Hospital1 18] surgery. Past Medical History: CAD s/p CABG [2187] aortic stenosis h/o breast CA s/p lumpectomy radiation therapy R breast carotid stenosis-bilateral 50-70% lesions DM-type 2 elevated cholesterol venous stasis Physical Exam: discharge physical exam: T:98.1 P63 atrial fibrillation BP:123/62 RR:18 RA:SpO2 95% RA weight:[12-21] 91.4kg Neurological exam:She awake, alert, oriented x3, non-focal. Cardiovascular exam: regular rate rhythm without rub murmur Respiratory:breath sounds clear without wheezes rales GI:positive bowel sounds, soft, obese, non-tender, non-distended, nausea Extremities:warm well perfused, bilateral lower extremeties mild erythema, chronic venous stasis changes plaques. warmth tenderness. Sternal incision clean dry, area proximal portion incision 2 areas scabbed skin tears. erythema drainage. veing harvest site knee clean, dry intact Pertinent Results: [2191-12-21] 05:58AM BLOOD WBC-8.4 RBC-4.27 Hgb-12.9 Hct-37.9 MCV-89 MCH-30.3 MCHC-34.1 RDW-15.7* Plt Ct-277 [2191-12-21] 05:58AM BLOOD Plt Ct-277 [2191-12-21] 05:58AM BLOOD PT-20.3* PTT-32.6 INR(PT)-2.6 [2191-12-21] 05:58AM BLOOD Glucose-66* UreaN-16 Creat-1.0 Na-138 K-4.2 Cl-95* HCO3-34* AnGap-13 Brief Hospital Course: Mrs. [Known lastname ] admitted [Hospital1 18] [11-28] pre-operative evaluation. started IV heparin coronary disease. taken operating room [12-2] induced general anesthesia. noted purulent drainage lower extremeties area venous stasis. surgery canceled transferred ICU allow awaken started antibiotics. vascular surgery infectious disease consult obtained patient underwent ultrasound studies LE show significant reflux arterial occlusion. antibiotics, erythema drainage improved continued Lasix edema improved patient taken operating room [12-7] redo sternotomy, CABGx1-SVG-PDA, AVR 21 mm pericardial valve. patient transferred ICU stable condition. weaned extubated mechanical ventilation [12-7] without difficulty. episodes nausea started Reglan antiemetic relief. chest tubes pacing wires removed without incident. started lo dose Lopressor tolerated well, escalating doses Lasix achieve adequate diuresis. transferred ICU regular floor POD#5. early morning POD 6, developed atrial fibrillation rate controlled. thrombocytopenia postoperatively heparin antibody test found positive. hematology consult obtained recommended started argatroban anticoagulation. started well Coumadin argatroban turned INR became therapeutic. underwent ultrasound R arm due swelling show venous clot obstruction. postoperative course, continued nauseaus, KUB showed lot stool aggressive bowel regime. time, PO intake poor. GI consult obtained recommended continue current therapy POD#13 nausea improving. POD#12 noted periods bradycardia atrial fibrillation decided discontinue Lopressor, pauses. Medications Admission: aspirin 325mg qd lisinopril 5mg qd insulin 70/30 18 units qam, 15units qpm lopressor 50mg qam 25mg qpm nitropaste lasix 80mg iv qd Discharge Medications: 1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) needed. 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) needed constipation. 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) needed constipation. 7. Rosuvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed. 10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) needed. 11. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 6 hours) needed pain. 12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 14. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Reglan 10 mg Tablet Sig: One (1) Tablet PO four times day needed nausea. 16. Insulin 70/30 70-30 unit/mL Suspension Sig: Five (5) units Subcutaneous twice day. 17. Insulin Regular Human 300 unit/3 mL Syringe Sig: directed Subcutaneous four times day: BS 121-140 2units SC BS 141-160 3units SC BS 161-180 4units SC BS 181-200 5units SC BS 201-220 6units SC BS 221-240 7units SV . Discharge Disposition: Extended Care Facility: [Location (un) ] [Location (un) 701] Discharge Diagnosis: AS/CAD h/o CHF DM PVD s/p breast lumpectomy d/t CA s/p radiation R breast carotid stenosis 50-70% bilaterally s/p CABG [2187] s/p redo sternotomy/AVR/redo CABG bilateral LE venous stasis bilateral LE cellulitis post op atrial fibrillation post op urinary retention post op gastroparesis/ileus/constipation +heparin antibodies Discharge Condition: good Discharge Instructions: may take shower wash incisions mild soap water swim take bath 1 month drive 1 month lift anything heavier 10 pounds 1 month apply lotions, creams, ointments powders incisions Followup Instructions: follow Dr. [Last Name (STitle) ] 2 weeks follow [Doctor Last Name ] 2 weeks follow Dr. [Last Name (STitle) ] [3-31] weeks Completed by:[2191-12-21]	[ "412" ]
Admission Date: [2107-1-17] Discharge Date: [2107-2-12] Date Birth: [2042-4-4] Sex: F Service: MEDICINE Allergies: Keflex / Penicillins / Erythromycin Base / Demerol / Ceclor Attending:[First Name3 (LF) 2932] Chief Complaint: SOB Major Surgical Invasive Procedure: None. History Present Illness: 64 yo woman w/ h/o recurrent PEs s/[Initials (NamePattern4) ] [Last Name (NamePattern4) 260] filter, GIB anticoagulated, COPD, discharged [2107-1-12] treated new PE presented ED SOB productive cough. readmitted [2107-1-17] found multifocal pneumonia treated Levo/Flagyl Vanco. Cultures positive MRSA. Levo Flagyl continued suspected aspiration PNA. pt recovered quickly since admission back home O2 requirement. getting bridged anticoagulation Lovenox starting [1-18] preparation discharge. However, developed severe abdominal pain palpable mass L abdomen. CT showed new large hematoma muscles left anterior lateral lower abdominal pelvic wall, without intraperitoneal retroperitoneal extent, associated mass effect lower abdominal pelvic bowel loops. Surgery [Month/Year (2) 4221] suggested intervention, monitoring now. HCT dropped 6 points setting, remained hemodynamically stable tachycardia present throughout hospital stay (95-115). required total 5 units PRBC 4 units FFP transfusions transferred MICU monitoring. hematocrit since stable serial checks. . ROS: baseline left mid chest pain exertion currently bothering her. denies current chest pain, SOB, dysuria, increased urinary frequency. stable R knee pain. Past Medical History: 1. H/O Rheumatic Fever - age 8 -dx'ed last year rheumatic heart disease per pt (states ED diagnosed this) syndenham chorea 2. ?CHF per pt. although [12-13] Echo revealed low normal LVEF, mildly thickened aortic mitral valves mild MR [First Name (Titles) ] [Last Name (Titles) ]. 3. Orthostatic hypotension 4. Chest pain - nearly monthly visits ED negative ischemic w/u past 5. Duodenal/gastric ulcer 6. Seven miscarriages 7. Ulcerative colitis 8. Diverticulosis-s/p colostomy reversal colostomy-had Colonoscopy [1-12] showed diverticuli without e/o active bleed 8. Panic attacks x 15 yrs 9. Depression - several SA past 10. Schizoaffective disorder 11. h/o polysubstance abuse 12. Iron deficiency anemia (baseline unclear-high 20's 30's) 13. COPD 14. PE [7-13], c/b GIB anticoagulation, s/[Initials (NamePattern4) ] [Last Name (NamePattern4) 260] filter. New PE [2107-1-2], anticoagulation Social History: Lives lodge house. homemaker help cleaning. gets meals wheels. limited funds. Smoked 2 PPD X 40 yrs, quit smoking 4 months ago. Former drinker, reports drinking two 6 packs per day 2 yrs; quit 27 yrs ago. Denies h/o illicits IVDA. H/O domestic violence. Family History: Daughter -40 - colitis. 6 siblings. One sister died, 35, ovarian CA. Brother, died 48, stroke. Sister, died 64 infection. Father died 65 MI. Mom "psychotic", died stroke 93 Physical Exam: VS: 97.6 HR 114, Bp 118/74 RR 20-30 Sats 98% 2L. Gen: NAD, pleasant HEENT: PEERLA, MMM. Neck: supple, LAD Lungs: moderate air movement, decreased breath sounds bases CV: RRR, S1S2 present, distant heart sounds, murmurs Abd: +BS, S/ND, + umbilical hernia, ulcer mid abdomen-reportedly chronic, unchanged, mildy errythematous base. secretions. Tenderness L abdomen, palpable mass unclear extension, guarding, rebound Back: CVA tenderness. Ext: 2+ RLE, 1+ edema LLE/ c/c/ 1+ DP Neuro: A&Ox3, CN II-XII intact. moving extremities. Pertinent Results: ADMISSION LABS: [2107-1-16] 08:40PM PT-87.9* PTT-41.3* INR(PT)-11.8* [2107-1-16] 08:40PM WBC-16.2# RBC-3.63 HGB-11.6* HCT-33.5* MCV-93 MCH-32.1* MCHC-34.7 RDW-14.0 [2107-1-16] 08:40PM NEUTS-90.5* BANDS-0 LYMPHS-4.7* MONOS-2.4 EOS-2.0 BASOS-0.5 [2107-1-16] 08:40PM GLUCOSE-127* UREA N-16 CREAT-1.0 SODIUM-136 POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-29 ANION GAP-13 [2107-1-16] 11:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2107-1-17] 12:47AM LACTATE-1.3 [2107-1-22] 03:07AM BLOOD WBC-7.5 RBC-2.85# Hgb-8.6# Hct-25.6* MCV-90 MCH-30.3 MCHC-33.6 RDW-14.4 Plt Ct-243 [2107-1-22] 03:07AM BLOOD PT-22.4* PTT-31.1 INR(PT)-2.2* [2107-1-22] 03:07AM BLOOD Glucose-105 UreaN-11 Creat-0.6 Na-141 K-4.0 Cl-102 HCO3-35* AnGap-8 [2107-1-22] 03:07AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.1 [2107-1-23] 04:34PM BLOOD PEP-HYPOGAMMAG IgG-535* IgA-254 IgM-109 . CTA chest: 1. Interval development patchy areas consolidation mucous plugging, particularly right lower lobe, right upper mid lobes suggest new infectious process aspiration. 2. Resolution previously identified pulmonary embolism. 3. Extensive centrilobular paraseptal emphysematous change. 4. Fluid-attenuating structure adjacent right T11-12 neural foramen also unchanged could perineural cyst. . CT abdomen/pelvis: 1. New large hematoma muscles left anterior lateral lower abdominal pelvic wall, without intraperitoneal retroperitoneal extent, associated mass effect lower abdominal pelvic bowel loops. 2. Unchanged infectious inflammatory opacities right middle lower lobes. . [2107-2-1] IR Embolization: 1. Right inferior epigastric arteriogram demonstrates extravasation contrast successful embolization Gelfoam stagnation flow. 2. right internal mammary artery demonstrated areas active extravasation contrast. . [2107-2-3] CXR: irregular opacity right lower lobe concerning pneumonia. pleural effusions. pneumothorax. left subclavian catheter tip overlies mid SVC. Heart size normal. Mediastinal hilar contours normal. IMPRESSION: Opacity right lower lobe concerning pneumonia. . [2107-2-8] LENIS: Extensive occlusive thrombus demonstrated common femoral vein takeoff greater saphenous vein extending distally popliteal veins bilaterally. color flow, compressibility, waveforms demonstrated within areas thrombus. IMPRESSION: Extensive, completely occlusive, bilateral deep venous thrombi extending common femoral veins popliteal veins. . [2107-2-9] ECG: Sinus tachycardia, Normal ECG except rate Brief Hospital Course: 64F w/ h/o recurrent PE s/[Initials (NamePattern4) ] [Last Name (NamePattern4) 260] filter, GIB anticoagulation, COPD, recently admitted new PE, readmitted multifocal PNA, developed large abdominal wall hematoma context enoxaparin injections. # Multifocal Pneumonia: admitted multifocal pneumonia. started levofloxacin vancomycin. completed 7 day course levofloxacin. MRSA found grow sputum continued 14 day course vancomycin. originally presented elevated WBC count left shift quickly resolved initiation antibiotics. productive cough improved well remained baseline home O2 2L. Approximately 4 days completion 14 day course Vancomycin, patient developed worsening cough, SOB, upper respiratory symptoms. repeat CXR showed evidence new consolidation RLL. patient started back Levofloxacin/Flagyl. Vancomycin added regimen blood cultures showed 2/4 bottles GPC clusters chains. Additionally, sputum culture grew GNRs. Levofloxacin discontinued Meropenem started concern Pseudomonas given patient's long hospital course. O2 sat remained stable 93-100% 2L nasal cannula (which baseline). given mucomyst inhaled nebulizers assist breaking thick sputum. GNRs sputum grew E. coli. sensitivity profile E. coli patient's allergy penicillin cephalosporins, patient continued Meropenem. GPCs found grow Coag negative Staph. Surveillance cultures growth coag negative staph thought likely contaminant. Vancomycin discontinued. continue 14 day course Meropenem discharged PICC complete course. . # Pulmonary embolism/DVTs: multiple PEs one even since placement TrapEase IVC filter. CT recent previous hospitalization revealed appropriate location filter CTA admission showed improvement clot. Admission labwork revealed INR 7.9. Coumadin thus held reversed FFP vitamin K given history GIB anticoagulation. interim, therapeutic lovenox injections initiated, within days starting, developed large abdominal wall hematoma near lovenox injection site. hematocrit stabilized, started heparin gtt coumadin overlap. [Last Name (NamePattern4) 9533] Coumadin INR 1.2, found large Hct drop CT scan abdomen showed new rectus hematoma. subsequently transferred MICU closer monitoring. decided second hematoma anticoagulation, risks anticoagulation outweigh benefits time anticoagulated. terms hypercoagulable workup, negative thus far hyperhomocysteinemia, Factor V Leiden antiphospholipid antibody. Malignancy workup included colonoscopy EGD well CEA, within normal limits. SPEP revealed hypogammaglobulinemia, otherwise unremarkable. hospital course, also began complain worsening lower extremity pain. LENIs obtained showed evidence extensive, completely occlusive, bilateral deep venous thrombi extending common femoral veins popliteal veins. Radiology felt clots likely acute subacute nature. setting, hematology/oncology saw patient consider risks vs benefits anticoagulation. Antithrombin III, prothrombin mutation, Lupus anticoagulation [Location (un) 1169] Venom Viper sent reevaluate reason hypercoagulability. hematology/oncology team still felt risks coagulation outweigh potential benefits given patient multiple bleeding episodes setting anticoagulation. # Abdominal wall hematoma: mentioned above, developed large left-sided abdominal wall hematoma Lovenox injection site caused significant hct drop (originally 28.1-->19.4). Despite drop, remained hemodynamically stable (has sinus tachycardia baseline prior bleed). received 3 units prbcs, 4 units FFP. hematocrit stabilized stable, restarted heparin gtt. Coumadin re-initiated heparin gtt continued awaiting INR become therapeutic. [Location (un) 9533] Coumadin INR 1.2, found another Hct drop (25.9-> 22.2) CT scan abdomen showed new right-sided rectus hematoma. subsequently transferred MICU closer monitoring. given 1 unit FFP 9 units PRBCs [Date range (1) 39125] hematocrit became stable bumped appropriately transfusion. decided second hematoma anticoagulation, risks anticoagulation outweigh benefits time anticoagulated. complained [6-16] abdominal pain movement maintained stable hematocrits. pain likely [3-11] large rectus hematoma resolve time. Hct remained stable anticoagulation discontinued. # Thoracic mass: CT chest abdomen revealed stable thoracic mass (stable x 3years) thought potentially consistent neural cyst. evaluated MRI given long term stability also metal hardware place s/p elbow surgery facial plates. followed imaging ensure remains unchanged future. # ? Zoster: Patient reports history "herpes" right buttock. stay, developed tingling, itchiness multiple small erythematous skin lesions right buttock S2, S3 dermatomal distribution. vesicles appreciated. treated acyclovir. # Candidal vaginitis: Treated fluconazole x 2 resolution symptoms. # H/o GI bleeding recent admission: Recent colonoscopy showed diverticulosis active signs bleeding. blood stools admission even anticoagulated. stools guiac-ed multiple times found guiac negative. # Constipation: constipated baseline requires daily scheduled bowel regimen maintian regularity. # Hyperlipidemia: Continued lipitor. # Depression/SAD: Continued Prozac, risperdone, wellbutrin, klonopin. # Ulcerative Colitis: Remains remission. continued mesalamine. # Orthostatic hypotension: remained asymptomatic even ambulating physical therapy. continued midodrine. Medications Admission: 1. Fluoxetine 30 mg daily 2. Risperidone 3 mg PO HS 3. Bupropion SR 150 mg [Hospital1 ] 5. Nicotine 7 mg/24 hr Patch 6. Hexavitamin daily 7. ascorbic acid 500 tab 1 [Hospital1 ] 8. Calcium Carbonate 500 tab [Hospital1 ] 9. Ferrous gluconate 325 PO daily 10. Atorvastatin 20 mg daily 11. Fluticasone Salmeterol 250/50 [Hospital1 ] 12. Midodrine 5 mg tab 1 TID 13. Tiotropium bromide capsule one cap /day 14. Mesalamine 1200 TID 15. Pantoprazole 40/ day 16. Albuterol nebs prn (tid generally) 17. docusate sodium 18. Warfarin 5 mg/day 19. Ipratropium nebs prn (tid generally) 20. clonazepam 1mg po tid Discharge Medications: 1. Fluoxetine 10 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 2. Risperidone 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 3. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times day). 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times day). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk Device Sig: One (1) Disk Device Inhalation [Hospital1 ] (2 times day). 7. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times day). 8. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO TID (3 times day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 11. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 12. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): please take levofloxacin. 13. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane Q4H (every 4 hours) needed. Disp:100 Lozenge(s) Refills:0 14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [2-8] Sprays Nasal QID (4 times day). Disp:QS bottle Refills:2 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day). Disp:60 Tablet(s) Refills:2 17. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times day) needed anxiety. Disp:20 Tablet(s) Refills:0 18. Saline Flush 0.9 % Syringe Sig: Three (3) ml Injection twice day 20 doses: prior vanco dose. Disp:20 syringe Refills:0 19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice day. 20. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times day) needed. 21. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times day) needed. 22. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) needed constipation. 23. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 6 hours) needed pain. 24. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD (). 25. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 26. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times day). 27. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) needed wheezing. 28. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 29. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) needed pain. 30. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) needed: PICC line. 31. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) 7 days. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary: 1) Pulmonary Embolism history DVT IVC filter placement [2106-7-8] 2) Community Acquired Pneumonia 3) History GI Bleed (extensive) [2106-7-8] anticoagulated 4) Abdominal wall hematoma, acute blood loss anemia requiring 10 units PRBCs anticoagulated current pulmonary embolism 5) Noscomial Pneumonia GNR sputum, 6) Coagulopathy 7) Noscomial UTI E. coli - quinolone resistant 8) Vagnitis, attributed broad spectrum antibiotic usage 9) otitis externa 10) tachycardia 11) diarrhea 12) incidentally noted left renal cyst/mass NOS 13) Coagulase negative staphylococcal bacteremia 14) Rectus sheath hematoma setting anticoagulation . Secondary: 1) chronic orthostatic hypotension 2) recurrent otitis externa 3) ulcerative colitis remission 4) chronic obstructive pulmonary disease 5) depression 6) h/o schizoaffective disorder Discharge Condition: Stable. Discharge Instructions: Please take medications prescribed, please keep follow-up appointments. Please call primary care doctor, Dr. [First Name8 (NamePattern2) 1158] [Last Name (NamePattern1) ], return Emergency Department experience fevers, chills, worsening shortness breath, dizziness, lightheadedness, worsened chest pain, nausea, vomiting, diarrhea, blood stools symptoms concern you. . Please take medications prescribed follow primary care doctor [First Name (Titles) 3] [Last Name (Titles) 4030] below. Followup Instructions: need set followup appointment see Dr. [First Name8 (NamePattern2) 1158] [Last Name (NamePattern1) ] [2-8] weeks. Please call ([Telephone/Fax (1) 39126] set appointment. . following appointment scheduled prior hospitalization: Provider: [Name10 (NameIs) ] SURGERY CLINIC Phone:[Telephone/Fax (1) 4652] Date/Time:[2107-1-28] 1:00 *Follow CT scan ultrasound left kidney recommended well Urologic follow due incidentally noted left renal cyst/mass may malignant.*** [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 2937] Completed by:[2107-2-12**]	[ "496" ]
Admission Date: [2146-11-17] Discharge Date: [2146-11-25] Service: NEUROLOGY Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 8747] Chief Complaint: Left sided weakness Major Surgical Invasive Procedure: None History Present Illness: Mr. [Known lastname 65376] 83 yo RHM USOH afternoon sudden-onset left-sided weakness led falling ground. managed couple bystanders help get back motor scooter drive home. went apartment tried go bathroom. fell toilet found could get toilet called neighbor. [Name (NI) ] denies head trauma, HA, N/V, vertigo. ambulance brought [Hospital3 1443] Hospital head CT revealed right thalamocapsular hemorrhage transferred [Hospital1 18] management. sister reported recent weight loss. f/c/s/n/v/d, changes voice, difficulty swallowing, hearing, dizziness, vertigo, diplopia, blurry vision, headache, head trauma. Past Medical History: Inguinal hernia ORIF hip fx History MVA dragged car 70 years ago Social History: Lives alone, previously able care himself. Unmarried. intermittent contact two sisters daughter. Denies smoking, drugs, EtOH use. Family History: neurological disease. CA. Mother diabetes died CHF complication parathyroid abnormality. Father died 87 accident. Brother recently admitted [Hospital1 18] traumatic intracranial bleed. Physical Exam: PE: Gen, thin HEENT AT/NC, MMM lesions, bruits Neck Supple, thyromegaly, [Doctor First Name ], bruits Chest Clear, slightly decreased BS right base CVS RRR w/o MGR ABD soft, NTND, + BS, large left sided inguinal hernia. EXT C/C/E. petechiae, asterixis, rash penis, much lower extremities. Severe nail disease. Neuro MS: AA&Ox3, appropriately interactive, normal affect, normal fund knowledge [Doctor Last Name 1841] errors, simple calculations intact, fluent without paraphrasic errors. Prosody slow flat. Naming, [Location (un) 1131], intact. 0/3 5 minutes,[3-3] prompting L/R confusion. Normal graphesthesia. Able mimic brushing teeth either hand. CN: I--not tested; II,III-PERRLA, VFF confrontation, optic discs sharp normal vasculature; III,IV,VI-EOMI w/o nystagmus, ptosis; V--sensation intact LT/PP, masseters strong symmetrically; VII-Left facial weakness sparing forehead; VIII-hears finger rub bilaterally; IX,X--voice normal, palate elevates symmetrically, uvula midline, gag intact; [Doctor First Name 81]--SCM/trapezii [5-5]; XII--tongue protrudes midline, slight apraxia Motor: Normal bulk tone. rigidity, tremor, bradykinesia Strength: Left sided hemiplegia. Coord: FFM slow LEFT accurate. Refl: [Hospital1 ] Tri Brachio Pat [Doctor First Name ] Toe R 2 2 2 2 2 L 2 2 2 2 2 [Last Name (un) ]: LT, PP, temperature, vibration, position sense intact. evidence extinction. Pertinent Results: [2146-11-25] 11:25AM BLOOD WBC-9.3 RBC-3.86* Hgb-12.5* Hct-36.0* MCV-93 MCH-32.4* MCHC-34.8 RDW-13.6 Plt Ct-180# [2146-11-24] 05:15AM BLOOD WBC-6.8 RBC-3.73* Hgb-11.9* Hct-34.9* MCV-93 MCH-32.0 MCHC-34.3 RDW-13.5 Plt Ct-115* [2146-11-23] 05:50AM BLOOD WBC-6.9 RBC-3.79* Hgb-12.3* Hct-35.3* MCV-93 MCH-32.4* MCHC-34.8 RDW-13.7 Plt Ct-85* [2146-11-22] 10:40AM BLOOD WBC-11.2* RBC-3.98* Hgb-12.7* Hct-35.8* MCV-90 MCH-31.9 MCHC-35.5* RDW-14.0 Plt Ct-77* [2146-11-22] 05:15AM BLOOD WBC-14.5* RBC-3.79# Hgb-12.0# Hct-34.3# MCV-91 MCH-31.6 MCHC-34.9 RDW-14.2 Plt Ct-67 [2146-11-21] 01:57AM BLOOD WBC-15.4* RBC-2.91* Hgb-9.4* Hct-26.5* MCV-91 MCH-32.3* MCHC-35.5* RDW-13.9 Plt Ct-65* [2146-11-20] 03:00AM BLOOD WBC-19.6* RBC-2.98* Hgb-9.8* Hct-28.1* MCV-94 MCH-32.8* MCHC-34.8 RDW-13.4 Plt Ct-70* [2146-11-19] 02:30AM BLOOD WBC-25.1# RBC-3.44 Hgb-11.2* Hct-32.3* MCV-94 MCH-32.6* MCHC-34.7 RDW-13.4 Plt Ct-106* [2146-11-18] 04:58AM BLOOD WBC-5.7 RBC-3.66* Hgb-12.4* Hct-34.2* MCV-93 MCH-33.9* MCHC-36.3* RDW-12.9 Plt Ct-118* [2146-11-17] 07:30PM BLOOD WBC-6.7 RBC-3.78* Hgb-12.4* Hct-34.0* MCV-90 MCH-32.7* MCHC-36.4* RDW-13.1 Plt Ct-117* [2146-11-25] 11:25AM BLOOD Plt Ct-180# [2146-11-25] 11:25AM BLOOD Glucose-110* UreaN-23* Creat-0.7 Na-138 K-4.6 Cl-104 HCO3-27 AnGap-12 [2146-11-24] 05:15AM BLOOD Glucose-111* UreaN-32* Creat-1.1 Na-139 K-4.4 Cl-106 HCO3-26 AnGap-11 [2146-11-23] 05:50AM BLOOD Amylase-53 [2146-11-22] 10:40AM BLOOD ALT-102* AST-52* Amylase-56 TotBili-0.6 [2146-11-19] 02:30AM BLOOD CK(CPK)-1600* [2146-11-21] 01:57AM BLOOD CK(CPK)-120 [2146-11-25] 11:25AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.8 [2146-11-18] 04:58AM BLOOD VitB12-786 [2146-11-18] 04:58AM BLOOD %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE [2146-11-18] 04:58AM BLOOD Triglyc-40 HDL-98 CHOL/HD-2.1 LDLcalc-98 [2146-11-22] 10:40AM BLOOD Ammonia-20 [2146-11-18] 04:58AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Barbitr-NEG Tricycl-NEG Urine Culture KLEBSIELLA PNEUMONIAE \| ENTEROBACTERIACEAE \| \| KLEBSIELLA PNEUMONIAE \| \| \| AMPICILLIN/SULBACTAM-- 4 4 <=2 CEFAZOLIN------------- <=4 <=4 <=4 CEFEPIME-------------- <=1 <=1 <=1 CEFTAZIDIME----------- <=1 <=1 <=1 CEFTRIAXONE----------- <=1 <=1 <=1 CEFUROXIME------------ 2 2 <=1 GENTAMICIN------------ <=1 <=1 <=1 IMIPENEM-------------- <=1 2 <=1 LEVOFLOXACIN----------<=0.25 <=0.25 <=0.25 MEROPENEM-------------<=0.25 <=0.25 <=0.25 NITROFURANTOIN-------- 32 =>512 R <=16 PIPERACILLIN/TAZO----- <=4 <=4 <=4 TOBRAMYCIN------------ <=1 <=1 <=1 TRIMETHOPRIM/SULFA---- <=1 <=1 <=1 Blood culture [11-18] KLEBSIELLA PNEUMONIAE \| AMPICILLIN/SULBACTAM-- 4 CEFAZOLIN------------- <=4 CEFEPIME-------------- <=1 CEFTAZIDIME----------- <=1 CEFTRIAXONE----------- <=1 CEFUROXIME------------ 2 GENTAMICIN------------ <=1 IMIPENEM-------------- <=1 LEVOFLOXACIN----------<=0.25 MEROPENEM-------------<=0.25 PIPERACILLIN/TAZO----- <=4 TOBRAMYCIN------------ <=1 Repeat Urine culture <10,000 colonies Repeat Blood cultures negative three days. Head CT [11-17]:Right basal ganglia 21 x 10 mm intraparenchymal hemorrhage mild surrounding edema. prior studies available comparison. Head CT [11-18]: stable hemorrhage MRI/MRA: MRI demonstrates right thalamic hemorrhage, visualized CT scan [2146-11-17]. additional areas susceptibility artifact detected. signs acute infarction. MRA demonstrates flow major branches circle [Location (un) 431] abnormal vascularity. LEFT X-ray Knee Hip: fracture, dislocation, evidence hardware loosening. CXR:A feeding tube withdrawn slightly interval. Although tip still terminates stomach, proximal portion radiodense tip likely GE junction level. Cardiac silhouette stable size demonstrates left ventricular configuration. interval marked improved aeration left retrocardiac region minimal residual atelectasis remaining. Bilateral pleural effusions improved, resolved right nearly resolved left. new worsening areas opacification suggest pneumonia. Echo/TTE:The left atrium mildly dilated. patent foramen ovale small atrial septal defect could excluded color Doppler study. Left ventricular wall thicknesses normal. left ventricular cavity size normal. mild regional left ventricular systolic dysfunction probable distal septal hypokinesis. Overall left ventricular systolic function borderline depressed. [Intrinsic left ventricular systolic function may depressed given severity valvular regurgitation.] Right ventricular chamber size free wall motion normal. aortic valve leaflets mildly thickened. Mild (1+) aortic regurgitation seen. mitral valve leaflets mildly thickened. Moderate (2+) mitral regurgitation seen. tricuspid valve leaflets mildly thickened. trivial/physiologic pericardial effusion. cardiac source embolus identifed. Brief Hospital Course: Neurology - Mr. [Known lastname 65376] admitted ICU monitoring discovered left-sided secondary right sided thalmocapsular hemorrhage. ICU, remained hemodynamically stable however neurological exam worsened left sided hemiparesis essentially, hemiplegia involving left side, including face, arm, leg. differential included hypertensive hemorrhage, mass, aneurysm, hemorrhagic conversion embolic. patient little recorded reportable medical history unclear history HTN, clearly likely diagnosis mass observed MRA negtive vascular malformation. quite hypertensive admission, BPs 200/100s requiring IV hydralazine control. patient deterioration mental status transfer ICU. encephalopathy work-up revealed bilateral pleural effusions thought secondary possible aspiration pneumonia. antibiotic regimen changed Levofloxacin Metronidazole became alert oriented within 24 hrs. complete another 6 days Levofloxacin Flagyl. Physical therapy involved care moved bed chair. HbA1C, Lipids normal. Trans-thoracic Echocardiogram revealed normal EF without vegetations. Respiratory - pt intermittently required oxygen NC. diagnosed bilateral pleural effusions possible left sided pneumonia repeat CXR [11-25] showed interval resolution. currently oxygen requirement. FEN/GI - patient difficulty swallowing maintained NGT adequate fluid nutritional intake. Speech swallow recommended: 1. Continue NG tube feedings maintain nutrition/hydration 2. PO diet consistency nectar thick liquids purees SNACK 3. Basic aspiration precautions followed: a. Pt awake alert eating b. Pt seated upright bed meals. likely benefit f/u nutrionist Rehab. Pt. also large left inguinal hernia. [Last Name 19390] problem presented acute issues him. Renal/GU - Patient admitted hyophosphatemia hypomagnesemia responded well oral IV supplementation. recent Mg Phos normalized. [Doctor First Name ] kept Neuta Phos packets [Hospital1 ]. Patient evaluated Urology service difficulty Foley catheter placement ICU. catheter placed GU; recommended voiding trial [11-25] catheter pulled patient voided spontaneously. patient microscopic hematuria GU made aware this. recommendation could followed outpatient. ID - patient Klebsiella pneumoniae urosepsis. initially placed Gentamicin. subsequently drop platelets. bacteria also sensitive ceftriaxone switched concern thrombocytopenia (low 65) secondary gentamicin. gent discontinued, platelets subsequently recovered normal range. treated Levaquin IV Flagyl 2 days complete another 6 days two antibiotics Klebsiella pneumonia. HEME - Thrombocytopenia mentioned above. Pt. developed anemia tranfussed two units PRBCs ICU. since stable CBCs. anemia likely secondary acute illness. placed Heparin 5000 U SC DVT prophylaxis. Musculoskeletal: Pt c/o pain left knee. underwent X-rays knee left hip earlier hospitalization presented fall. tests negative fracture change hardware (secondary left hip ORIF past). PODIATRY - patient severe nail fungus Podiatry debrided nails. receiveing LacHydrin moisturizing cream feet severe dryness. much improvement hospital course. DISPO - Patient PCP would definitely benefit regular medical follow-up. phone number [Hospital ] provided. patient f/u appointments Urology Neurology/Stroke. Patient require long-term assistance ADLs benefit inpatient rehabilitation. DIAGNOSIS: Right thalamocapsular hemorrhage likely secondary hypertension Medications Admission: None Discharge Medications: 1. Potassium & Sodium Phosphates [Telephone/Fax (3) 4228] mg Packet Sig: One (1) Packet PO BID (2 times day). Disp:60 Packet(s) Refills:2 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times day): Hold SBP<100 HR<60. Disp:60 Tablet(s) Refills:2 3. Lansoprazole 30 mg Susp,Delayed Release Recon Sig: Thirty (30) mg PO DAILY (Daily). Disp:900 mg Refills:2 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times day) 6 days. Disp:18 Tablet(s) Refills:0 5. Ammonium Lactate 12 % Lotion Sig: One (1) application Topical [Hospital1 ] (2 times day). Disp:60 applications Refills:2 6. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) mL PO BID (2 times day). Disp:600 mL Refills:2 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times day). Disp:90 mL Refills:2 8. Levofloxacin D5W 500 mg/100 mL Piggyback Sig: One (1) Intravenous day 6 days. Disp:6 units Refills:0 Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: Right thalamocapsular hemorrhage Left hemiplegia HTN BPH Discharge Condition: Fair Discharge Instructions: Please take medications experience new wekaness, trouble speaking swallowing, chest pain, palpitations, please inform physician Followup Instructions: Neurology/Stroke - Please call [Telephone/Fax (1) 3767] schedule apopointment Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Urology f/u BPH [Telephone/Fax (1) 164] appt. Patient require referral PCP [Name9 (PRE) 15973]. number Helath Care Assocaites is:	[ "431" ]
Admission Date: [2174-10-13] Discharge Date: [2174-11-2] Date Birth: [2121-11-5] Sex: F Service: SURGERY Allergies: Lisinopril/Hydrochlorothiazide Attending:[First Name3 (LF) 6346] Chief Complaint: bright red blood per rectum transfer outside hospital Major Surgical Invasive Procedure: Exploratory laparotomy, lysis adhesions right colectomy ileocolostomy History Present Illness: 52 F Jehovah's witness w/ pmhx HTN presents 1 day hx BRBPR rectum, occured last night 4 episodes dark red blood mixed loose stools, clots time, denies maroon stools, dark tarry stools, 1st episode. associated lightheadness, weakness later evening w/ LOC, falls, also nausea, vomitting, abdominal pain. . Presented OSH HCT noted 30 stable VS 164/85 104 16 98RA, tx'd [Hospital1 18] ED pt jehovah's witness. . ED VS 98 88 142/70 16 99RA, received 1L NS, BRB rectal vault, GI consulted recommended bowel prep colonoscopy. Here, denies weakness, cp/sob/palpitations, dysuria Past Medical History: Diverticulosis - cscope 2 yrs ago Lap CCY [9-2] Csection x3 HTN Social History: smoking, scoial drinker adminstrative assistant Family History: colon ca/ibd, NC Physical Exam: 98.8 99 118/88 16 100RA GEN: NAD, pleasant, speaking full sentences HEENT: PERRL, EOMI, OP Clear, MMM, JVD nondistended, anicteric CV: tachycardic mrg CHEST: CTA b/l mrg ABD: Soft, +BS, NT/ND, midline cscetion scar EXT: c/c/ce Neuro: AAOx3, focal deficits Pertinent Results: OSH HCT 31.9 . EKG-NSR 90bpm, NA, NI, q wave III, STT changes [2174-10-14] 06:31AM BLOOD WBC-2.9* RBC-1.52# Hgb-4.8# Hct-13.7# MCV-90 MCH-31.3 MCHC-34.7 RDW-14.0 Plt Ct-168 [2174-10-19] 10:20AM BLOOD WBC-4.9 RBC-0.94 Hgb-2.8* Hct-8.8* MCV-94 MCH-29.4 MCHC-31.3 RDW-15.3 Plt Ct-293 [2174-11-2] 12:10PM BLOOD WBC-5.7 RBC-2.58# Hgb-6.5 Hct-23.9# MCV-92 MCH-25.1 MCHC-27.2* RDW-21.7* Plt Ct-708* [10-14] Tagged RBC Scan - Moderately brisk intermittent bleeding originating ascending colon. [10-28] CT - ?cortical infarct pyelonephritis, small simple left pleural effusion adjacent atelectasis Brief Hospital Course: Patient admitted [10-13] OSH lower GI bleed since patient Jehovah's witness continued bloody bowel movements. Patient admitted medical ICU underwent tagged RBC scan suggested bleeding eminated ascending colon. Angiography performed visualize source bleeding. patient continued BRBPR general surgery service consulted. Upon consultation patient found hematocrit 13.7 emergent colectomy offered resolve active bleeding. patient refused blood products citing religious perference patient aware risks procedure consented. patient went [10-14] underwent right hemicolectomy ileocolostomy. procedure without complications patient transfered TSICU critical condition. Patient remained ventilator several days, started erythropoetin IV Iron maximize RBC production capability. started parenteral nutritional prior return bowel function. successfully extubated pod# 10 transfered floor hematocrit stabilized. patient transferred floor hematocrit slowly increased day upon discharge 23. GI Bleed - patient continued guiac positive stool ICU however felt result retained blood colon. patient transferred floor patient episodes BRBPR evidence GI bleeding. Heme - Upon discharge patients hematocrit 23.9 significantly higher post op Hct 8. patient started 20K Units EPO continue therapy 1 week well Iron supplementation 1 month. Pulm - Post operatively patient developed left lower lobe pneumonia treated one week course cipro. Upon discharge patient afrebrile normal WBC. GI - patient started parenteral nutrition unit however advanced regular diet admission floor. Patient discharged able tolerate regular diet. CV - Patient continued tachycardic throughout hospital course result anemia. also hypertensive several occassions treated IV PO Lopressor. Upon discharge patient remained tachycardic continued episodic hypertension PCP follow on. GU - ICU patient developed enterococcal urinary tract infection treated appropriately antibiotics Dispo - Patient discharged short term rehab follow Dr. [First Name (STitle) 2819] approximately 1-2 weeks Medications Admission: Diovan 160mg Daily HCTZ 25mg Daily ASA 81mg daily MVI Discharge Medications: 1. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) injection Injection QMOWEFR (Monday -Wednesday-Friday) 1 weeks. Disp:3 injection Refills:0 2. NuvaRing Vaginal 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times day) 1 months. Disp:60 Tablet(s) Refills:0 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical 12 HOURS DAY (). Disp:20 Adhesive Patch, Medicated(s) Refills:1 7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) needed pain/fever. 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times day). 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) needed breakthrough pain only. Disp:20 Tablet(s) Refills:0 10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice day. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Lower GI bleeding Hemorrhagic Shock Acute Blood loss anemia Urinary tract infection Left Lower Lobe pneumonia Post op fluid overload Discharge Condition: Good, patient afebrile stable vital signs, tolerating regular diet, ambulating without bloody bowel movements. Discharge Instructions: Please [Name8 (MD) 138] MD go ER experience Temp>101.5, severe chest pain, shortness breath, bloody stools, severe abdominal pain, severe nausea/vomiting inability tolerate food. steri strips covering incision fall own. may shower, however keep incision clean dry. Followup Instructions: Please call Dr.[Name (NI) 11471] office schedule follow appointment approximately 1-2 weeks.	[ "486" ]
Admission Date: [2115-9-20] Discharge Date: [2115-10-16] Service: OBSTETRICS/GYNECOLOGY Allergies: Ultram / Ether Attending:[First Name3 (LF) 7141] Chief Complaint: abdominal pain, transfer OSH care Major Surgical Invasive Procedure: PICC line placement CT guided abdominal Biopsy Exploratory laparotomy Resection pelvic mass lymph node dissection Small bowel resection anastomosis Cystectomy Ileo-conduit placement Omentopexy Sigmoidoscopy 11 units blood transfusion 1 unit FFP transfusion ICU admission x 2 hypotension hemolytic transfusion reaction. History Present Illness: HPI: Ms [Known lastname ] presents daughter 3 month history worsening nausea, weight loss decreased appetite. initially evaluated admitted [Hospital 1474] hospital [Date range (1) 39208] fell back slipping wet surface. arrival, also found nausea abdominal pain time pelvic mass discovered exam. underwent CT evaluation received IVF pain meds. abdominal back pain improved vicodin darvocet. Following discharge [9-13], informed PCP Dr [Last Name (STitle) 3314] likely ovarian malignancy undergo colonoscopic evaluation. started prep Golytely felt awful this, declined actually undergo colonoscopy. . Patient came [Hospital1 18] care. Continues experience abdominal pain, confirmed large pelvic mass, 16cm, small lesions liver (cannot characterize) uncinate process. Pathology consistent either GYN primary (ovarian) vs Renal. . Per Med consult, history angina (but use NTG past months). able ADLs walk around mall without CP SOB. Denied recent RVR episodes CHF hospitalizations (maintained 40mg [Hospital1 ] lasix). Previous cardiac catheterization >2 yrs ago, interventions done. Hx MI. DM. . Per family, prior admission lost weight w/ decreased energy. Also, bowel movement 10 days. Otherwise ROS neg. Past Medical History: CHF (EF 55% echo several years ago) Mitral regurgitation Afib pacemaker osteoporosis hypothyroid PSH: TAH-BSO (40 years ago unclear reasons daughters entirely sure whether ovaries removed time), pacemaker placement [2112] Social History: Remote smoking hx. etoh. Lives independent driving previously. Several children live nearby. Family History: hx colon, breast, ovarian CA Mother hodgkin's disease Father oral cancer mets. Physical Exam: time admission: 98.2 75 120/61 16 95%RA Lying bed, appears mildly uncomfortable Gen: A&O x 3. Gait inspected. Answers questions appropriately. HEENT: thrush, [Doctor First Name ] Breasts: [Doctor First Name ], masses, nipple discharge inversion LUNGS: CTAB CVS: RRR, murmurs Back: tenderness elicited level lumber spine along bony processes. bruising seen. ABD: moderately distended, tympanic percussion RUQ/LUQ, dull percussion RLQ/LLq. Firm, non-mobile mass lower quadrants tender palpation rebound guarding. +BS. RECTAL: deferred (guaiac neg per ED resident) BIMANUAL: deferred (pt uncomfortable time) LE: 1+ pitting edema mid-calf LLE. palpable cord tenderness. Ecchymosis along medial aspect right knee shin mildly tender palpation. [4-27] motor strength hip knee flexion/extension. limited ROM kness bilaterally. effusion swelling knees bilaterally. Pertinent Results: STUDIES: PATHOLOGY: Procedure date Tissue received Report Date Diagnosed [2115-10-2] [2115-10-2] [2115-10-10] DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/lo?????? Previous biopsies: [-6/3848] ABDOMEN BX. DIAGNOSIS: Pelvic mass resection: I. Pelvic mass (A-E): Epithelioid malignant mesothelioma (see note). II. Lymph node, left external iliac (F-H): malignancy identified (0/2) nodes. III. Segment bladder dome (I Z): Malignant mesothelioma involving bladder wall undermining mucosa. tumor appear arise bladder mucosa in-situ carcinoma seen. IV. Peritoneal tumor (J): Malignant mesothelioma adipose tissue. V. Bladder, vagina, pelvic mass (K-R, X-Y): Malignant mesothelioma extending vagina bladder walls. tumor appear arise vaginal bladder mucosa precursor lesion seen. VI. Segment small bowel (S-T): Malignant mesothelioma involving serosa small intestine bowel. tumor arise bowel mucosa precursor lesion seen. VII. Omentum (U-W): Malignant mesothelioma. [10-11] CXR: REASON EXAM: Assess pleural effusions pulmonary edema. Patient S/P surgery. Comparison made prior studies including recent one dated [2115-10-10]. Cardiomediastinal contour unchanged. Right transvenous pacemaker leads terminate standard position right atrium right ventricle. CHF. minimal vascular engorgement stable. Blunting left lateral costophrenic angle adjacent lung opacity unchanged, due small pleural effusion adjacent atelectasis. [10-10]: LENIs FINDINGS: Grayscale color Doppler imaging common femoral, superficial femoral, popliteal veins performed bilaterally. Normal compressibility, flow, waveform, augmentation demonstrated. intraluminal thrombus identified. IMPRESSION: evidence DVT. [10-8] LENIs RIGHT LOWER EXTREMITY VENOUS ULTRASOUND: [Doctor Last Name ]-scale Doppler son[Name (NI) 1417] right common femoral, superficial femoral, popliteal veins performed. Normal compressibility, augmentation, flow, waveforms demonstrated. evidence intraluminal thrombus. . CT [2115-10-9] IMPRESSION: 1. New small bilateral pleural effusion associated atelectasis (left greater right). 2. Small amount ascites slightly increased size since prior study. 3. Pelvic loculated fluid collection may represent organizing postoperative fluid collection/ hematoma. Alternatively, less likely, may reflect residual tumor.There 3.7 x 4.2 cm cystic collection left aspect pelvis (series 2, image 6 7). collection faint peripheral hyperdense rim may reflect organizing postoperative fluid/hematoma. Although frank pocket gas seen within fluid collection, superimposed infection cannot excluded. Alternatively, may related residual tumor. 4. evidence colitis, free air, pneumatosis bowel obstruction. CT Scan Pelvis [2115-9-19] IMPRESSION: 1. Large heterogeneous, lobulated pelvic mass seen, likely gynecological origin. Patient recalls history TAH/BSO, however, prior records available time dictation. Less likely considerations include lymphoma (although unlikely given lymphadenopathy identified elsewhere), bladder origin. 2. Marked extrinsic compression sigmoid colon, without evidence obstruction. 3. Right sided hydronephrosis proximal hydroureter. 4. Small hypoattenuating lesions seen within liver. Metastases cannot excluded. 6. Compression fracture L1, [Last Name (un) 5487] chronicity. 7. Poorly defined low attenuation lesion uncinate process pancreas, incompletely evaluated study. Primary versus secondary neoplasm suspected. Brief Hospital Course: #Pelvic Mass: [2115-9-19] patient admitted [Hospital 61] evaluated surgical gynecological services. Abdominal CT scan showed - 15.9 x 14.2 x 15.9 cm mass , incompletely encasing sigmoid colon. Small amount oral contrast seen passing sigmoid colon. Mild dilation colon proximal mass. Given involvement sigmoid colon, patient admitted General Surgery team possible surgical resection. [9-24], CT guided biopsy performed showed features suggestive unusual ovarian adenocarcinoma. staining pattern suggests clear cell carcinoma ovary, possibly metastatic endometrial carcinoma. Adrenal, renal colonic origin unlikely. Mesothelioma unlikely, cannot entirely excluded based available information. Given pathology findings, patient transferred GYN ONC service management. patient underwent exploratory laparotomy, pelvic mass resection cystectomy ileoconduit placement Drs [First Name8 (NamePattern2) ] [Name (STitle) 1022] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 365] [10-2]. Please see operative note details. patient admitted ICU postoperatively given 2 minutes hypotension surgery. #Nutrition/GI: Preoperatively, PICC line placed TPN given minimal PO intake. Postoperatively, patient's TPN restarted. TPN restarted following surgery. Nutrition consult following. patient passed flatus bowel movement postoperatively; diet advanced regular. TPN continued time discharge due limited PO intake. patient refused TPN time discharge. patient underwent sigmoidoscopy revealed normal 15cm unable advance scope due insufficient bowel cleansing. #ID: patient started Flagyl/Keflex postoperatively empiric treatment given extent surgery. -Pseudomonas infection: Postoperatively, WBC noted double 12 25. Peak WBC 39 ICU. Blood cultures, JP fluid cultures, urine culture ileo-conduit wound culture obtained. Pan-sensitive pseudomonas returned urine, wound JP drainage. ID consult recommended IV PO vancomycin Zosyn. CT scan performed demonstrated post operative fluid collection vs hemotoma vs. organizing infection. interventional radiology consult stated fluid not-amenable drainage. patient's WBC improved IV antibiotic treatment patient remained afebrile, surgical management pursued. antibiotics narrowed Zosyn IV. patient receive PICC line IV treatments total 14 days following discharge. WBC normal time discharge. repeat urine culture pending time discharge; bacteria present urinalysis. #Respiratory: patient extubated postoperative 2. patient remained room air. CT scan [9-27] performed evaluate pulmonary metastasis; workup negative. patient experienced acute dyspnea postoperative day 9 blood transfusion. received 2 doses albuterol nebulizers; desaturated 89% room air. needed minimal oxygen support upon readmission ICU. discharged room air. #Heme: patient's HCT followed closely. patient received 9 units blood surgery initial postoperative stay keep HCT 25. postoperative day 9, patient's hematocrit noted slowly dropping 28 -> 26 -> 23. unclear cause hematocrit drop: slow bleeding operative site vs hematoma. patient transfused [12-25] unit blood hemolytic reaction occurred (see below). blood transfusion discontinued immediately. 2nd ICU stay, patient received 2 additional pRBC units screened Blood Bank consultation transfusion fellow. postoperative HCT remained stable daily hemolytic reaction (bewlow) 29-30. -Hemolytic Reaction: patient experienced acute hemolytic reaction manifested acute onset dyspnea postoperative day 9. unit blood discontinued immediately. received 2 doses Albuterol nebulizer treatment. received 25 mg Benadryl, 40 mg Lasix IV 20 mg proton pump inhibitor. Due patient's acute pulmonary distress elevated respiratory rate 40, code Blue called facilitate need possible intubation. intubation cardiac resuscitation needed. transfusion fellow consult called stat. repeat type screen found JKA antibody patient's blood. patient transferred ICU monitoring. #Cardiac: patient noted atrial fibrillation prior surgery. patient rate controlled prior surgery Metoprolol Diltiazem 80s-90s. followed telemetry. medicine consult called preoperatively assessment cardiac function. Prior cardiac evaluation obtained PCP documenting ejection fracture 55% recent Echo 65% recent stress test. Following surgery, postoperative cardiac enzymes negative x 3. -Hypotension: Occurred intraoperatively patient placed 2 pressors weaned ICU. patient maintained MAP 65 per A-line. pressors discontinued time ICU discharge Metoprolol restarted. -Atrial Fibrillation: patient maintained telemetry rate controlled Metoprolol 80s-90s. restarted Coumadin tolerating adequate PO postoperative day 11. . # Pain: Patient high level post-operative pain treated morphine PCA transitioned PO due patient somnolence. Patient able wean pain medications [10-9] required minimal PO medications. . # Coagulopathy: INR elevated following surgery 1.6 attributed multiple transfusions intraoperatively. patient responded well one unit FFP INR 1.2. INR trended 1.0 spontaneously prior discharge. INR followed daily following restart Coumadin. INR 1.1 time discharge. VNA follow INR daily upon discharge. . # Hypothyroidism: levothyroxine continued . # Prophylaxis: PPI, sc heparin, aspiration precautions, pneumoboots patient accepted. . # Code: Full, confirmed w/ HCP #Dispo: Patient discharged [10-16] VNA services, ostomy care, follow Urology, INR checks followed PCP, [Name10 (NameIs) 39209] Thoracic oncology. Medications Admission: coumadin 2-5mg cardizem 240 atenolol 25 synthroid 150mcg furosemide 40 qd Discharge Medications: 1. Simvastatin 40 mg Tablet [Name10 (NameIs) ]: One (1) Tablet PO DAILY (Daily). Disp:50 Tablet(s) Refills:2 2. Latanoprost 0.005 % Drops [Name10 (NameIs) ]: One (1) Drop Ophthalmic HS (at bedtime). Disp:qs bottles Refills:2 3. Docusate Sodium 100 mg Capsule [Name10 (NameIs) ]: One (1) Capsule PO BID (2 times day) needed. Disp:60 Capsule(s) Refills:2 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). Disp:60 Tablet,Rapid Dissolve, DR(s) Refills:2 5. Acetaminophen 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q6H (every 6 hours) needed. Disp:60 Tablet(s) Refills:0 6. Salmeterol 50 mcg/Dose Disk Device [Last Name (STitle) ]: One (1) Disk Device Inhalation Q12H (every 12 hours). Disp:60 Disk Device(s) Refills:2 7. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times day). Disp:90 Tablet(s) Refills:2 8. Warfarin 2.5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY 10AM (). Disp:50 Tablet(s) Refills:2 9. Nystatin 100,000 unit/mL Suspension [Last Name (STitle) ]: Five (5) ML PO TID (3 times day) 5 days. Disp:75 ML(s) Refills:0 10. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback [Last Name (STitle) ]: One (1) Intravenous Q8H (every 8 hours) 5 days. Disp:qs piggyback Refills:0 11. Senna 8.6 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times day) needed. Disp:60 Tablet(s) Refills:0 12. Levofloxacin 500 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO day. Disp:30 Tablet(s) Refills:2 13. Xanax 0.5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO bedtime. Disp:60 Tablet(s) Refills:0 14. Codeine Sulfate 30 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q4H (every 4 hours) needed. Disp:50 Tablet(s) Refills:0 15. Levothyroxine 150 mcg Tablet [Last Name (STitle) ]: One (1) Tablet PO day. Disp:30 Tablet(s) Refills:2 16. picc line care [Last Name (STitle) ]: One (1) day: PICC line care [First Name8 (NamePattern2) ] [Last Name (un) 6438] protocol . Disp:1 1 Refills:2 Discharge Disposition: Home Service Facility: Partners [Name (NI) ] [Name2 (NI) ] Discharge Diagnosis: Primary Diagnosis: -Peritoneal mesothelioma -L1 compression fracture -Acute hemolytic reaction -Pseudomonas infection Secondary Diagnoses: -Afib pacemaker -CHF -COPD -Osteoporosis -Hypothyroid Discharge Condition: Tolerating regular diet, afebrile, normal white blood cell count, ambulating. Pain controlled. Voiding ileo-conduit. Discharge Instructions: Call Dr. [First Name (STitle) 1022] if: shortness breath, fever > 100.4, abdominal pain relieved medicine, chest pain, redness around incision expanding, drainage incision, diarrhea, decreased urine output ostomy concerns ostomy. driving surgery. Please daughters/son drive you. heavy lifting 6 weeks. tub baths; may shower. scrub incision. Let water run incision. may take Codeine pain prescribed may take stool softener keep bowels regular. -Please take Levoquin 500 mg daily (1 tablet). -Please continue: -Coumadin 2.5 mg daily. Coumadin dosing checked visiting nurse dose may adjusted. Dr. [Last Name (STitle) 3314] follow dosing. -Levothyroxine 150 mcg -Latanoprost eye drops -Metoprolol 25 mg three times day -Nystatin swish/swallow three times day x 3 days -Zosyn (IV antibiotic) 5 days three times day -Salmeterol inhaler twice day -Zocor 1 tablet daily high cholesterol -Xanax 1 tablet night help sleep Followup Instructions: Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 7613], MD Phone:[Telephone/Fax (1) 5777] Date/Time:[2115-10-24] 10:45am [Location (un) ] [Hospital Ward Name 23] Center Thoracic Oncology [10-29] 3pm Dr. [First Name (STitle) ] [Name (STitle) ] [Location (un) ] [Hospital Ward Name 23] Building [0-0-] Dr. [Last Name (STitle) 365], Urology [11-6] 12 noon [Hospital1 9384] (across [Hospital3 1810] next [Company 38877]) [Location (un) 448] ([Telephone/Fax (1) 6441]	[ "496" ]
Admission Date: [2155-7-22] Discharge Date: [2155-7-26] Service: CHIEF COMPLAINT: Chest pain shortness breath requiring BiPAP. HISTORY PRESENT ILLNESS: patient 82-year-old gentleman past medical history significant coronary artery disease unrevascularized three-vessel disease ischemic cardiomyopathy ejection fraction 20% also history VTs sinus node dysfunction status post VT ablation pacer ICD placement, peripheral vascular disease, hypertension, hypercholesterolemia, admitted acute onset substernal chest pain one hour rest. patient reported associated symptoms diaphoresis shortness breath. patient took six sublingual nitroglycerins without relief given Lasix 80 mg IV en route Emergency Department. patient refused aspirin. emergency room heart rate 96, blood pressure 194/88 oxygen saturation 86% face mask, improved 95% BiPAP. Chest x-ray consistent congestive heart failure EKG uninterpretable due pacer. given aspirin, nitroglycerin transferred coronary care unit aggressive diuresis initiated congestive heart failure. diuresis, developed abdominal pains laboratory studies showed elevated amylase lipase. patient poor historian, reported vague abdominal pain approximately two weeks ago went pacer check Dr. [Last Name (STitle) ]. patient coronary care unit given gentle hydration response acute pancreatitis, patient transferred floor pancreatic enzymes trending down, however developed leukocytosis temperature 101.1. floor taking clear liquids without abdominal pain. denied back epigastric pain, patient poor historian. PAST MEDICAL HISTORY: 1. Coronary artery disease, three-vessel disease [2150-3-8]. catheterization showed 30% stenosis LM 30% PLAD 30% D1. 2. Peripheral vascular disease, status post right iliofemoral bypass [10-9] status post percutaneous transluminal coronary angioplasty left iliac [7-9]. 3. Ischemic congestive heart failure ejection fraction 20%. 4. History VT sinus node dysfunction, status post ablation pacer placement [2149]. 5. Chronic obstructive pulmonary disease. 6. Chronic renal insufficiency baseline creatinine 2.1 3.6. 7. Hypertension. 8. Hypercholesterolemia. 9. History penile implant. ALLERGIES: patient states report known drug allergies, however review computerized medical records reports allergy ACE inhibitors. SOCIAL HISTORY: previous smoker, 120-pack-year history, quit 10 years ago, denies alcohol use, lives [Location 11206], wife. FAMILY HISTORY: father died secondary leukemia mother died liver disease; information provided. MEDICATIONS ADMISSION: 1. Amiodarone 200 mg p.o. q.d. 2. Lasix 80 mg p.o. q.d. 3. Isordil 30 mg p.o. q. day. 4. Plavix 75 mg p.o. q. day. 5. Hydralazine 25 mg p.o. q. day. 6. Aspirin day. PHYSICAL EXAMINATION: Vital signs transfer floor coronary care unit temperature 101.2, blood pressure 103/58, pulse 61, respiratory rate 28, saturating 95% two liters. general confused gentleman sitting chair apparent distress. HEENT examination showed left pterygium, pupils minimally reactive bilaterally. oropharynx clear. mucous membranes dry. neck supple without jugular venous distension. chest bilateral crackles one-half way lung fields. cardiac examination revealed 2/6 systolic murmur best heard right upper sternal border greater left upper sternal border. Abdominal examination revealed positive bowel sounds, nontender palpation, tenderness epigastrium right upper quadrant palpation. Extremities revealed edema. Neurologically, cranial nerves II-XII grossly intact. [4-12] right lower extremity strength, otherwise 5/5 strength extremities right lower extremity cooler left lower extremity. LABORATORY DATA: admission white count 17, hematocrit 41, platelet count 781. Differential showed white blood cell count 63.5 neutrophils, 26 lymphocytes, 7 monocytes, 3 eosinophils, 1 basophil. Sodium 139, potassium 4.5, chloride 103, bicarbonate 24, BUN 38, creatinine 3.0, glucose 155. calcium 9.1, magnesium 2.2 phosphorous 4.5. INR 1.1, PTT 24.0. Laboratory studies admission floor showed white count elevated 21.3, hematocrit 36.6, sodium 139, potassium 4.2, chloride 100, bicarbonate 26, BUN 48, creatinine 3.2 glucose 123. phosphorous 4.0 magnesium 2.1. ALT 18, AST 24 alkaline phosphatase 84. amylase, three values, 442 911 424; lipase 882 946 166. total bilirubin 1.0. cardiac enzymes drawn, set three, showing troponins 0.01, 0.04 0.03. patient also MCV 63, TIBC 442, elevated, ferritin 11, increased. HOSPITAL COURSE: 1. Pancreatitis: patient experienced initial symptoms abdominal pain coronary care unit aggressive diuresis. ultrasound liver gallbladder showed gallbladder stones sludge. acute cholecystitis. nondilated biliary tree. atrophic left kidney limited view pancreas. obtain better imaging, obtained abdominal pelvis CT without contrast concerning chronic renal insufficiency showed inflammation pancreas. patient tolerating clears full diet floor without abdominal pain. patient's pain control purely p.r.n. basis. standing medications provided. believe pancreatitis secondary transient passage gallstones. GI consult appropriate time onset pain 24 hours, thus sphincterotomy indicated. 2. Congestive heart failure: patient weaned oxygen day discharge O2 saturation 93% room air. patient's lung examination improved diminished crackles lungs. patient kept diuretics hospital secondary chronic renal insufficiency, importantly, secondary acute pancreatitis fluid balance. patient discharged smaller dose Lasix. originally came 80 p.o. q. day discharged 40 p.o. q. day follow primary care physician regards adjustment Lasix dosage. 3. Leukocytosis: patient experienced increase white count 17.0 21.3 bandemia transferred floor neutrophils 88. patient left shift differential blood count received patient floor, 88 neutrophils. believe leukocytosis related urinary tract infection. Urine cultures pending, however two urinalyses consistent urinary tract infection elevated white blood cells bacteria. patient response treated levofloxacin 250 mg p.o. q. 48 hours total seven days. renal dosing levofloxacin. discharged medication complete course therapy. 4. Chronic obstructive pulmonary disease: patient given metered dose inhalers p.r.n. chronic renal insufficiency. creatinine higher end baseline coronary artery disease obtained pressure control hydralazine rate control amiodarone. 5. Anemia: patient microcytic anemia consistent iron deficiency anemia. started ferrous sulfate 325 mg hospital hemoglobin electrophoresis sent analysis possible thalassemia. CONDITION DISCHARGE: Fair. DISCHARGE DIAGNOSES: 1. Congestive heart failure. 2. Pancreatitis. 3. Urinary tract infection. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q. day. 2. Amiodarone 200 mg p.o. q. day. 3. Hydralazine 10 mg p.o. q. 6 hours. 4. Iron 325 mg p.o. q. day. 5. Levofloxacin 250 mg p.o. q. 48 hours total seven day. 6. Clopidogrel 75 mg p.o. q. day. 7. Protonix 40 mg p.o. q. day. 8. Isosorbide dinitrate 30 mg p.o. q. day. FOLLOW-UP PLANS: call primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 6680] follow next two weeks. DR.[First Name (STitle) ],[First Name3 (LF) ] 12-953 Dictated By:[Last Name (NamePattern1) 11207] MEDQUIST36 D: [2155-7-25] 17:53 T: [2155-7-29] 15:09 JOB#: [Job Number 11208]	[ "496" ]
Admission Date: [2111-3-15] Discharge Date: [2111-3-22] Service: [Doctor Last Name 1181] HISTORY PRESENT ILLNESS: [Age 90 ]-year-old female history restrictive lung disease, diastolic congestive heart failure, atrial fibrillation, obstructive sleep apnea developed upper respiratory symptoms two days prior admission. Mildly productive cough. fevers, chills. pain. shortness breath. nausea, vomiting. dysuria. pharyngitis. stiff neck. headache. apparently lethargic approximately three days. day admission patient's daughter spoke phone noticed extremely lethargic falling asleep phone speaking her. Patient's daughter called 9-1-1 emergency medical services found patient oriented times three oxygen saturations 50% room air. Emergency Department patient's O2 sats 84% 6 liters nonrebreather mask. Chest x-ray revealed right lower lobe infiltrate. given Albuterol nebulizers times two, Solu-Medrol 125 times one, Rocephin 1 gram intravenously times one, Clindamycin 600 mg intravenously times one, subsequently transferred Medical Intensive Care Unit noninvasive ventilation. Medical Intensive Care Unit patient placed continuous positive air pressure improved oxygenation CO2 exchange. treated Azithromycin Ceftriaxone pneumonia. additionally given Albuterol Atrovent inhalers improve pulmonary function given Lasix diuresis patient mildly overloaded chest x-ray. Code discussed made "Do Resuscitate"/ "Do Intubate." subsequently called floor. PAST MEDICAL HISTORY: 1. Restrictive lung disease. 2. Pulmonary function tests [12/2110]: FVC 0.75, 38% predicted; FEV1 0.55, 46% predicted; FEV1/FVC 73, 120% predicted. 3. Congestive heart failure: Reported diastolic dysfunction. Echo [4-/2109]: Left atrium mildly dilated, left ventricular hypertrophy, left ejection fraction 55%, right ventricle dilated, signs aortic stenosis, mild 1+ mitral regurgitation, moderate pulmonary hypertension, trace pericardial effusion. 4. Atrial fibrillation. 5. Hypertension. 6. Obstructive sleep apnea. 7. Lacunar infarcts. 8. Spinal stenosis. 9. Grave's disease. 10. Hypothyroidism. 11. Right breast cancer status post XRT. 12. Cerebrovascular accident [2101] left eye visual disturbance. 13. Left cataract surgery. 14. Total abdominal hysterectomy secondary fibroids. 15. Cholecystectomy. 16. PFO. 17. Scoliosis. SOCIAL HISTORY: Patient widow, two children, lives daughter. Denies alcohol. 100-pack-year history tobacco. Worked bookkeeper past. FAMILY HISTORY: Three siblings died heart attacks. Father died CVA. Mother died 60s hypertension renal dysfunction. MEDICATIONS HOME: 1. Colace. 2. Coumadin 5 mg alternating 7.5 mg mouth every day. 3. Salmeterol. 4. Diltiazem 30 mg mouth twice per day. 5. Furosemide needed. 6. Nifedipine 30 mg p.o. evening. 7. Folic acid 1 mg q. day. 8. Multivitamin one q. day. 9. Levothyroxine 100 mcg q. day. 10. Aspirin. 11. Isosorbide dinitrate 20 mg t.i.d. PHYSICAL EXAMINATION: Vital signs: Temperature 97.6, pulse 76, blood pressure 136/54, respirations 21, satting 89% 4 liters nasal cannula. General: irritable difficult, elderly, disheveled female; compliant exam. EENT: Extraocular movements intact; pupils equal reactive light; dentures appreciated; mucous membranes moist. Jugular venous distention approximately 7 8 cm. Neck: Supple without masses thyromegaly; lymphadenopathy appreciated. Cardiovascular: Regular rate rhythm; laterally displaced point maximal impulse; prominent S1 greater S2; murmurs, rubs, gallops. Pulmonary: Bibasilar crackles wheezes diffusely throughout lung fields; breath sounds decreased bases bilaterally. Abdomen: Normoactive bowel sounds, soft, nontender, nondistended; hepatosplenomegaly, masses, bruits. Extremities: clubbing, cyanosis, edema; 2+ dorsalis pedal posterior tibial pulses bilaterally. Skin: Multiple skin tags actinic keratoses back; rashes bruises. Neuro: Motor [6-3] extremities. Sensation generally intact light touch. Reflexes, patellar, brachioradialis 1+ bilaterally. Cranial nerves II-XII grossly intact. LABORATORY STUDIES ADMISSION: ABG 7.29/83/95 CPAP. Chem-7: Sodium 141, potassium 4.1, chloride 105, bicarbonate 27, BUN 30, creatinine 0.9, glucose 152, white blood count 8.3, hematocrit 36, platelets 152, INR 2.3, troponin 0.07. Urinalysis within normal limits. chest x-ray showed right lower lobe infiltrate cardiomegaly. Chest x-ray done [2111-3-15] showed right lower lobe pneumonia, mild cardiac failure, left pleural effusion. Chest x-ray [2111-3-16] showed slight improvement right lower lobe consolidation, improving left retrocardiac opacity, slight decrease left pleural effusion. Chest x-ray [2111-3-17] showed progression right upper lobe opacity; stable right lower lobe left lower lobe consolidation; improving left pleural effusion; persistent uppers vascular redistribution. CONCISE SUMMARY HOSPITAL COURSE: 1. Hypercarbic respiratory failure: Ms. [Known lastname 32729] admitted directly Medical Intensive Care Unit management hypercarbic respiratory failure noninvasive ventilation. chronic CO2 retainer ranging 50s 110s CO2. Serial arterial blood gases checked monitor progress. initial presentation Chem-7 ABG consistent respiratory acidosis without metabolic compensation hypoxia. anion gap. started Solu-Medrol 100 mg t.i.d., changed Prednisone 60 mg q. day upon discharge floor. patient initially improving BiPAP noted ABGs. However, tolerate BIPAP refused continue it. agreement made patient team keep face mask nasal cannula periods BiPAP. remainder MICU stay. started antibiotics MICU treatment pneumonia. used Rocephin Azithromycin treat community-acquired pneumonia. likely development pneumonia may cause hypercarbic respiratory failure. addition, patient noted somewhat volume overloaded subsequent exams MICU also noted congestion chest x-ray. started Lasix 20 mg intravenously b.i.d. MICU assist diuresis resolution pulmonary edema. Patient transferred floor continued refuse BiPAP CPAP assistance. Patient additionally refused antibiotic medications last day MICU stay called floor. hospital day five. Team, nursing, Attending meeting patient address refusal oxygen medication management. Patient convinced keep oxygen 2 liters throughout remainder stay also agreed continue taking medications improve pneumonia. Repeat chest x-rays showed improvement pneumonia pulmonary congestion. Whenever patient oxygen patient would episodes agitation confusion. Prior discharge patient's mentation sensorium improved, pneumonia treatment, volume overload significantly improved. 2. Diastolic dysfunction: Patient noted pulmonary edema volume overloaded exam elevated jugulovenous pressure subsequent exams MICU. Patient started 20 mg intravenous Lasix b.i.d. euvolemic. Euvolemia assessed measuring JVP, serial weights, monitoring daily input output. Patient euvolemic prior discharge. 3. Right lower lobe pneumonia: Patient treated community-acquired pneumonia Azithromycin Rocephin. hospital day five admission patient refused two three doses antibiotics likely secondary confusion, agitation patient oxygen quite time. Meeting held patient, team, Attending, nurse convince comply treatment goals. agreed continue taking medications keeping oxygen thanks Dr.[Name (NI) 9920] persuasion. Pneumonia treatment prior discharge. Repeat chest x-rays showed improvement pneumonia. 4. History atrial fibrillation: Patient continued Diltiazem throughout remainder hospital course. normal sinus throughout hospital stay. patient continued Coumadin INR goal 2 2.5. Patient taken Coumadin hospital day three hospital day five noted supertherapeutic INR. Coumadin reinstituted two days prior discharge discharged therapeutic INR. 5. Obstructive sleep apnea: CPAP attempted; however, patient refused on. CPAP well tolerated patient throughout remainder hospital course. Agreed two liter nasal cannula times. 6. Endocrine: Hypothyroidism: Patient continued outpatient dose Synthroid. Hyperglycemia: patient placed regular insulin sliding scale time steroids. Steroids stopped patient hospital day five, allowing taper. Ultimately, regular sliding scale discontinued two days prior discharge since good blood glucose levels within normal range. 7. Code: Long discussion held patient daughter Dr. [Last Name (STitle) ]. Patient agreed "Do Resuscitate"/"Do Intubate" made comfortable sick. However, sign Comfort Measures form reluctant discuss [First Name8 (NamePattern2) 2270] [Last Name (NamePattern1) 1764]. discussion arranged Dr. [Last Name (STitle) ] subsequent office visits. is, however, DNR/DNI. 8. Acute renal failure: Patient noted acute renal failure MICU course. However, discharged floor patient's renal failure resolved. peak creatinine 1.3 creatinine prior discharge 1.0. DISCHARGE CONDITION: Fair. DISPOSITION: home VNA services; discussions held subsequent visits Dr. [Last Name (STitle) ] regarding Hospice care. DISCHARGE DIAGNOSES: 1. Hypercarbic respiratory failure. 2. Pneumonia. 3. Alkalemia. 4. Thrombocytopenia. 5. Hypertension. 6. Hypothyroidism. 7. Diastolic heart failure. 8. Obstructive sleep apnea. 9. Restrictive lung disease. 10. Acute renal failure. DISCHARGE MEDICATIONS: 1. Fluticasone. 2. Salmeterol 250 50 mcg, one puff b.i.d. 3. Diltiazem 30 mg tablets, one tablet p.o. b.i.d. 4. Furosemide 50 mg tablet, one tablet p.o. q. day. 5. Nifedipine 30 mg tablet, Sustained Release, one tablet p.o. q. h.s. 6. Aspirin 81 mg tablet, one tablet p.o. q.d. 7. Folic acid 1 mg tablet, one tablet p.o. q. day. 8. Synthroid 100 mcg tablet, one tablet, p.o. q. day. 9. Multivitamin, one capsule q. day. 10. Colace 100 mg, one capsule p.o. b.i.d. 11. Isosorbide dinitrate 10 mg, one tablet p.o. t.i.d. 12. Levofloxacin 250 mg tablets, one tablet p.o. q. 24 times five days. DISCHARGE INSTRUCTIONS: 1. Patient follow Dr. [Last Name (STitle) ] one two weeks. Patient call schedule appointment ([Telephone/Fax (1) 102295]). 2. Patient follow Clinical Center Radiology mammography done [2111-11-16] 10 a.m. call [Telephone/Fax (1) 327]. [Name6 (MD) ] [Last Name (NamePattern4) 5467], M.D. [MD Number(1) 5468] Dictated By:[Last Name (NamePattern1) 9622] MEDQUIST36 D: [2111-5-23] 15:17 T: [2111-5-23] 21:36 JOB#: [Job Number 102296]	[ "486", "496" ]
Admission Date: [2162-3-29] Discharge Date: [2162-4-19] Date Birth: [2075-12-17] Sex: F Service: MEDICINE Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 602] Chief Complaint: shortness breath Major Surgical Invasive Procedure: 1. Intubation mechanical ventilation. 2. Placement 2 pleurex catheters History Present Illness: 86F history DM2, HTN, HLD, cardiac problem, transferred [Name (NI) ]. Pt presented one month breathing difficulty, weight loss, cough, decreased apetite getting progressively worse time. Family trie bring pt earlier refused go hospital. Last night pt became acute SOB family called ambulance pt brought [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. [Hospital1 ] found WBC 44, HR 170's fib, lactate=4; concern possible malignant process ? PE. Got dilt 30mg PO 10mg IV HR, improved. Also got 4L IVF. LENI showed R DVT. Got head CT showed nothing acute. Deferred CTA chest due elevated Cr (Cr 1.8). Started heparin gtt DVT concern PE. Got azithro ceftriaxone [Hospital1 ]. transport pt developed worsened rales/crackles possibly secondary 4 L IVF given. . [Hospital1 18] ED, initial VS were: 65, RR 32, 128/59, 97% 15L NRB. ECG showed AFib RVR. Patient started nitro gtt, heparin gtt, given vancomycin/zosyn, placed BiPAP resp distress didnt tolerate. Labs notable lactate 8.5, WBC count 49.3, INR 1.6 Cr 1.8. CXR: air fluid level abscess lung. Patient initially trialed BiPAP, tolerate, thus intubated (straight forward intubation). Placed R IJ. CVP=13. Lactate rose 10 concern gut ischemia. CTA chest torso: PE, revealed multiple abscess L lung- Rim enhancing fluid collection. Multiple hypodensisities kidney liver suggestive embolic infectious process. ED given: Vanco, zosyn, flagyl. Thoracics consult: Poor surgical candidate. Recc drainage per IR right now. K=6-->insulin/D50, Kayexlate. Gave 1 UPRBC elevated lactate. ED attempted call family several times give update, never got through. . arrival MICU, pt intubated, sedated, Levo 0.2 Dopamine 8. family meeting son 3 grandchildren. Family tearful, request FULL code continue discuss goals care. report pt usualy active baseline, ambulatory, takes care great grandchildren. Past Medical History: Dm2 HTN HLD Cardiac process- seen [Hospital 1263] hospital, family sure process is. Social History: Lives son, normally active baseline babysits grandchildren. Ambulatory. Rarely admitted hospital. history smoking drug use. Family History: cancers. Physical Exam: Vitals:T 98.1, HR 83, BP 110/51, fib, 98% AC FiO2 40, TV 350, F 20, PEEP 5, MV 8.2. IVF in: 6L plus 1 PRBC. UO: 230 [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] 180 [Hospital1 18] ED. General: sedated HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP elevated, LAD CV: irregular rate, mrg. Lungs: anterior breath sounds, crackles, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis edema Neuro: sedated Pertinent Results: Cytology [2162-3-29] NEGATIVE MALIGNANT CELLS. Acellular specimen bacterial overgrowth; Correlate microbiology report. ECG Study Date [2162-3-29] 2:29:44 rhythm regular likely junctional escape rhythm 60 beats per minute without clear atrial activity. Delayed R wave transition. previous tracing available comparison. Possible prior anteroseptal myocardial infarction. CHEST (PORTABLE AP) Study Date [2162-3-29] 2:45 FINDINGS: extensive opacification left hemithorax air-fluid level identified superiorly. findings representative large mass, possibly abscess fissure. Less likely would large hiatal hernia. rightward shift normally midline structures. Otherwise, right hemithorax appears clear. acute fractures identified. dedicated chest CT recommended evaluation Portable TTE (Complete) Done [2162-3-29] 12:03:01 PM FINAL left atrium elongated. thrombus/mass seen body left atrium. right atrium markedly dilated. atrial septal defect seen 2D color Doppler. estimated right atrial pressure least 15 mmHg. Left ventricular wall thicknesses normal. left ventricular cavity unusually small. Regional left ventricular wall motion normal. Overall left ventricular systolic function normal (LVEF>55%). masses thrombi seen left ventricle. ventricular septal defect. right ventricular free wall hypertrophied. right ventricular cavity mildly dilated normal free wall contractility. abnormal diastolic septal motion/position consistent right ventricular volume overload. ascending aorta mildly dilated. aortic valve leaflets (3) mildly thickened aortic stenosis present. masses vegetations seen aortic valve. aortic regurgitation seen. mitral valve leaflets mildly thickened. mitral valve prolapse. mass vegetation seen mitral valve. Mild (1+) mitral regurgitation seen. tricuspid valve leaflets mildly thickened. Moderate [2+] tricuspid regurgitation seen. moderate pulmonary artery systolic hypertension. vegetation/mass seen pulmonic valve. Significant pulmonic regurgitation seen. trivial/physiologic pericardial effusion. echocardiographic signs tamponade CT ABD & PELVIS CONTRAST Study Date [2162-3-29] 3:05 IMPRESSION: 1. Multilobulated large left hemithorax pleural empyema foci gas noted. Given foci gas differential includes recent instrumentation versus infection gas-forming organism versus bronchopleural fistula. 2. Multiple hypodense areas also visualized throughout bilateral nonenlarged kidneys. findings may representative multiple cysts superinfectious process multiple abscesses cannot excluded. 3. Small subsegmental right upper lobe pulmonary emboli. 4. mild gallbladder wall edema mottled apparance liver likely due congestive hepatopathy. 5. Endotracheal tube tip level carina. Retraction 2cm recommended. 6. Bilateral small pleural effusions. 7 . Severe cardiomegaly. CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date [2162-3-29] 3:05 IMPRESSION: 1. Multilobulated large left hemithorax pleural empyema foci gas noted. Given foci gas differential includes recent instrumentation versus infection gas-forming organism versus bronchopleural fistula. 2. Multiple hypodense areas also visualized throughout bilateral nonenlarged kidneys. findings may representative multiple cysts superinfectious process multiple abscesses cannot excluded. 3. Small subsegmental right upper lobe pulmonary emboli. 4. mild gallbladder wall edema mottled apparance liver likely due congestive hepatopathy. 5. Endotracheal tube tip level carina. Retraction 2cm recommended. 6. Bilateral small pleural effusions. 7 . Severe cardiomegaly. Multiple CXR performed, representative reads shown. CHEST (PORTABLE AP) Study Date [2162-3-31] 2:17 FINDINGS: left pigtail catheter unchanged position. right IJ ET tubes terminate standard position. NG tube terminates outside field view. Compared [3-30], increasing bilateral pleural effusions, pulmonary vascular congestion, parenchymal opacities suggesting developing pulmonary edema. Cardiomegaly unchanged. Tere pneumothorax. Findings discussed Dr. [Last Name (STitle) ] Dr. [Last Name (STitle) ] phone 11:45 a.m. [2162-3-31]. CT CHEST W/O CONTRAST Study Date [2162-3-31] 9:08 IMPRESSION: Interval resolution dominant gas/fluid collection within left hemithorax, near-resolution adjacent medial collection. remains loculated posterior collection appear tocommunicate catheter. 2. Adjacent severe left lower lobe atelectasis consolidative component. Slightly enlarged small right pleural effusion. Trace pericardial effusion. New moderate anasarca. Increased caliber main pulmonary artery likely reflects chronic pulmonary hypertension. . CT Torso [4-4] IMPRESSION: 1. Reaccumulation left sided localized hydropneumothorax s/p pigtail catheter removal. 2. Bilateral peribronchial ground glass opacity patchy opacities non-specific finding. 3. Slight decrease size right pleural effusion. 4. Stable increased diameter main pulmonary artery likely due pulmonary hypertension. 5. Persistent non-mobile 1.3cm filling defect within left main bronchus suspicious polyp, neoplasm mucus plug. . CT Chest [4-6] IMPRESSION: 1. Mid-esophageal soft tissue mass severly narrows may invade left main bronchus. 2. Interval placement second left lower lung drain interval decrease size air fluid collection. Persistent left lower lung consolidation either pneumonia atelectasis. 3. Markedly enlarged right atrium. 4. Thinning renal cortices hyperdensity could represent retained contrast nephrocalcinosis. . ECHO [4-6] left atrium elongated. right atrium markedly dilated. atrial septal defect seen 2D color Doppler. estimated right atrial pressure 5-10 mmHg. mild symmetric left ventricular hypertrophy normal cavity size regional/global systolic function (LVEF>55%). ventricular septal defect. borderline normal free wall function. abnormal septal motion/position consistent right ventricular pressure/volume overload. diameters aorta sinus, ascending arch levels normal. aortic valve leaflets (3) mildly thickened aortic stenosis present. masses vegetations seen aortic valve. Trace aortic regurgitation seen. mitral valve leaflets mildly thickened. mass vegetation seen mitral valve. eccentric, posteriorly directed jet mild (1+) mitral regurgitation seen. tricuspid valve leaflets mildly thickened. Moderate severe [3+] tricuspid regurgitation seen. severe pulmonary artery systolic hypertension. small pericardial effusion. effusion echo dense, consistent blood, inflammation cellular elements. Compared prior study (images reviewed) [2162-3-29], degree TR pulmonary hypertension increased. .. INDICATIONS: 86-year-old female esophageal cancer, lung empyema ischemic right foot. Bilateral lower extremity ABIs, Doppler waveforms, PVRs performed rest. FINDINGS: RIGHT: right ABI 0.65 DP. signal present PT. Doppler waveforms biphasic level popliteal artery. Posterior tibial waveform absent. dorsalis pedis waveform monophasic. PVRs artifactually diminished proximally aphasic metatarsal level suggesting severe tibial disease. left ABI 0.61 DP. PT waveform absent. Left-sided Doppler waveforms triphasic popliteal level monophasic dorsalis pedis. PVRs show significant dropoff calf ankle ankle metatarsal level suggesting severe tibial occlusive disease. IMPRESSION: ABIs likely falsely elevated. Based Doppler waveforms PVRs, severe tibial disease bilaterally. . COMPARISON: CT [4-4] [2162-4-6]. TECHNIQUE: MDCT data acquired chest without intravenous contrast. Images displayed multiple planes. FINDINGS: two pigtail catheters left lung base. small-to-moderate effusion layers posteriorly. large air-fluid collection communication anterior posterior drain. Moderate left basilar atelectasis and/or consolidation unchanged. moderate right effusion slightly larger. new consolidation, nodule, pneumothorax present. Since prior exam, esophageal catheter removed. boundaries large mid esophageal mass hard delineate without contrast. lesion measures approximately 1.9 x 3.4 cm (2:20). Since preceding exam five days ago, left main bronchus become completely effaced (2:20) combination mass effect thickened esophagus, bronchial secretions. extensive secretions distal left lower lobe segmental bronchus (2:25). tracheo-esophageal connection directly visualized would suprising given appearence. non-contrast appearance heart great vessels shows cardiomegaly, massive right atrial enlargment, minimal aortic arch calcification. tip right subclavian line terminates low SVC. thyroid normal attenuation. mesenteric, hilar axillary adenopathy present. residual renal excretion contrast [3-29]. peripheral hyperdense foci visualized portions kidneys. Previously, cortices kidneys uniformly hyperdense. Residual oral contrast seen nondistended loops large bowel. BONES SOFT TISSUES: concerning lytic sclerotic lesions. Bilateral lower old rib fractures. diffuse soft tissue edema. IMPRESSION: 1. Large mid esophageal soft tissue mass complete opacification left main bronchus either invasion, hemorrhage, and/or secretions. Persistent post-obstructive left lower lobe consolidation bronchial secretions. 2. Improving small-to-moderate left pleural effusion. large collection site two pigtail catheters. 3. Increasing moderate right effusion. 4. Stable right atrial enlargement. Final Report CHEST RADIOGRAPH INDICATION: Query pneumothorax, 86-year-old woman large esophageal neoplasm extending left mainstem. TECHNIQUE: Portable upright chest view read comparison multiple prior radiographs recent [2162-4-13]. FINDINGS: Lower lung opacity due combination effusion atelectasis involves entire left hemithorax suggestive increased large left pleural effusion. Two pleural pigtail catheters left lower hemithorax unchanged position. Increase left pleural effusion. much change position mediastinum probably due associated left lung volume loss. Moderate right pleural effusion right basilar atelectasis similar. Upper lung clear. IMPRESSION: Left pleural effusion progressed last two days. Two left pleural pigtail catheters unchanged position moderate right pleural effusion bibasilar atelectasis unchanged. study report reviewed staff radiologist. Microbiology: [2162-4-15] 8:12 pm URINE Source: Catheter. FINAL REPORT [2162-4-16] URINE CULTURE (Final [2162-4-16]): GROWTH. [2162-4-5] 6:36 pm PLEURAL FLUID PLEURAL FLUID. GRAM STAIN (Final [2162-4-5]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. MICROORGANISMS SEEN. FLUID CULTURE (Final [2162-4-8]): GROWTH. ANAEROBIC CULTURE (Final [2162-4-11]): GROWTH. FUNGAL CULTURE (Preliminary): FUNGUS ISOLATED. ACID FAST SMEAR (Final [2162-4-6]): ACID FAST BACILLI SEEN DIRECT SMEAR. ACID FAST CULTURE (Preliminary): MYCOBACTERIA ISOLATED. [2162-3-29] 4:40 pm FLUID RECEIVED BLOOD CULTURE BOTTLES Site: PLEURAL FINAL REPORT [2162-4-2] Fluid Culture Bottles (Final [2162-4-2]): GRAM NEGATIVE ROD(S). REFER SPECIME # 343-4776A [2162-3-29]. STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. SENSITIVITIES PERFORMED CULTURE # 343-4776A [2162-3-29]. GRAM POSITIVE RODS. REFER SPECIMEN # 343-4776A [2162-3-29]. Anaerobic Bottle Gram Stain (Final [2162-3-29]): GRAM NEGATIVE ROD(S). GRAM POSITIVE COCCI PAIRS CHAINS. GRAM POSITIVE ROD(S). Reported read back [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 27395] [2162-3-29] @ 740 PM. Aerobic Bottle Gram Stain (Final [2162-3-29]): GRAM NEGATIVE ROD(S). GRAM POSITIVE COCCI PAIRS CHAINS. GRAM POSITIVE ROD(S). [2162-3-29] 3:30 BLOOD CULTURE # 2. FINAL REPORT [2162-4-4] Blood Culture, Routine (Final [2162-4-4]): GROWTH. [2162-4-16] 04:08AM BLOOD WBC-11.3* RBC-3.46* Hgb-10.0* Hct-33.9* MCV-98 MCH-28.9 MCHC-29.6* RDW-22.8* Plt Ct-270 [2162-4-15] 03:04AM BLOOD WBC-11.2* RBC-3.57* Hgb-10.2* Hct-34.7* MCV-97 MCH-28.5 MCHC-29.3* RDW-22.6* Plt Ct-286 [2162-4-14] 05:06AM BLOOD WBC-8.9 RBC-3.28* Hgb-9.3* Hct-33.9* MCV-103* MCH-28.3 MCHC-27.3* RDW-23.0* Plt Ct-262 [2162-4-12] 03:03PM BLOOD WBC-10.5 RBC-3.60* Hgb-10.1* Hct-33.0* MCV-91 MCH-28.1 MCHC-30.7* RDW-22.6* Plt Ct-304 [2162-4-12] 06:00AM BLOOD WBC-10.4 RBC-3.71* Hgb-10.6* Hct-34.8* MCV-94 MCH-28.5 MCHC-30.4* RDW-23.1* Plt Ct-299 [2162-4-10] 03:25AM BLOOD WBC-13.3* RBC-3.75* Hgb-10.6* Hct-35.4* MCV-94 MCH-28.2 MCHC-29.9* RDW-24.0* Plt Ct-292 [2162-4-11] 03:42AM BLOOD WBC-11.6* RBC-3.78* Hgb-10.4* Hct-34.4* MCV-91 MCH-27.4 MCHC-30.1* RDW-22.6* Plt Ct-305 [2162-4-10] 03:25AM BLOOD WBC-13.3* RBC-3.75* Hgb-10.6* Hct-35.4* MCV-94 MCH-28.2 MCHC-29.9* RDW-24.0* Plt Ct-292 [2162-4-9] 02:57AM BLOOD WBC-14.2* RBC-3.62* Hgb-10.1* Hct-33.7* MCV-93 MCH-28.0 MCHC-30.1* RDW-23.5* Plt Ct-265 [2162-4-8] 03:48AM BLOOD WBC-20.4* RBC-3.62* Hgb-10.3* Hct-32.8* MCV-91 MCH-28.5 MCHC-31.4 RDW-22.2* Plt Ct-247 [2162-4-7] 02:27AM BLOOD WBC-22.8* RBC-3.41* Hgb-9.6* Hct-30.1* MCV-88 MCH-28.1 MCHC-31.8 RDW-19.8* Plt Ct-226 [2162-4-6] 02:20AM BLOOD WBC-23.5* RBC-3.86* Hgb-10.9* Hct-35.7* MCV-93 MCH-28.2 MCHC-30.5* RDW-19.6* Plt Ct-206 [2162-4-5] 01:57AM BLOOD WBC-20.3* RBC-3.76* Hgb-10.6* Hct-34.2* MCV-91 MCH-28.1 MCHC-30.9* RDW-19.2* Plt Ct-180 [2162-4-4] 03:04AM BLOOD WBC-22.3* RBC-3.85* Hgb-10.7* Hct-34.7* MCV-90 MCH-27.7 MCHC-30.7* RDW-18.6* Plt Ct-165 [2162-4-3] 02:56AM BLOOD WBC-27.4* RBC-3.94* Hgb-11.4* Hct-35.6* MCV-90 MCH-29.0 MCHC-32.1 RDW-17.7* Plt Ct-175 [2162-4-2] 03:22AM BLOOD WBC-24.2* RBC-4.21 Hgb-11.7* Hct-38.3 MCV-91 MCH-27.8 MCHC-30.5* RDW-17.4* Plt Ct-204 [2162-4-1] 03:34AM BLOOD WBC-24.2* RBC-3.99* Hgb-11.2* Hct-35.4* MCV-89 MCH-28.2 MCHC-31.8 RDW-17.6* Plt Ct-212 [2162-3-31] 01:10PM BLOOD WBC-27.0* RBC-4.15* Hgb-11.4* Hct-37.2 MCV-90 MCH-27.4 MCHC-30.6* RDW-16.8* Plt Ct-310 [2162-3-31] 04:24AM BLOOD WBC-24.9* RBC-3.96* Hgb-11.0* Hct-34.9* MCV-88 MCH-27.8 MCHC-31.6 RDW-17.2* Plt Ct-264 [2162-3-30] 11:17PM BLOOD WBC-23.3* RBC-3.85* Hgb-10.3* Hct-33.1* MCV-86 MCH-26.8* MCHC-31.2 RDW-16.3* Plt Ct-288 [2162-3-30] 07:07PM BLOOD WBC-28.8* RBC-3.31* Hgb-9.3* Hct-28.8* MCV-87 MCH-28.0 MCHC-32.3 RDW-16.0* Plt Ct-408 [2162-3-29] 11:58PM BLOOD WBC-36.1* RBC-4.10* Hgb-11.0* Hct-36.1 MCV-88 MCH-26.7* MCHC-30.3* RDW-15.9* Plt Ct-425 [2162-3-29] 01:37PM BLOOD WBC-48.5* RBC-3.99* Hgb-10.5* Hct-35.7* MCV-90 MCH-26.3* MCHC-29.3* RDW-15.4 Plt Ct-541* [2162-3-29] 10:41AM BLOOD WBC-46.5* RBC-3.79* Hgb-9.8* Hct-34.3* MCV-91 MCH-25.9* MCHC-28.6* RDW-15.0 Plt Ct-501* [2162-3-29] 08:20AM BLOOD WBC-44.7* RBC-3.74* Hgb-9.9* Hct-34.6* MCV-93 MCH-26.5* MCHC-28.7* RDW-15.0 Plt Ct-514* [2162-3-29] 02:45AM BLOOD WBC-49.3* RBC-3.71* Hgb-9.7* Hct-33.7* MCV-91 MCH-26.2* MCHC-28.8* RDW-15.2 Plt Ct-589* [2162-3-29] 02:45AM BLOOD Neuts-85* Bands-3 Lymphs-4* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [2162-3-29] 08:20AM BLOOD Neuts-95.9* Lymphs-2.5* Monos-1.2* Eos-0 Baso-0.4 [2162-4-1] 03:34AM BLOOD Neuts-90.9* Lymphs-8.1* Monos-0.5* Eos-0.2 Baso-0.2 [2162-4-2] 03:22AM BLOOD Neuts-93.0* Lymphs-5.2* Monos-1.0* Eos-0.2 Baso-0.6 [2162-4-16] 04:08AM BLOOD PT-15.7* PTT-103.7* INR(PT)-1.5* [2162-4-15] 03:04AM BLOOD PT-14.4* PTT-33.5 INR(PT)-1.3* [2162-4-14] 05:06AM BLOOD PT-15.4* PTT-150* INR(PT)-1.4* [2162-4-6] 02:20AM BLOOD PT-14.4* PTT-87.4* INR(PT)-1.3* [2162-4-1] 09:30PM BLOOD PT-12.8* PTT-103* INR(PT)-1.2* [2162-4-1] 05:10PM BLOOD PT-12.6* PTT-150* INR(PT)-1.2* [2162-3-29] 01:37PM BLOOD PT-18.0* PTT-28.7 INR(PT)-1.7* [2162-4-16] 04:08AM BLOOD Glucose-115* UreaN-32* Creat-1.4* Na-141 K-4.3 Cl-113* HCO3-25 AnGap-7* [2162-4-15] 03:04AM BLOOD Glucose-228* UreaN-33* Creat-1.4* Na-143 K-4.1 Cl-114* HCO3-25 AnGap-8 [2162-4-14] 09:52AM BLOOD Glucose-145* UreaN-34* Creat-1.5* Na-145 K-3.4 Cl-115* HCO3-24 AnGap-9 [2162-4-14] 05:06AM BLOOD Glucose-826* UreaN-30* Creat-1.5* Na-133 K-6.5* Cl-105 HCO3-21* AnGap-14 [2162-4-10] 02:59PM BLOOD Creat-1.8* Na-146* K-3.8 Cl-114* HCO3-22 AnGap-14 [2162-4-9] 02:57AM BLOOD Glucose-119* UreaN-54* Creat-2.2* Na-146* K-3.6 Cl-114* HCO3-24 AnGap-12 [2162-4-8] 03:48AM BLOOD Glucose-201* UreaN-61* Creat-2.6* Na-143 K-4.1 Cl-114* HCO3-20* AnGap-13 [2162-4-6] 02:20AM BLOOD Glucose-153* UreaN-54* Creat-2.8* Na-139 K-4.2 Cl-106 HCO3-20* AnGap-17 [2162-4-6] 02:20AM BLOOD Glucose-153* UreaN-54* Creat-2.8* Na-139 K-4.2 Cl-106 HCO3-20* AnGap-17 [2162-4-5] 01:57AM BLOOD Glucose-182* UreaN-51* Creat-2.7* Na-142 K-3.8 Cl-110* HCO3-21* AnGap-15 [2162-4-2] 03:22AM BLOOD Glucose-146* UreaN-43* Creat-1.9* Na-143 K-3.4 Cl-113* HCO3-19* AnGap-14 [2162-3-31] 04:24AM BLOOD Glucose-208* UreaN-48* Creat-1.7* Na-139 K-3.5 Cl-111* HCO3-16* AnGap-16 [2162-3-29] 10:41AM BLOOD Glucose-128* UreaN-56* Creat-1.7* Na-142 K-4.8 Cl-112* HCO3-15* AnGap-20 [2162-3-29] 02:45AM BLOOD Glucose-141* UreaN-60* Creat-1.8* Na-138 K-6.5* Cl-109* HCO3-13* AnGap-23* [2162-4-13] 05:32AM BLOOD ALT-12 AST-16 AlkPhos-73 TotBili-0.5 [2162-4-12] 03:03PM BLOOD ALT-15 AST-18 LD(LDH)-261* Amylase-129* [2162-4-1] 03:34AM BLOOD ALT-88* AST-76* LD(LDH)-246 AlkPhos-201* TotBili-0.8 [2162-3-31] 04:24AM BLOOD ALT-119* AST-206* LD(LDH)-320* AlkPhos-116* TotBili-0.8 [2162-3-29] 10:41AM BLOOD ALT-111* AST-600* LD(LDH)-1689* AlkPhos-119* TotBili-0.6 [2162-4-12] 03:03PM BLOOD CK-MB-4 cTropnT-0.04* [2162-3-29] 01:37PM BLOOD CK-MB-4 cTropnT-0.04* [2162-3-29] 10:41AM BLOOD CK-MB-4 cTropnT-0.03* [2162-3-29] 08:20AM BLOOD cTropnT-0.03* [2162-3-29] 02:45AM BLOOD cTropnT-0.04* [2162-4-16] 04:08AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.0 [2162-4-15] 03:04AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.0 [2162-3-29] 02:45AM BLOOD Albumin-2.3* [2162-3-29] 08:20AM BLOOD Calcium-7.0* Phos-6.6* Mg-2.1 [2162-3-29] 10:41AM BLOOD Albumin-1.8* Calcium-6.9* Phos-5.1* Mg-1.9 [2162-3-29] 01:37PM BLOOD Calcium-7.4* Phos-5.2* Mg-2.1 UricAcd-10.6* [2162-3-29] 01:37PM BLOOD Hapto-326* [2162-3-30] 10:02AM BLOOD Vanco-9.5* [2162-3-31] 06:04PM BLOOD Vanco-15.4 [2162-4-1] 07:07PM BLOOD Vanco-20.5* [2162-4-2] 08:10AM BLOOD Vanco-18.5 [2162-4-8] 05:43AM BLOOD Vanco-22.8* [2162-4-9] 05:57AM BLOOD Vanco-20.4* [2162-4-12] 06:00AM BLOOD Vanco-18.9 [2162-4-13] 05:32AM BLOOD Vanco-24.9* [2162-3-29] 02:58AM BLOOD Lactate-8.5* K-6.5* [2162-3-29] 04:44AM BLOOD Glucose-124* Lactate-9.6* K-6.2* [2162-3-29] 04:53AM BLOOD Lactate-9.3* [2162-3-29] 06:22AM BLOOD Lactate-9.6* [2162-3-29] 08:48AM BLOOD Glucose-205* Lactate-7.0* Na-139 K-5.4* Cl-113* calHCO3-13* [2162-3-29] 11:12AM BLOOD Lactate-4.7* [2162-3-29] 11:53PM BLOOD Lactate-2.9* [2162-3-30] 12:27PM BLOOD Lactate-2.7* [2162-3-31] 12:52AM BLOOD Lactate-2.2* [2162-3-31] 09:16AM BLOOD Lactate-2.7* [2162-3-31] 04:23PM BLOOD Lactate-2.4* [2162-3-31] 06:14PM BLOOD Lactate-2.1* [2162-4-1] 03:17PM BLOOD Lactate-1.7 [2162-4-2] 03:37AM BLOOD Lactate-1.5 [2162-4-4] 04:17AM BLOOD Lactate-2.1* [2162-4-6] 02:28AM BLOOD Lactate-3.8* [2162-4-6] 10:01AM BLOOD Lactate-5.4* [2162-4-6] 02:18PM BLOOD Lactate-4.4* [2162-4-14] 10:33AM BLOOD Lactate-1.7 [2162-4-5] 06:36PM PLEURAL WBC-[Numeric Identifier 110572]* RBC-[Numeric Identifier 28746]* Polys-98* Lymphs-0 Monos-1* Meso-1* [2162-4-3] 06:21PM PLEURAL WBC-1700* RBC-800* Polys-75* Lymphs-20* Monos-0 Baso-1* Meso-1* Other-3* [2162-3-29] 02:45AM estGFR-Using Brief Hospital Course: 86 yo F known medical problems admitted shortness breath cough. Hospital course notable admission ICU found lung renal abscesses, septic shock requiring vasopressor support, DVT PE, difficult control atrial fibrillation. also noted large esophageal mass suggestive esophageal cancer compression left main stem bronchus causing intermittent lung collapse esophageal compression dysphagia/aspiration. Patient long ICU course transferred floor ICU multiple times. Ultimately, given patient's multiple significant severe medical problems, age, progressively declining course despite maximal medical care, discussion held family decision transition patient's care comfort centered care patient passed away [2162-4-19] 2:10AM. #Septic shock/Lung renal abscesses: Patient presented septic shock pneumonia empyema found lung renal abscesses. required multiple pressors intubation. lactate peaked 10. CT demonstrated multiple fluid collections well esophageal mass (see below) compressing L mainstem bronchus believed predisposing polymicrobial infection. Interventional pulmonology placed two chest tubes drain fluid collections. Gram stain showed GPCs, GNRs gram positive rods. Cultures grew strep angionosis. initially treated broad spectrum antibiotics weaned vancomycin flagyl per ID recommendations planned course four weeks date last chest tube placement (day one [4-5]). weaned pressors succesfully extubated. treated vanc/flagyl made CMO [2162-4-16]. #DVT/PE: Patient found DVT lower extremity ultrasound. CTA showed small subsegmental RLL PE. Patient placed heparin gtt. goals care discussion anticoagulation held [2162-4-16]. #Esophageal Mass, likely esophageal cancer, bronchial esophageal obstruction: CT showed large mid esophageal soft tissue mass complete opacification left main bronchus either invasion, hemorrhage, and/or secretions. persistent post-obstructive left lower lobe consolidation bronchial secretions patient suffer collapse left lung. believed mass etiology polymicrobial septic shock, well persistent pleural effusions left sided atelectatsis. Secondary obstruction esophagus risks aspiratoin, patient made NPO. transiently receive TPN, discontinued care transitioned comfort centered care. #Atrial fibrillation: Unclear patient history afib, likely exacerbated caused infection/sepsis. may also contribution irritation esophageal mass. hypotension resolved patient managed medical floor IV betablockers required transfer back ICU rapid atrial fibrillation low blood pressures 90s. subsequently rate controlled IV amiodarone drip ICU transferred back medical floor. family discussion regarding overall goals care amiodarone eventually discontinued. # Acute Renal failure: Creatinine 1.8 unclear baseline. creatinine later increased peak 2.8 believed ATN septic shock. creatinine trended back 1.8. floor creatinine remained baseline. # Anemia: required 3 UPRBC setting elevated lactate septic shock. Hct stabilzed mid 30s. #Goals care discussion: Throughout hospitalization multiple family meetings/updates held multiple providers/teams. Palliative care involved social work case management teams. patient's age >80 years multiple medical problems continued progress despite medical care (including IV amiodarone drip, TPN, antibiotics, IV anticoagulation), family decided focus comfort centered care [2162-4-16]. patient passed away [2162-4-19] 2AM. Medications Admission: None Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: 1. Esophageal neoplasm 2. Septic shock 3. Atrial fibrillation 4. Deep venous thrombosis 5. Pulmonary Emboli 6. Digital necrosis [3-8] metatsarsals 7. Occlusive narrowing tibial arteries bilaterally 8. Pleural effusions 9. Pulmonary empyema Discharge Condition: expired	[ "486", "570" ]
Admission Date: [2146-12-22] Discharge Date: [2146-12-28] Service: NEUROLOGY Allergies: Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 1838] Chief Complaint: ICH s/p fall Major Surgical Invasive Procedure: none History Present Illness: Ms. [Known lastname 89562] 89 year-old right-handed woman history hypertension initially evaluated BIDN following fall transferred [Hospital1 18] found right thalamic hemorrhage intraventricular extension. . patient high-functioning baseline. lives independently. According patient's daughter, Ms. [Known lastname 89562] usual state health least day prior presentation. morning, answer patient's door meal service came deliver food. Emergency services contact[Name (NI) ]. patient reportedly found floor bathroom. patient's daughter shares prior transfer BIDN, patient "groggy" could identify family members. was, however, disoriented (eg thought living room actually bathroom) speaking "rag-time." . transferred BIDN evaluation. given morphine head, left shoulder, left hip pain fall. Imaging left hip, shoulder, c-spine, facial bones head performed. transferred [Hospital1 18] non-contrast CT head discovered show right thalamic hemorrhage. Past Medical History: - hypertension - hypothyroidism - macular degeneration - bilateral cataracts s/p repair Social History: - lives independently - 2 living children - previously worked high school cafeteria - avid reader prior [First Name8 (NamePattern2) ] [Last Name (un) ] Family History: - negative stroke, sz, migraine Physical Exam: NEUROLOGIC EXAMINATION: Mental Status: * Degree Alertness: Sleeping, arouses loud voice tactile stim. States hospital "boo boo ear." * Orientation: Oriented person, birthay (except year), indicates current year 1829 * Attention: inttentive. Able name days week forwards x 3 days * Memory: able correctly identify day, month birthdate. * Language: Language fluent semantic paraphasic errors neologisms. Often makes statements grammatically correct completely unrelated context (eg "what get brithday?") Repetition intact. Comprehension appears intact; pt able correctly follow midline appendicular commands. Prosody normal. Pt unable name high (pen= "pediwinkle", knuckles = "cars") low frequency objects (knuckles) without difficulty. * Calculation: Pt able calculate number quarters $1.50 Cranial Nerves: * I: Olfaction evaluated. * II: Pupils surgical, left slightly reactive right. * III, IV, VI: EOMI horizontal plane * VII: Face grossly symmetric * VIII: Hearing intact voice * IX, X: Palate difficult visualuze * XII: Tongue protrudes midline. Strength: * Left Upper Extremity: less voluntary movement tnan right, able grip * Right Upper Extremity: lifts least versus gravity, offers resistance push, pull, grip strong * Left Lower Extremity: moves least plane bed (difficult evaluate) * Right Lower Extremity: able lift versus gravity Sensation: * Intact tickle extremities Neuro exam discharge/ changes admit: Alert. Oriented self sometimes hospital. Able move right side gravity able hold >5 seconds. left bicep [1-21]. Delt /5 IP /5 Pertinent Results: [2146-12-22] 08:40PM GLUCOSE-171* UREA N-24* CREAT-1.1 SODIUM-140 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-21* ANION GAP-18 [2146-12-22] 08:40PM CALCIUM-10.4* PHOSPHATE-3.8 MAGNESIUM-2.1 [2146-12-22] 08:40PM WBC-15.8* RBC-4.57 HGB-13.7 HCT-39.7 MCV-87 MCH-30.0 MCHC-34.5 RDW-13.4 [2146-12-22] 08:40PM PLT COUNT-325 [2146-12-22] 08:40PM PT-12.2 PTT-23.1 INR(PT)-1.0 CT head [2146-12-25] IMPRESSION: change right thalamic hemorrhage extending ventricles, significant change ventricular size shape suggest developing hydrocephalus. new hemorrhage. CXR [2146-12-24] Lungs clear. Heart size normal. pulmonary edema, pleural effusion pneumothorax b/l Hip XR IMPRESSION: Degenerative changes throughout imaged field view detailed above. definite traumatic injury pelvis bilateral hips identified. Left Wrist XR IMPRESSION: 1. definite fractures. 2. Degenerative changes thumb CMC STT joints, described above. 3. Chondrocalcinosis suggesting CPPD. Brief Hospital Course: [Known lastname 89562] admitted found AMS. Initial evaluation [Hospital1 ] [Location (un) 620] revealed right thalamic bleed transfer [Hospital1 18] ICU done. reevaluated clnically CT scan head neck. bleed stable examination stable transferred floor care. wards stable occasional events A-fib RVR 140's responsive IV Beta Blocker. complications started heparin SC. inital event thought secondary hypertension. blood pressure within goal needed titration IPH: Secondary HTN. Stable IVH extension A-fib occasional RVR 140's: responsive metop 5mg IV. occured every day. HTN: Goal less 160 sytolic: Changed amlodipine 7.5 mg daily [2146-12-28] Speech swallow: able tolerate soft foods thin liquids. ID: developed fever [2146-12-28]. Urine [2146-12-24] grew Klebsiella P. Sensitive Ceftriaxone. started [2146-12-28]. Medications Admission: - toprol XL 200 mg po daily - norvasc 10 mg po daily - synthroid 88 mcg po daily - simvastatin 30 mg po daily Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed constipation. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 3. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily). 4. simvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) needed pain, fever. 7. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) needed pain. 8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times day). 9. Metoprolol Tartrate 5 mg IV Q4H:PRN SBP > 160 Hold HR < 55 10. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush 3 mL Normal Saline every 8 hours PRN. 11. HydrALAzine 10 mg IV Q6H:PRN SBP > 160 12. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. amlodipine Oral 15. CeftriaXONE 1 gm IV Q24H Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] [Hospital 1108] Rehab Unit [Hospital6 1109] - [Location (un) 1110] Discharge Diagnosis: New - Right Thalamic IPH - acute delirium Old - Hypothyroid - HTN - Macular degeneration - b/l cateract Discharge Condition: Mental Status: Confused - always. Level Consciousness: Alert interactive. Activity Status: Bed assistance chair wheelchair. Discharge Instructions: admitted right sided thalamic bleed. multiple images brain completed revealed stable bleed. surgical intervention done. Atrial fibrillation controlled time required PRN medications help control. also found UTI started antibiotic this. Followup Instructions: Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]- Neurology Location: [Hospital Ward Name 23] Center Floor 8. Time/Date: [2-27] 3:30 Please call ensure date/time one week prior. ([Telephone/Fax (1) 7394] Completed by:[2146-12-28]	[ "431" ]
Admission Date: [2114-12-24] Discharge Date: [2115-1-6] Date Birth: [2070-12-17] Sex: Service: MEDICINE Allergies: Heparin Agents Attending:[First Name3 (LF) 943] Chief Complaint: Hypotension elevated lactate, code sepsis. Major Surgical Invasive Procedure: Right internal jugular venous catheter placement. History Present Illness: 44 yoM PMH ESRD secondary Brights disease HD s/p two failed renal transplants, HCV, CHF EF 20%, AF coumadin presented ED two week history diffuse abdominal pain one day nausea vomiting [2114-12-24]. Two weeks prior admission patient began experience diffuse dull abdominal pain without nausea vomiting loose stools 2-3 times per day. patient believed secondary fluid overload. One week prior presentation patient complained subjective fevers, cough productive yellow sputum. nephrologist gave five-day course azithromycin. patient persistent symptoms started levofloxacin PCP two days prior admission. patient history tylenol use 3g/day 5 days prior admission fever, body aches. day prior admission patient began experience worsened abdominal pain associated nausea, episodes vomiting, nonbilious/nonbloody, diarrhea 4-5 times per day, watery, nonbloody. . ED patient found hypotensive lactate 5.6 code sepsis called. given Vanco, Flagyl Zosyn presumed infection. given Decadron presumed adrenal insufficiency. also given Calcium gluconate, sodium bicarbonate, Insulin D50 hyperkalemia. CVL placed received 3L NS normalization pressures. transferred MICU. . MICU patient's LFTs significantly elevated peaked ALT 3016, AST 2956, LDH [2064], INR 4.3 [12-25]. thought secondary shock liver setting hypotension/sepsis versus tylenol toxicity despite negative serum tylenol. LFTs subsequently trending down. . Upon transfer floor, patient continues complain cough productive yellow sputum. Denies chest pain, shortness breath. patient denied fevers/chills, abdominal pain, nausea, vomiting. Diarrhea improving. Denies dysuria/hematuria; minimal urine output HD. Denies lightheadedness. Denies myalgias/arthralgias. Review systems otherwise negative detail. Past Medical History: 1. End-stage renal disease secondary glomerulonephritis hemodialysis status post two failed transplants [2089] [2097] 2. Coronary artery disease status post myocardial infarction stent [2105] 3. Congestive heart failure ejection fraction 10%, status post right sided placement ICD 4. Cerebrovascular accident [2105] without residual complications deficits 5. Atrial fibrillation 6. Hypertension 7. Basal cell squamous cell skin cancers status post excision radiation lower face 8. Gout 9. Erectile dysfunction 10. Right lung pneumonia pleurisy 11. Hepatitis C, genotype 2 Social History: married, lives [Location 13011] wife 11 years, son daughter. [Name (NI) ] owns runs landscaping/contracting business works city sanding streets winter. denies tobacco recreational drug use. Family History: Mother, maternal uncle, grandfather [Name2 (NI) ] grandmother, Lymphoma paternal grandfather, peripheral vascular disease maternal grandmother, h/o kidney disease, CA, heart disease, CVA, psychiatric diseases. Physical Exam: VITAL SIGNS: 98.6 112/68 130 18 98RA GENERAL: NAD, pleasant cooperative. HEENT: PERRL, EOMI, OP clear, MMM, anicteric sclerae NECK: masses, LAD, JVD, carotid bruit, RIJ place HEART: irreg irreg, nl s1s2, holosystolic murmur [3-5] precordium, laterally displaced PMI, rub LUNGS: cta b/l, crackles wheezes. ABDOMEN: soft, nd, +bs, organomegaly, tender RLQ, negative [Doctor Last Name ] sign, rebound, guarding EXTREMITIES: cyanosis, clubbing; edema, 1+ dp, pulses b/l. NEUROLOGIC: awake, alert, a&ox3, cn ii-xii intact; strength 5/5 bilaterally, sensory coordination grossly intact, reflesxes 1+ bilaterally SKIN: petechia trunk, AV fistula L arm, positive thrill Pertinent Results: Labwork admission: [2114-12-24] 12:15PM WBC-14.0# RBC-3.54 HGB-11.5* HCT-34.7* MCV-98 MCH-32.5* MCHC-33.2 RDW-14.6 [2114-12-24] 12:15PM PLT COUNT-286 [2114-12-24] 12:15PM NEUTS-77.9* LYMPHS-14.1* MONOS-6.7 EOS-0.2 BASOS-1.1 [2114-12-24] 12:15PM PT-23.1* PTT-29.9 INR(PT)-2.3* [2114-12-24] 12:15PM GLUCOSE-62* UREA N-90* CREAT-14.8# SODIUM-139 POTASSIUM-7.1 CHLORIDE-86* TOTAL CO2-23 ANION GAP-37* [2114-12-24] 12:15PM ALT(SGPT)-1122* AST(SGOT)-1469* LD(LDH)-1523* ALK PHOS-156* AMYLASE-59 TOT BILI-1.5 [2114-12-24] 12:15PM LIPASE-43 [2114-12-24] 12:15PM ALBUMIN-4.0 CALCIUM-10.7* PHOSPHATE-11.2# MAGNESIUM-2.8 [2114-12-24] 12:15PM CORTISOL-36.0* [2114-12-24] 12:27PM LACTATE-5.9* . CHEST (PA & LAT) [2114-12-24] IMPRESSION: Clear lungs, mild pulmonary congestion cardiomegaly, unchanged. . CT ABD W&W/O C [2114-12-25] IMPRESSION: 1) Cardiomegaly hepatomegaly abnormal liver perfusion likely secondary passive congestion (nutmeg liver). focal hepatic abscess adjacent hematoma. 2) Cholelithiasis sludge/vicarious excretion IV contrast. Small amount pericholecystic fluid present. fluid could due patient's liver dysfunction/third spacing CHF. cholecystitis clinical concern, HIDA scan performed provided total bilirubin elevated. 3) Hyperdense renal cortex left lower quadrant transplanted kidney. Findings likely due chronic rejection prior ATN. apparent thickening arterial wall supplying transplant. hydronephrosis perinephric collection. 4) Minor anatomic variant involving liver vasculature described above. Hepatic veins portal venous system appear widely patent. 5) 6 mm lesion head pancreas. Continued follow area recommended future studies. 6) Areas ground glass opacity intralobular septal thickening lung bases, likely due fluid overload/CHF. Nodular areas opacity also present could due infection. Continued followup reccomended. 7) Small lymph nodes vague retroperitoneal stranding. Findings could due CHF. . ECG Study Date [2114-12-25] 2:41:34 Atrial fibrillation rapid ventricular response Intraventricular conduction delay - possible atypical left bundle branch block Anterior myocardial infarct, age indeterminate - may old Nonspecific ST-T wave changes Since previous tracing [2114-2-7], ventricular rate faster . ECHO Study Date [2114-12-28] Conclusions: 1. left atrium moderately dilated. 2. left ventricular cavity severely dilated. severe global left ventricular hypokinesis. Overall left ventricular systolic function severely depressed. Left ventricular dysnchrony present. 3. right ventricular cavity dilated. Right ventricular systolic function appears depressed. 4. aortic valve leaflets mildly thickened. Mild (1+) aortic regurgitation seen. 5. mitral valve leaflets mildly thickened. Moderate severe (3+) mitral regurgitation seen. effective regurgitant orifice >=0.40cm2 6. Moderate [2+] tricuspid regurgitation seen. moderate pulmonary artery systolic hypertension. 7. trivial/physiologic pericardial effusion. 8. Compared report prior study [2114-1-8], LV function probably worse. . CHEST (PA & LAT) [2114-12-29] IMPRESSION: Evidence pulmonary venous hypertension. Cardiomegaly. focal consolidation. . Labwork discharge: [2115-1-6] 06:30AM COMPLETE BLOOD COUNT White Blood Cells 8.7 K/uL 4.0 - 11.0 Red Blood Cells 2.74* m/uL 4.6 - 6.2 Hemoglobin 9.7* g/dL 14.0 - 18.0 Hematocrit 29.3* % 40 - 52 MCV 107* fL 82 - 98 MCH 35.6* pg 27 - 32 MCHC 33.3 % 31 - 35 RDW 18.1* % 10.5 - 15.5 BASIC COAGULATION (PT, PTT, PLT, INR) Platelet Count 128* K/uL 150 - 440 [2115-1-6] 06:30AM RENAL & GLUCOSE Glucose 121* mg/dL 70 - 105 Urea Nitrogen 56* mg/dL 6 - 20 Creatinine 7.5# mg/dL 0.5 - 1.2 Sodium 138 mEq/L 133 - 145 Potassium 3.8 mEq/L 3.3 - 5.1 Chloride 99 mEq/L 96 - 108 Bicarbonate 27 mEq/L 22 - 32 Anion Gap 16 mEq/L 8 - 20 ENZYMES & BILIRUBIN Alanine Aminotransferase (ALT) 146 IU/L 0 - 40 Asparate Aminotransferase (AST) 45* IU/L 0 - 40 Lactate Dehydrogenase (LD) 274* IU/L 94 - 250 Alkaline Phosphatase 151* IU/L 39 - 117 Bilirubin, Total 1.6* mg/dL 0 - 1.5 CHEMISTRY Albumin 3.1* g/dL 3.4 - 4.8 Calcium, Total 7.4* mg/dL 8.4 - 10.2 Phosphate 4.1 mg/dL 2.7 - 4.5 Magnesium 2.2 mg/dL 1.6 - 2.6 [2115-1-6] 06:30AM RENAL & GLUCOSE Glucose 121* mg/dL 70 - 105 Urea Nitrogen 56* mg/dL 6 - 20 Creatinine 7.5# mg/dL 0.5 - 1.2 Sodium 138 mEq/L 133 - 145 Potassium 3.8 mEq/L 3.3 - 5.1 Chloride 99 mEq/L 96 - 108 Bicarbonate 27 mEq/L 22 - 32 Anion Gap 16 mEq/L 8 - 20 ENZYMES & BILIRUBIN Alanine Aminotransferase (ALT) 146 IU/L 0 - 40 Asparate Aminotransferase (AST) 45* IU/L 0 - 40 Lactate Dehydrogenase (LD) 274* IU/L 94 - 250 Alkaline Phosphatase 151* IU/L 39 - 117 Bilirubin, Total 1.6* mg/dL 0 - 1.5 CHEMISTRY Albumin 3.1* g/dL 3.4 - 4.8 Calcium, Total 7.4* mg/dL 8.4 - 10.2 Phosphate 4.1 mg/dL 2.7 - 4.5 Magnesium 2.2 mg/dL 1.6 - 2.6 [2115-1-6] 10:29AM BASIC COAGULATION (PT, PTT, PLT, INR) PT 27.9* sec 10.4 - 13.1 PTT 47.7* sec 22.0 - 35.0 INR(PT) 2.9* 0.9 - 1.1 Brief Hospital Course: 44 year-old male past medical history ESRD HD, HCV, presenting hypotension elevated lactate, presumed sepsis without source found. patient noted elevated LFTs admission. patient found HIT Ab positive. . 1. Sepsis: source found, patient received antibiotics prior admission. patient remained afebrile hemodynamically stable throughout transfer floor. patient leukocytosis admission resolved prior transfer. patient completed empiric seven-day course vancomycin/zosyn ten-day course flagyl. patient's immunosuppressive therapy cyclosporine history renal transplant discontinued; prednisone 10 mg QOD continued. CXR x 2 without evidence pneumonia. patient's blood, urine, stools, sputum cultures negative time discharge. C. difficile toxin B negative. patient complained continued cough loose stools improving prior discharge. . 2. Hypotension: Resolved prior transfer floor. Likely sepsis given elevated lactate. Hypovolemia possible setting poor po prior admission. Cardiac etiology unlikely; significant change cardiac function cardiac enzymes unrevealing. Adrenal insufficiency unlikely random cortisol 36, however, patient chronic steroids; patient continued prednisone 10 mg every day history renal transplant. patient received treatment sepsis above. . 3. Elevated LFTs/coagulopathy: Secondary shock liver versus tylenol toxicity. patient initially maintained mucomyst gtt discontinued patient's liver function tests improved. likely component congestion secondary CHF. unlikely secondary HCV change immunosuppression mild active inflammation recent biopsy. Unlikely due recent liver biopsy. patient's liver function tests continued trend prior discharge. . 4. Atrial fibrillation: patient's coumadin initially held setting liver failure elevated INR. patient's digoxin amiodarone initially held setting renal liver failure patient's rate subsequently poorly-controlled heart rate 130-140s. patient followed primary cardiologist, Dr. [Last Name (STitle) 911], admission. patient's amiodarone restarted increased previous per recommendations. Digoxin restarted. patient's elanopril discontinued admission patient started captopril; attempt up-titrate dose patient's blood pressure tolerate increase. patient discharged captopril 6.25 twice daily. patient's blood pressure tolerate beta-blocker therapy. patient restarted coumadin prior discharge. patient's rapid ventricular rate likely compensatory low ejection fraction; rate control 110-120s acceptable. patient's rate goal 110s-120s discharge. patient follow-up Dr. [Last Name (STitle) 911] outpatient. . 5. Acute chronic renal failure: Baseline creatinine [5-2]. patient HD status post two failed renal transplants. differential patient's acute renal failure included acute tubular necrosis cyclotoxicity (recently azithromycin). patient's ACE inhibitor initially held. patient's creatinine improve baseline 7.5 prior discharge. patient followed renal service throughout hospitalization. patient continued receive hemodialysis per MWF schedule. patient started sensipar elevated PTH. patient continued prednisone 10 mg QOD history renal transplant. patient's cyclosporine discontinued. Amphogel discontinued cinecalcet added patient's regimen. . 6. Thrombocytopenia/HIT Ab positive: HIT antibodies sent patient's thrombocytopenia. patient's HIT antibodies positive. patient heparin SC heparin flushes MICU discontinued prior transfer floor. patient followed hematology admission. patient right basilic vein thrombosis visualized signs symptoms thrombosis. discussion hematology pharmacy, patient started argatroban bridged coumadin. patient's INR goal 2.5-3.5 given history liver disease. . 7. Congestive heart failure. EF 10% per echo [12-28] 3+ MR, 2+ TR. Mixed ischemic/nonischemic dilated cardiomyopathy. Patient fixed LAD/anterior defect MIBI 2/[2114]. patient status post ICD placement [1-1]. patient started captopril above. patient's blood pressure tolerate beta-blocker therapy. patient's volume status addressed hemodialysis. patient assessed biventricular ICD EP; decision made place time given patient's narrow QRS duration especially setting recent sepsis. patient follow-up Drs. [Last Name (STitle) 911] [Name5 (PTitle) 437] [5-3] weeks. patient receive outpatient cardiopulmonary assessment possible cardiac transplant. . 8. Coronary artery disease status post myocardial infarction stent [2105]. patient without complaints chest pain throughout admission. patient continued aspirin. patient's elanopril discontinued patient started captopril above. patient's blood pressure tolerate beta-blocker therapy. . 9. Nucleated red blood cells. 20 NRBC/100 white blood cells patient's blood smear transfer floor, low grade hemolysis high reticulocyte count. Hematology consulted believed likely secondary hyperactive marrow stimulated setting recent sepsis. resolved prior discharge. Medications Admission: Prednisone 10 mg PO QOD B Complex-Vitamin C-Folic Acid 1 mg PO DAILY Aspirin 81 mg Tablet PO DAILY Coumadin 1 mg PO DAILY Amiodarone 100 mg [Hospital1 ] Cyclosporine Amphogel Elanopril Discharge Medications: 1. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times day). Disp:30 Tablet(s) Refills:2 2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QOD (). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES DAY MEALS). Disp:90 Tablet, Chewable(s) Refills:2 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 9. Coumadin 1 mg Tablet Sig: Two (2) Tablet PO bedtime. Disp:60 Tablet(s) Refills:2 10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) needed abdominal pain. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Sepsis 2. Shock liver 3. Heparin-induced thrombocytopenia . Secondary: 1. End-stage renal disease hemodialysis 2. Coronary artery disease status post myocardial infarction stent [2105] 3. Congestive heart failure ejection fraction 10%, status post right sided placement ICD 4. Cerebrovascular accident [2105] without residual complications deficits 5. Atrial fibrillation 6. Hypertension 7. Basal cell squamous cell skin cancers status post excision radiation lower face 8. Gout 9. Erectile dysfunction 10. Right lung pneumonia pleurisy 11. Hepatitis C, genotype 2 Discharge Condition: Afebrile, vital signs stable. Discharge Instructions: Please contact physician experience fevers, chills, abdominal pain, nausea, vomiting, diarhea, black stools blood stools, concerning symptoms. . Please take medications prescribed. - cyclosporine discontinued now; restart outpatient dialysis per Dr. [Last Name (STitle) 1860]. - amphogel discontinued. - elanopril discontined. - take captopril 6.25 mg twice daily control heart rate. - amiodarone increased 200 mg daily. - take fosrenal 500 mg three times daily meals control phosphorus kidney failure. - take cinecalcet 30 mg daily control calcium phosphorus kidney failure. - take protonix 40 mg daily protect stomach taking prednisone. - take coumadin 2 mg daily follow-up coumadin clinic Monday. . Please keep appointments below. Followup Instructions: Please follow-up coumadin clinic Monday regarding INR levels. . office Drs. [Last Name (STitle) 911] [Name5 (PTitle) 437] contact regarding follow-up appointments. Please contact Dr.[Name (NI) 5786] office ([Telephone/Fax (1) 7236] Dr.[Name (NI) 3536] office ([Telephone/Fax (1) 13786] hear representatives questions. . Follow-up nephrologist: Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) ], [Name Initial (NameIs) ].D., PH.D.[MD Number(3) 708]:[Telephone/Fax (1) 435] Date/Time:[2115-1-7] 2:00 . [Month/Day/Year ] test heart transplant evaluation: Provider: [Name10 (NameIs) 10081] TESTING Phone:[Telephone/Fax (1) 1566] Date/Time:[2115-1-14] 1:15 . Follow-up primary care doctor, Dr. [Last Name (STitle) 14757] [Name (STitle) 13674], [1-17] 5:30pm. Please call [Telephone/Fax (1) 14758] need reschedule. . Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2115-4-16] 3:30 Provider: [Known firstname ] [Last Name (NamePattern4) 1008], M.D. Phone:[Telephone/Fax (1) 285] Date/Time:[2115-4-16] 4:00	[ "570", "486", "412" ]
Admission Date: [2185-7-20] Discharge Date: [2185-8-8] Date Birth: [2185-7-20] Sex: F Service: NB HISTORY PRESENT ILLNESS: 2315 gm product 34 5/7 weeks gestation born 34 year old gravida 4, para 2 mother prenatal screens, positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, Rubella immune Group B Streptococcus unknown. Pregnancy complicated partial previa bleeding episodes pregnancy. born cesarean section due previa. Apgar scores 8 one minute 9 five minutes. fever rupture membranes delivery. infant transferred Neonatal Intensive Care Unit evaluation. PHYSICAL EXAMINATION ADMISSION: Birthweight 2315 gm, 50th percentile, length 46.5 cm, 50th percentile, head circumference 31.5 cm, 50th percentile. Normocephalic, anterior fontanelle open flat. Palate intact. Neck supple. Intercostal retractions, intermittent grunting occasional nasal flaring noted. murmur, regular rate rhythm. Femoral pulses equal bilaterally. Abdomen soft active bowel sounds, masses distention. Capillary refill, brisk, warm well perfused. Hips stable, clavicles intact, normal premature female genitalia. Anus patent. Spine intact. sacral dimple. HOSPITAL COURSE: Respiratory - Infant initially room air, increased continuing retractions noted. Infant placed nasal prongs CPAP 7 cm water, decreased 6 cm water, requiring room air. Day life No. 1, increasing respiratory distress FIO2 requirement. Decision made intubate. infant received total three doses Surfactant hospitalization. Maximum ventilatory settings 20/6 rate 20 requiring 30 40 percent FIO2. Chest x-ray revealed left pneumomediastinum/pneumothorax. Repeat chest x-ray day life No. 3 showed resolution pneumomediastinum. Ventilatory settings decreased infant extubated nasal cannula day life No. 3. infant required nasal cannula day life No. 4 day life No. 7. infant remained room air day life No. 7 respiratory rates 40s 60s oxygen saturations greater 95 percent. infant apnea bradycardia hospitalization. infant receive methylxanthines hospitalization. Cardiovascular - murmur. Infant remained hemodynamically stable hospitalization. Fluids, electrolytes nutrition - infant initially receiving nothing mouth, 80 cc/kg/day D10/W. Glucoses remained stable hospitalization. Enteral feedings started day life No. 3 advanced full volume feedings 150 cc/kg/day day life No. 5. Maximum caloric density Similac Special Care 24 cal/oz achieved day life No. 7. infant currently taking minimum 130 cc/kg/day Similac 20 cal/oz p.o., calories decreased day life No. 18 recent weight 2695 gm ([2185-8-7]). recent electrolytes day life No. 4 showed sodium 138, potassium 4.7, chloride 108, bicarbonate 21. infant received single phototherapy total four days day life No. 4 day life No. 7. Maximum bilirubin level day life No. 4 14.1 direct 0.4. recent bilirubin level day life No. 8 4.8 direct 0.3. Hematology - Complete blood count admission revealed white count 8900, hematocrit 47.3 percent, platelets 250,000, 28 neutrophils 1 band. infant received transfusions hospitalization. Infectious disease - infant received total 48 hours Ampicillin Gentamicin rule sepsis upon admission. Blood cultures remain negative date. Neurology - Normal neurologic examination. Sensory - Hearing screening performed automated auditory brain stem response, infant passed ears. Psychosocial - Parents involved. CONDITION DISCHARGE: Stable room air. DISCHARGE DISPOSITION: Home parents. PRIMARY PEDIATRICIAN: [First Name8 (NamePattern2) 2174] [Last Name (NamePattern1) 38807], MD, phone number [Telephone/Fax (1) 37949]. CARE/RECOMMENDATIONS: Feedings discharge - Similac 20 cal/oz p.o. minimum 130 cc/kg/day p.o. Medications - None. Carseat position screening - State newborn screen - Sent [7-23], [8-3], abnormal results reported. Immunizations received - Hepatitis B vaccine given [2185-7-31]. Immunizations recommended - Synagis respiratory syncytial virus prophylaxis considered [Month (only) 359] [Month (only) 547] infants meet following three criteria: 1. Born less 32 weeks; 2. Born 32 35 weeks two following, daycare respiratory syncytial virus season, smoker household, neuromuscular disease, airway abnormalities school age siblings; 3. chronic lung disease. Influenza Immunizations recommended annually fall infants reach six months age, age first 24 months child's life immunization influenza recommended household contacts home caregivers. Follow appointments - 1. Primary pediatrician. 2. [Hospital6 407]. DISCHARGE DIAGNOSIS: Prematurity. Status post respiratory distress. Status post rule sepsis. Status post indirect hyperbilirubinemia. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2185-8-8] 03:29:26 T: [2185-8-8] 07:46:04 Job#: [Job Number 57751]	[ "769" ]
Admission Date: [2102-4-20] Discharge Date: [2102-4-26] Date Birth: [2055-2-21] Sex: Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 7744] Chief Complaint: Found Major Surgical Invasive Procedure: Central venous line placement Intubation mechanical ventilation Extubation History Present Illness: patient 47 year old PMHx COPD found hotel room. Per report, several days N/V/D possible AMS x1 day. taken [Hospital3 ] found unconcious, hypotensive, altered, mumbling, responding pain. right CVL placed, started levophed, intubated. difficult intubation requiring 30 Etomidate 10 Vec 2 passes glide scope. 7.0mm tube placed. Labs returned Cr 9.7, K 7.7 peaked waves widened QRS. given CaCl x2, insulin/D50, 2 amps bicarb, 3L NS. started zosyn, stopped reached [Hospital1 18] discovered allergy penicillin. initially difficult ventilate [Hospital3 15402] paralyzed 2 doses vec given solumedrol/albuterol ?obstructive process. Transported via [Location (un) ] [Hospital1 18] time became easier ventilate. Labs showed K remaining elevated 6.8 - got Cagluconate, amp bicarb. EKG improved, slightly peaked waves, QRS 78. CT Head/Neck done ok. CT A/P showed RLL consolidation, confirmed CT Chest. ABG shoed increased CO2 RR increased 28. given Levaquin/flagyl/vanco well lasix 40mg IV 3L urine output ED. . arrival MICU, intubated sedated pressors. . Review systems: Unable obtain Past Medical History: - Stroke 6 months ago per sister -HTN -DM -COPD -migraines -chronic LBP s/p low back surgery '[86] spinal stenosis sciatica, oxycodone - muscle spasms, valium 10 tid -tobacco -alcoholism, sober [2083] -remote PUD [1-26] etoh -insomnia seroquel -R index finger injury [1-26] tablesaw, s/p fusion [Doctor First Name ] -R broken jaw s/[Initials (NamePattern4) ] [Last Name (NamePattern4) ] ~[2091] -CCY ~[2089] -appy child -stable vision loss since accident child Social History: Lives home w/ common-law wife daughter. Disabled [1-26] back pain, gets SSI income. Tob [12-26] ppd x 35yrs. Etoh sober since [2083]. Remote marijuana habit, infrequent recreational cocaine use remotely, none many yrs. [Doctor First Name 26692], moved Mass ~7-8y ago. Monogamous w/ wife. Family History: mom died metastatic cancer 59yo dad died CA unknown type 4 siblings, 1 died MVA, 1 sis diabetes/HTN 4 children healthy Physical Exam: Admission Physical Exam: General: Intubated, sedated, intermittent myoclonic jerks HEENT: Sclera anicteric, MMM, poor dentition, EOMI, PERRL 2-->1 Neck: supple, LAD, difficult appreciate JVD [1-26] habitus CV: Regular rate rhythm, normal S1 + S2, murmurs, rubs, gallops Lungs: right sided inspiratory wheezing markedly decreased breath sounds base, CTA left Abdomen: soft, non-distended, obese, bowel sounds present, organomegaly, tenderness palpation, rebound guarding GU: foley place, right femoral CVL place - dressing c/d/i Ext: Warm, well perfused, 2+ pulses, clubbing, cyanosis edema, trackmarks along left posteromedial calf ankle knee, multiple track marks puncture wounds along legs Neuro: Moves 4 extremities equally . Discharge Physical Exam: Vitals: Tmax 99.0 Tc 98.8 BP 129/83 HR 83 RR 20 O2 Sat 99% RA; patient desaturated 91-94% RA ambulation; FSBG 124, 175, 175, 142 General: Sitting bed eating breakfast. HEENT: EOMI. MMM. Tongue midline. CV: RRR. M/R/G. Lungs: Auscultated posteriorly. Patient diffusely wheezy throughout lung fields posteriorly. Nml work breathing. accessory muscle use. Abd: Overweight. NABS+. Soft. NT/ND. Ext: WWP. Trace pitting edema bilaterally. clubbing cyanosis. Neuro: Patient alert interactive AM. Pertinent Results: Admission labs: [2102-4-20] 06:15PM BLOOD WBC-22.8* RBC-3.74* Hgb-12.2* Hct-35.3* MCV-94 MCH-32.5* MCHC-34.5 RDW-15.0 Plt Ct-173 [2102-4-20] 10:57PM BLOOD Neuts-97.1* Lymphs-1.4* Monos-0.9* Eos-0.5 Baso-0.1 [2102-4-20] 06:15PM BLOOD PT-11.3 PTT-26.8 INR(PT)-1.0 [2102-4-20] 10:57PM BLOOD Glucose-180* UreaN-68* Creat-6.0# Na-138 K-7.3 Cl-100 HCO3-26 AnGap-19 [2102-4-20] 10:57PM BLOOD ALT-26 AST-21 LD(LDH)-158 CK(CPK)-151 AlkPhos-72 TotBili-2.3* [2102-4-20] 10:57PM BLOOD Calcium-9.1 Phos-6.6* Mg-1.7 UricAcd-9.7* [Hospital3 ]: [2102-4-20] 06:15PM BLOOD Fibrino-540* [2102-4-20] 06:15PM BLOOD Lipase-36 [2102-4-21] 04:29PM BLOOD Lipase-15 [2102-4-20] 10:57PM BLOOD CK-MB-6 [2102-4-21] 11:30AM BLOOD Cortsol-8.1 Lactate trend: [2102-4-20] 11:05PM BLOOD Lactate-0.8 K-6.8* [2102-4-21] 08:56AM BLOOD Lactate-1.2 [2102-4-21] 04:01PM BLOOD Lactate-0.9 [2102-4-22] 04:38AM BLOOD Lactate-0.8 [2102-4-23] 03:01AM BLOOD Lactate-0.4* Discharge labs: [2102-4-26] 06:10AM BLOOD WBC-3.8* RBC-2.98* Hgb-9.1* Hct-28.3* MCV-95 MCH-30.7 MCHC-32.3 RDW-15.5 Plt Ct-141* [2102-4-26] 06:10AM BLOOD Glucose-99 UreaN-16 Creat-1.0 Na-137 K-3.6 Cl-103 HCO3-28 AnGap-10 [2102-4-26] 06:10AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.6 Imaging: [2102-4-20] Portable CXR: FINDINGS: endotracheal tube terminates near thoracic inlet, approximately 7.5 cm carina. orogastric tube passes beneath left hemidiaphragm, distal course imaged. Opacification right lower hemithorax suggests pleural effusion volume loss including mild rightward shift mediastinal structures suggestive atelectasis. infectious causes excluded, however. left lung appears clear. Although extreme left costophrenic sulcus partly excluded, evidence pleural effusion left side. Allowing technique, cardiac, mediastinal hilar contours unremarkable. IMPRESSION: 1. Endotracheal tube somewhat high lying position, approximately 7.5 cm carina. clinically indicated, tube could advanced approximately 3 cm. 2. Right basilar opacification volume loss including suspicion pleural effusion. . [2102-4-20] Head CT: FINDINGS: evidence intracranial hemorrhage, mass effect, shift normally midline structures, vascular territorial infarct. [Doctor Last Name ]-white matter differentiation preserved throughout. ventricles sulci normal size configuration. fractures noted. Opacification within paranasal sinuses likely related recent intubation. Mastoid air cells clear. IMPRESSION: evidence acute intracranial process. . [2102-4-20] CT Chest: FINDINGS: right middle lower lobe collapsed. Bronchiectasis mild segmental subsegmental bronchi middle lobe, subsegmental divisions superior basal segments. central bronchial occlusion. constellation suggests atelectasis may well chronic. indication pneumonia pleural pericardial abnormality. small bronchi posterior segment right upper lobe impacted mild heterogeneity background density upper lobes suggesting small airway obstruction mild emphysema. Mediastinal lymph nodes pathologically enlarged. absence contrast administration, cannot say enlarged right hilar lymph nodes (there none left), even right hilar nodes present, contributing atelectasis bronchial obstruction. Heart normal size study notable virtual absence atherosclerotic calcification, except small plaques bifurcation innominate artery. ET tube standard placement. Excretions pooled inflated cuff. study designed subdiaphragmatic diagnosis except note adrenal mass. small Bochdalek hernia posterior right hemidiaphragm transmits subphrenic fat. IMPRESSION: 1. Combination mild diffuse bronchiectasis collapsed right middle lower lobes. absence bronchial obstruction, suggests collapse acute. evidence pneumonia. Minimal mucoid impaction small bronchi upper lobe. 2. Either small airway obstruction mild emphysema. . CT C-spine: FINDINGS: Imaged portions brain better visualized concurrent head CT. Patient intubated. Nasogastric endotracheal tubes appropriate position. evidence fractures acute alignment abnormalities. evidence critical spinal canal stenosis. Visualized portions lung bases show scarring right upper lobe. Left upper lobe unremarkable. IMPRESSION: evidence fracture. . CT Abdomen/pelvis: CT ABDOMEN: right lower lung bases consolidative processes air bronchograms volume loss including rightward shift. pericardial effusion. pleural effusion. left lung clear. Within abdomen, evaluation structures limited without IV contrast, however, limitations mind, liver unremarkable. gallbladder surgically removed. spleen, bilateral kidneys pancreas unremarkable. fat stranding unclear significance around left adrenal. adrenals unremarkable. NG tube seen coursing stomach ending pylorus. remainder small bowel unremarkable. Large bowel also unremarkable. mesenteric adenopathy appreciated. CT PELVIS: Rectum, sigmoid colon, bladder, prostate unremarkable. patient Foley catheter. OSSEOUS STRUCTURES: osseous structures unremarkable. concerning lytic sclerotic lesions. IMPRESSION: 1. evidence acute intra-abdominal process. 2. Consolidative process right lower lobe consistent pneumonia versus atelectasis; sequelae aspiration could also considered particularly noting historical circumstances. . [2102-4-21] Portable CXR: IMPRESSION: 1. Interval placement right internal jugular central line tip mid superior vena cava. endotracheal tube tip approximately 5.5 cm carina, unchanged. nasogastric tube seen coursing diaphragm tip identified. Patchy linear opacity right base stable suggestive patchy subsegmental atelectasis. Probable small layering right effusion. lungs otherwise clear without evidence pulmonary edema pneumothorax. Overall, cardiac mediastinal contours stable given differences positioning. . Microbiology: [2102-4-20] 6:15 pm BLOOD CULTURE TRAUMA. FINAL REPORT [2102-4-26] Blood Culture, Routine (Final [2102-4-26]): GROWTH. [2102-4-20] 6:50 pm URINE FINAL REPORT [2102-4-21] URINE CULTURE (Final [2102-4-21]): GROWTH. [2102-4-20] 10:57 pm MRSA SCREEN Source: Nasal swab. FINAL REPORT [2102-4-22] MRSA SCREEN (Final [2102-4-22]): POSITIVE METHICILLIN RESISTANT STAPH AUREUS. [2102-4-21] 1:52 URINE Source: Catheter. FINAL REPORT [2102-4-21] Legionella Urinary Antigen (Final [2102-4-21]): NEGATIVE LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed Immunochromogenic assay. negative result rule infection due L. pneumophila serogroups Legionella species. Furthermore, infected patients excretion antigen urine may vary. [2102-4-21] 1:36 BRONCHIAL WASHINGS FINAL REPORT [2102-4-23] GRAM STAIN (Final [2102-4-21]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. PAIRS CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [2102-4-23]): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. [2102-4-23] 3:53 BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending) times 2 [2102-4-25] 5:54 IMMUNOLOGY Source: Line-cvl. FINAL REPORT [2102-4-26] HCV VIRAL LOAD (Final [2102-4-26]): HCV-RNA DETECTED. Performed using Cobas Ampliprep / Cobas Taqman HCV Test. Linear range quantification: 43 IU/mL - 69 million IU/mL. Limit detection: 18 IU/mL. Rare instances underquantification HCV genotype 4 samples [Doctor Last Name ] COBAS Ampliprep/COBAS TaqMan HCV test method used laboratory may occur, generally range 10 100 fold underquantitation. patient HCV genotype 4 virus clinically appropriate, please contact molecular diagnostics laboratory ([Telephone/Fax (1) 6182]) results confirmed alternate methodology. [2102-4-25] 12:15 pm IMMUNOLOGY Source: Line-PICC. HBV Viral Load (Pending): Hepatits B Ag Negative Hepatitis B Ab Negative Brief Hospital Course: 47 year old male past medical history significant COPD, DM, HTN presents found hypoxic hypercarbic respiratory failure, RLL consolidation, hyperkalemia, [Last Name (un) ]. # Hypoxic hypercarbic respiratory failure - Patient history COPD, admission prolonged expiration phase, expiratory wheezing exam. CT showed large right lower lobe consolidation concerning pneumonia, possibly aspiration. evidence fluid overload exam. Given body habitus, may component hypoventilation OSA. Urgent bronchoscopy MICU showed secretions RLL mass obstructing lesion - sample sent culture/gram stain. treated health-care acquired pneumonia vancomycin/meropenem/levofloxacin atypical coverage pending culture results. Legionella antigen negative. patient self-extubated [4-23] able maintained non-invasive ventilation thereafter. # Aspiration pneumonia- Patient started vancomycin, meropenem levofloxacin (for atypical coverage) MICU. Upon transfer general medicine floor, patient continued broad spectrum antibiotics. patient clinically improved, patient transitioned oral antibiotics, Levofloxacin Clindamycin (for coverage anaerobic bacteria). patient remained afebrile oral antibiotics. patient discharged home another 3 days Levofloxacin Clindamycin complete 10-day course treatment aspiration pneumonia. Supplemental oxygen weaned discontinued. patient saturating mid high 90s rest room air ambulatory saturation 91-94% room air day prior discharge. # Shock - likely hypovolemia sepsis. Bedside ultrasound showed collapse IJ hyperdynamic fully contracting ventricles consistent hypovolemia. EKG showed low voltages, evidence pericardial effusion low EF bedside U/S. Per OMR note, recently steroids COPD risk AI. treated pneumonia, provided aggressive fluid resuscitation, provided stress dose steroids. weaned pressors 24 hours pressure normalized. # Hyperkalemia - patient exhibited persistent kyperkalemia despite adequate treatment, despite good renal function. EKGs initially showed mild peaked waves, QRS remained stable. Normalized first 24 hours. # Acute renal failure - Likely related hypovolemia given patient's admission exam. CK initially flat patient's acute renal failure attributed rhabdomyolysis. Serum creatinine improved hydration 1.6, although clear baseline patient. Serum creatinine trended admission, patient's serum creatinine normalized, ranging 0.9 1.0. OUTPATIENT ISSUES: Patient need renal function reassessed next PCP [Name Initial (PRE) 648]. # Pancytopenia - Upon transfer ICU floor, patient's cell counts noted falling. Thrombocytopenia initially pronounced. patient receive heparin admission; 4T score 4, classifying patient's probability HIT intermediate. patient's CBC trended daily, white count hematocrit noted falling well. differential included marrow suppression secondary sepsis secondary medication. day discharge, patient's blood cell lines noted uptrending. OUTPATIENT ISSUES: Patient need follow-up CBC next PCP [Name Initial (PRE) 648]. CHRONIC ISSUES: # Hypertension - Patient history hypertension; outpatient, patient maintained amlodipine 10, HCTZ 12.5mg, lisinopril 20mg daily. medications initially held light shock. Patient's blood pressure initially ran 150s systolic. patient started amlodipine 10mg daily initially. stable trend patient's serum creatinine, patient's lisinopril hydrochlorothiazide restarted. initiation patient's full anti-hypertensive regimen, patient's systolic blood pressure ranged 120s-130s systolic. # Chronic Obstructive Pulmonary Disease - patient albuterol ipratropium inhalers available admission. patient also given nicotine patch admission. Multiple times admission, importance smoking cessation emphasized patient. also empirically started Tiotropium inhaler daily discharge. Upon discharge, patient provided prescription nicotine patches aid smoking cessation. OUTPATIENT ISSUES: PFTs outpatient already done. Smoking cessation counseling patient's primary care provider. # Type 2 Diabetes Mellitus - outpatient, patient 500mg metformin [Hospital1 ]. Upon admission, patient transitioned insulin sliding scale hyperglycemic coverage. medicine floor, patient's finger stick blood glucose ranged 125-175, required minimal insulin coverage. patient discharged home instructions continue taking 500mg metformin [Hospital1 ]. # History muscle spasm - Patient continued home dose standing Valium 10mg TID. # Chronic Low Back Pain - Oxycodone restarted patient transferred medicine floor. Dosing up-titrated original home dose frequency day discharge. # History substance abuse - patient's stay MICU, placed CIWA scale. patient score ICU. medicine floor, patient score, CIWA scale discontinued. note, patient sober alcohol past 17 years. OUTPATIENT ISSUES: Follow-up pending HIV serology. # Hepatitis C - Patient serology confirmed admission. Viral load negative. Patient pursued treatment past. Hepatitis B serology HIV also drawn admission. OUTPATIENT ISSUES: Discussion patient PCP regarding treatment hepatitis C. Patient need hepatitis B vaccination given hepatitis B serology. Follow-up pending HIV serology. # History insomnia - Patient's home Seroquel held upon admission light patient's serious illness. initially held medicine floors patient still appeared drowsy. day discharge, patient instructed continue Seroquel home dosing. # Code: Full (presumed) # Pending studies: --Blood cultures --Hepatitis B viral load --HIV serology # PCP [Last Name (NamePattern4) 702]: --Repeat CBC chemistry patient's next PCP appointment [Name9 (PRE) 110669] COPD therapy --Smoking cessation discussion Medications Admission: lisin-HCTZ 20-12.5 amlodipine 10 metformin 500 [Hospital1 ] fioricet prn valium 10 TID standing oxycodone 30mg 5-6x/day albuterol prn seroquel 150 qhs Discharge Medications: 1. lisinopril-hydrochlorothiazide 20-12.5 mg Tablet Sig: One (1) Tablet PO day. 2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO day. 3. metformin 500 mg Tablet Sig: One (1) Tablet PO twice day. 4. Fioricet 50-325-40 mg Tablet Sig: One (1) Tablet PO three times day needed Migraine Headache . 5. diazepam 10 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours). 6. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:14 Patch 24 hr(s) Refills:0 7. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) 1 days. Disp:2 Tablet(s) Refills:0 8. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) 3 days. Disp:3 Tablet(s) Refills:0 9. clindamycin HCl 300 mg Capsule Sig: Two (2) Capsule PO twice day 3 days. Disp:12 Capsule(s) Refills:0 10. Seroquel XR 150 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO bedtime. 11. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours needed shortness breath wheezing. 12. Spiriva HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Capsule Inhalation day. Disp:14 capsules Refills:0 13. oxycodone 10 mg Tablet Sig: Three (3) Tablet PO every four (4) hours needed pain. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Aspiration pneumonia Acute renal failure Secondary diagnosis: Chronic Obstructive Pulmonary Disease Hypertension Type 2 Diabetes Mellitus Chronic low back pain Pancytopenia Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], pleasure taking care hosptalization [Hospital1 69]. hospitalized pneumonia acute renal failure. Initially ICU requirining mechanical ventilation. stay ICU, able taken ventilator kidney function improved. transferred general medicine floor continued treatment pneumonia. initially received IV antibiotics pneumonia, transitioned oral antiobitics. 3 days antiobitics take leave hospital. STOP SMOKING one best things yourself. Discuss options available quitting smoking primary care physician. Take medications prescribed. Note following medication changes: 1. ADDED Levofloxacin 750mg daily Clindamycin 600mg every 12 hours next 3 days continued treatment pneumonia 2. ADDED Nicotine patch apply daily; discontinue continue bad dreams patch you. 3. ADDED Prednisone 40mg one day 4. ADDED Spiriva 1 capsule daily treatment underlying COPD Keep hospital follow-up appointments. [Hospital 14776] hospital appointments listed you. Followup Instructions: Department: [Hospital3 249] When: WEDNESDAY [2102-5-3] 2:40 PM With: [Name6 (MD) ] [Last Name (NamePattern4) 25193], MD [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 249] When: WEDNESDAY [2102-5-17] 5:20 PM With: [Name6 (MD) ] [Last Name (NamePattern4) 25193], MD [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "496" ]
Admission Date: [2200-11-10] Discharge Date: [2200-11-18] Service: MEDICINE Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 10593] Chief Complaint: shortness breath Major Surgical Invasive Procedure: Thoracentesis [2200-11-10] History Present Illness: [Age 90 ] year old female brought ED tonight shortness breath. family noticed patient appeared quite dyspnic AM. shortness breath exacerbated exertion. patient fever cough. N/V/D. abdominal complaints. patient denied chest discomfort. family also noted cyanotic fingers toes new patient. denies associated pain. ED patient chest x-ray consistent significant left pleural effusion. thoracentesis performed removed 1.5L. Post procedure chest x-ray showed improvement. patient symptomatically improved required lower oxygen requirements. found lactic acidosis improved 1L crystalloid. given IV vancomycin cefepime empiric antimicrobial coverage. ED, initial VS were: Sinus tachycardia, 108, 125/76, 29, 5L NC . arrival MICU, patient awake mildly confused. Patient aware location self confused time. acute distress. reports breathing much better initially presented ED. Denies current chest pain abdominal pain. Patient still somewhat tachypnic appears comfortable. Past Medical History: hyperlipidemia, dementia, osteoperosis Social History: Denies tobacco, EtOH, recreational drug use Family History: Non-contributory Physical Exam: admission: Vitals: T:97.3 BP:154/73 P:110 R:28 O2: 94% 4L NC General: Alert, confused place, appear distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP elevated, LAD CV: sinus tachycardia, normal S1 + S2, murmurs, rubs, gallops Lungs: Crackles left lobes Abdomen: soft, non-tender, non-distended, bowel sounds present, organomegaly GU: foley place Ext: cyanotic digits hands feet, +radial pulses bilaterally, +DP/PT left, right foot difficult obtain Doppler pulses Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred discharge: Vitals: 98.6 150/90 103 21 92%1L NC GEN: Frail elderly female, acute distress. HEENT: Dry mucous membranes, lesions noted. Sclerae anicteric. conjunctival pallor noted. NECK: JVP elevated. lympadenopathy. CV: Regular rate rhythm, murmurs, rubs [Last Name (un) 549] PULM: Bibasilar crackles, diminished breath sounds left base. Resp unlabored, accessory muscle use. ABD: Soft, non-tender, non distended, bowel sounds present. hepatosplenomegaly EXTR: edema, 2+ Dorsalis pedis radial pulses bilaterally. NEURO: & x 1. Moving extremities, following commands SKIN: ulcerations rashes noted. Pertinent Results: admission: [2200-11-10] 07:05PM BLOOD WBC-15.6* RBC-5.88* Hgb-16.9* Hct-52.7* MCV-90 MCH-28.7 MCHC-32.0 RDW-14.0 Plt Ct-131* [2200-11-10] 07:05PM BLOOD Neuts-89.2* Lymphs-5.9* Monos-3.7 Eos-0.9 Baso-0.3 [2200-11-10] 07:05PM BLOOD PT-17.8* PTT-22.4 INR(PT)-1.6* [2200-11-10] 07:05PM BLOOD Glucose-394* UreaN-59* Creat-1.5* Na-138 K-5.5* Cl-95* HCO3-20* AnGap-29* [2200-11-10] 07:05PM BLOOD LD(LDH)-523* [2200-11-10] 07:05PM BLOOD proBNP-[Numeric Identifier 1199]* [2200-11-10] 07:05PM BLOOD cTropnT-0.03* [2200-11-10] 07:05PM BLOOD Calcium-9.6 Phos-6.2* Mg-2.2 [2200-11-12] 07:08AM BLOOD %HbA1c-10.8* eAG-263* [2200-11-11] 04:41AM BLOOD TSH-5.7* [2200-11-11] 08:25PM BLOOD Vanco-9.8* [2200-11-10] 07:25PM BLOOD Type-ART pO2-77* pCO2-31* pH-7.45 calTCO2-22 Base XS-0 [2200-11-10] 07:13PM BLOOD Glucose-339* Lactate-5.3* [2200-11-11] 12:18AM BLOOD O2 Sat-95 [2200-11-11] 12:18AM BLOOD freeCa-1.10* [2200-11-11] 01:15AM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.017 [2200-11-11] 01:15AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.0 Leuks-NEG [2200-11-11] 01:15AM URINE RBC-5* WBC-3 Bacteri-FEW Yeast-NONE Epi-1 [2200-11-11] 01:15AM URINE CastHy-64* [2200-11-11] 01:15AM URINE Hours-RANDOM UreaN-897 Creat-159 Na-10 K-74 discharge: [2200-11-17] 07:00AM BLOOD WBC-11.7* RBC-4.65 Hgb-13.5 Hct-42.3 MCV-91 MCH-29.0 MCHC-31.9 RDW-14.6 Plt Ct-211 [2200-11-14] 08:30AM BLOOD PT-13.2* PTT-26.7 INR(PT)-1.2* [2200-11-17] 07:00AM BLOOD Glucose-157* UreaN-11 Creat-0.6 Na-138 K-4.3 Cl-100 HCO3-26 AnGap-16 [2200-11-12] 07:08AM BLOOD proBNP-3694* [2200-11-17] 07:00AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.7 [2200-11-16] 06:30AM BLOOD Triglyc-183* HDL-29 CHOL/HD-6.0 LDLcalc-108 [2200-11-12] 06:51AM BLOOD Lactate-1.6 Pleural Fluid: [2200-11-10] 09:37PM PLEURAL WBC-299* RBC-179* Polys-34* Lymphs-16* Monos-0 Meso-2* Macro-18* Other-30* [2200-11-10] 09:37PM PLEURAL TotProt-3.8 LD(LDH)-115 Cholest-119 GRAM STAIN (Final [2200-11-10]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. MICROORGANISMS SEEN. FLUID CULTURE (Final [2200-11-13]): GROWTH. ANAEROBIC CULTURE (Final [2200-11-16]): GROWTH. Cytology: POSITIVE MALIGNANT CELLS, Consistent metastatic adenocarcinoma. Immunohistochemical stains show tumor cells stain positive B72.3, [Last Name (un) ]-31 (weak) cytokeratin 7; cells negative CD15 (LeuM1), cytokeratin 20, TTF-1, mammoglobin, GCDFP, ER, PR CDX2. Immunostains calretinin WT-1 highlight background mesothelial cells. immunophenotype non-specific. Possibilities include (but limited to) lung, breast gynecologic primary malignancies. Microbiology: Blood Culture, Routine (Final [2200-11-16]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. TWO COLONIAL MORPHOLOGIES. Isolated one set previous five days. SENSITIVITIES PERFORMED REQUEST.. Aerobic Bottle Gram Stain (Final [2200-11-11]): GRAM POSITIVE COCCI CLUSTERS URINE CULTURE (Final [2200-11-12]): GROWTH. Blood Culture, Routine (Final [2200-11-17]): GROWTH. Blood Culture, Routine (Final [2200-11-18]): GROWTH. CLOSTRIDIUM DIFFICILE TOXIN & B TEST (Final [2200-11-16]): Feces negative C.difficile toxin & B EIA. CLOSTRIDIUM DIFFICILE TOXIN & B TEST (Final [2200-11-18]): Feces negative C.difficile toxin & B EIA. Portable CXR [2200-11-10]: IMPRESSION: Large left pleural effusion associated lower lung atelectasis. Please note underlying pneumonia cannot excluded. Recommend followup resolution. Portable CXR [2200-11-10]: Previous left pleural effusion nearly resolved following thoracentesis. obvious pneumothorax. Heterogeneous opacification left lung could residual atelectasis reexpansion edema followed. Mild interstitial abnormality possible bronchiectasis noted right lung, nothing acute. heart moderately enlarged. TTE [2200-11-11]: left atrium normal size. Left ventricular wall thicknesses normal. left ventricular cavity unusually small. Due suboptimal technical quality, focal wall motion abnormality cannot fully excluded. Left ventricular systolic function hyperdynamic (EF>75%). borderline normal free wall function. aortic valve leaflets (3) appear structurally normal good leaflet excursion aortic stenosis aortic regurgitation. mitral valve leaflets mildly thickened. Trivial mitral regurgitation seen. left ventricular inflow pattern suggests impaired relaxation. mild pulmonary artery systolic hypertension. pericardial effusion. anterior space likely represents prominent fat pad. CT chest w/o contrast [2200-11-11]: FINDINGS: Extensive calcifications aorta noted. Mediastinal lymph nodes pathologically enlarged based size criteria. normal diameter pulmonary arteries. left lower lobe extensive consolidation associated pleural effusion. addition multiple pulmonary nodules ill-defined margins noted throughout lungs bilaterally. Multiple pulmonary nodules bilateral, ranging 15 mm left upper lobe, 10.5 mm right upper lobe. nodules cavitated. definite dominant lesion noted lungs, potentially could obscured extensive consolidation lingula left lower lobe. Small amount pleural effusion current study appears decreased compared [2200-11-10] likely unchanged since chest radiograph obtained thoracocentesis. Airways patent level subsegmental bronchi bilaterally. bone abnormalities suggest lytic sclerotic lesions worrisome neoplasm infectious process demonstrated. imaged portion upper abdomen demonstrates sludge gallbladder otherwise unremarkable within limitations study technique. IMPRESSION: 1. Substantial consolidation left lower lobe lingula degree volume loss associated currently minimal amount pleural effusion. Infectious etiology would first choice, although underlying neoplasm vasculitis cannot excluded. etiologies may potentially explain presence multiple ill-defined pulmonary nodules seen lungs well consolidation, correlation clinical symptoms tissue diagnosis required. 2. extensive consolidations might potentially obscure pulmonary lesions dominant case malignancy. Portable CXR [2200-11-13]: FINDINGS: Since recent examination, interval increase small-to-moderate left layering pleural effusion. mild improvement ill-defined nodular opacification scattered throughout lung fields better characterized recent CT. evidence pneumothorax. right-sided effusion. cardiomediastinal hilar contours stable, demonstrating borderline enlarged heart size. Pulmonary vascularity increased. IMPRESSION: 1. Mild interval increase small-to-moderate left layering pleural effusion since recent examination. 2. Mild improvement multifocal ill-defined nodular opacification, better characterized CT [2200-11-11]. MRI head w w/o contrast [2200-11-14]: FINDINGS: Diffusion images demonstrate small area high signal right occipital lobe near midline without corresponding enhancement. Subtle T2-hyperintensity also seen region. Additionally, focus hyperintensity left centrum semiovale, demonstrates area enhancement. areas abnormal enhancement seen. moderate-to-severe brain atrophy seen prominence temporal horns indicating temporal lobe atrophy. Mild-to-moderate changes small vessel disease seen. IMPRESSION: focus hyperintensity diffusion images right occipital lobe without corresponding enhancement small characterize ADC map, could represent small acute infarct. abnormality left centrum semiovale demonstrates T2 abnormality subtle enhancement. Given faint enhancement T2 abnormality, differential diagnosis includes small deep white matter subacute infarct versus metastatic lesion. followup study two weeks would help assessment. areas abnormal enhancement seen. territorial infarcts identified. Brain atrophy seen. Brief Hospital Course: [Age 90 ]yo F dementia, HL, osteoporosis presented SOB found large left sided pleural effusion CXR. #Pleural Effusion, malignant: Patient presented ED shortness breath, tachypnea hypoxia. Chest x-ray significant large left pleural effusion. Thoracentesis performed removed 1.5L fluid. Analysis showed 300 WBC 33% PMN. Light criteria negative exudate. Gram stain negative. Differential broad based history, physical, labs question parapneumonic effusion vs malignancy. Less likely CHF, PE. TTE performed showed EF >75%. BNP [Numeric Identifier 1199] admission dramatically decreased 3694 thoracentesis. Patient transitioned ceftriaxone azithromycin empiric coverage CAP treated 7 days antibiotics. Repeat chest x-ray consistent intersitial edema questionable consolidation left lower lobe. Oxygen requirements weaned patient transferred 2L nasal cannula. remained mostly room air, intermittently 1-2L oxygen, throughout remainder hospital course floor. Repeat CXRs showed slow re-accumulation left pleural effusion. Cytology pleural fluid returned positive malignant cells, showing metastatic adenocarcinoma. Interventional pulmonary continued follow patient floor. Discussion therapeutic options pleural effusion held, including possible options chest tube drain pleurodesis. Prior discharge, option performing repeat thoracentesis drain remaining fluid discussed family. Given risks procedure, family declined interventions. palliative care team consulted guidance end life care. [2200-11-17], family meeting held palliative care team discuss goals care options care home vs extended care facility. family decided home hospice patient discharged [2200-11-18] home hospice service place. need 24 hour care home, home oxygen home oxygen saturation 90%, wheelchair. also provided medications help comfort, including morphine. # Somnolence/Encephalopathy: Pt exhibited waxing [Doctor Last Name 688] levels somnolence hospital stay. Per family report, also increasingly sleep home prior admission hospital. likelihood malignancy possibility metastatic spread, MRI head pursued discussion family risks benefits head imaging. MRI showed focus hyperintensity right occipital lobe could represent small acute infarct well abnormality left centrum semiovale consistent either subacute infarct vs metastatic lesion. Patient started baby aspirin remain simvastatin. LDL 108. #Lactic acidosis: Patient presented lactate 5.3. thoracentesis fluid resuscitation lactate improved 4.1. Etiology includes hypovolemia hypoperfusion vs sepsis vs hypoxia. Patient elevated WBC 15.6 left shift. Patient hemodynamically stable. Received IV vancomycin cefepime ED transitioned ceftriaxone/azithromycin. Lactate normalized 1.6 prior transfer floor. #Acute Kidney Injury: admission, patient acute elevation Cr 0.8 1.5 elevated BUN 59. Pre-renal azotemia likely secondary hypovolemia. Differential also includes ATN. FeNa <1%. likely secondary hypovolemia. Cr improved fluid resusciation. Cr baseline 0.6 time discharge. given conservative IV fluids prn signs volume depletion, including tachycardia low 100s low urine output. #Hyperglycemia/DM type 2, uncontrolled, without complications: Patient history diabetes glimepiride home presenting serum glucose 394. Patient started sliding scale insulin. Prior discharge home, fingersticks remained 100s-200s without insulin. Hemoglobin A1c 10.8. Risks benefits oral agents diabetes discussed family. risks hypoglycemia minimal po intake, patient discharged home oral hypoglycemics. #Cyanotic Digits: Patient cyanosis fingers toes. associated pain. Positive radial pulses. Left DP/PT present Doppler able obtained right. Currently appear ischemic likely chronic PVD. re-examining patient HD 1 morning rounds extremity cyanosis resolved pulses present extremities. ABI showed bilateral aortoiliac likely infrainguinal arterial occlusive disease . ABIs 0.7 right 0.6 left. Given overall limited life expectancy, work-up PVD pursued. # Bacteremia: Blood culture arrival ED [2200-11-10] grew GPCs clusters; started vancomycin empirically. Speciation returned coag negative staph. felt one positive blood culture likely contaminant pt afebrile downtrending WBC. Subsequent blood cultures showed growth. Vancomycin discontinued one day. #Diarrhea: Two days prior discharge, pt developed increased frequency loose stools. C.diff negative x 2. may find symptomatic relief anti-diarrheal agents loperamide. given conservative IV fluids prn volume depletion. diarrhea day discharge. #Poor po intake: Family concerned pt's minimal oral intake, ongoing problem prior admission. seen swallow therapist performed bedside evaluation found risk aspiration. Although swallow therapist felt restrictions diet, kept soft dysphagia diet family requested it. Medications Admission: ALENDRONATE - 70 mg Tablet - 1 Tablet(s) mouth weekly DONEPEZIL - 5 mg Tablet - 1 Tablet(s) mouth day glimepiride 1 mg tab QD SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) mouth bedtime Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:0 2. Wheelchair Please provide 1 wheelchair 3. Compression stockings Provide 1 pair compression stockings 4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO day. Discharge Disposition: Home Service Facility: Hospice [Location (un) 1121] Discharge Diagnosis: Primary: Pleural effusion Adenocarcinoma Acute/subacute infarct Secondary: Diabetes mellitus type II Peripheral vascular disease Discharge Condition: Mental Status: Confused - always. Level Consciousness: Lethargic arousable. Activity Status: Bed assistance chair wheelchair. Discharge Instructions: pleasure taking care hospital. admitted shortness breath. found large fluid collection around lungs; fluid removed. fluid showed cancer cells. MRI head also showed possible stroke possibly spread cancer brain. family met palliative care team decided would go home hospice care. hospice team provide family medications keep comfortable. following medication changes made: 1) STOP glimepride 2) START aspirin 81mg daily 3) may continue take simvastatin 10mg daily 4) STOP alendronate Followup Instructions: cared hospice team home. Completed by:[2200-11-18]	[ "486" ]
Admission Date: [2162-7-28] Discharge Date: [2162-7-31] Date Birth: [2080-3-22] Sex: Service: ORTHOPAEDICS Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3190] Chief Complaint: ?Guillain-[Location (un) ] Major Surgical Invasive Procedure: Bronchoscopy bronchial lavage: 8/3 [2162-7-29] 1. Total laminectomy C3, 4, 5, 6 7. 2. Fusion C3 7. 3. Autograft allograft. History Present Illness: 82 y/o male PMHx breast CA s/p mastectomy [5-/2162] c/b right frozen shoulder, squamous cell CA penis s/p resection, glaucoma transferred concern Guillain-[Location (un) ] syndrome. Per pt's niece, usual state health [7-24], fell unloading piece furniture car. Per OSH notes, lose conciousness complain cardiac prodrome - felt mechanical fall. weak get ground ~2 hours prior found neighbor. [Name (NI) ] taken [Hospital3 ] admitted telemetry unit. noted elevated CK, peaked 3320, trended IVF. Cardiology consulted felt mechanical fall planned obtain echocardiogram. [7-25], patient noted increased weakness progressed feeling inability move extremities [7-26]. Shortly this, became bradycardic hypotensive went respiratory failure. intubated, CPR performed, transferred CCU. intermittently pressors felt developed aspiration pneumonia. initially clindamycin, broadened vancomycin cefepime. O2 requirement improved plans extubate [7-28], however NIF noted -10 patient noted complete paralysis bilateral extremities. CT negative, neuro consulted felt may ascending paralysis GBS recommended transfer tertiary care facility. . ICU, patient intubated. able shake head yes questions. Past Medical History: Breast CA s/p mastectomy [5-/2162] penile Squamous cell CA s/p resection Glaucoma Social History: - Tobacco: none - Alcohol: none - Illicits: none Family History: Unknown Physical Exam: Vitals: T: BP: P: RR: SpO2: General: Intubated HEENT: Sclera anicteric, MMM, oropharynx clear Lungs: Decreased breath sounds left, coarse breath sounds right CV: RRR, normal S1 + S2, tachycardic Abdomen: soft, non-tender, non-distended, bowel sounds present, rebound tenderness guarding, organomegaly GU: foley place Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis edema Neuro: able shake head yes simple questions, Pupils track across midline. Right hand minimal movement asked squeeze, movement rest extremities - sensation unable assessed - reflexes noted exam Rectal exam deferred collar able placed Pertinent Results: Admission Labs: [2162-7-28] 07:40PM WBC-7.1 RBC-4.07* HGB-12.9* HCT-35.6* MCV-87 MCH-31.7 MCHC-36.3* RDW-13.0 [2162-7-28] 07:40PM NEUTS-83* BANDS-3 LYMPHS-5* MONOS-8 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [2162-7-28] 07:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2162-7-28] 07:40PM PT-13.3 PTT-30.0 INR(PT)-1.1 [2162-7-28] 07:40PM GLUCOSE-147* UREA N-16 CREAT-0.6 SODIUM-139 POTASSIUM-3.5 CHLORIDE-106 TOTAL CO2-27 ANION GAP-10 [2162-7-28] 07:40PM ALT(SGPT)-67* AST(SGOT)-52* LD(LDH)-219 CK(CPK)-629* ALK PHOS-43 TOT BILI-0.8 [2162-7-28] 07:40PM CK-MB-4 cTropnT-<0.01 [2162-7-28] 07:40PM ALBUMIN-3.2* CALCIUM-7.6* PHOSPHATE-2.7 MAGNESIUM-2.2 [2162-7-28] 08:00PM TYPE-ART TEMP-37.2 RATES-14/6 TIDAL VOL-500 PEEP-5 O2-100 PO2-65* PCO2-40 PH-7.45 TOTAL CO2-29 BASE XS-3 AADO2-617 REQ O2-99 INTUBATED-INTUBATED . Microbiology: Bronchial lavage ([7-28]): [2162-7-28] 10:37PM BODY FLUID POLYS-86* LYMPHS-1* MONOS-13* . Imaging: CXR ([7-28]): MR [Name13 (STitle) ] ([8-24]: FINDINGS: exaggerated lordosis cervical spine. minimal retrolisthesis C4 C5 vertebra 4 mm. vertebral bodies normal height marrow signal intensity. evidence acute fracture. Prevertebral soft tissue noted C1 C5 level. Hyperintensity noted posterior paraspinal muscles soft tissues C1 C6 levels. small hypointense area noted right paraspinal muscles C7-T1 level measuring 1.8 x 1.4 x 1.7 cm craniocaudad, AP, transverse dimensions. likely represents calcification. multilevel disc degenerative disease. desiccation cervical intervertebral discs. C2-C3 level, significant spinal canal neural foraminal narrowing. C3-C4 level, broad-based posterior disc protrusion causing indentation compression spinal cord. severe spinal canal stenosis. disc uncovertebral facet osteophytes causes moderate bilateral foraminal stenosis. C4-C5, posterior disc protrusion causing indentation compression spinal cord severe spinal canal narrowing. disc uncovertebral facet osteophytes causes moderate right mild left foraminal narrowing. C5-C6, diffuse posterior disc bulge causing indentation anterior subarachnoid space. evidence significant spinal canal neural foraminal narrowing. C6-C7 level, diffuse posterior disc bulge without significant spinal canal neural foraminal narrowing. Hyperintense signal noted cervical spinal cord C2 C7 level. likely represents combination compressive edema contusion secondary fall. Brief Hospital Course: 82 y/o male PMHx breast CA s/p mastectomy [5-/2162] c/b right frozen shoulder, squamous cell CA penis s/p resection, glaucoma neurologic signs concerning cervical spine injury vs GBS vs myositis. . # Weakness/paralysis - Concerning cervical spine injury (may occurred intubation) vs ascending paralysis GBS vs myositis/myopathy given elevated CK admission. Patient clear history prodromal illness GBS, necessary diagnosis. CK trending without intervention myositis making less likely. MR [Name13 (STitle) 2853] performed early [7-29] showed chronic DJD C-spine significant narrowing spinal canal, compression spinal cord, associated edema C3-T1. Spine surgery consulted felt paralaysis secondary spinal cord compression poor prognosis patient taken low probability recovery function. Spine surgery discussion family chose pursue surgical repair. . # Hypoxemic respiratory failure - [1-27] diaphragmatic weakness pneumonia/mucus plugging. CXR presentation showed complete whiteout left lung - bronchoscopy evening [7-28] showed copious amounts mucus plugging suctioned out. Post bronch, able weaned 60% FiO2. repeat CXR [7-29] showed substantial improvement, possible consolidation LLL. Due neuromuscular dysfunction, continued ventilation. . # HCAP - Signs LLL PNA seen bronchoscopy edematous, red airways. thought aspirated OSH covered vanco/cefepime. hospital > 48 hours needs covered HCAP. Plan continue coverage request sputum culture results OSH. . # Thrombocytopenia - Platelets 114 [7-28], 147 admission OSH. signs spontaneous bleeding time. Differential includes med effect vs decreased production. . # Anemia - Mild normocytic anemia. admission Hgb 14.7. [Month (only) 116] [1-27] dilution vs decreased production vs bleed (although evidence). Plan follow CBC. . # Elevated AST/ALT - mildly elevated, LFTs normal including bili. [Month (only) 116] related periods hypotension. Plan trend LFTs. . # Bradycardia - Bradycardic OSH, stable here. [Month (only) 116] secondary [Last Name (un) 4584]-[Location (un) ] neuro problem affecting autonomic nervous system. Presumably, ruled MI happened unknown happen. EKG shows evidence infarct. Echo planned [7-29], may deferred given emergent surgical intervention. . # Elevated CK - Likely secondary rhabdo fall, CK's trending without acute intervention renal function stable. . # FEN: IVF needed, replete electrolytes, NPO # Prophylaxis: Pneumoboots subQ heparin # Access: peripherals # Communication: Patient # Disposition: Patient transferred [Hospital Ward Name ] trauma ICU possible surgical intervention per Spine surgery evening [2162-7-30], discussion patient family members, patient's code status changed Comfort Measures Only. pain controlled IV morphine. 1030pm, patient noted respiratory drive, pulse heart/lung sounds. call resident called evaluate patient, patient pronounced dead 1040pm [2162-7-30]. Medications Admission: Home Medications: Xalatan Combivent MVI Advil Discharge Disposition: Expired Discharge Diagnosis: Cervical stenosis/spondylosis Quadraplegia Pneumonia Discharge Condition: Expired Completed by:[2162-8-16]	[ "486" ]
Admission Date: [2103-5-24] Discharge Date: [2103-5-27] Service: [Location (un) ] NOTE: partial dictation. rest dictation done Internal Service. CHIEF COMPLAINT: Explosive diarrhea. HISTORY PRESENT ILLNESS: patient [Age 90 ]-year-old female past medical history significant coronary artery disease, atrial fibrillation (on Coumadin), congestive heart failure presents severe explosive diarrhea. patient recently hospitalized [Hospital1 346] discharged [2103-5-24]; day re-presented Emergency Room explosive diarrhea. prior hospitalization, noted pneumonia started antibiotic therapy. discharged levofloxacin. reportedly discharged good condition; however, ambulance ride nursing home developed explosive diarrhea became tachycardic. Upon arrival nursing home redirected [Hospital1 69] management. Emergency Department, noted tachycardic 140 dehydrated. treated one liter intravenous fluids 5 mg intravenously Lopressor times two. also started Flagyl empiric coverage Clostridium difficile. chest x-ray obtained revealed stable cardiomegaly tortuous calcified aorta. noted upper zone redistribution pulmonary vasculature. consistent congestive heart failure. also bibasilar effusions consolidation left lung base. underlying pneumonia could excluded. overall impression chest x-ray revealed improvement underlying congestive heart failure. PAST MEDICAL HISTORY: 1. Atrial fibrillation. 2. Coronary artery disease; status post non-ST-elevation segment myocardial infarction. 3. History peptic ulcer disease. 4. Status post cataract surgery. 5. History gastrointestinal bleed. 6. History carotid stenosis. MEDICATIONS ADMISSION: 1. Aspirin 325 mg mouth per day. 2. Atorvastatin 10 mg mouth per day. 3. Ipratropium nebulizers needed. 4. Levofloxacin 250 mg mouth q.24h. 5. Metoprolol 50 mg mouth three times per day. 6. Sublingual nitroglycerin. 7. Pantoprazole 40 mg mouth per day. 8. Psyllium mouth needed. 9. Warfarin 3 mg mouth hour sleep. ALLERGIES: known drug allergies. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: patient denies history tobacco. patient consume alcohol. history intravenous drug use. PHYSICAL EXAMINATION PRESENTATION: patient's temperature 98.6 degrees Fahrenheit, blood pressure 138/72, heart rate 93, respiratory rate 90, saturating 94% room air. general, patient elderly female sitting comfortably bed apparent distress. Head, eyes, ears, nose, throat examination revealed extraocular movements intact. pupils equal, round, reactive light. mucous membranes dry. Neck revealed jugular venous distention approximately 9 cm. lymphadenopathy appreciated examination. Pulmonary examination revealed diffuse crackles throughout mild expiratory wheezes. Cardiovascular examination revealed irregularly irregular rhythm. Normal first heart sounds second heart sounds. abdomen soft, nontender, nondistended. normal active bowel sounds. Extremities revealed clubbing, cyanosis, edema. calf tenderness. BRIEF SUMMARY HOSPITAL COURSE: setting explosive diarrhea tachycardic, felt patient mildly volume depleted. addition, dry mucous membranes. resuscitated approximately one liter normal saline. also felt due recent antibiotic therapy pneumonia, likely etiology diarrhea could Clostridium difficile. started empiric antibiotics Flagyl. reported subjective improvement intravenous hydration; however, remained tachycardic. given 5 mg intravenous Lopressor times two 15 minutes apart. heart rate stabilized middle 90s; 160 140. following day cardiac echocardiogram obtained showed mild left ventricular hypertrophy. left ventricular cavity size normal left ventricular ejection fraction greater 55%. mild aortic valve stenosis trace aortic regurgitation. 1 2+ mitral regurgitation. moderate pulmonary artery systolic hypertension. electrocardiogram also obtained demonstrated atrial fibrillation rapid ventricular response. mild left axis deviation. nonspecific extensive ST segment changes. Cardiac enzymes cycled. patient noted elevated troponin. However, believed secondary non-ST-segment elevation myocardial infarction reportedly [Hospital Ward Name 332] Intensive Care Unit stay. creatine kinase CK/MB remained within normal limits hospitalization. patient continued support subjective improvement. discharged back nursing home, however, white blood cell count remained elevated. time dictation, Clostridium difficile toxin assay still pending. plan discharge patient white blood cell count improved Flagyl therapy Clostridium difficile toxin assay positive. DR [First Name8 (NamePattern2) 312] [Last Name (NamePattern1) 5408] 12.766 Dictated By:[Last Name (NamePattern1) 9725] MEDQUIST36 D: [2103-5-26] 09:54 T: [2103-5-26] 10:13 JOB#: [Job Number 106490]	[ "486" ]
Admission Date: [2136-2-9] Discharge Date: [2136-3-6] Date Birth: [2061-6-24] Sex: F Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 3984] Chief Complaint: CC: Fever, altered mental status, hypotension, sepsis Major Surgical Invasive Procedure: [2136-3-2]-Open tracheostomy [2136-3-2]-percutaneous endoscopic gastrostomy tube History Present Illness: . PCP: [Last Name (NamePattern4) ]. [Last Name (STitle) 45938] office [Telephone/Fax (1) 45939], [Hospital ] Hospital ED ([Telephone/Fax (1) 77108]. . HPI: 74yoF PMH tobacco use glaucoma (no regular medical care last PCP [Name Initial (PRE) ] 6 years ago) developed fever body aches [2136-2-1] progressively worsening confusion since presented PCP's office today complaints generalized malaise feeling unwell. specifically complained inability sleep requested sleep medication however also endorsed generalized weakness perhaps dizziness. PCP referred [Hospital ] Hospital ED given symptoms reportedly looked "overall unwell". (and family) report symptoms began [2136-2-1] time developed "body aches" subjective fevers/chills. also mild dry cough. daughter reports progressive confusion mainly past days. also poor PO intake (food fluid) [3-10] poor appetite. denies sore throat, runny nose, N/V/diarrhea/abdominal pain, dysuria/hematuria. denies night sweats, signifiant weight loss. also denies HA, changes vision, neck stiffness. . OSH ED, noted peripheral blood WBC >60K reported "left shift". RUL infiltrate noted CXR received 1 dose levofloxacin IV. ABG initially showed pCO2=59 however became increasingly lethargic repeat ABG showed pCO2=78. simultaneously noted hypoxemic (paO2 clear), SaO2 70% NRB prior intubation. intubated noted hypotensive nadir 65/40 (? post sedation vs. before) started dopamine via peripheral IV initially 20mcg/kg/min. Dopamine decreased 5mcg/kg/min prior transfer maintenance SBPs 90s. became tachycardic 140s dopamine changed levophed without tachycardia maintenance MAPS approximately 50-60. . Transferred MICU presumed sepsis. . ROS: above, also denies rashes. + DOE walking stairs, PND, orthopnea (per family history). melena/hematochezia. Medications: Glaucoma eye gtts . Allergies: NKDA Past Medical History: Past Medical History: Tobacco use, ? COPD Glaucoma Social History: Social History: Quit tobacco 15years ago, previously approximately 20-30packyear history. EtOH illicits. Formerly worked parking permit department police dept. 9 children (7 daughters, 2 sons). Family History: Family History: non-contributory Physical Exam: Physical Exam: VS: Temp: 97.0 BP: 96/61 HR: 101 ST RR: 12 O2sat 95-96% AC 500/12 PEEP 10 FiO2 0.60 GEN: intubated HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions, superior lip mild blood oozing ETT tape NECK: supraclavicular cervical lymphadenopathy appreciated, jvd, carotid bruits, thyromegaly thyroid nodules RESP: Rhonchorus anteriorly CV: RRR, S1 S2 wnl, systolic murmur heard greatest LUSB ABD: nd, +b/s, soft, nt, masses hepatosplenomegaly EXT: trace 1+ edema b/l feet, warm, good pulses SKIN: rashes/no jaundice NEURO: Somnolent sedation, arousable able answer yes/no questions, nods appropriately. Able cooperate strength exam/follow commands. 5/5 strength throughout. sensory deficits light touch appreciated. Pertinent Results: EKG: Sinus tachy rate 103, normal access, q II, III, aVF, 1mm ST depression II aVF, 1mm ST depression V5, 1mm ST elevation V2. Isolated biphasic TW aVL. . Imaging: . [2136-2-9] OSH CXR: Per verbal report showed opacity upper portion RLL. (Need review CD) . [2136-2-9] CXR presentation ICU (WET): Opacity superior portion right lower lobe, left upper lobe opacity hiatal hernia vs. left hemidiaphragm elevation. Hilar fullness likely representing LAD. . ADMISSION LABS: [2136-2-9] . [2136-2-9] 08:55PM BLOOD Neuts-91* Bands-3 Lymphs-2* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [2136-2-9] 08:55PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Schisto-OCCASIONAL [2136-2-9] 08:55PM BLOOD Plt Smr-HIGH Plt Ct-538* [2136-2-9] 10:55PM BLOOD PT-12.5 PTT-23.4 INR(PT)-1.1 [2136-2-9] 05:58PM BLOOD Glucose-188* UreaN-63* Creat-1.3* Na-136 K-3.5 Cl-98 HCO3-28 AnGap-14 [2136-2-9] 05:58PM BLOOD estGFR-Using [2136-2-9] 05:58PM BLOOD ALT-33 AST-37 LD(LDH)-311* AlkPhos-235* TotBili-1.2 [2136-2-9] 05:58PM BLOOD Albumin-2.2* Calcium-7.4* Phos-4.5 Mg-2.5 [2136-2-9] 05:58PM BLOOD Cortsol-59.3* [2136-2-9] 08:05PM BLOOD Type-ART pO2-62* pCO2-70* pH-7.26* calTCO2-33* Base XS-1 [2136-2-9] 09:34PM BLOOD Type-MIX Temp-36.7 [2136-2-9] 08:05PM BLOOD Lactate-1.3 K-3.3* [2136-2-9] 09:34PM BLOOD Hgb-10.9* calcHCT-33 O2 Sat-74 [2136-2-9] 08:05PM BLOOD freeCa-0.99* . . MICRO DATA [2136-3-2] 11:42 SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. LEGIONELLA CULTURE (Preliminary): LEGIONELLA ISOLATED. ASPERGILLUS FUMIGATUS. IDENTIFICATION PERFORMED CULTURE # 244-2449B ([2136-2-26]). . [2136-2-9] 9:31 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. FINAL REPORT [2136-2-12] GRAM STAIN (Final [2136-2-10]): >25 PMNs <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. PAIRS SHORT CHAINS. 2+ (1-5 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [2136-2-12]): OROPHARYNGEAL FLORA ABSENT. STREPTOCOCCUS PNEUMONIAE. SPARSE GROWTH. PRESUMPTIVELY PENICILLIN SENSITIVE OXACILLIN SCREEN. SENSITIVITIES: MIC expressed MCG/ML _________________________________________________________ STREPTOCOCCUS PNEUMONIAE \| PENICILLIN------------ . [2136-2-10] 10:33 URINE Site: CATHETER FINAL REPORT [2136-2-11] Legionella Urinary Antigen (Final [2136-2-11]): NEGATIVE LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed Immunochromogenic assay. negative result rule infection due L. pneumophila serogroups Legionella species. Furthermore, infected patients excretion antigen urine may vary. . [2136-2-14] 2:24 pm BRONCHOALVEOLAR LAVAGE FINAL REPORT [2136-2-20] GRAM STAIN (Final [2136-2-16]): POLYMORPHONUCLEAR LEUKOCYTES SEEN. MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2136-2-18]): GROWTH, <1000 CFU/ml. VIRAL CULTURE (Final [2136-2-20]): HERPES SIMPLEX VIRUS TYPE 1. CONFIRMED MONOCLONAL FLUORESCENT ANTIBODY.. . [2136-2-17] 3:05 pm SKIN SCRAPINGS FINAL REPORT [2136-3-2] VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final [2136-3-2]): VIRUS ISOLATED. . [2136-2-17] 2:40 pm EAR LEFT EAR. SITE CONFIRMED [Numeric Identifier 77109] DR [Last Name (STitle) ] [2136-2-21]. FINAL REPORT [2136-2-21] GRAM STAIN (Final [2136-2-17]): POLYMORPHONUCLEAR LEUKOCYTES SEEN. MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [2136-2-19]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. YEAST. MODERATE GROWTH. . [2136-2-17] 2:40 pm SWAB Site: EAR RIGHT EAR. SITE CONFIRMED DR [Last Name (STitle) ] [Numeric Identifier 77109] [2136-2-21]. FINAL REPORT [2136-2-21] GRAM STAIN (Final [2136-2-17]): POLYMORPHONUCLEAR LEUKOCYTES SEEN. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [2136-2-21]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. 2ND TYPE. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE GROWTH . [2136-3-1] 5:29 pm ASPIRATE Site: SINUS Source: Sinus. GRAM STAIN (Final [2136-3-1]): POLYMORPHONUCLEAR LEUKOCYTES SEEN. MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2136-3-3]): GROWTH. POTASSIUM HYDROXIDE PREPARATION (Final [2136-3-1]): Test cancelled laboratory. PATIENT CREDITED. Inappropriate specimen Fungal Smear (KOH). FUNGAL CULTURE (Preliminary): FUNGUS ISOLATED. RELEVANT IMAGING Echo [3-2]: left atrium normal size. Left ventricular wall thickness, cavity size, systolic function normal (LVEF>55%). Due suboptimal technical quality, focal wall motion abnormality cannot fully excluded. aortic valve leaflets (3) mildly thickened aortic stenosis present. definite aortic regurgitation seen. mitral valve leaflets mildly thickened. mitral valve prolapse. severe mitral annular calcification. mild functional mitral stenosis (mean gradient 7 mmHg) due mitral annular calcification. Mild (1+) mitral regurgitation seen. [Due acoustic shadowing, severity mitral regurgitation may significantly UNDERestimated.] tricuspid valve leaflets mildly thickened. pulmonary artery systolic pressure could determined. pericardial effusion. Compared prior study (images reviewed) [2136-2-10], findings similar. . [3-1] CT sinuses IMPRESSION: 1. Improvement mucosal thickening paranasal sinuses described above. Resolution fluid within middle ear cavities bilaterally. 2. Persistent partial opacification mastoid air cells bilaterally. . [2-29] chest CT IMPRESSION: 1) Persisting multifocal consolidation, significantly changed. 2) Interval development underlying pulmonary edema increasing, moderate, bilateral pleural effusions. 3) Enlarged mediastinal lymph nodes likely reactive underlying infectious process and/or CHF. 4) Lobulated, hypodense hepatic dome lesion, likely cyst. 5) Left adrenal mass Hounsfield Units 5 15, likely adenoma. . [2-17]-CT orbit, sella, IAC IMPRESSION: 1. Paranasal sinus opacification described above. 2. Soft/fluid density within bilateral mastoid air cells right middle ear cavity without bony erosions destructive changes. Findings may represent effusions mastoid air cells right middle ear cavity, versus otomastoiditis. 3. 7-mm well-circumscribed lytic area within left occipital lobe, likely arachnoid granulation. clinical concern previous history malignancy, bone scan could considered characterization. . [2136-2-11] CT Torso 1. Extensive bilateral pulmonary consolidations consistent pneumonia. 2. Small bilateral pleural effusions. 3. Suboptimal position right internal jugular central line tip inferior vena cava. 4. Ascites. 5. Cholelithiasis. 6. Left adrenal mass, cannot characterized study. evaluation MRI may obtained clinically feasible . echo [2136-2-10] left atrium mildly dilated. estimated right atrial pressure 10-20mmHg. mild symmetric left ventricular hypertrophy. left ventricular cavity unusually small. Left ventricular systolic function hyperdynamic (EF 70-80%). ventricular septal defect. Right ventricular chamber size free wall motion normal. ascending aorta mildly dilated. aortic valve leaflets (3) mildly thickened aortic stenosis present. aortic regurgitation seen. mitral valve leaflets mildly thickened. mitral valve prolapse. severe mitral annular calcification. mild valvular mitral stenosis (area 1.5-2.0cm2). Mild (1+) mitral regurgitation seen. [Due acoustic shadowing, severity mitral regurgitation may significantly UNDERestimated.] tricuspid valve leaflets mildly thickened. Moderate [2+] tricuspid regurgitation seen. moderate pulmonary artery systolic hypertension. pericardial effusion. Brief Hospital Course: Mrs. [Known lastname ] admitted [Hospital1 18] MICU. 74F h/o tobacco use, glaucoma (no past regular medical care) developed fever body aches [2136-2-1], progressively worsening confusion since then, presented OSH ED found WBC 60+, RUL hypotension requiring pressors, intubated transferred management septic shock [3-10] pneumococcal RUL PNA. resolved WBC continued respiratory failure ventilator dependancy; s/p Trach/PEG. Also new growth mold [2-26] sputum culture, staph coag (-) CVL tip [2-28], completed treatment pneumococcal pneumonia, well herpes lung infection, still treated mold sputum-aspergillus infection. . Problems: . RESPIRATORY FAILURE: presented hypercarbic hypoxic respiratory failure acute chronic respiratory acidosis secondary pneumonia developed ARDS. chest CT showed multifocal pneumonia, sputum culture showed penicillin resistant strep pneumonia. Empirical Vancomycin Flagyl discontinued, levofloxacin zosyn continued completed course. also component underlying COPD exacerbation albuterol atrovent. Diuresis initiated component volume overload felt present. However allowed self diurese became euvolemic. also found herpetic pulmonary infection (tracheobronchitis). BAL washings ([2-14])confirmed HSV-positive herpetic lesions trachea. Acyclovir started [2-21], ending [3-6] (2 week course); liver (AST 13. ALT 17), renal function monitored. previously aspergillus sputum negative beta-glucan galactomannan. Whether pathogen contaminant clear. started voriconazole [2-29], CT sinus CT chest show invasive disease. continue two weeks LFTs monitored weekly. also follow sputum KOH fungal culture [3-12] weeks stopping voriconazole. . Vent settings d/c ventilator settings: CPAP 46% FiO2 PEEP 5 Pt averaging tidal volumes 20 respiratory rate 30 . chronic respiratory failure tolerate weaning vent given need high PEEP & FIO2. Thus, tracheostomy placed slowly weaning vent. Trach: Dead space:tidal volume 78%. needs PRN decreases FiO2, PEEP. . HYPOTENSION: admission leukocytosis WBC 60, fever, tachycardia c/w SIRS since pneumonia hypotension spetic shock. requiring Norepinephrine. presence murmur exam subacute bacterial endocarditis felt possible etiology, thus echo done negative vegetations, Normal LVEF >55%, +1MR. random cortisol 59, appropriate decrease cortisol challenge. ischemic changes continguous leads cardiogenic etiology felt likely. [2-12] weaned successfully pressor support. occasionally required small boluses occasional decreases blood pressure aid urine output. . ACUTE RENAL FAILURE: known CRI history (although consistent medical care several years). BUN/creatinine ratio suggestive prerenal etiology, improved nml range IVFs. Admission BUN=63, Cr=1.3, Discharge BUN=23, Cr=0.5. . ILEUS: increasing abdominal distention BM. KUB done [2-10] c/w ileus. Abd CT demonstrated ascites SBO. bowel regimen TF appropriate holding residuals done. resolved [2-13]. . ALTERED MENTAL STATUS: ARDS, infection, also heavy sedation intubated. [3-4], decreased scheduled diazepam goal autotaper, decreased fentanyl patch 12.5mg. [3-5] patient found awakening, able communicate somewhat family staff. Diazepam discontinued [3-6] ativan 1mg Q6h:PRN started. . ANEMIA: slowly decreasing Hct. guiaic negative gross bleeding. Likely secondary blood draws, hemolysis labs negative, continue monitor. Admit HCT 32. Discharge HCT 26, stable 3 days prior discharge. admission patient transfused 1 unit packed RBCs w/o complications. . RIGHT OTITIS MEDIA: ENT irrigated ear, evidence otitis externa, likely otitis media s/p perforation drained fluid collection behind cerumen collection. Recieved ciprofloxacin/dexamethasone drops 5 drops TID ear 10 days. Started first full day [2-18], ended [2-28]. resolved. . NUTRITION: PEG placed time tracheostopy. Tube feed recs. tube feeds-Nutren Pulmonary Full strength; Additives:Beneprotein, 10 gm/day Starting rate: 40 ml/hr; advance rate Goal rate: 40 ml/hr Residual Check: q4h Hold feeding residual >= : 100 ml instructions: Please add 150 ml H20 TID TF . GLAUCOMA: remained home medications timolol travatan . ACCESS: PICC line placed [2-27]: signs infection picc site. . Follow up: Pt continue voriconazole [3-14] total 2weeks therapy -Pt needs LFTs drawn [3-12]. -sputum culture needed [2136-3-28] (for fungal culture KOH) -galactomannan B-glucan [2136-3-12] -Please contact PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 45938] [Telephone/Fax (1) 77110] follow appointment within 2 weeks. -Pt appointment infectious disease clinic; [4-2], 11:00am, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7443] [Hospital Ward Name ] [Hospital1 18] [Hospital Ward Name 23] building [Location (un) ]. Medications Admission: `Glaucoma eye gtts Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Injection Q8H (every 8 hours). 2. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 6-10 Puffs Inhalation Q4H (every 4 hours). 5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 6. Outpatient Lab Work LFTs Monday [2136-3-12] 7. Outpatient Lab Work sputum culture [2136-3-28] (for fungal culture KOH) 8. Outpatient Lab Work galactomannan B-glucan [2136-3-12] 9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times day). 10. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours) needed pain fever. 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times day). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times day). 14. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) needed. 15. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Five (5) ML Mucous membrane [Hospital1 ] (2 times day). 16. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) 8 days: last day [2136-3-14]. 17. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 18. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) needed: re-assess necessary intention taper. 19. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) needed. 20. Insulin Lispro 100 unit/mL Cartridge Sig: per scale Subcutaneous every six (6) hours: per scale. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 86] Discharge Diagnosis: Pneumococcal Pneumonia Herpetic pulmonary infection Aspergillus Acute Respiratory Distress Syndrome history tobacco use glaucoma Discharge Condition: stable -------- tube feeds-Nutren Pulmonary Full strength; Additives:Beneprotein, 10 gm/day Starting rate: 40 ml/hr; advance rate Goal rate: 40 ml/hr Residual Check: q4h Hold feeding residual >= : 100 ml instructions: Please add 150 ml H20 TID TF ------------------- ventilator settings: CPAP 46% FiO2 PEEP 5 Pt averaging tidal volumes 20 respiratory rate 30 Discharge Instructions: admitted pneumonia required intubation respiratory failure. also herpetic pulmonary infection continued require ventilation tracheostomy done. also PEG tube placed feeding. treated pneumonia herpetic lung infection antibiotics completed. also mold sputum requiring treatment antibiotic called voriconazole. continue take complete two week course, liver function tests checked weekly. discharged pulmonary rehab facility. call doctor fevers, chills, increased sputum production, concerning symptoms. Please follow outlined below. Followup Instructions: Follow up: Pt continue voriconazole [3-14] total 2weeks therapy -Pt needs LFTs drawn [3-12]. -sputum culture needed [2136-3-28] (for fungal culture KOH) -galactomannan B-glucan [2136-3-12] -Please contact PCP [Last Name (NamePattern4) ]. [Last Name (STitle) 45938] [Telephone/Fax (1) 77110] follow appointment within 2 weeks. -Pt appointment infectious disease clinic; [4-2], 11:00am, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 7443] [Hospital Ward Name ] [Hospital1 18] [Hospital Ward Name 23] building [Location (un) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] Completed by:[2136-3-6]	[ "496" ]
Admission Date: [2122-9-16] Discharge Date: [2122-9-25] Date Birth: [2056-8-21] Sex: Service: MEDICINE Allergies: Heparin Agents Attending:[First Name3 (LF) 398] Chief Complaint: Transfer OSH fevers, back pain, pathologic evidence Sweet Syndrome Major Surgical Invasive Procedure: Intubation mechanical ventilation Bone marrow biopsy Central venous line placement History Present Illness: (Primary historians: wife & daughter): 66 y/o male lung cancer s/p RUL lobectomy, back pain w/ spondylolisthesis, s/p lumbar laminectomes x2, initially admitted OSH back pain, transferred [Hospital1 18] fevers, leukocytosis, delirium. . Patient usual state health mid-[8-11]-2 weeks returning [State 350] [State 8842]. initially complained acute onset R lower back pain started leaning quickly. went see chiropractor. Pain worsened developed L sided back pain well. Also + constipation LE weakness. Around time, patient started developing productive cough fevers. . presented [Hospital ] Hospital [9-2]. Initially alert oriented x 3, noted "say odd things". febrile 101 ED, intermittently confused. MRI back showed L5-S1 central disc protrusion without mass effect abnormal enhancement. CT head showed diffuse mild cerebral atrophy evidence intracranial hemorrhage. MRI without contrast showed evidence meningitis enhancing mass lesion. Neurosurgery consulted felt intervention needed based lumbar imaging. ID consulted, felt patient clear signs infection, aside fevers, antibiotics generally held. Neurology assessment assess patient viral illness, including viral meningitis, less likely paraneoplastic disorder. Lumbar puncture attempted x 4, records indicating one attempt may yielded venous blood. Acyclovir temporarily started d/c'd LP fluid negative HSV PCR. Heme/onc consulted leukocytosis, bone marrow aspirate revealed myelodysplasia evidence leukemia. Chromosomal cytogenetic studies sent. . Required ICU stay angioedema tongue rash neck cheek. require intubation, angioedema resolved dexamethasone. developed nodules face neck; biopsies revealed neutrophilic dermatosis, c/w Sweet Syndrome (acute febrile neutrophilic dermatosis. . Found hypercalcemic low albumin levels ionized calcium 1.61 day prior transfer. PTHrP PTH sent Vitamin studies. pending time transfer. . Timeline: [9-3]: Tmax 102. LP fluoro - ?was venous blood per dc summary. Acyclovir. [9-4]: Tmax 102.7. Joint arthrocentesis ? - culture neg crystals neg. [9-5]: Tmax 102.2. [9-6]: Tmax 102.6. WBCs 18.2K. skin biopsy neutrophilic dermatosis (Sweet). AFB negative. Started IV decadron 6mg Q6H. Vanco ceftriaxone started. [9-7]: Tmax 99.2. Antibiotics stopped. [9-8]: afebrile. BMBx performed - aspirate c/w myelodysplasia, leukemia. [9-11]: decadron decreased 3 mg Q8H. Tmax 101.9. WBC 20.5K. [9-12]: Tmax 102.2 [9-13]: Tmax [9-14]: Tmax 101.4. WBC 34.8K. [9-15]: Tmax 100.8. WBC 33.1K. Ca [23].9/alb 2 (corrected 13.8) ionized 1.61. Received pamidronate IV 60 mg. PTH PTHrP pending. . Review sytems: (+) Per HPI; feels clammy. Wife believes patient hallucinating seeing people room. asked room him, patient states "just family." (-) Deniesheadache, sinus tenderness, rhinorrhea congestion. Denied shortness breath. Denied chest pain tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation abdominal pain. recent change bowel bladder habits. dysuria. Denied arthralgias myalgias. Past Medical History: - Lung ca, unknown path, s/p RUL lobectomy 6 years ago - Chronic back pain s/p back surgery x 2 disc herniation - Hyperlipidemia - s/p L TKR Social History: Recently quit smoking. EtOH. Lives [State 8842] wife. Former [Name2 (NI) ] welder Family History: Mother died unknown cancer, potentially GI. Grandmother DM. Physical Exam: Vitals: T:96.5 BP:98/64 P:84 R:20 O2:92% RA General: Caucasian well nourished male NAD, unclear mental status. HEENT: Mildly icteric conjunctivae. MMM without OP exudate hyperemia. appreciable JVD. Sclera anicteric, MMM, oropharynx clear. PERRLA 3 mm -> 2mm. Lungs: Dry crackles bilateral lung bases. wet crackles wheeze. Good inspiratory effort. CV: Regular rate rhythm, normal S1 + S2, murmurs, rubs, gallops Abdomen: softly distended, non-tender, bowel sounds present, rebound tenderness guarding, organomegaly. pulsatile masses. Ext: Warm, well perfused, 2+ pulses, clubbing, cyanosis edema. asterixis. Skin: Scattered small telangiectasias face Neuro: Speech halting, long pauses mid-sentence. Able repeat three words immediately cannot recall one minute. Oriented person time ("Football season"), oriented "hospital" know city. Cranial nerves II-XII grossly intact. nystagmus. Motor: 5/5 strength upper/lower extrems proximally & distally. Sensation: Grossly intact touch, pinprick. DTR: 2+ biceps/brachoradialis/patellar reflexes bilaterally. Coordination: Intact finger-to-nose test. Gait: Deferred. Pertinent Results: Admission labs: [2122-9-16] 09:00PM BLOOD WBC-38.9* RBC-3.58* Hgb-11.6* Hct-35.5* MCV-99* MCH-32.4* MCHC-32.6 RDW-15.4 Plt Ct-180 [2122-9-16] 09:00PM BLOOD Neuts-65 Bands-4 Lymphs-8* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-6* Myelos-8* Promyel-2* [2122-9-16] 09:00PM BLOOD PT-14.4* PTT-27.3 INR(PT)-1.3* [2122-9-16] 09:00PM BLOOD ESR-124* [2122-9-16] 09:00PM BLOOD Glucose-145* UreaN-41* Creat-1.1 Na-136 K-4.3 Cl-103 HCO3-26 AnGap-11 [2122-9-16] 09:00PM BLOOD ALT-47* AST-26 LD(LDH)-600* AlkPhos-186* TotBili-0.7 [2122-9-17] 08:40AM BLOOD Lipase-25 [2122-9-16] 09:00PM BLOOD TotProt-5.9* Albumin-2.6* Globuln-3.3 Calcium-12.1* Phos-3.7 Mg-2.6 [2122-9-16] 09:00PM BLOOD PTH-106* [2122-9-16] 09:00PM BLOOD TSH-0.27 [2122-9-16] 09:00PM BLOOD CRP-GREATER TH [2122-9-16] 09:00PM BLOOD ASA-NEG Ethanol-NEG Bnzodzp-NEG Barbitr-NEG [2122-9-17] 09:03AM BLOOD freeCa-1.54* ------------ [2122-9-16] Chest X-ray: FINDINGS: Lung volumes low, apical lordotic projection portable technique also contribute accentuation cardiomediastinal contours. Patchy opacities present lung bases, may reflect atelectasis setting low lung volumes. Differential diagnosis includes aspiration early infectious pneumonia. Followup PA lateral radiographs suggested patient's condition permits. ----------- CSF: Cytology-NEGATIVE MALIGNANT CELLS. [2122-9-17] 02:31PM CEREBROSPINAL FLUID (CSF) WBC-288 HCT,Fl-5.5* Polys-60 Lymphs-33 Monos-4 Other-3 [2122-9-17] 02:31PM CEREBROSPINAL FLUID (CSF) TotProt-363* Glucose-76 --------------- [2122-9-17] CT Head: evidence acute hemorrhage [2122-9-17] CT Abdomen/Pelvis: 1. evidence spinal paraspinal abscess. Note concern exists focal discitis osteomyelitis, MR would sensitive modality evaluation. 2. Nodularity pancreas left adrenal gland. Given history previous lung malignancy, metastatic disease primary consideration pancreas. Additionally, though adrenal nodule statistically likely adenoma, metastatic disease must considered. Ongoing followup recommended repeat CT within 6 months, comparison prior imaging. 3. Large bilateral consolidations lower lobes bilaterally. Given history fever cough reported previous chest radiograph, concerning infectious pneumonia. Nevertheless underlying mass excluded. Followup resolution recommended. 4. Large mediastinal lymphadenopathy detailed above. 5. Numerous healing left lateral rib fractures well deformity right sixth rib, presumably post-surgical. ---------------- [2122-9-18] EEG: abnormal routine EEG due reduced voltage, slowing, disorganization background rhythm. findings suggestive mild moderate encephalopathy involving cortical subcortical structures. Medications, toxic/metabolic disturbances, infection among common causes. areas prominent focal slowing although encephalopathies obscure focal findings. clearly epileptiform features. --------------- [2122-9-18] Echo: left atrium normal size. Left ventricular wall thickness, cavity size, global systolic function normal (LVEF>55%). Due suboptimal technical quality, focal wall motion abnormality cannot fully excluded. Right ventricular chamber size free wall motion normal. Trace aortic regurgitation seen. Trivial mitral regurgitation seen. pericardial effusion. IMPRESSION: Limited study. significant aortic mitral regurgitation seen. Grossly preserved biventricular systolic function Brief Hospital Course: # Fevers: Transferred outside hospital pathologic diagnosis Sweet's Syndrome, based skin biopsy persistent fevers/leukocytosis. patient febrile first day floor. Initial infectious workup including blood urine cultures unrevealing. Stable infiltrate opacities OSH CXR may represent PNA, especially setting productive cough. CT chest revealed large bilateral consolidations, patient started broad antibiotic coverage hospital acquired pneumonia, including vancomycin ceftriaxone. patient underwent lumbar puncture IR guidance, yielded ~15 cc bloody CSF. Initial gram stain CSF revealed gram negative rods, ampicillin added potential listeria meningitis, event gram negative rods reported gram stain actually gram variable. CSF gram stain findings subsequently changed gram negative rods "no organisms." Infectious disease consulted prior CT findings, initially recommended holding antibiotic therapy, well sending number serologic infectious studies (HSV PCR CSF, VZV PCR, West [Doctor First Name ] PCR, Eastern Equine Encephalitis PCR, enteroviral PCR, mycoplasma PCR, VDRL per ID). treated broad spectrum antibiotics eventually tapered doxycyline. patient underwnet TTE, evaluate fever unknown origin. vegetations noted. Rheumatology also consulted, recommended tapering patient's dexamethasone, patient's fevers clearly responding steroid treatments. also underwent bone marrow biopsy; pathology pending. # Mental status changes/Delirium: patient clearly confused disoriented, which--per family's report--was strikingly different baseline cognition/personality. Potential etiologies thought include infectious (meningoencephalitis, abscess non-CNS infection), metabolic/endocrine (hypercalcemia), renal failure/uremia, hepatic encephalopathy, persistently febrile state. thought unlikely hydrocephalus brain metastases unknown primary (hx lung CA), given reportedly normal OSH imaging. Toxicology screens negative. Liver function tests benign. EEG revealed mild moderate encephalopathy involving cortical subcortical structures, without epileptiform features. patient's mental status seemed wax wane somewhat proportion fevers; would engaged responsive questioning afebrile. # Leukocytosis: patient reportedly undergone bone marrow aspiration OSH, findings consistent myelodysplastic syndrome. WBC count increased rapidly 47,000. Hematology/oncology consulted performed another bone marrow aspiration assess leukocytosis. Marrow analysis pending. # Hypercalcemia: Calcium highly elevated OSH, received pamidronate treatment prior transfer. arrival initial calcium levels measured 12.1, albumin 2.6. PTH levels elevated 106. PTHrP sent outside lab. calcium trended downwards receiving pamidronate. Endocrine following suspect primary hyperparathyroidism. . # Hypotension: Per patient's family, never difficulty high low blood pressures, home anti-hypertensives. limited PO intake 2-3 weeks prior admission. initially placed maintenance IV fluids, subsequently rate infusion increased. transiently required vasopressors unit. . # History carcinoid syndrome: lung cancer found carcinod. Endocrine consulted felt symptoms unlikely carcinoid-mediated. Chromogranin 5-HIAA sent pending. . # HIT: HIT antibody returned positive started Argatroban. SRA sent pending. LENIs negative clot. . # Respiratory failure: Patient required intubation [9-19]. due ARDS; initiated ARDSnet ventilation. difficultly oxygenating required high PEEPs directed balloon. . # Mediastinal lymphadenopathy: Unclear etiology. Patient stable enough biopsy. . Patient acutely decompensated morning [9-25]. Patient made CMO family. died day. Autopsy pending. Medications Admission: UPON TRANSFER OSH - omeprazole 20 mg daily - nystatin susp QID - heparin SQ 5000 TID - bisacodyl 10 mg daily - ibuprofen 600 mg QID prn - acetaminophen rectal 650 mg Q6H prn - NS 75 cc/hr - dexamethasone 3 mg IV Q8H Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Primary: Fevers unknown origin Concern MDS Hypoxemia respiratory failure Acute Respiratory Distress Syndrome Acute renal failure Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A	[ "486" ]
Admission Date: [2172-1-12] Discharge Date: [2172-2-7] Date Birth: [2136-12-17] Sex: Service: CARDIOTHORACIC Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 2969] Chief Complaint: Abdominal pain Major Surgical Invasive Procedure: [2172-1-14] bronchoscopy, VATS, Thoracotomy, decortication, chest tube insertion [2172-1-22] Left diagnostic thoracentesis History Present Illness: 35 syndrome transferred [Hospital3 ] fevers, jaundice, RUQ pain outside ultrasound revealing sludge CBD distension, elevated white count. Transferred workup presumed cholecystitis. history biliary colic. Denies n/v. + anorexia. BMs WNL. Chest Xray showed R lateral effusion L consolidation, CT revealed multiple loculated R pleural fluid collections. Thoracic surgery consulted. Past Medical History: s/p b/l tympanic tubes seasonal allergies Social History: Works landscaper, denies tobacco, EtOH week. Family History: Noncontributory Physical Exam: admission: VS: & 99.2, HR 58, BP 116/54, RR 18, O2 95% RA Gen: NAD, AAO HEENT: PERRLA, EOMI, NC/AT, anicteric, neck supple, LAD Lungs: Decreased breath sounds R, esp lower lung fields Cards: S1S2 RRR M/G/R GI: Mild RUQ tenderness palpation, nondistended, + BS Ext: C/C/E Pertinent Results: [2172-1-12] 06:00PM WBC-21.7* RBC-3.66* HGB-11.3* HCT-33.9* MCV-93 MCH-30.8 MCHC-33.2 RDW-14.0 [2172-1-12] 06:00PM GLUCOSE-107* UREA N-18 CREAT-1.5* SODIUM-134 POTASSIUM-5.5* CHLORIDE-96 TOTAL CO2-29 ANION GAP-15 [2172-1-12] 06:00PM PLT COUNT-464* [2172-1-12] 06:19PM LACTATE-2.3* [2172-1-12] 06:00PM ALT(SGPT)-36 AST(SGOT)-67* ALK PHOS-40 AMYLASE-15 TOT BILI-0.9 *** [2172-1-12] CT CHEST: Reason: Please eval extent location loculation PNA [Hospital 93] MEDICAL CONDITION: 35 year old man Downs syndrome lg PNA loculations CXR REASON EXAMINATION: Please eval extent location loculation PNA CONTRAINDICATIONS IV CONTRAST: None. STUDY: CT chest without contrast reconstructions. INDICATION: 35-year-old male syndrome pleural loculations chest x- ray. Initial presentation right upper quadrant pain fever. COMPARISON: Chest x-ray date. TECHNIQUE: MDCT axially acquired images obtained thoracic inlet upper abdomen without intravenous contrast administration. Multiplanar reformatted images obtained. Intravenous contrast administered secondary elevated creatinine. CT CHEST WITHOUT CONTRAST: thyroid gland grossly unremarkable. major airways patent subsegmental level. unopacified heart great vasculature grossly unremarkable without pericardial effusion given limitation IV contrast administration. scattered prominent lymph nodes within mediastinum, largest measures 1.5cm short axis subcarinal location. axillary adenopathy present. Limited views upper abdomen without contrast demonstrate abnormalities within liver, stomach, adrenal glands spleen far visualized. left lung clear. small left pleural effusion. Multiple loculated right-sided pleural fluid collections noted. largest along right upper lobe measuring approximately 12.2 x 4.4 cm greatest dimension. Two prominent loculations lie right lung base, larger measures 7.4 x 7.2 cm. attenuation pleural collections consistent simple fluid. Compressive atelectasis noted right lung septal thickening right lung base. pneumothorax. OSSEOUS STRUCTURES: suspicious lytic sclerotic lesions detected. IMPRESSION: 1. Loculated right pleural fluid collections. Given absence contrast evaluation enhancement nodularity along pleura limited. 2. Septal thickening atelectasis right lung. 3. Borderline mediastinal lymphadenopathy, may reactive. 4. Small left pleural effusion. * [2172-1-12] RUQ ULTRASOUND: Reason: Please eval GB pathology pathology contributing [Hospital 93] MEDICAL CONDITION: 35 year old man fever, jaundice, RUQ tenderness REASON EXAMINATION: Please eval GB pathology pathology contributing sx INDICATION: 35-year-old man fever, jaundice, right upper quadrant tenderness. COMPARISON: None. FINDINGS: subtle rounded hyperechoic area seen adjacent right hepatic vein, measuring approximately 2.5 cm greatest dimension. definite Doppler flow seen within lesion. definite focal lesion identified within liver. Gallbladder appears unremarkable, without evidence stones. Normal direction flow seen portal vein. Right pleural effusion incidentally noted. IMPRESSION: 1. evidence cholecystitis. 2. Subtle hypoechoic lesion seen within right lobe liver without significant mass effect, possibly representing focal fatty infiltration, hemangioma FNH. Multiphasic MRI (with "echo-offset" sequences) CT recommended evaluation non-emergent basis. 3. Right pleural effusion. * [2172-1-18] ECHOCARDIOGRAM: left atrium normal size. Left ventricular wall thickness, cavity size, systolic function normal (LVEF>55%). Due suboptimal technical quality, focal wall motion abnormality cannot fully excluded. Right ventricular chamber size free wall motion normal. aortic valve leaflets appear structurally normal good leaflet excursion. aortic valve stenosis. aortic regurgitation seen. mitral valve appears structurally normal trivial mitral regurgitation. pulmonary artery systolic pressure could quantified. pericardial effusion. IMPRESSION: Normal biventricular cavity sizes preserved global biventricular systolic function. pericardial effusion pathologic flow identified. CLINICAL IMPLICATIONS: Based [2171] AHA endocarditis prophylaxis recommendations, echo findings indicate prophylaxis recommended. Clinical decisions regarding need prophylaxis based clinical echocardiographic data. * [1-25] CT ABDOMEN/PELVIS REASON EXAMINATION: Please perform w/ PO IV contrast - hypoechoic liver lesion previous US [2172-1-12], w/ elevated LFTs, fever CONTRAINDICATIONS IV CONTRAST: None. INDICATION: Hypoechoic liver lesion previous ultrasound elevated liver function tests. COMPARISON: ultrasound abdomen [2172-1-12]. TECHNIQUE: Axial volumetric images obtained abdomen pelvis according triphasic liver protocol. Pre-contrast, arterial face, portovenous phase images obtained. FINDINGS: liver appears normal evidence abnormal lesions corresponding son[Name (NI) 493] finding within right lobe. spleen, pancreas, gallbladder appear unremarkable. bilateral adrenal glands within normal limits. NG tube place tip seen within stomach. bowel appears unremarkable evidence pneumatosis obstruction. evidence free fluid within abdomen. Foley catheter place. bilateral basilar atelectases consolidation right lower lobe. also bilateral chest tubes place. small right- sided pleural effusion. subcutaneous collection seen right hemithorax laterally image 122 measuring 4.4 anteroposteriorly x 2.5 cm axially. collection surrounded fat stranding inflammatory changes. suspicious bony lesions. IMPRESSION: 1. hepatic lesion detected would correspond ultrasonographic finding within right lobe. 2. Bilateral lower lobe atelectases consolidation within right lower lobe small effusion. bilateral two chest tubes place. 3. collection within subcutaneous tissues lateral aspect right hemithorax evidence surrounding inflammatory changes. Findings communicated Dr. [First Name (STitle) ] day 6:45 p.m. Brief Hospital Course: Mr. [Known lastname 77155] [Last Name (Titles) 1834] VATS decortication converted thoracotomy bilateral chest tubes [2172-1-14]. remained intubated transferred SICU postoperatively empiric Vancomycin Zosyn. continued spike fevers elevated white count, cultures grew strep viridans pleural fluid yeast sputum. ID consulted antibiotic management, felt yeast likely contaminant. Echo done negative vegetations, lines changed. [1-25] CT abdomen/pelvis rule intraabdominal source, revealed fluid collection thoracotomy wound, incision opened. Minimal purulent fluid old clotted blood expressed. Subsequently fever curve began trend down, pressors ventilation weaned. subsequent cultures negative. extubated [1-26], transferred floor [1-28]. [Month/Year (2) 1834] speech swallow evaluation started PO diet. right chest tube converted empyema tube, left chest tube pulled [2-5]. small left apical pneumothorax post-pull stable subsequent xray. completed course Zosyn [2-4], developed C diff colitis started PO flagyl. vital signs stable, tolerating regular diet, feeling well, discharged rehab [2172-2-6]. Medications Admission: PRN [Doctor First Name ] (seasonal) Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed constipation. 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) needed wheeze. 4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times day) needed prn wheeze. 5. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 3-5 MLs Miscellaneous Q6H (every 6 hours) needed mucus. 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times day) 11 days. 7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [Hospital1 ] (2 times day). 8. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 9. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours needed pain. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Right lower lobe pneumonia Right pleural empyema syndrome Clostridium dificile colitis Discharge Condition: Good Discharge Instructions: Call Dr.[Doctor Last Name 4738] office [Telephone/Fax (1) 170] experience: -Fever > 101 chills -Increased shortness breath, cough sputum production -Chest pain -Incision develops redness discharge lifting greater 10 pounds 4 weeks driving taking narcotics: take stool softners narcotics swimming tub baths 6 weeks Continue ambulate frequently Diet: Ground, regular diet thin liquids, supervised feeds, sitting meals. Activity: tolerated Followup Instructions: Provider: [First Name11 (Name Pattern1) 2389] [Last Name (NamePattern1) 2390], MD Phone:[0-0-] Date/Time:[2172-2-13] 4:00 Completed by:[2172-2-7**]	[ "486" ]
Admission Date: [2200-3-3] Discharge Date: [2200-3-11] Date Birth: [2150-10-7] Sex: Service: MEDICINE Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 602] Chief Complaint: increased lethargy, cough Major Surgical Invasive Procedure: None History Present Illness: Mr. [Known lastname 1932] 49-year-old right-handed man history [Location (un) 849]-Gastaut syndrome intractable epilepsy intellectual disability presented transfer [Hospital 7912] due increased lethargy. staff group home reported somnolent last days. also reported cough congestion think might fever. increase baseline seizure frequency (usually 1-2 drop attacks per day). morning admission eating breakfast reportedly fell forward hit head table: unclear fell asleep drop attack. evidence convulsive activity. EMS called taken [Hospital6 33]. Upon arrival vitals within normal limits (99.1F 77 102/65 16). received aspirin 81mg 1L NS subsequently transferred [Hospital1 18] evaluation. . Upon arrival [Hospital1 18] [Name (NI) ], pt noted somnolent inattentive, answering questions appropriately difficulty following commands. Otherwise focal neurologic deficits noted. ROS positive recent cough/congestion, negative headache, chest pain, shortness breath, nausea/vomiting, abdominal pain, changes bowel/bladder habits. Past Medical History: 1. [Location (un) 849]-Gasteau syndrome; refractory seizure disorder baseline [1-6] seizures per day (drop attacks per group home assistant, [Male First Name (un) 17661]) despite multiple AEDs vagal nerve stimulator. VNS implanted [2187]; staff swipes magnet wrist drop attacks. Followed clinic Dr. [First Name (STitle) ]. Recently cross-titrating zonegran onto clobezam (as above). Seizure Types (per [12/2199] discharge summary): Type 1: Atonic Aura: none Ictal: head falls forward, sudden drop ground TB/incont: Postictal: confused 30-40 min First: age 7-8 years Frequency: 4/wk Precipitants: none Type 2: Tonic Aura: none Ictal: loud cry, arm elevation stiffening, head moves forward, fall TB/incont: incontinence, tongue biting Postictal: confused 30 min First: age 7-8 years Frequency: [1-6]/wk, often clusters Precipitants: none Type 3: Probable atypical absence Aura: none Ictal: staring, blinking, altered awareness, sometimes drooling TB/incont: Postictal: none First: childhood Frequency: Unclear, many per day Precipitants: none Type 4: Generalized tonic clonic Aura: none Ictal: Ictal cry, generalized stiffening, jerking extremities, last 2-4 minutes, 10 min TB/incont: yes Postictal: obtunded, confused hours First: childhood Frequency: 1-2 per year Precipitants: none PMH: 2. Intellectual disability (moderate severe neuropsych testing [2191]) depression behavioral disorder (h/o aggression, agitation, violent behavior intermittently), followed [Hospital1 18] Dr. [Last Name (STitle) ]. 3. Obstructive Sleep apnea, followed Dr. [Last Name (STitle) ] sleep clinic, per past notes "unable use CPAP mask well." 4. Left preauricular skin squamous cell carcinoma s/p excision [2188], superficial parotidectomy, left supralmohyoid neck dissection, skin graft left cheek left thigh. 5. s/p Inguinal hernia repair childhood. Social History: Lives group home (Road Responsibility), medications given workers home blister packs. Visits sister mother. Family History: Non-contributory, seizures psychiatric history. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 97.5 BP 112/70 HR 80 RR 18 O2 94% 2L General: Lethargic, arouses voice, answers basic questions, intermittently cooperative exam, NAD. HEENT: NC/AT, scleral icterus noted, MMM, lesions noted oropharynx Neck: Supple, nuchal rigidity Pulmonary: Lungs rhonchi crackes L>R Cardiac: RRR, nl. S1S2, M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, masses organomegaly noted. Extremities: C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: rashes lesions noted. Neurologic: -Mental Status: Lethargic, arouses voice. Oriented [Hospital1 18], [2200-2-5]. Says Tuesday (one day off). Follows simple commands, otherwise somewhat inattentive. -Cranial Nerves: I: Olfaction tested. II: PERRL 3 2mm brisk. VFF confrontation. III, IV, VI: EOMI without nystagmus. V: Facial sensation intact light touch. VII: facial droop, facial musculature symmetric. VIII: Hearing intact voice bilaterally. IX, X: Palate elevates symmetrically. [Doctor First Name 81]: 5/5 strength trapezii SCM bilaterally. XII: Tongue protrudes midline. -Motor: Normal bulk, tone throughout. pronator drift bilaterally. adventitious movements, tremor, noted. asterixis noted. Lifts extremities anti-gravity wiggles toes b/l. difficulty cooperating formal strength testing individual muscle groups time. -Sensory: Responds light touch throughout, testing modalities limited cooperation -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response flexor bilaterally. -Coordination: Reaches well b/l -Gait: Deferred . DISCHARGE PHYSICAL EXAM: Vitals: 98.4 106/64 57-74 16-22 94% 2L (90-95% RA) General: pleasant NAD, AAOx3, talking comfortably. EEG leads place. HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL Neck: supple, JVP elevated CV: RRR, normal S1 + S2, murmurs, rubs, gallops Lungs: Coarse BS b/l bases L>R; wheezes; faint bibasilar crackles Abdomen: soft, non-tender, non-distended, bowel sounds present GU: foley Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis edema; calf tenderness Neuro: AAOx3, moving 4 extremities. CN II-XII grossly intact. Pertinent Results: ADMISSION LABS: WBC-5.2 RBC-3.18* HGB-10.3* HCT-29.0* MCV-91 MCH-32.3* MCHC-35.4* RDW-12.4 NEUTS-52.7 LYMPHS-34.4 MONOS-9.3 EOS-2.9 BASOS-0.6 PLT COUNT-203 ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG VALPROATE-100 AMMONIA-48 CALCIUM-8.6 PHOSPHATE-3.7 MAGNESIUM-2.1 GLUCOSE-91 UREA N-13 CREAT-0.6 SODIUM-138 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-25 ANION GAP-11 LACTATE-0.8 URINE: BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.012 . Imaging: CHEST X-RAY ([2200-3-4]): compared previous radiograph, newly appeared bilateral parenchymal opacities. better seen lateral frontal radiographs located lower lobes. opacities ill-defined show multiple air bronchograms well bronchocentric predominance. appropriate clinical setting, opacities highly suggestive pneumonia. . CTA CHEST ([2200-3-6]): 1. Bilateral pulmonary emboli involving distal left main pulmonary artery bilateral segmental subsegmental arterial branches. Mild contrast reflux IVC suggests mild right heart strain. 2. Moderate bibasilar atelectasis, worse left lower lobe, superimposed pneumonia and/or aspiration. 3. 4 mm right minor fissure nodule, may represent inflammatory focus. dedicated followup required higher risk factors malignancy. 4. Small left pleural effusion. . TRANSTHORACIC ECHO ([2200-3-7]): left atrium normal size. Left ventricular wall thicknesses normal. left ventricular cavity size normal. Overall left ventricular systolic function normal (LVEF 60%). right ventricular cavity dilated borderline normal free wall function. aortic valve leaflets (3) appear structurally normal good leaflet excursion aortic stenosis aortic regurgitation. mitral valve appears structurally normal trivial mitral regurgitation. mitral valve prolapse. estimated pulmonary artery systolic pressure normal. pericardial effusion. . LE ULTRASOUND ([2200-3-7]): evidence deep vein thrombosis either right left lower extremity. . VIDEO SWALLOW [2200-3-7]: RECOMMENDATIONS: 1. PO diet: regular solids, thin liquids. 2. PO meds whole thin tolerated, whole puree pt pocketing meds. 3. [Hospital1 ] oral care. 4. Assist meals needed maintain standard aspiration precautions. Discharge/Notable Labs: [2200-3-11] 07:35AM BLOOD WBC-12.5* RBC-3.79* Hgb-11.7* Hct-33.8* MCV-89 MCH-30.9 MCHC-34.6 RDW-13.1 Plt Ct-486* [2200-3-11] 10:40AM BLOOD PTT-127* [2200-3-11] 07:35AM BLOOD Glucose-98 UreaN-13 Creat-0.6 Na-141 K-4.5 Cl-107 HCO3-25 AnGap-14 [2200-3-8] 04:35AM BLOOD ALT-15 AST-18 LD(LDH)-209 AlkPhos-48 TotBili-0.1 [2200-3-6] 04:11PM BLOOD cTropnT-<0.01 proBNP-148* [2200-3-11] 07:35AM BLOOD Calcium-9.5 Phos-4.2 Mg-1.8 [2200-3-6] 04:11PM BLOOD Albumin-3.3* Calcium-9.1 Phos-4.6* Mg-2.0 Iron-34* [2200-3-6] 04:11PM BLOOD calTIBC-270 VitB12-759 Ferritn-217 TRF-208 [2200-3-6] 04:11PM BLOOD TSH-3.7 [2200-3-3] 02:45PM BLOOD Valproa-100 Studies pending discharge: None Brief Hospital Course: 49 year-old right-handed man h/o Lennaux-Gastaut syndrome intractable epilepsy mild intellectual impairment admitted several day history increased somnolence, initially felt due upper respiratory tract infection/anti-epilpetic drug uptitration found pneumonia bilateral pulmonary emboli requiring transient ICU admission. . #SOMNOLENCE/Community Acquired Pneumonia: Per patient's group home, patient noted lethargy cough, increase baseline seizure frequency neuro exam unchanged exam intermittent subtle twitching right thumb. Chest X-ray revealed bilateral lower lobe pneumonia, felt likely cause patient's somnolence. treated community acquired pneumonia Ceftriaxone azithromycin completed full course antibiotics hospital. #Epilepsy: Patient maintained continuous EEG throughout hospitalization showed slow encephalopathic pattern throughout recording frequent bursts rapid generalized epileptiform discharges, consistent patient's diagnosis symptomatic generalized epilepsy well superimposed toxic-metabolic encephalopathy. Per previous titration schedule specified Dr. [First Name (STitle) ], zonegran discontinued. clobazam initially uptitrated 10mg/20mg per previous titration level, decreased back 10mg/10mg due concern could increasing somnolence. rest home AED's continued current doses (Levetiracetam 2500mg [Hospital1 ], Lacosamide 300mg [Hospital1 ], Depakote ER 500mg q8am / 750mg q8pm). somnolence improved treatment underlying pneumonia. followed Neurology throughout hospital course. . #PULMONARY EMBOLI: Although patient initially satting mid-90s 1-3L per nasal cannula admission, working physical therapy [3-6] acute desaturation required O2 50% ventimask maintain O2 saturation >90%. transferred Medical ICU antibiotics initially broadened Vanc/Zosyn/Azithromycin. Chest CTA subsequently showed bilateral pulmonary emboli distal left main pulmonary artery bilateral segmental subsegmental arterial branches. transthoracic echocardiogram done showed minimal right heart strain bilateral lower extremity ultrasounds showed DVT. treated anticoagulation IV heparin gtt transferred floor [2200-3-8]. O2 saturation remained high 90s RA-2L O2 nasal canula. extensive discussion Neurology team patient's mother case worker group home, decision made discharge patient Lovenox bridge Coumadin. Given frequent seizures falls, felt Coumadin would better option given ability reversed patient suffer bleed. interactions coumadin patient's anti-epileptic drugs discussed patient's outpatient Neurologist, decision made try manage anticoagulation coumadin, lovenox second option goal INR [2-7] difficult obtain. Patient continue anticoagulation 6-12 months INR followed Coumadin titrated patient's PCP [Hospital6 33] [Hospital 3052]. Patient also require use helmet ambulating minimize risk bleed. . #Obstructive sleep apnea: Pt known OSA tolerated CPAP past. Trial CPAP performed medical floor patient seemed tolerate however. Pt's outpatient neurologist Dr. [Last Name (STitle) ] follow initiate nasal CPAP outpatient. . #ANEMIA: Pt hypoproliferative anemia, HCT stable throughout hospitalization. B12 folate WNL. Iron studies relatively normal. #Disposition: Patient discharged rehab. =================== TRANSITIONS CARE: -Upon discharge rehab, please arrange INR checks done VNA laboratory faxed patient's PCP ([First Name8 (NamePattern2) ] [Last Name (NamePattern1) 17662], phone #[Telephone/Fax (1) 17663] fax #[Telephone/Fax (1) 17664]) -Pt needs PT/INR Dilantin levels checked q2 days 2 weeks discharge. Dilantin levels supra/subtherapeutic, please fax epileptologist Dr. [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) ], phone #[Telephone/Fax (1) 3294] fax #[Telephone/Fax (1) 7020] -Please overlap Lovenox coumadin INR 2 3 >24 hours Medications Admission: 1. clobazam - currently uptitrated last 3 weeks, taking 10mg QAM 20mg QPM. 2. zonisamide - tapering 600mg/d --> taking 100mg [Hospital1 ] 3. levetiracitam 2500mg [Hospital1 ] 4. lacosamide 300mg [Hospital1 ] 5. VPA (Depakote ER) 500mg q8am / 750mg q8pm 6. sertraline 200mg q.8am 7. sinmvastatin 10mg q.8pm 8. MVI 9. Ca/D3 10. Perdex mouthwash [Hospital1 ] 11. melatonin 1mg q8pm 12. loratadine PRN Discharge Medications: 1. Outpatient Lab Work Please check PT/INR Depakote level [2200-3-13]. Depakote supratherapeutic/subtherapeutic, please call Dr. [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) ] [Telephone/Fax (1) 3294]. 2. Outpatient Lab Work Please check PT/INR Depakote level [2200-3-15]. Depakote supratherapeutic/subtherapeutic, please call Dr. [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) ] [Telephone/Fax (1) 3294]. 3. Outpatient Lab Work Please check PT/INR Depakote [2200-3-17] Depakote supratherapeutic/subtherapeutic, please call Dr. [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) ] [Telephone/Fax (1) 3294]. 4. Outpatient Lab Work Please check PT/INR Depakote level [2200-3-19]. Depakote supratherapeutic/subtherapeutic, please call Dr. [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) ] [Telephone/Fax (1) 3294]. 5. Outpatient Lab Work Please check PT/INR Depakote level [2200-3-21]. Depakote supratherapeutic/subtherapeutic, please call Dr. [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) ] [Telephone/Fax (1) 3294]. 6. Outpatient Lab Work Please check PT/INR Depakote level [2200-3-23]. Depakote supratherapeutic/subtherapeutic, please call Dr. [First Name8 (NamePattern2) 553] [Last Name (NamePattern1) ] [Telephone/Fax (1) 3294]. 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous DAILY (Daily): Stop INR therapeutic ([2-7]) Warfarin 48 hours. 9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times day). 10. clobazam 10 mg Tablet Sig: One (1) Tablet PO twice day. 11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times day). 12. sertraline 100 mg Tablet Sig: Two (2) Tablet PO day. 13. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. lacosamide 150 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). 15. clobazam 10 mg Tablet Sig: One (1) Tablet PO twice day. 16. levetiracetam 500 mg Tablet Sig: Five (5) Tablet PO BID (2 times day). 17. melatonin 1 mg Tablet Sig: One (1) Tablet PO q8 PM. 18. loratadine Oral 19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 20. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 21. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) needed constipation. 22. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) needed cough, secretions. 23. warfarin 2 mg Tablet Sig: DIRECTED Tablet PO DIRECTED 6 months: Please start 2mg daily increase dosing based INR checks (goal INR [2-7]). 24. divalproex 500 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO Q8AM (). 25. divalproex 250 mg Tablet Extended Release 24 hr Sig: Three (3) Tablet Extended Release 24 hr PO Q8PM (). Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 38] Discharge Diagnosis: 1. Community-acquired pneumonia 2. Bilateral pulmonary emboli 3. [Location (un) 849]-Gastaut syndrome intractable epilepsy Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 1932], admitted [Hospital1 69] [2200-3-3] due increased somnolence. found pneumonia lungs, started antibiotics. developed worsening shortness breath, found pulmonary emboli (blood clots lungs). started blood thinner called heparin, oxygen requirements improved. need stay blood thinners (called Warfarin) 6 months dissolve clots. epilepsy, put continuous EEG, showed changes due sick pneumonia well underlying seizure activity. anti-epileptic medications decreased seemed making overly sleepy/lethargic. . Please attend follow appointments neurology listed below. . made following changes medications: 1. STARTED Enoxaparin (Lovenox) 120mg subcutaneously daily, continued therapeutic blood levels Warfarin least 48 hours 2. STARTED Coumadin (Warfarin) 2mg mouth daily today, increased based blood levels (goal INR [2-7]). levels followed rehab Dr. [Name (NI) 17665] office ([Hospital3 ]). need continue least SIX MONTHS discharge. 3. STOPPED Zonisamide (Zonegram) 4. DECREASED Clobazam 10mg morning 20mg night 10mg morning 10mg night Followup Instructions: Department: COGNITIVE NEUROLOGY UNIT When: THURSDAY [2200-4-10] 4:00 PM With: [Known firstname 251] [Initials (NamePattern4) ] [Last Name (NamePattern4) 6929], MD [Telephone/Fax (1) 1690] Building: Ks [Hospital Ward Name 860] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage Department: NEUROLOGY When: MONDAY [2200-6-9] 4:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7025], MD [Telephone/Fax (1) 3294] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: SLEEP UNIT NEUROLOGY When: THURSDAY [2200-6-12] 4:00 PM With: DRS. [Name5 (PTitle) ] & [Doctor Last Name ] [Telephone/Fax (1) 6856] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "486" ]
Admission Date: [2161-10-29] Discharge Date: [2161-11-2] Service: SURGERY Allergies: Codeine / Keflex Attending:[First Name3 (LF) 4691] Chief Complaint: right hip pain Major Surgical Invasive Procedure: [10-29] pelvic arteriogram History Present Illness: HPI: [Age 90 ]F s/p fall [Hospital3 ] c/o R hip pain. Patient usual state health notes mechanical fall bathroom. Walks w assistance cane baseline cane time fall. Denies syncope, lightheadedness, chest pain shortness breath time fall. Denies head strike. Patient brought [Hospital1 18] ED ambulance evaluation. Surgery consultation obtained traumatic injury. time evaluation patient complains severe R hip pain denies associated symptoms per above. Denies headache, blurry vision, fever, chills, blurry vision, double vision, chest pain, shortness breath, abdominal pain, dysuria. Past Medical History: 1. Breast cancer, bilaterally. 2. Hypertension. 3. History recurrent urinary tract infection. 4. Inferior myocardial infarction [2126]. 5. Osteoporosis. 6. Depression. 7. Rectocele. 8. Left arm lymph edema secondary breast cancer treatment. 9. Herpes zoster [2157]. 10. Memory loss. 11. Status post CVA [2157] 12. Cystocele 13. History falls. 14. Hemorrhoidectomy. 15. Left cataract surgery. 16. Right carotid endarterectomy [2148]. 17. Left dermoid ovarian cyst removal. 18. Two lumpectomies left breast, followed XRT. 19. CAD (per nursing home records) Social History: patient currently resident [Location (un) ] [Hospital3 400]. widowed since [2148] son [Name (NI) 449] [Name (NI) ] lives [Name (NI) 7349]. Tobacco: Quit many years ago, cannot quantify use ETOH: None Illicits: None Family History: Non-contributory Physical Exam: PHYSICAL EXAMINATION upon admission: [2161-10-29] Temp: 98.3 HR: 93 BP: 114/56 Resp: 18 O(2)Sat: 95 Normal Constitutional: Uncomfortable. HEENT: Normocephalic., Pupils equal, round reactive light, Extraocular muscles intact Chest: Clear auscultation Cardiovascular: Regular Rate Rhythm, Normal first second heart sounds Abdominal: Soft Extr/Back: Tenderness right greater trochanter. Decreased ROM, , cyanosis, clubbing edema Neuro: Speech fluent. Alert oriented x 3. Psych: Normal mood, Normal mentation Pertinent Results: [2161-11-2] 04:40AM BLOOD WBC-5.6 RBC-2.81* Hgb-9.0* Hct-26.6* MCV-95 MCH-31.9 MCHC-33.8 RDW-14.8 Plt Ct-184 [2161-11-2] 12:31AM BLOOD WBC-5.9 RBC-2.76* Hgb-8.5* Hct-26.5* MCV-96 MCH-31.0 MCHC-32.2 RDW-13.9 Plt Ct-238 [2161-11-1] 09:10PM BLOOD WBC-5.7 RBC-2.61* Hgb-8.3* Hct-24.4* MCV-94 MCH-32.0 MCHC-34.2 RDW-14.4 Plt Ct-183 [2161-10-31] 05:00PM BLOOD Hct-22.5* [2161-10-29] 09:21PM BLOOD WBC-7.9 RBC-3.30# Hgb-10.5# Hct-30.8# MCV-93 MCH-31.6 MCHC-33.9 RDW-14.1 Plt Ct-185 [2161-11-1] 04:45AM BLOOD Neuts-77.6 Lymphs-15.4* Monos-3.4 Eos-2.9 Baso-0.6 [2161-10-29] 07:45AM BLOOD Neuts-85.9* Lymphs-9.7* Monos-2.6 Eos-1.1 Baso-0.8 [2161-11-2] 04:40AM BLOOD Plt Ct-184 [2161-11-2] 04:40AM BLOOD PT-15.5* PTT-49.3* INR(PT)-1.4* [2161-11-2] 04:40AM BLOOD Glucose-100 UreaN-23* Creat-1.2* Na-139 K-5.1 Cl-105 HCO3-24 AnGap-15 [2161-11-1] 04:45AM BLOOD Glucose-94 UreaN-26* Creat-1.3* Na-142 K-4.3 Cl-106 HCO3-28 AnGap-12 [2161-10-31] 08:40AM BLOOD Glucose-127* UreaN-26* Creat-1.2* Na-139 K-4.3 Cl-104 HCO3-28 AnGap-11 [2161-10-29] 07:45AM BLOOD Glucose-114* UreaN-25* Creat-1.2* Na-138 K-5.9* Cl-102 HCO3-24 AnGap-18 [2161-11-2] 04:40AM BLOOD Albumin-3.4* Calcium-8.6 Phos-2.9 Mg-2.4 [2161-11-1] 04:45AM BLOOD Albumin-3.3* Calcium-8.3* Phos-2.8 Mg-2.3 [2161-10-31] 08:40AM BLOOD Calcium-7.9* Phos-2.8 Mg-2.1 0/29/11: EKG: Normal sinus rhythm. Leftward axis. Non-specific ST segment depression leads aVL ST segment elevation leads II, III, aVF V6. tiny R waves small QR deflections leads V3-6 consistent extensive anterior wall myocardial infarction undetermined age. Consider left ventricular hypertrophy. Consider inferior wall myocardial infarction. Compared previous tracing [2161-6-3] voltage leads V3-V6 decreased tiny R waves tiny Q waves. Consider anterior wall myocardial infarction inferior wall infarction undetermined age. [2161-10-29]: hip x-ray: IMPRESSION: Comminuted fracture right iliac [Doctor First Name 362] associated widening diastasis right sacroiliac joint better seen subsequent CT pelvis. [2161-10-29]: chest x-ray: IMPRESSION: Low lung volumes without acute cardiopulmonary abnormality [2161-10-29]: cat scan head: IMPRESSION: 1. acute intracranial process. 2. Age related global atrophy. 3. Soft tissue swelling overlying left posterior vertex left frontal bone without underlying fracture. [2161-10-29]: cat scan hip: IMPRESSION: 1. Comminuted fracture right iliac [Doctor First Name 362] involving right sacroiliac joint without widening diastasis sacroiliac joint. overlying extraperitoneal hematoma measuring 7 x 3 cm extends right hemipelvis measuring 6 x 6 cm displaces urinary bladder left. Active extravasation cannot assessed unenhanced study. 2. Degenerative changes bilateral femoroacetabular joints visualized portion lumbar spine without fracture. 3. Sigmoid diverticulosis without evidence diverticulitis. 4. Calcified atherosclerosis visualized distal infrarenal abdominal aorta extending bilateral common iliac, internal iliac femoral arteries [2161-10-29]: CTA pelvis: IMPRESSION: Focus active extravasation pelvis adjacent right superior pubic ramus surrounding extraperitoneal hematoma concerning active arterial bleed. [2161-10-29]: pelvic arteriogram: CONCLUSION: evidence active arterial extravasation pelvic arteriogram targeted catheterization right internal iliac artery, right superficial pudendal artery addition bilateral common iliac artery angiograms [2161-10-29]: arteriogram: CONCLUSION: evidence active arterial extravasation pelvic arteriogram targeted catheterization right internal iliac artery, right superficial pudendal artery addition bilateral common iliac artery angiograms Time Taken Noted Log-In Date/Time: [2161-10-30] 5:31 URINE Site: SPECIFIED 0603C. FINAL REPORT [2161-11-1] URINE CULTURE (Final [2161-11-1]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available request. GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent alpha streptococcus Lactobacillus sp. SENSITIVITIES: MIC expressed MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 CEFAZOLIN------------- <=4 CEFEPIME-------------- <=1 CEFTAZIDIME----------- <=1 CEFTRIAXONE----------- <=1 CIPROFLOXACIN---------<=0.25 GENTAMICIN------------ <=1 MEROPENEM-------------<=0.25 NITROFURANTOIN-------- <=16 TOBRAMYCIN------------ <=1 TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: [Age 90 ] year old female presents acute care service mechanical fall. Upon admission, made NPO, given intravenous fluids, underwent radiographic imaging. reported comminuted fracture right iliac [Doctor First Name 362] note extraperitoneal hematoma. findings, underwent pelvic angiogram negative extravasation required embolization. evaluated orthopedics recommmended non-surgical intervention time follow-up 2 weeks. head cat scan show inter-cerebral bleed. admitted intensive care unit monitoring hematocrit. required additional intravenous fluids hemodynamic support, hematocrit stablized without blood products. Initial EKG show q waves V3-V6 normal CPK. resume aspirin plavix. transferred surgical floor HD #2. vital signs remained stable afebrile. tolerating regular diet voiding without difficulty. evaluated physical therapy recommended discharge rehabilitation facility regain strength mobility. discharged extended care facility instructions follow acute care service, orthopedics, primary care provider. note: started ciprofloxacin [11-2] UTI. Medications Admission: MED: [Last Name (un) 1724]: AMLODIPINE 2.5', CITALOPRAM 15', PLAVIX 75', MIRTAZAPINE 30', 15 prn, ASA 325', CALCIUM CARBONATE-VITAMIN D3 600-400'', VITAMIN D-3 400', CO Q-10 (unknown), MVI' Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day): hold loose stools. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed constipation. 3. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO TID (3 times day). 4. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times day). 5. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) needed pain. 6. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) 5 days: started [11-2]. 7. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold systolic blood pressure <110. 8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times day). 12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Celexa 10 mg Tablet Sig: One (1) Tablet PO day. 15. Celexa 10 mg Tablet Sig: 0.5 Tablet PO day. 16. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q3H (every 3 hours) needed pain: hold increased sedation, resp. rate <12. Discharge Disposition: Extended Care Facility: [Hospital1 599] Senior Healthcare [Location (un) 55] Discharge Diagnosis: Trauma: fall right posterior ring pelvic fracture (large iliac [Doctor First Name 362] fx) UTI extra-peritoneal hematoma Discharge Condition: Mental Status: Clear coherent ( HOH) Level Consciousness: Alert interactive. Activity Status: Bed assistance chair wheelchair. Discharge Instructions: admitted hosptial fell home. reported right hip pain brought hospital. x-rays hip taken found smalll fracture pelvis small amount bleeding around hip. hematocrit stabilzed need intervention. seen Orthopedics recommended put weight leg, surgery warrented time. need follow-up visit Orthopedics 2 weeks primary care provider Followup Instructions: Please follow-up Orthopedics, Nurse Practitioner, [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], 2 weeks [Hospital 1957] clinic AP pelvis radiograph. telephone number is#[Telephone/Fax (1) 1228] Please follow acute care service 2 weeks. schedule appointment callling # [Telephone/Fax (1) 600] need follow primary care provider, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] # [Telephone/Fax (1) 719] 1 week Completed by:[2161-11-2]	[ "412", "311" ]
Admission Date: [2120-2-14] Discharge Date: [2120-2-24] Service: CARDIOTHORACIC SURGERY HISTORY PRESENT ILLNESS: patient 86-year-old woman history hypothyroidism, B12 deficiency, referred primary care provider evaluation chest pain exertion lasted five ten minutes time resolving rest. nausea, vomiting, palpitations. headache dizziness. recurrent symptoms since episode. patient referred Emergency Department, afebrile, vital signs stable. patient EKG showed possible anterior infarct undetermined age ruled MI negative enzymes. stress echo showed reversible ischemia. patient admitted catheterization. ALLERGIES: patient known drug allergies. ADMISSION MEDICATIONS: 1. Levoxyl 50 micrograms q.d. five times week, 75 micrograms q.d. two times week. 2. Vitamin B12 1 gram IM q. month. 3. Calcium carbonate q.d. PAST MEDICAL HISTORY: 1. Hypothyroidism. 2. Vitamin B12 deficiency. 3. history coronary artery disease, hypertension, hypercholesterolemia. SOCIAL HISTORY: patient nonsmoker. Social drinker. PHYSICAL EXAMINATION ADMISSION: Heart: admission, patient regular rate rhythm. Lungs: Clear auscultation. LABORATORY DATA/STUDIES: White count 7.4, hematocrit 34.3, 02 saturations within normal limits. cardiac enzymes negative. Chest x-ray showed failure, infiltrates, effusions. Normal size heart. Hyperinflated lungs consistent COPD. Echocardiogram showed positive regional LV systolic dysfunction mid distal anteroseptal, mid distal anterior apical akinesis, moderate MR, AR, worsening basilar anterior wall motion exercise. EF 35-40%. HOSPITAL COURSE: patient admitted catheterization underwent hospital day two. showed left main stenosis three vessel disease. patient asymptomatic present. issues obtaining type cross and, therefore, surgery postponed hospital day number five. underwent CABG times three. tolerated procedure well. transferred unit. Postoperatively, extubated transferred floor postoperative day number one. patient continued uncomplicated hospital course couple short episodes fib lasting less one minute spontaneously converted back sinus p.o. medications. postoperative day number five, patient tolerating regular diet, ambulating well, good p.o. pain control. patient felt ready discharge [Hospital3 ] facility VNA. follow-up Dr. [Last Name (STitle) ] four weeks primary care provider one two weeks cardiologist two three weeks. DISCHARGE MEDICATIONS: 1. Lopressor 12.5 mg b.i.d. 2. Zantac 150 mg q.d. follow-up surgeon. 3. Levothyroxine 75 micrograms Wednesday Saturday, 50 micrograms Sunday, Monday, Tuesday, Thursday, Friday. 4. Percocet one two tablets p.o. q. four six hours p.r.n. 5. Tylenol 650 mg q. four six hours p.r.n. 6. Enteric coated aspirin 325 mg q.d. 7. Colace 100 mg b.i.d. 8. Milk magnesia 30 milliliters q.h.s. p.r.n. 9. Lasix 20 mg b.i.d. times seven days. 10. Potassium chloride 20 mEq b.i.d. times seven days. CONDITION DISCHARGE: Good. DISCHARGE STATUS: [Hospital3 ] facility VNA. DISCHARGE DIAGNOSIS: Status post coronary artery bypass graft times three; left internal mammary artery left anterior descending artery, saphenous vein graft diagonal obtuse marginal. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Name8 (MD) 5915] MEDQUIST36 D: [2120-2-24] 07:19 T: [2120-2-24] 19:36 JOB#: [Job Number 110556] cc:[Initial (NamePattern1) 110557]	[ "412" ]
Admission Date: [2187-8-12] Discharge Date: [2187-8-29] Date Birth: [2116-11-8] Sex: Service: MEDICINE Allergies: Zosyn Attending:[First Name3 (LF) 689] Chief Complaint: hemoptysis Major Surgical Invasive Procedure: Intubation History Present Illness: 70 yo CAD, s/p CABG x2, atrial fibrillation (on coumadin presentation) presented OSH (> 2 weeks ago) 3 days fever, hemoptysis, cough, chills, dyspnea. CT revealed diffuse airspace disease, predominant R lower lobes. initial labs WBC 6.6, HCT 38, Plt 199, Cr 0.6, TBili 2.7, DBili 0.7, AST 19, ALT 33. treated empirically CAP ceftriaxone/azithromycin continuing hemoptysis, dyspnea, developed [First Name3 (LF) 5283] abdominal pain. Patient noted dropping HCT despite transfusion worsening respiratory distress. transferred ICU, intubated given additional pRBC FFP. TBili increased 4.3 Direct Bili 1.8 ALT increased 32 AST 63. Patient [First Name3 (LF) 5283] ultrasound CT remarkable layering gallbladder sludge vs. small stones. GI consult suggested [Doctor Last Name 9376] disease. transferred [Hospital1 18] MICU. time admission MICU ([2187-8-12]): Tmax= 102, Hct 25, INR 1.3, TBili 4.5, AST 58, LDH 366, Lipase 92, Alb 3.0, Na 130. Flexible bronchoscopy performed demonstrated frank blood airways without endobronchial lesions. Due multilobe involvement diffuse bleeding high temperature 102 placed triple Abx presumed necrotizing pneumonia: Vancomycin, Azithromycin, ZOSYN. intubated 1 week hypoxemia ARDS. bleeding coumadin (which normally takes A-fib) aspirin held. [8-12] [8-13], given total 6 u pRBC, raised HCT 33 (an inappropriate increase suggesting possible hemolysis). Patient found p-ANCA +. suggested either microscopic polyangiitis (MPA) Churg-[Doctor Last Name 3532] syndrome. findings make Churg-[Doctor Last Name 3532] less likely absence asthma eosinophilia. Consistent MPA findings hemoptysis hematuria (with wich patient presented). Even though p-ANCA nearly 70% specific MPA, biopsy could used definite diagnosis (specifically necrotizing inflammation arterioles, capillaries, venules w/o granulomas eosin). Accordingly, Rheumatology consulted suggested likely MPA, rec starting high dose IV steroids Bactrim PCP [Name Initial (PRE) 1102]. Patient's pulmonary function improved successfully extubated [8-20]. However, elevated TBili kept increasing, following bimodal pattern: ([8-14]): TBili 16 ([8-18]): TBili 7.2 ([8-22]): TBili 23 ([8-25]): TBili 10 IndirectBilli range [1-23]. Concurrently LFT's started increasing considerably: ([8-19]): ALT 60, AST 69, LDH 657, AlkPhos 93 ([8-22]): ALT 168, AST 147, LDH 1103, AlkPhos 164 ([8-25]): ALT 267, AST 100, LDH 608, AlkPhos 160, Amylase 123. Due increasing LFTs Hepatology consulted, suggested pattern lab abnormalities combined patient's clinical picture point drug reaction. Based lab/imaging studies evidence viral alcoholic hepatitis history imaging consistent NASH. Although many medications cause cholestatic jaundice, suspect reaction Zosyn. Expected resolve stopping offending [Doctor Last Name 360] however MRCP performed [8-24] showed evidence intrahepatic biliary disease. [8-13] [Name (NI) 5283] sono showed gallbladder sludge [Doctor Last Name 5691], biliary ductal dilatation trace perihepatic free fluid. Furthermore, increased LDH TBilli, well low haptoglobin (<20) suggestive delayed hemolytic anemia setting multiple blood transfusion. examining transfused blood determined 5 u pRBCs transfused JK positive patients blood JK antibody positive, suggestive transfusion reaction would increase IndirectBilli. Concomitantly, presumed liver toxicity induced zosyn resulting intrahepatic cholestatis could potentially explain increase DirectBilli. morning [8-22] patient tonic-clonic seizure. bed pan talking nurse, suddenly gave yelp, body became tense, head eye movement turned right, followed jerking right arm 1 minute. nurse administered 2mg Ativan IV gradual resolution movement, followed 15 min confusion. apparent bowel incontinence tongue biting. patient remember seizure returned basline mental status (AOx3). Neurology consulted, differential included new stroke due vasculitis vs. cardioembolic (off coumadin) Another possiblity re-expression prior stroke due toxic metabolic infectious abnormalities. seizure unlikely related hyperbilirubinemia. head MRI done [8-22] showing acute infarcts, minimal amount chronic microangiopathic changes, normal MRA head. Past Medical History: Hyperlipidemia Hypertension Coronary Artery Bypass Grafting [2163] Multiple percutaneous coronary interventions Sleep apnea Restless leg syndrome Past bilateral hernia repairs Right knee arthritis Social History: Widowed, 3 sons. lives 2 sons [Name (NI) 1268], retired works golf course spring/summer season, rare ETOH. Used work electrical engineer. Family History: Father 1st MI age 51, died MI age 62. Physical Exam: VS- Tc 96.8, Tm 98.9, HR 79 , BP 103-140/65-89, 13, 98% RA HEENT- icteric sclerae, MMM, OP clear, skin tenting noted LUNGS- CTA HEART- irregular irregular. + gallop; unclear S3 S4. + systolic murmur somewhat difficult appreciate setting irregular rhythm. ABDOM- soft, ND, NT, BS+, liver nl span percussion. stigmata chronic liver disease EXTRE- wwp, edema NEURO- AO3 Pertinent Results: [2187-8-12] 03:13PM PT-14.7* PTT-34.2 INR(PT)-1.3* [2187-8-12] 03:13PM PLT COUNT-173# [2187-8-12] 03:13PM WBC-9.7 RBC-2.74* HGB-8.3* HCT-24.9* MCV-91 MCH-30.3 MCHC-33.3 RDW-14.8 [2187-8-12] 03:13PM NEUTS-89.1* LYMPHS-7.4* MONOS-2.9 EOS-0.4 BASOS-0.2 [2187-8-12] 03:13PM [Doctor First Name ]-POSITIVE TITER-1:40 [Last Name (un) ] [2187-8-12] 03:13PM ANCA-POSITIVE [2187-8-12] 03:13PM ALBUMIN-3.0* CALCIUM-8.3* PHOSPHATE-2.2* MAGNESIUM-2.1 [2187-8-12] 03:13PM LIPASE-92* GGT-43 [2187-8-12] 03:13PM ALT(SGPT)-32 AST(SGOT)-58* LD(LDH)-366* ALK PHOS-82 AMYLASE-65 TOT BILI-4.5* [2187-8-12] 03:13PM estGFR-Using [2187-8-12] 03:13PM GLUCOSE-115* UREA N-21* CREAT-0.6 SODIUM-130* POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-32 ANION GAP-7* [2187-8-12] 03:14PM BODY FLUID WBC-0 RBC-0 POLYS-77* LYMPHS-8* MONOS-15* [2187-8-12] 03:50PM freeCa-1.08* [2187-8-12] 03:50PM LACTATE-1.9 [2187-8-12] 03:50PM TYPE-[Last Name (un) ] PH-7.35 [2187-8-12] 05:13PM URINE MUCOUS-FEW [2187-8-12] 05:13PM URINE RBC-54* WBC-5 BACTERIA-NONE YEAST-NONE EPI-0 [2187-8-12] 05:13PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-12* PH-6.5 LEUK-TR [2187-8-12] 05:13PM URINE COLOR-Amber APPEAR-Clear SP [Last Name (un) 155]-1.021 [2187-8-12] 05:13PM URINE HOURS-RANDOM CREAT-120 SODIUM-LESS [2187-8-12] 05:40PM TYPE-ART TEMP-37.3 O2-100 PO2-245* PCO2-42 PH-7.49* TOTAL CO2-33* BASE XS-8 AADO2-444 REQ O2-74 -ASSIST/CON INTUBATED-INTUBATED [2187-8-12] 09:21PM HCT-25.5* [2187-8-22] 03:42AM BLOOD ALT-168* AST-147* LD(LDH)-1103* AlkPhos-164* TotBili-22.7* DirBili-18.9* IndBili-3.8 [2187-8-29] 05:20AM BLOOD ALT-218* AST-68* AlkPhos-134* TotBili-6.4* [2187-8-29] 05:20AM BLOOD WBC-12.7* RBC-3.64* Hgb-10.9* Hct-35.0* MCV-96 MCH-30.0 MCHC-31.1 RDW-17.5* Plt Ct-280 [2187-8-29] 05:20AM BLOOD PT-12.6 PTT-25.7 INR(PT)-1.1 [2187-8-29] 05:20AM BLOOD Glucose-129* UreaN-22* Creat-0.6 Na-133 K-4.6 Cl-98 HCO3-29 AnGap-11 [2187-8-29] 05:20AM BLOOD ALT-218* AST-68* AlkPhos-134* TotBili-6.4* [2187-8-29] 05:20AM BLOOD Calcium-9.1 Phos-2.6* Mg-2.3 [2187-8-12] 03:13PM BLOOD ANCA-POSITIVE [2187-8-12] 03:13PM BLOOD [Doctor First Name ]-POSITIVE Titer-1:40 [Last Name (un) ] [2187-8-21] 11:41AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE IgM HAV-NEGATIVE [2187-8-23] 04:13AM BLOOD ALPHA-1-ANTITRYPSIN-Test [2187-8-12] BAL: negative malignant cells. Blood, pulmonary macrophages - hemosiderin-laden, rare bronchial epithelial cells. [2187-8-12] CXR: Extensive right lung alveolar consolidation rounded parenchymal opacities left lung. Although nonspecific, findings might represent extensive right lung hemorrhage due vasculitis given history hemoptysis. Differential diagnosis includes multifocal pneumonia multiple pulmonary infarcts left lung asymmetric pulmonary edema right. chronic entity bronchoalveolar cell carcinoma also possible. [2187-8-13] Abdominal US: focal textural hepatic abnormality. Unremarkable Doppler interrogation liver. small amount free fluid described. Cholelithiasis equivocal mild gallbladder wall thickening, though clinical correlation recommended. Left pleural effusion partially imaged. [2187-8-15] CXR: Endotracheal tube tip terminates 8 cm carina. nasogastric tube continues coil stomach distal tip directed cephalad, directed toward GE junction. Diffuse air space opacities throughout right lung involving left mid lower lung appear slightly worse compared previous study, may accentuated lower lung volumes. [2187-8-18] CXR: Lines tubes unchanged. significant change bilateral airspace disease. [2187-8-21] CXR: comparison study [8-20], little change diffuse opacification involving right lung. Areas increased opacification seen left base. endotracheal nasogastric tubes removed. right subclavian catheter persists tip mid superior vena cava level carina. [2187-8-22] ECHO: left right atria moderately dilated. left atrial mass/thrombus seen (best excluded transesophageal echocardiography). estimated right atrial pressure 11-15mmHg. right ventricular cavity mildly dilated. Free wall motion good. ascending aorta mildly dilated. aortic arch mildly dilated. aortic valve leaflets (3) mildly thickened aortic stenosis present. Trace aortic regurgitation seen. mitral valve leaflets mildly thickened. eccentric, inferolaterally directed jet mild moderate ([11-21]+) mitral regurgitation seen. mild pulmonary artery systolic hypertension. pericardial effusion. [2187-8-22] MR head w/ w/o contrast: acute infarcts. Minimal amount chronic microangiopathic changes. Normal MRA head. [2187-8-23] CXR: Partial additional improvement right lung consolidation. [2187-8-24] MRCP: Biliary sludge stones without biliary dilatation evidence cholecystitis. choledocholithiasis. Known adrenal calcifications, basilar pulmonary atelectasis/effusion, scattered pulmonary opacities. Brief Hospital Course: # Hemoptysis/Vasculitis: Patient presents Outside Hospital hemoptysis, described several teaspoons dark red blood mixed sputum, cough, shortness breath, chills fever Tmax=102 3 days prior admission. There, CT scan performed revealing diffuse alveolar disease, mainly Right Middle Right Lower Lobes. started Ceftriaxone Azithromycin. Warfarin stopped persistent hemoptysis. next two days Hematocrit dropped 38 29 transfused 1 unit Packed Red Blood Cells. [8-12] due worsening hemoptysis shortness breath, well decrease Hematocrit 27 , transferred ICU Outside Hospital. given blood, vitamin K, vancomycin 2 units Fresh Frozen Plasma. intubated transferred [Hospital3 ] MICU. Due multilobe involvement diffuse bleeding fever placed triple Abx presumed necrotizing pneumonia: Vancomycin, Azithromycin, ZOSYN (Piperacillin Tazobactam). first 48hrs [Hospital3 ] MICU given 6 units pRBCs HCT increased 33. Labs sent out: P-ANCA positive MPO positivity, [Doctor First Name ] positive (1:40, diffuse)) Rheumatology: High dose IV steroids Bactrim (Trimethoprim/ Sulfamethoxazole) PCP [Name Initial (PRE) 1102]. Patient's pulmonary function improved successfully extubated [8-20] episodes hemoptysis. Based presentation believed kidney-sparing microscopic polyangiitis treatment steroids continued. Rheumatology Pulmonary felt need lung biopsy time. patient fails steroids would consider cytoxan vs. cellcept vs. methotrexate. . # Hyperbilirubinemia/LFTs: stay MICU patient's LFTs increased drastically: ([8-12]): ALT 32, AST 58, LDH 366, AlkPhos 82, Tbili 4.5 ([8-19]): ALT 60, AST 69, LDH 657, AlkPhos 93 , Tbili 8.5 ([8-22]): ALT 168, AST 147, LDH 1103, AlkPhos 164, Tbili 18.9 ([8-25]): ALT 267, AST 100, LDH 608, AlkPhos 160, Tbili 10.7 (IndirectBili: 3-5 range) MRCP performed [8-24] showed evidence intrahepatic biliary disease. [Name (NI) 5283] sono showed gallbladder sludge [Doctor Last Name 5691], biliary ductal dilatation. Hepatology consulted suggested Zosyn induced hepatotoxicity Zosyn stopped followed gradual decrease Tbili. Hepatology also considering liver biopsy outpatient. examining transfused blood determined 5 u pRBCs transfused JK positive patient's blood JK antibody positive, suggesting possible delayed transfusion reaction could contributed hyperbilirubinemia. . # Seizure: MICU morning [8-22] patient tonic-clonic seizure. bed pan talking nurse, suddenly gave yelp, body became tense, head eye movement turned right, followed jerking right arm 1 minute. nurse administered 2mg Ativan IV gradual resolution movement, followed 15 min confusion. apparent bowel incontinence tongue biting. patient remember seizure returned basline mental status (AOx3). started Keppra. Imaging studies head (MR & CT) suggested evidence acute infarcts intracranial hemorrhage. CT head: evidence intracranial hemorrhage. stay patient seizure events sent home Keppra. . # CAD: Several days prior discharge patient reported chest pain consistent stable agina, acute pain overnight/morning, unchanged EKG. placed telemetry pauses >2sec beats occured multiple times 24hrs. metoprolol decreased 12.5mg [Hospital1 ] (which home dose). MI ruled negative cardiac enzymes. ASA, beta blocker continued. Patient episodes. . # Afib: metoprolol dose decreased 12.5mg [Hospital1 ] due presence pauses (>2sec) beats. Due vasculitis coumadin stopped. . Medications Admission: Protonix 40 mg daily Metoprolol 12.5 mg [Hospital1 ] Isosorbide mononitrate 60 mg [Hospital1 ] Simvastatin 80 mg daily Zolpidem (Ambien) 5 mg qhs Warfarin 2-4mg directed Lorazepam 1 mg tid Aspirin 81 mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice day. Disp:60 Capsule(s) Refills:2 2. Outpatient Lab Work Please draw LFTs, INR, Tbili, Indirect bili, albumin, alk. phos., CBC [2187-9-4]. . Please fax results: Dr. [Last Name (STitle) 4469], fax: [Telephone/Fax (1) 23978] Dr. [First Name (STitle) ], fax: [Telephone/Fax (1) 44524] Dr. [Last Name (STitle) ], fax: [Telephone/Fax (1) 9730] Dr. [First Name (STitle) ], fax: [Telephone/Fax (1) 33403] Dr. [Last Name (STitle) ], fax: [Telephone/Fax (1) 4400] Dr. [Last Name (STitle) ], fax: [Telephone/Fax (1) 3341] 3. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) needed. Disp:1 inhaler Refills:0 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Calcium Citrate 950 mg Tablet Sig: One (1) Tablet PO q12hr () 4 months. Disp:62 Tablet(s) Refills:4 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO Q12HR (). Disp:120 Tablet(s) Refills:2 9. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times day) needed restless leg syndrome. 10. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice day. Disp:60 Tablet(s) Refills:1 11. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO qAM. Disp:90 Tablet(s) Refills:2 12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) needed anxiety. 13. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual q 5min x 3 needed chest pain: take one tongue every five minutes pain subsides maximum three nitroglycerin pills. chest pain resolved then, please go ED. Disp:20 Tablet, Sublingual(s) Refills:0 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times day). 15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Primary: p-ANCA vasculitis . Secondary: 1. Coronary artery disease: s/p CABG [2175] (SVG PDA, OM-1 jump graft D1 distal LAD), ostial stent placed [2176], LAD stent [2180]. [2180] cath demonstrated occlusion SVG-OM SVG-PDA. re-do CABG LIMA-LAD, SVG-OM, SVG-PDA. Last cath [2184] revealed proximal LAD occlusion first septal filled LIMA. LCx proximally occluded filled graft. SVG-PDA patent, SVG-OM (86) occluded new SVG-OM1 patent. SVG-D1-LAD 86 CABG occluded LIMA-LAD patent. --Last Echo: [2-22]: mod [Name Prefix (Prefixes) ] [Last Name (Prefixes) 1915], RA dilated, LVSF 45%, RV wall hypokinesis. 2. Atrial fibrillation/Atrial flutter: developed post-operatively 2nd CABG--s/p ablation Aflutter, chronic atrial fibrillation. 3. Hyperlipidemia 4. Hypertension 5. Sleep apnea 6. Restless leg syndrome 7. Past bilateral hernia repairs 8. Right knee arthritis 9. Gastroesophageal reflux disease Discharge Condition: Good Discharge Instructions: seen [Hospital1 18] pulmonary hemorrhage. subsequently needed transferred intensive care intubation. recovered MICU transferred general medicine [Hospital1 ] continued stable. diagnosed vasculitis started prednisone. continue prednisone seen rheumatology advise medication regimen. . follow below. also labs drawn Tuesday, [9-4], provided prescription. . following medications changed home regimen: - Prednisone 60mg every morning. - started Keppra, 1000mg twice daily seizure. continue taking month. - started sulfamethoxazole/trimethoprim SS one tab daily guard bacterial infections immunosuppressant (prednisone). - started calcium vitamin - given albuterol inhaler shortness breath - started folic acid 5mg daily. - Imdur stopped - simvastatin stopped - ambien stopped - coumadin stopped - rheumatology pulmonology along primary care physician follow restart this. - aspirin dose increased 325mg/day - point, liver specialists may want hold 5 days liver biopsy. . return ED call primary care provider experience coughing vomiting blood, blood urine, chest pain, abdominal pain, fever greater 101.4 degrees F, symptoms concern you. Followup Instructions: Provider: [Name10 (NameIs) 703] WEST INTERVENTIONAL/PROSTATE US RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2187-8-30] 8:00 . Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. Phone:[Telephone/Fax (1) 285] Date/Time:[2187-9-5] 4:20pm . Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) 4469] Phone:[Telephone/Fax (1) 4475] [2187-9-6] 11:30am . Provider: [Name10 (NameIs) 454],THREE [Name10 (NameIs) 454] Date/Time:[2187-9-7] 8:00 . Provider: [Name10 (NameIs) 703] WEST INTERVENTIONAL/PROSTATE US RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2187-9-7] 9:30 . Provider: [First Name11 (Name Pattern1) 2890] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], MD Rheumatology Phone:[Telephone/Fax (1) 2226] Date/Time:[2187-9-11] 8:30 . Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) ], pulmonology. Phone:[Telephone/Fax (1) 612]. [2187-9-18] 8:00am, please 7:30 pulmonary function tests. . Test consideration post-discharge: Hepatitis C Virus RNA PCR, Qualitative . Also, Dr.[Name (NI) 19783] office contact liver appointment one month. Phone: [Telephone/Fax (1) 2422] . Dr.[Name (NI) 10444] office contact neurology appointment Dr. [First Name (STitle) ] one month. currently appointment [2187-11-8] 4pm, set earlier one. Phone: [Telephone/Fax (1) 541] . Please call need change appointment times questions. Completed by:[2187-9-25]	[ "486" ]
Admission Date: [2201-4-30] Discharge Date: [2201-5-8] Date Birth: [2115-1-13] Sex: Service: SURGERY Allergies: Indomethacin Attending:[First Name3 (LF) 4691] Chief Complaint: GI Bleed Major Surgical Invasive Procedure: [2201-4-30] 1. Exploratory laparotomy, resection gastrojejunostomy Billroth II anastomosis, Roux-en-Y reconstruction. 2. Partial transverse colectomy primary anastomosis. 3. Feeding jejunostomy. History Present Illness: 86M h/o gastric cancer s/p partial gastrectomy Billroth II reconstruction [2178], jejunostomy tube placement 2/[2199]. also medical history significant NSTEMI [2181] [2199] s/p CABG well critical aortic stenosis s/p valvuloplasty (peak AV gradient 10 mm Hg, valve area 1.1). experiencing GI bleeds site gastrojejunal anastamosis, requiring multiple hospitalizations. EGD cauterization EGD clipping performed site bleeding performed, unable control GI bleeding. Prior EGDs concerning gastro-jejunal anastamotic polyps bleeding ulcers high-grade dysplasia. concerning recurrence gastric carcinoma, s/p redo gastrojejunostomy roux en reconstruction, resection recurrent carcinoma, clear margins frozen section. entry abdomen, perforation transverse colon contained abscess discovered, partial transverse colectomy primary anastamosis performed. Feeding jejunosotmy tube placed. Past Medical History: Gastric Cancer s/p partial gastrectomy BII [2178], h/o GIBs site anastamosis, recent EGDs clipping cauterization, severe s/p emergent valvuloplasty [2201-1-8] c/b ARDS requiring prolonged intubation leading dysphagia, Cholangitis s/p sphincterotomy stent [2189], Coronary artery disease, prior NSTEMI [2181] [2199] ([Month (only) ]), s/p CABG, Cerebrovascular Disease, prior stroke [2195], Carotid Disease, Hypertension, Dyslipidemia, BPH, Gout, Chronic Anemia Social History: Romanian-Russian. married lives wife 84 yo. 2 [Year (4 digits) ], [Name (NI) 24006] (HCP) helps care [Name (NI) ] . recent VNA refusing help tube feeds. 40+ pack-year hx, quit [2179]. Since [2201-1-23] D/C (for severe ARDS requiring emergent valvuloplasty AS) [Hospital1 1501] walking independently walker close supervision recent went back home post discharge. Family History: Father died MI age 78 Mother died liver cancer age 81 Physical Exam: Vitals: Pain 4 97.9 HR 80 BP 155/53 RR 16 SpO2 100%RA GEN: A&O, NAD HEENT: scleral icterus, mucus membranes moist CV: RRR, M/G/R PULM: Clear auscultation b/l, W/R/R ABD: Soft, nondistended, minimal TTP lower quadrants, rebound guarding, normoactive bowel sounds, palpable masses DRE: pt refused. Ext: LE edema, LE warm well perfused Pertinent Results: [2201-4-30] 09:50PM WBC-4.4 RBC-2.94* HGB-9.9* HCT-29.3* MCV-100* MCH-33.6* MCHC-33.7 RDW-16.0* [2201-4-30] 09:50PM PLT COUNT-133* [2201-4-30] 09:50PM PT-13.9* PTT-28.0 INR(PT)-1.2* [2201-4-30] 09:50PM GLUCOSE-131* UREA N-23* CREAT-0.9 SODIUM-144 POTASSIUM-4.4 CHLORIDE-117* TOTAL CO2-22 ANION GAP-9 [2201-4-30] 09:50PM CALCIUM-7.6* PHOSPHATE-3.4 MAGNESIUM-1.6 [2201-5-4] UGI : evidence leak gastrojejunostomy site. [2201-5-5] Video swallow : Aspiration thin liquids residue valecula piriform sinuses. [2201-5-6] CT Abd/pelvis : 1. Fat- fluid-containing right inguinal hernia without bowel content. 2. Status post recent abdominal surgery postoperative pneumoperitoneum fluid within abdomen. 3. Increased bilateral moderate pleural effusions, left greater right. 4. Status post gastrectomy gastrojejunostomy revision well partial transverse colectomy. Anastomoses appear within normal limits. 5. Previously noted upper pole left renal cyst increased density contrast-enhanced exam demonstrates lower density non-contrast study. evaluation could obtained ultrasound. 6. Interval resolution anterior abdominal wall hematoma. Brief Hospital Course: Mr. [Known lastname 2262] taken [4-30] exploratory laparotomy, resection gastrojejunostomy Billroth II anastomosis, Roux-en-Y reconstruction, partial transverse colectomy primary anastomosis, feeding jejunostomy recurrent GIB history gastric CA. Postoperatively, patient taken SICU recovery. extubated well course POD 0. hematocrits stable 26-27 range. TF started via J tube. NGT suction. POD 1, remained hemodynamically stable tolerated tube feeds however hematocrits started slowly decrease. transferred floor POD 2 given persistent anemia hct 21, transfused two units PRBC. Following transfer Surgical floor hematocrit remained stable 30-32 range. began tube feeds via J tube tolerated well. speech swallow service evaluated multiple occasions frank aspiration video swallow therefore given sips nectar thick liquids comfort. need followed up. required mineral oil via J tube start bowel function effective. prone constipation narcotic pain medication stopped given scheduled Tylenol pain. continue Senna Colace well. Surgical wound healing well staples removed prior discharge. remaining staples removed first post op appointment. abdominal CT [2201-5-6] right inguinal hernia nut bit pain palpation. CT done confirmed hernia sac fat fluid filled opposed bowel pain gradually resolved. Physical Therapy service evaluated recommended stay short term rehab prior returning home increase mobility endurance hospitalization. Medications Admission: atorvastatin 40 mg daily, metoprolol tartrate 25 mg [Hospital1 ], lansoprazole 30 mg daily, mirtazapine 15 mg Tablet [Hospital1 ]: 0.5 Tablet PO HS (at bedtime), docusate sodium 100 mg [Hospital1 ], senna [Hospital1 ], acetaminophen 650 prn Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution [Hospital1 ]: 5000 (5000) Injection TID (3 times day). 2. metoprolol tartrate 25 mg Tablet [Hospital1 ]: 1.5 Tablets PO BID (2 times day): Hold SBP < 110, HR < 65. 3. haloperidol 1 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times day). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. mirtazapine 30 mg Tablet [Hospital1 ]: 0.5 Tablet PO HS (at bedtime). 6. acetaminophen 325 mg Tablet [Hospital1 ]: Two (2) Tablet PO Q6H (every 6 hours) needed pain. 7. Colace 60 mg/15 mL Syrup [Hospital1 ]: Twenty Five (25) ml PO twice day. 8. atorvastatin 40 mg Tablet [Hospital1 ]: One (1) Tablet PO day. 9. senna 8.8 mg/5 mL Syrup [Hospital1 ]: Ten (10) ml PO twice day. Discharge Disposition: Extended Care Facility: [Hospital1 599] Senior Healthcare [Location (un) 55] Discharge Diagnosis: 1. Recurrent gastric cancer. 2. Colonic perforation abscess 3. Acute blood loss anemia Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - requires assistance aid (walker cane). Discharge Instructions: Please call doctor nurse practitioner return Emergency Department following: You experience new chest pain, pressure, squeezing tightness. New worsening cough, shortness breath, wheeze. If vomiting cannot keep fluids medications. You getting dehydrated due continued vomiting, diarrhea, reasons. Signs dehydration include dry mouth, rapid heartbeat, feeling dizzy faint standing. You see blood dark/black material vomit bowel movement. You experience burning urinate, blood urine, experience discharge. Your pain improving within 8-12 hours gone within 24 hours. Call return immediately pain getting worse changes location moving chest back. You shaking chills, fever greater 101.5 degrees Fahrenheit 38 degrees Celsius. Any change symptoms, new symptoms concern you. Please resume regular home medications , unless specifically advised take particular medication. Also, please take new medications prescribed. Please get plenty rest, continue ambulate several times per day, drink adequate amounts fluids. Avoid lifting weights greater [4-21] lbs follow-up surgeon. Avoid driving operating heavy machinery taking pain medications. Incision Care: Please call doctor nurse practitioner increased pain, swelling, redness, drainage incision site. Avoid swimming baths follow-up appointment. You may shower, wash surgical incisions mild soap warm water. Gently pat area dry. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8941], MD Phone:[Telephone/Fax (1) 4537] Date/Time:[2201-5-12] 11:30 Provider: [Name10 (NameIs) ] CARE CLINIC Phone:[Telephone/Fax (1) 2359] Date/Time:[2201-5-14] 1:30 Completed by:[2201-5-8]	[ "412" ]
Admission Date: [2133-9-9] Discharge Date: [2133-9-15] Service: cardiothoracic surgery. HISTORY PRESENT ILLNESS: Briefly, 79 year old woman previous history scarlet fever status post [Last Name (un) 3843]-[Doctor Last Name ] mitral valve mitral stenosis [2126]. time surgery, found normal coronaries normal aortic valve. also history atrial fibrillation managed Coumadin. past year, complaining fatigue increasing shortness breath walking exertion. denied chest pain, palpitations, dizziness syncope. Echocardiogram revealed biatrial enlargement, severe aortic stenosis aortic valve area 0.6 centimeters, concentric left ventricular hypertrophy normal left ventricular function, moderate tricuspid regurgitation moderate pulmonic regurgitation. patient taken Cardiac Catheterization Laboratory evaluation aortic valve well evaluation coronary arteries. PAST MEDICAL HISTORY: 1. Scarlet fever. 2. Atrial fibrillation. 3. Prior transient ischemic attacks mild carotid disease noted recent testing. 4. Hypertension. 5. High cholesterol. 6. Obstructive pulmonary disease noted chest x-ray. PAST SURGICAL HISTORY: 1. Hernia repair. 2. Mitral valve replacement. 3. Elbow surgery. ALLERGIES: known drug allergies. MEDICATIONS ADMISSION: 1. Aspirin 81 mg p.o. q. day. 2. Lipitor 10 mg p.o. q. day. 3. Toprol 100 mg p.o. twice day. 4. Coumadin 2.5 mg Monday Saturday none Sunday. 5 Fosamax one tablet week. LABORATORY: admission white blood cell count 9.1, hematocrit 38.0 platelets 299. sodium 140, potassium 4.8, chloride 104, bicarbonate 29, BUN 24, creatinine 1.1 INR 1.3. PHYSICAL EXAMINATION: physical examination, patient afebrile vital signs stable. lungs clear auscultation bilaterally. neck supple jugular venous distention. heart irregularly irregular loud systolic ejection murmur. HOSPITAL COURSE: patient taken Cardiac Catheterization Laboratory cardiac surgery consultation time. patient taken Operating Room [2133-9-10], aortic valve replacement done using 19 centimeter pericardial valve. patient transferred CSRU postoperatively well. slowly weaned ventilator extubated, drips epinephrine Nitroglycerin stopped. patient started beta blockers lasix time. patient transferred Floor postoperatively continued improve. postoperative day number two chest tubes removed wires removed. patient started back Coumadin atrial fibrillation chest x-ray done normal, however, showed slightly enlarged heart x-ray. Physical Therapy consulted time testing ambulation felt patient could possible able discharged home. patient continued improve Coumadin continued regular dose followed, INR slowly increased. patient well Physical Therapy felt time patient could discharged home medically cleared. cardiac echo performed [2133-9-14] showed normal LV function good aortic mitral prosthetic valve function. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. q. day. 2. Albuterol one nebulizer q. six hours p.r.n. 3. Lipitor 10 mg p.o. q. day. 4. Coumadin 2.5 mg p.o. q. h.s. times six days week. 5. Percocet one two tablets p.o. q. four hours p.r.n. 6. Zantac 150 p.o. twice day. 7. Colace 100 mg p.o. twice day. 8. [First Name5 (NamePattern1) 233] [Last Name (NamePattern1) 1002] 20 mEq p.o. twice day. 9. Lasix 20 mg p.o. twice day. 10. Lopressor 25 mg p.o. twice day. CONDITION DISCHARGE: patient discharged home stable condition. DISCHARGE INSTRUCTIONS: 1. instructed follow-up Dr. [Last Name (STitle) ] four weeks. 2. instructed follow-up primary care physician one two weeks. 3. follow-up Cardiology two four weeks. DISCHARGE DIAGNOSES: 1. Scarlet fever. 2. Atrial fibrillation. 3. Mitral valve regurgitation status post mitral valve repair. 4. Aortic stenosis status post aortic valve repair. 5. Prior transient ischemic attacks. 6. Hypertension. 7. High cholesterol. 8. Chronic obstructive pulmonary disease chest x-ray. patient discharged home stable condition. Please see Addendum changes medications correct discharge date. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Last Name (NamePattern4) 7148] MEDQUIST36 D: [2133-9-13] 22:10 T: [2133-9-14] 05:02 JOB#: [Job Number 41721] 1 1 1 DR	[ "496" ]
Admission Date: [2159-8-12] Discharge Date: [2159-8-16] Service: MEDICINE Allergies: Pneumococcal Vaccine / Influenza Virus Vaccine / Sulfa (Sulfonamides) / Penicillins Attending:[First Name3 (LF) 13386] Chief Complaint: BRBPR coffee ground emesis Major Surgical Invasive Procedure: LIJ placed Transfusion 5 units PRBCs History Present Illness: [Age 90 ] yo F history CAD, CVA, GERD, MRSA UTI, DM, dementia (verbal confused baseline) presents ED Heb Reb, hypotension. one episode emesis (non bloody [8-11]). reportedly complained abd pain day admission ([8-12]), 1 episode coffee ground emesis, followed BRBPR clots. BP [Hospital1 1501] 60/p. . arrival ED blood pressure 80/palp. [Hospital1 ] 26 (was 33 [2158-8-9]), lactate 5.5, UA grossly positive. FAST negative. Abd CT revealed 2 cm clot vs mass duodenum. GI surgery consulted. fluid resucutated, initially BP improved 100 systolic, trended 70's. . Potassium initially 7.6, given Calcium Cl 1 g, Insulin 5U. Code sepsis called, L IJ placed (following failed attempt R IJ). given 3.2L IVF, Vanco/levo/flagyl transfused 2 units PRBCs. transfer MICU afebrile HR 110, BP 90-100/40, satting 97% 2L NC. . ROS: unable obtain . Past Medical History: CAD s/p angioplasty [2143] h/o CVA DM2 peripheral neuropathy (HgbA1c = 6.6) CKD (b/l Cr 1.8) diverticulitis s/p partial colectomy chronic hypotension (b/l BP = 90) hyperlipidemia dementia (oriented x 1 baseline) h/o chronic anemia h/o MRSA UTI recent CDiff (last dose [2159-8-10]) possible chronic renal failure GERD SLE h/o gallstone pancreatitis COPD OA h/o cystitis low back pain h/o R knee surgery s/p sympathectomy Social History: [Hospital 100] Rehab, former smoker- [12-6] ppd x 80 years. etoh. uses walker. Son [Name (NI) ] HCP. requires assistance adl's, Family History: NC Physical Exam: VS - Temp 97.3 F, BP 112/80, HR 102, R 18, O2-sat 96% RA GEN: sleepy arousable--lapses back sleep easily, oriented x1 self only. follows simple commands, frail elderly woman, confused, moaning, hard hearing HEENT: [Last Name (LF) 12476], [First Name3 (LF) 13775], EOMI, anicteric , dry MM , OP clear Neck: supple, JVD, bruits, LAD Heart: RRR, S1, S2, 2/6 SEM base, ectopy Lungs: crackles b/l bases; rh/wh, accessory muscle use Abd: generally tender/no rebound/no guard. mass; organomegaly; obese; bruisig skin site medication injection. Ext: CCE/erythema (blanching) Rt foot; dp/pt dopplerable Skin: Stage I-II sacral decub Neuro: AA&Ox1(to name), 5/5 strength arms; 4/4 strength legs; cn2-12 grossly normal except left hearing loss; babinski downgoing bilat. reflexes hard elicit. Pertinent Results: EKG: sinus tach 108, 1st degree AV block, nonspecific stt changes . [2159-8-14]: Baseline artifact. Sinus rhythm. Leftward axis. Since previous tracing axis leftward. . CT pelvis w/o contrast [8-12]: 4 cm hyperdense collection duodenum concerning Upper GI bleed(likely bleeding duodenual ulcer, cannot rule underlying mass). intraperitoneal free fluid, free air obstruction. . . [2159-8-12] 02:32PM GLUCOSE-251* UREA N-47* CREAT-1.7* SODIUM-137 POTASSIUM-5.5* CHLORIDE-111* TOTAL CO2-21* ANION GAP-11 [2159-8-12] 02:32PM CALCIUM-6.5* PHOSPHATE-4.4 MAGNESIUM-1.4* [2159-8-12] 02:32PM WBC-14.9* RBC-3.10* HGB-9.4* [Month/Day/Year ]-27.2* MCV-88 MCH-30.3 MCHC-34.5# RDW-15.5 [2159-8-12] 02:32PM PLT COUNT-222 [2159-8-12] 01:07PM LACTATE-1.5 [2159-8-12] 11:27AM LACTATE-2.6* [2159-8-12] 09:45AM LACTATE-2.9* [2159-8-12] 09:30AM URINE COLOR-Yellow APPEAR-Cloudy SP [Last Name (un) 155]-1.015 [2159-8-12] 09:30AM URINE BLOOD-LG NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-MOD [2159-8-12] 09:30AM URINE RBC-[5-15]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-[2-7] [2159-8-12] 08:10AM GLUCOSE-267* UREA N-46* CREAT-2.0* SODIUM-138 POTASSIUM-5.6* CHLORIDE-108 TOTAL CO2-25 ANION GAP-11 [2159-8-12] 08:10AM estGFR-Using [2159-8-12] 08:10AM ALT(SGPT)-9 AST(SGOT)-12 CK(CPK)-17* ALK PHOS-43 TOT BILI-0.3 [2159-8-12] 08:10AM LIPASE-16 [2159-8-12] 08:10AM CK-MB-NotDone [2159-8-12] 08:10AM ALBUMIN-1.9* CALCIUM-6.0* PHOSPHATE-4.7* MAGNESIUM-1.5* [2159-8-12] 08:10AM CORTISOL-27.3* [2159-8-12] 08:10AM CORTISOL-27.3* [2159-8-12] 08:10AM CRP-3.4 [2159-8-12] 07:19AM LACTATE-5.5* K+-7.6* [2159-8-12] 07:15AM cTropnT-0.03* [2159-8-12] 07:15AM WBC-12.7* RBC-2.93* HGB-8.1* [Month/Day/Year ]-26.1* MCV-89 MCH-27.8 MCHC-31.2 RDW-16.8* [2159-8-12] 07:15AM NEUTS-81.2* LYMPHS-14.8* MONOS-3.1 EOS-0.1 BASOS-0.8 [2159-8-12] 07:15AM PLT COUNT-440 [2159-8-12] 07:15AM PT-12.9 PTT-25.7 INR(PT)-1.1 . COMPLETE BLOOD COUNT WBC RBC Hgb [Month/Day/Year ] MCV MCH MCHC RDW Plt Ct [2159-8-16] 10:50AM 34.9* [2159-8-16] 05:55AM 7.9 3.82* 11.4* 33.7* 88 29.8 33.8 16.5* 138* [2159-8-16] 04:06AM 8.5 4.02* 11.7* 36.4 90 29.1 32.2 16.3* 155 [2159-8-15] 03:40PM 8.4 3.96* 12.1 36.1 91 30.5 33.5 16.2* 154 Source: Line-Central [2159-8-15] 06:10AM 8.3 4.11* 12.2 36.1 88 29.6 33.7 16.4* 188 [2159-8-15] 12:18AM 35.3* Source: Line-CVL [2159-8-14] 03:22PM 35.7* Source: Line-Central [2159-8-14] 05:56AM 12.3* 3.62* 11.0* 31.6* 87 30.2 34.7 16.2* 203 Source: Line-CVL [2159-8-13] 11:23PM 32.8* [2159-8-13] 07:28PM 33.9* Source: Line-central [2159-8-13] 04:36PM 17.1* 4.10* 11.9* 35.7* 87 29.1 33.4 16.0* 190 Source: Line-CVL [2159-8-13] 02:23PM 33.3* Source: Line-left ij [2159-8-13] 09:28AM 35.1* Source: Line- left ij [2159-8-13] 05:56AM 15.4* 4.17# 12.3# 35.7 86 29.5 34.4 15.8* 196 . . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2159-8-16] 05:55AM 101 28* 1.3* 141 4.81 110* 19* 17 [2159-8-15] 06:10AM 113* 39* 1.4* 142 4.6 112* 22 13 [2159-8-14] 05:56AM 157* 51* 1.5* 141 4.7 112* 20* 14 Source: Line-CVL [2159-8-13] 04:36PM 196* 57* 1.6* 138 5.3* 109* 20* 14 Source: Line-CVL [2159-8-13] 02:23PM 152* 58* 1.5* 137 5.7* 111* 21* 11 Source: Line-left ij [2159-8-13] 09:28AM 5.7* Source: Line- left ij [2159-8-13] 05:56AM 177* 62* 1.6* 136 5.8* 109* 21* 12 Source: Line-central [2159-8-12] 02:32PM 251* 47* 1.7* 137 5.5* 111* 21* 11 Source: Line-tlc [2159-8-12] 08:10AM 267* 46* 2.0* 138 5.6* 108 25 11 . . . Cortisol [2159-8-12] 08:10AM 27.31 . Lactate: [2159-8-12] 01:07PM 1.5 [2159-8-12] 11:27AM 2.6 [2159-8-12] 09:45AM 2.9* [2159-8-12] 07:19AM 5.5* . ALT AST CK AlkPhos TotBili [2159-8-12] 9 12 17 43 0.3 . Final [Year (4 digits) ] discharge 34.9 . [2159-8-15] CATHETER TIP-IV WOUND CULTURE-PRELIMINARY INPATIENT [2159-8-15] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2159-8-14] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2159-8-14] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2159-8-14] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2159-8-12] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI, ESCHERICHIA COLI} EMERGENCY [Hospital1 ] [2159-8-12] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [Hospital1 ] [2159-8-12] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY {LACTOBACILLUS SPECIES}; Aerobic Bottle Gram Stain-FINAL EMERGENCY [Hospital1 ] . URINE CULTURE (Final [2159-8-15]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. 2ND MORPHOLOGY. SENSITIVITIES: MIC expressed MCG/ML _________________________________________________________ ESCHERICHIA COLI \| ESCHERICHIA COLI \| \| AMPICILLIN------------ 16 <=2 AMPICILLIN/SULBACTAM-- 8 <=2 CEFAZOLIN------------- <=4 <=4 CEFEPIME-------------- <=1 <=1 CEFTAZIDIME----------- <=1 <=1 CEFTRIAXONE----------- <=1 <=1 CEFUROXIME------------ 16 4 CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ <=1 <=1 MEROPENEM-------------<=0.25 <=0.25 NITROFURANTOIN-------- <=16 <=16 PIPERACILLIN---------- <=4 <=4 PIPERACILLIN/TAZO----- <=4 <=4 TOBRAMYCIN------------ <=1 <=1 TRIMETHOPRIM/SULFA---- <=1 <=1 Brief Hospital Course: [Age 90 ]F presents history GERD, dementia, MRSA UTI admitted MICU [Hospital1 1501] shock, UTI GI bleed. . # Sepsis/UTI/bacteremia - initially hypotensive ED, baseline [Hospital1 ] per PCP [Last Name (NamePattern4) ] 36, 26 admission, thus hypotension felt likely hypovolemic GI bleed, may septic component well given +UA [8-12], +leukocytosis (WBC 17.1). CVP = 4. Given 3.2 L IVF, 2 units PRBC's ED. Never required pressors ICU. recieved ~4L IVF MICU, 4U PRBCs. treated broad spectrum abx vanc/cipro/flagyl 1d ICU. transferred floor [2159-8-13]. Vanco flagyl discontinued given presence gram negative rods urine culture, source infection. Urine speciated E.Coli resistant quinolones, switched oral bactrim based sensitivities. history reported bactrim allergy. discussion PCP, [Name10 (NameIs) ] determined taken bactrim past [4-10] without adverse reaction. tolerated bactrim without difficulty. . Blood cultures [2159-8-12] positive LACTOBACILLUS 1 2 bottles. Subsequent cultures [9-8], [8-15] showed growth time discharge. Left IJ catheter tip cultured showed growth time discharge. ID consult obtained, recommended clindamycin iv x 14 days treat potential lactbacillus bacteremia starting [8-16]. PICC line placed antibiotic. also started 21 day course oral vancomycin (starting [8-16]) c. difficile prophylaxis given recent c. difficille infection. hemodynamically stable upon transfer medical floor hypotension. . follow-up bacteremia either primary care physician gerontology service [Hospital 100] Rehab. require surveillence cultures. . # GIB bleed - likely due duodenal ulcer given CT scan. GI surgery consulted, given patient son's desire conservative management, agreed upon intervention would performed unless pt developed life threatening bleed. Pt received total 5U PRBCs last [8-14]. [Month/Day (4) ] stable 33-35 discharge [8-16]. tolerating regular pureed diet supervision given concern aspiration recovering UTI. discharged home omeprazole twice daily. aspirin plavix discontinued. discuss restarting aspirin primary care physician future. . . # Hyperkalemia - K 5.8 [8-13], 4.8 [8-16] without intervention. ekg changes. question RTA source chronic hyperkalemia. potassium resolved without intervention. follow-up PCP. . . # Recent C Diff - pt finished PO Vancomycin [8-10]. melanotic stools admission, though diarrhea. started PO vanco [8-16] 21 day course prophylax cdiff given starting new course bactrim UTI clindamycin bacteremia. . . # CKD: baseline Cr 1.8 per report, 1.3 [8-16]. medications renally dosed. evidence ATN. . # DM - pt covered sliding scale insulin inpatient. . # gout - pt continued home regimen allopurinol. . # anemia - baseline Hgb approximately 12 per discussion patients' PCP. [Name10 (NameIs) ] 26 admission consistent GIB. time discharge [Name10 (NameIs) ] 34.9. Iron supplementation held setting GIB, restarted outpatient. . # CAD - given ongoing GIB above, decision made hold aspirin plavix. clear indication continue plavix given lack recent NSTEM, CVA, PAD. Pt need discuss restarting aspirin PCP hematocrit stable. . # COPD - pt continued home regimen fluticasone spiriva. breathing comfortably room air time discharge. . # Access - L IJ placed setting hypotension ICU. discontinued [8-15], tip cultured. PICC placed IV antibiotics continue 14 days, afterwhich time PICC discontinued. . # FEN - pt advanced regular pureed diet [8-15]. Pt kept aspiration precautions given remains drowsy setting UTI. . # CODE: pt's code status made DNR/DNI per discussion son, HCP keeping patient's wishes. Son HCP. . # DISPO: pt discharged [Hospital 100] Rehab. Plan complete antibiotics (bactrim UTI, clindamycin lactobacillus bacteremia), oral vancomycin cdiff prophylaxis. readdress aspirin use above. Medications Admission: tylenol spiriva aspirin 81 mg feso4 daily plavix 75 mg fluticasone 220 mcg 1 puff [Hospital1 ] milk mag trazodone 50 HS PRN allopurinol 100 mg daily HISS prilosec TUMS [Hospital1 ] Vit 1000U dialy Maalox prn lactobacillus [Hospital1 ] Discharge Medications: 1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) needed pain. 3. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO day. 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times day). 5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times day) 8 days: Allegy noted. PCP said never documented reaction it. 7. Insulin Lispro 100 unit/mL Solution Sig: One (1) units Subcutaneous ASDIR (AS DIRECTED). 8. Vitamin 1,000 unit Capsule Sig: One (1) Capsule PO day. 9. Maalox 200-200-20 mg/5 mL Suspension Sig: One (1) PO every 4-6 hours needed heartburn. 10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice day. 11. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) 21 days: last day [2159-9-5]. 12. Clindamycin Phosphate 150 mg/mL Solution Sig: One (1) 600mg Injection Q8H (every 8 hours) 14 days: 600 mg IV q8hr, last day [2159-8-29]. Discharge Disposition: Extended Care Facility: [Hospital3 ] Center Discharge Diagnosis: Primary Diagnosis: Upper GI Bleed Urinary Tract Infection Bacteremia . Secondary Diagnosis: Coronary Artery Disease Dementia Discharge Condition: discharged baseline level functioning. vital signs stable assessed physical therapy. Discharge Instructions: admitted ulcer GI tract bled enough vital signs become unstable required admission intensive care unit. blood transfusions careful monitoring, vital signs stabilized followed regular floors. also treated antibiotics urinary tract infection infection blood stream. . following changes made medications" 1)You need take Bactrim urinary tract infetion. Please take 1 tablet mouth twice day next 8 days end [2159-8-15]. 2)We discontinued plavix, milk magnesia, tums, lactobacillus. 3)Please discuss rehab doctors [Name5 (PTitle) ] aspirin. 4)The prilosec taken twice day mouth. 5)Please take Clindamycin 600mg IV every 8 hours 5 days end [2159-8-20]. treat bacteria blood. 6)Please take Vancomycin 250mg mouth 4 times day 12 days end [2159-8-28]. prevent getting diarrhea antibiotics. . followed doctors [First Name (Titles) ] [Last Name (Titles) 100] Rehab. . develop following: chest pain, shortness breath, palpataion, dizziness, nausea vomiting, bloody stools, please notify doctors Rehab [Name5 (PTitle) ] go local Emergency Room. Followup Instructions: doctors rehab [Name5 (PTitle) ] take care make recommendations follow. Completed by:[2159-8-16]	[ "496" ]
Admission Date: [2162-12-28] Discharge Date: [2163-1-9] Date Birth: [2114-8-16] Sex: Service: MEDICINE Allergies: Codeine / Morphine Attending:[First Name3 (LF) 6021] Chief Complaint: fever Major Surgical Invasive Procedure: Central line placement PICC line placement History Present Illness: 48yo male AIDS related [Doctor Last Name 11579] Lymphoma CNS involvement s/p cycle 2 R-IVAC (discharged [12-24]) developed chills, checked temperature; noted fever 100.5 home presented ED. Denied cough, SOB, HA, urinary sx, CP, N/V/D/C. . ED Course: Febrile 101.2, initially BP normal fell 70/30, HR tachycardic 150's. Code sepsis called. Initial labs significant for: lactate 3.3->4.3, WBC 0.1 w/ 17% PMNs, Hct 27.4, platelets 27->13. UCX, Blood Cx drawn. UA negative, CXR showed acute cardiopulmonary process. RIJ CVL placed. CVP = 8. Given cefepime/vancomycin. Started levophed, titrated up; eventually dopamine added. received one unit pRBC's. . Regarding Burkitt's Lymphoma: Diagnosed [2162-10-2] w/ BM bx [10-18]. CODOX intrathecal cytarabine started [10-20]. [10-21], MRI demonstrated progressive CNS disease commenced whole brain XRT x 5 fractions radiation (completed [10-27]). admitted [12-16] [12-24] second cycle R-IVAC. Mr. [Known lastname ] received rituximab [2162-12-16], IVAC started [12-17]. also received intrathecal liposomal cytarabine [2162-12-22]. G-CSF started [2162-12-23]. admission reported numbness left shoulder well bilateral fingertip numbness, thought due vincristine-induced peripheral neuropathy, central process (MR [First Name (Titles) ] [Last Name (Titles) 11580]). patient sent home dexamethasone 4 mg PO bid x 2.5 days complete 5-day course. Plan 3 cycles CODOX (2 Rituxan) R-IVAC. Past Medical History: ONCOLOGIC HISTORY: initially admitted [10-14] ten days increasing axillary adenopathy, fevers, chills, night sweats. inguinal lymph node biopsy non-diagnostic diagnosis confirmed bone marrow biopsy performed [10-18]. transferred OMED service commenced CODOX received intrathecal cytarabine [10-20]. [10-21], MRI demonstrated progressive CNS disease commenced WBXRT [10-22]. received five fractions radiation completed therapy [10-27]. developed tumor lysis renal insufficiency following chemotherapy, resolved supportive care. received CODOX, R-IVAC, R-CODOX. planning 3 cycles CODOX (2 Rituxan) R-IVAC. . PAST MEDICAL HISTORY: 1. Burkitt's Lymphoma described above. 2. HIV above, diagnosed [5-/2159] thought contracted MSM contact developed viral-like syndrome. never HAART. 3. Left V1/V2 trigeminal zoster without ocular involvement [6-/2160] 4. Viral orchitis left testicle age 15; testicle chronically shrunken, "mushy", tender, per patient 5. Chronic low back pain herniated disc noted several yrs ago 6. Depression/Anxiety 7. HBcAb HBsAb (+) (HBsAg neg) 8. s/p cholecystectomy [2145] 9. Chronic anisocoria (per patient) R>L Social History: works small company computer programming. denies tobacco use. used marijuana past, denies IV drug use. uses occasional alcohol, though none since diagnosis. Family History: reports father died MI 50s. mother diabetes. sister zoster. Physical Exam: Physical Exam: VS - T99.0F, BP 116/61, HR 98, RR 15, Sat 99%RA GENERAL - Comfortable, acute distress HEENT - Dry mucus membranes. Right eyelid droop. NECK - cervical lymphadenopathy. LUNGS - CTA bilaterally HEART - RRR normal S1/S2, m/r/g ABDOMEN - Soft, NT, NT, + bowel sounds EXTREMITIES - Trace edema bilaterally SKIN - rashes NEURO - Alert, oriented x 3, conversational Brief Hospital Course: ASSESSMENT/PLAN: 48yo male AIDS related [Doctor Last Name 11579] Lymphoma CNS involvement s/p cycle 2 R-IVAC admitted sepsis pancytopenia. . # Sepsis/ Febrile neutropenia: GNR methicillin resistant staph aureus [5-5] blood cultures previously requiring pressors course [Hospital Unit Name 153]. Source unclear. Urine cx negative, CT sinus negative. TTE revealed evidence endocarditis EF 50-55% mild global systolic dysfunction likely secondary sepsis. TEE completed due thrombocytopenia. Patient initially treated cefepime vancomycin. sensitivities returned, coverage switched Cipro vancomycin. Vancomycin initially dosed level setting acute renal failure. renal function improved dosing switched 1 gram q 12 hours. PICC line placed patient sent home complete 3 week course cipro 4 weeks total vancomycin follow Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1075] Infectious Disease. Given scripts weekly lab surveillance Vancomycin including chemistries vancomycin levels. . # Acute renal failure: urine lytes consistent prerenal cause. FeNA 1%. Given IV fluids improvement. However return baseline time discharge. . # Altered mental status: Noted slowing parkinsonian type features yesterday. Sent CT head, revealed subdural hematomas. Seen neurosx felt evacuation necessary. Neurology consulted also completed felt need antiseizure meds time. Blood pressure kept 140 systolic repeat CT head showed progression. Platelets maintained 60 significantly improved prior discharge. Parkinsonian features completely attributable small subdural hematomas. Therefore seroquel discontinued patient cogwheel rigidity side effect seroquel. . # C difficile colitis: Stool C difficile toxin positive. Started course flagyl total 14 days. However per ID curbside, patient treated four weeks along vancomycin. Therefore, Dr. [First Name (STitle) ] contact[Name (NI) ] regarding appropriate duration therapy order extend total course antibiotics. . #Pancytopenia: [3-5] recent chemo complicated sespis. Hct drifts downwards w/o transfusions, bone marrow producing retics ANC increased Neupogen discontinued count rose 1000. . # Oral herpes: Treated topical acyclovir. . #AIDS: Cont home ARV therapy . #Hyperglycemia: Insulin SS. Sugars improved patient recovered sepsis. . # Full Medications Admission: Acyclovir 400 mg PO q12hr Ranitidine 150 mg PO BID Sertraline 100 mg daily Levofloxacin 500 mg daily x 10 days Neupogen 480 mcg daily x 10 days ATRIPLA [Telephone/Fax (3) 567] mg daily Mirtazapine 15 mg PO qhs -> 7.5 since constantly hungry Ambien CR 12.5 mg qhs Compazine 5-10mg q 6-8 hours PRN Zofran 4 mg q 8 hrs Benadryl 50 mg qhs PRN- taking- > nasal congestion Lorazepam 0.5-1 mg q 6 hr PRN Discharge Medications: 1. Vancomycin Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous every twelve (12) hours: Last day: [2163-1-28]. Disp:41 units Refills:0 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): Last day: [2163-1-11] . Disp:6 Tablet(s) Refills:0 3. Outpatient Lab Work WEEKLY LABS: CBC, BUN/Cr, LFTs, Vanco trough (goal = 20) FAX [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1075] ([Hospital ] CLINIC) [Telephone/Fax (1) 432]. (All questions regarding outpatient antibiotics directed infectious disease R.Ns. ([Telephone/Fax (1) 11581] [Name8 (MD) 11582] MD clinic closed.) 4. Heparin Flush 10 unit/mL Kit Sig: Two (2) mL Intravenous day. Disp:30 flushes Refills:1 5. Saline Flush 0.9 % Syringe Sig: [6-10] mL6 Injection SASH PRN. Disp:60 Refills:2 6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) needed nausea. 7. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 10. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times day) 10 days. Disp:30 Tablet(s) Refills:0 13. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:5 Patch 72 hr(s) Refills:2 Discharge Disposition: Home Service Facility: Critical Care Systems Discharge Diagnosis: PRIMARY: Bacteremia Hypotension Febrile neutropenia Mucositis Hyperglycemia SECONDARY: HIV/AIDS Burkitt's lymphoma Hepatitis B core/surface ab positive Anxiety Depression Eczema Low back pain/muscle spasm Discharge Condition: Hemodynamically stable, afebrile Discharge Instructions: admitted hospital infection blood. probably recently chemotherapy immune system compromised. treated antibiotics required brief stay ICU closer care monitoring. seem recovering discharged finish remaining course antiobiotics outpatient. Vancomycin [2163-1-28]. Ciprofloxacin [2163-1-11]. Remember blood work checked every week getting antibiotics. Details: * WEEKLY LABS * CBC, BUN/Cr, LFTs, vanco trough (goal = 20) FAX'ed [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1075] ([Hospital ] Clinic) [Telephone/Fax (1) 432]. (All questions regarding outpatient antibiotics directed infectious disease R.Ns. fevers chills, please call doctor immmediately. chest pain shortness breath, symptoms concerning you, seek medical attention immediately go nearest Emergency Department. Followup Instructions: Please follow Dr. [First Name8 (NamePattern2) 916] [Last Name (NamePattern1) ] within 1 week. Please call ([Telephone/Fax (1) 11583] . Please follow Infectious Disease Clinic: Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2163-1-28] 9:30 Please follow PCP [Name Initial (PRE) 176] 2 weeks: [Last Name (LF) ],[First Name3 (LF) ] C. [Telephone/Fax (1) 2393]	[ "042" ]
Admission Date: [2182-9-7] Discharge Date: [2182-9-18] Service: MEDICINE Allergies: Aspirin / Adhesive Tape Attending:[First Name3 (LF) 1436] Chief Complaint: Tachycardia Major Surgical Invasive Procedure: -Cardiopulmonary resuscitation -Endotracheal intubation History Present Illness: 89F CAD, Afib, DM2 felt "strange" around 9pm last night malaise. Denies CP SOB. Presented [Hospital3 4107] ED, HR 150s question SVT. given IV dilt HR came back SR 60/min. Patient reported feeling much better. denied CP time. uses walker ambulate denied DOE. N/V. ECG OSH showed ST elevations V2-V5 III, w/ Q waves V2-V4,inferior. transferred [Hospital1 18] management. Past Medical History: Coronary Artery Disease s/p MI 15y ago s/p angioplasty Afib coumadin Hypertension Hypercholesterolemia Upper GI [Last Name (un) ] 10y ago Osteoarthritis (primarily affecting knees) Social History: Lives [Hospital1 ], family nearby, mostly independent & takes care herself, tobacco, occ EtOH Family History: non-contributory Physical Exam: VS: T97.1 , BP 114/66 , P86 , SaO298%2L RR22 GENERAL: apparent distress HEENT: PERRLA, MMM NECK: JVD CHEST: CTAB CVS: irreg, 1/6 SEM ABD: +BS. soft, NT/ND. EXT: Warm, without edema. SKIN: rash NEURO: AO3, moving spontaneously Pertinent Results: Admission Labs: [2182-9-7] 07:50AM WBC-6.2 RBC-3.73* HGB-11.4* HCT-35.7* MCV-96 MCH-30.6 MCHC-32.0 RDW-14.6 PLT COUNT-156 [2182-9-7] TSH-1.9 [2182-9-7] CK-MB-24* MB INDX-15.7* cTropnT-1.23* [2182-9-7] CK(CPK)-153* [2182-9-7] GLUCOSE-146* UREA N-33* CREAT-1.3* SODIUM-142 POTASSIUM-5.1 CHLORIDE-110* TOTAL CO2-23 ANION GAP-14 . Discharge Labs: [2182-9-18] WBC-6.2 RBC-3.26* Hgb-9.8* Hct-31.2* MCV-96 MCH-30.1 MCHC-31.4 RDW-15.2 Plt Ct-269 [2182-9-18] PT-20.5* INR(PT)-2.0* [2182-9-18] Glucose-99 UreaN-22* Creat-1.2* Na-140 K-4.8 Cl-106 HCO3-27 AnGap-12 [2182-9-12] -32 AST-40 LD(LDH)-199 AlkPhos-122* TotBili-0.9 [2182-9-12] CK-MB-NotDone cTropnT-0.37* [2182-9-17] Calcium-8.4 Phos-3.0 Mg-2.2 Imaging: [2182-9-18] CXR - FINDINGS: comparison study [9-12], acute enlargement cardiac silhouette. Although retrocardiac area poorly seen, appear increased opacification would consistent atelectatic change. Mild prominence right hilar vessels, though definite increase pulmonary venous pressure appreciated. . [2182-9-9] TTE: EF 30%. left atrium mildly dilated. right atrium moderately dilated. atrial septal defect seen 2D color Doppler. Left ventricular wall thicknesses normal. left ventricular cavity size normal. severe regional left ventricular systolic dysfunction septal, anterior distal LV akinesis. masses thrombi seen left ventricle. Tissue Doppler imaging suggests increased left ventricular filling pressure (PCWP>18mmHg). ventricular septal defect. Right ventricular chamber size normal. Right ventricular systolic function normal. aortic valve leaflets (3) mildly thickened aortic stenosis present. aortic regurgitation seen. mitral valve leaflets mildly thickened. moderate thickening mitral valve chordae. Moderate (2+) mitral regurgitation seen. tricuspid valve leaflets mildly thickened. Moderate severe [3+] tricuspid regurgitation seen. moderate pulmonary artery systolic hypertension. small moderate sized pericardial effusion. echocardiographic signs tamponade. Brief Hospital Course: 89yo F w/ CAD s/p MI, Afib, DM2, transferred [Hospital1 18] w/ wide complex tachycardia elevated CEs. * Wide complex tachycardia: admission, pt thought supraventricular tachycardia right bundle branch block. given adenosine; however, adenosine break rhythm. rhythm lasted hours broke spontaneously. pt hemodynamically stable event. noted mild discomfort interscapular area. Approximately 24hr rhythm broke went again, w/o hemodynamic compromise symptoms. Again, rhythm broke spontaneously hours--metoprolol given event without apparent effect. EP consulted (Dr. [Last Name (STitle) ] initially EP attending, Dr. [Last Name (STitle) ]. determined rhythm actually narrow, monomorphic ventricular tachycadia RBBB inferior axis, likely arising in/near septum. (Of note, official EKG readings OMR describe rhythm VT--see EKG [2182-9-7] 4:23 example VT.) Pt third episode VT, given lidocaine good response. Discussion team, pt, pt's family whether pt undergo EP study start amiodarone empirically without EP study. Given patient's overall clinic picture wishes, amiodarone started, EP study done. loaded approximately 6grams amiodarone. continued 200mg daily maintenance. patient episodes ventricular tachycardia starting amiodarone. note patient normal thyroid & liver function prior starting amiodarone. scheduled follow-up Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Hospital1 ] office [2182-10-15] 2:40pm. likely need baseline pulmonary function tests, ophthomalogic exam, repeat thyroid & liver function tests. * PEA arrest: patient's third episode VT broke, severe coughing fit, became hypoxic 02 70s. went PEA arrest, presumably hypoxia, cause found. CPR performed less 5 minutes spontaneous rhythm achieved. However, patient intubated given concern ability proctect airway. patient intubated less 48hr. * Coronary artery disease: Pt remote history MI approximately 15yr, time underwent angioplasty. Prior transfer [Hospital1 18], diffuse ST elevations EKG OSH. resolved time admission here. Pt without chest pain. CE elevated admission & trended down. EKGs OSH reviewed questioned whether ST elevations ischemia vs. repolarization change pericarditis. Given lack CP overall clinical picture, felt need go cardiac catheterization. continued statin. b-blocker (coreg) given started amiodarone, time stopped due bradycardia occasionally 40s (without symptoms). discharged coreg. Caution used b-blockers given first degree AV block amiodarone. pt refuses aspirin due prior bleeding it. * Atrial fibrillation: Rate controlled amiodarone. Coreg discontinued due bradycardia (hr 40-50s amio). Coumadin dose decreased 1.5mg daily (from 2.5mg) starting amiodarone. INR day discharge 2. rechecked [2182-9-20] coumadin adjusted necessary. * Congestive heart failure: acute chronic systolic heart failure. Echo stay showed EF 30% moderate mitral regurgitation moderate severe tricuspid regurgitation. diuresed IV lasix necessary continued home dose lasix 20mg daily. day discharge, pt received dose 20mg IV lasix slight volume overload. aldactone (25mg daily) also restarted [2182-9-18]. ACEi [Last Name (un) ] started hospital stay due relatively low BP (90-100); though pt would likely benefit one agents future. * Cough: Pt dry cough admission, ecame severe hospital stay. clear pneumonia imaging. Pt thought likely viral lower respiratory tract infection. treated standing anti-tussives ipratropium nebulizer (avoided albuterol arrythmias). cough persists, consider evaluation primary care doctor. * Acute renal failure: pt episode pre-renal failure early hospital stay thought dehydration. Baseline crt unknown, though low 1.2 peaked 1.5. Discharge crt 1.2. * LE ulcers: stable & appear healing slowly. Pt received 7d course abx possible infection LE ulcer. Pt two ulcers, one left leg & R leg. Left lower leg traumatic ulcer approx 1.5 x 1 cm. wound bed 80% pink, 20% yellow. wound edges irregular. periwound tissue intact resolving cellulitis. Right lower extremity full thickness ulcer present anterior tibialis, approx 7 x 5.5 cm, wound bed 60% yellow, 20% black, 20% pink. moderate amount serosanguinos yellow drainage odor. periwound tissue discolored, dark purple. Pt seen wound care nurse plastic surgery. * DM: type II, low dose glipizide home. treated insulin sliding scale. Sugars well controlled. [Month (only) 116] continue insulin sliding scale rehab; however, pt likely resume home regimen near future. * PPx: Therapeutic INR * Code: Full Medications Admission: lasix 20 daily aldactone 25 daily lipitor 10 daily MV protonix 40 daily coreg 25 [Hospital1 ] detrol 2 [Hospital1 ] coumadin 2.5 daily glipizide 5 daily cranberry caps daily keflex q6h start [9-2] 7 days Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) 7 days: Con't 1 week cough resolves. 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) needed. 5. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times day): [Month (only) 116] stop cough resolves. 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed. 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) needed constipation. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) needed constipation. 11. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO DAILY16 (Once Daily 16). 12. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: Ten (10) ML PO Q4H (every 4 hours) needed cough: pt may refuse; discontinue cough resolves. 13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Insulin Regular Human 100 unit/mL Solution Sig: Per sliding scale Injection ASDIR (AS DIRECTED). 15. Aldactone 25mg daily (restarted [2182-9-18]) Discharge Disposition: Extended Care Facility: [Hospital ] health care center Discharge Diagnosis: Primary: - Monomorphic ventricular tachycardia right bundle branch block - Cardiac arrest pulseless electrical activity (in setting hypoxia) - Bronchitis - Lower extremity ulcers Secondary: Coronary artery disease s/p MI 15years ago s/p angioplasty Atrial fibrillation coumadin Hypertension Hypercholesterolemia UGIB 10y ago Osteoarthritis (primarily affecting knees) Discharge Condition: Good, ambulating assistance, 02 saturation 97% 2L NC. Afebrile, BP 110-120/50-60s, HR 50-80s atrial fibrillation. BM 4 days--got suppository today ([2182-10-18]) Discharge Instructions: admitted ventricular tachycardia. started new medication called amiodarone. need pulmonary function tests eye exam new medication called amiodarone. Additionally, need liver function tests followed time time. Please discuss cardiologist and, primary care doctor. dose warfarin decreased 1.5mg. new medication amiodarone may cause coumadin level increase, blood monitored closely coumadin dose adjusted needed. Please call doctor 911 develop fever, chills, shortness breath, chest pain, lightheadedness, concerning change condition. Followup Instructions: Please call PCP [Name9 (PRE) 61898],[Name9 (PRE) 278] [Name Initial (PRE) ]. [Telephone/Fax (1) 61899] schedule appointment . appointment scheduled Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], cardiologist electrophysiologist, [2182-10-15] 2:40pm [Hospital1 ] office. See address below. [Hospital3 ] Internal Medicine Address: [Street Address(2) ]. # 300 [Hospital1 ], [Numeric Identifier 4474] Phone: ([Telephone/Fax (1) 24747]	[ "412" ]
Admission Date: [2159-3-18] Discharge Date: [2159-3-24] Date Birth: [2159-3-18] Sex: Service: NB HISTORY: Baby [Name (NI) ] [Known lastname ] [Known lastname 6955], delivered 37-0/7 weeks gestation birth weight 3175 grams admitted Newborn Intensive Care Unit labor delivery management respiratory distress. Mother 30 year-old gravida II, para I, II mother estimated date delivery [2159-4-8]. Prenatal screens included blood type positive, antibody screen negative, RPR nonreactive, Rubella immune, hepatitis B surface antigen, group B strep negative. pregnancy uncomplicated. presented labor ruptured membranes. rapid second stage. maternal fever, fetal tachycardia. Membranes ruptured clear fluid around 4 hours prior delivery. delivery spontaneous vaginal delivery loose nuchal cord. infant emerged vigorous good cry. Apgar scores 9 1 minute 9 5 minutes. Around 1/2 hour age developed grunting improved short time reoccurred prompting admission Newborn Intensive Care Nursery. PHYSICAL EXAMINATION: admission weight 3175 grams (75th 90th percentile), length 50 cm (75th 90th percentile). Head circumference 33.5 cm (50th 75th percentile). examination term appropriate gestational age male grunting retracting. Pink free flow oxygen. Anterior fontanelle soft, flat, nondysmorphic. Intact palate. Breath sounds poor aeration, mild retracting. Intermittent grunting. Regular rate rhythm soft murmur, normal pulses perfusion. Abdomen soft, 3 vessel cord. hepatosplenomegaly. Normal male genitalia testes descended bilaterally. Patent anus. hip clicks. sacral dimple. Normal tone activity. SUMMARY HOSPITAL COURSE SYSTEMS: RESPIRATORY: infant initially free flow oxygen admission. Due persistent oxygen requirement grunting placed continuous positive airway pressure, 5 cm requiring around 25% oxygen decrease retracting grunting. Around 24 hours age intubated worsening respiratory distress associated left sided pneumothorax. treated needle thoracentesis. patient received total 2 doses ofsurfactant respiratory distress syndrome extubated around 44 hours age nasal cannula. weaned room air day life 4 remained room air since comfortable work breathing, respiratory rates 30s 50s. CARDIOVASCULAR: hemodynamically stable throughout hospital stay. murmur noted admission resolved day life 3. discharge murmur. heart rate ranges 140s 160s. recent blood pressure 74/51 mean 50. FLUIDS, ELECTROLYTES NUTRITION: initially NPO maintained IV fluid. started feeds extubation day life 2 ad lib feeding Enfamil 20, breast milk breast feeding mother visits. [Name2 (NI) ] well feeds, wetting stooling appropriately. Discharge weight: 3005 Length: 21 inches Head circumference: 33.5 cm GASTROINTESTINAL: Peak bilirubin total 5.5, direct .3. HEME: Hematocrit admission 42.7%. INFECTIOUS DISEASE: CBC blood culture drawn admission due respiratory distress. placed Ampicillin Gentamicin. received 48 hours normal CBC. Blood culture negative. Respiratory distress due surfactant deficiency. infection. NEUROLOGIC: Examination age appropriate. SENSORY: Hearing screening performed automated auditory brain stem responses. Baby passed ears. CONDITION DISCHARGE: Stable term infant, feeding well. DISCHARGE DISPOSITION: Discharged home parents. Name primary pediatrician Dr. [First Name (STitle) 11894] Shaft [Hospital ] Pediatrics. CARE RECOMMENDATIONS: FEEDS: Ad lib feeds breast feeding bottle feeding per mom's desire. MEDICATIONS: None. CAR SEAT POSITION SCREENING: Pending. STATE NEWBORN SCREEN: done [2159-3-21] pending. IMMUNIZATIONS RECEIVED: Hepatitis B immunization [2159-3-23]. Circumcision performed [2159-3-23]. FOLLOW APPOINTMENTS: Follow appointment recommended pediatrician Monday, [2159-3-26]. Mother make appointment. DISCHARGE DIAGNOSES: 1. Term appropriate gestational age male. 2. Respiratory distress syndrome, resolved. 3. Sepsis ruled out. 4. Left pneumothorax, resolved. 5. Physiologic jaundice. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2159-3-23] 18:43:56 T: [2159-3-23] 21:22:10 Job#: [Job Number 65757]	[ "769" ]
Admission Date: [2147-4-7] Discharge Date: [2147-4-11] Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 783] Chief Complaint: Fever, atrial fibrillation RVR Major Surgical Invasive Procedure: None History Present Illness: Mr. [Known lastname 77816] 84 yoM w/ hx AD, Afib, BPH, HTN, Anemia, Disphagia, Gastric ulcers hx DVT/PE, admitted NH setting hypotension diltiazem held five days due hypotension. report, NH stopped Diltiazem [4-2] low BP, noted systolics 60s mmHg today. reported fevers, cough, chest pain, abdominal pain. . arrival ED, BP 100/70 HR 130. Initially afebrile spiked 101R. Received 1 g CTX UTI, tylenol, 1 L NS, total 20mg IV Diltiazem, Hr remained 110-130. MICU patient received 2.5L NS resucitation, received another dose Ceftriaxone placed diltiazem gtt, eventually converted PO diltiazem currently 60mg QID. transferred medicine floor management. . floor VS 97.8F 108/60 72 16 98% RA. Patient unable answer ROS questions reproducibly, denies pain discomfort. Pt seen son, HCP, states baseline terms mental state. Past Medical History: Alzheimer's dementia Depression Restless leg syndrome Atrial fibrillation Lung mass-- right, paratracheal; picked incidentally chest CT [Month (only) 547]; bx deferred ? CHF HTN Syncope BPH Anemia Dysphagia ? Necrotizing Enterocolitis Abd surgeries ulcer disease 25 & 55 years ago Pulmonary embolism - unclear circumstances; happened years ago per son DVTs PVD per son. Social History: Lives [Initials (NamePattern4) ] [Last Name (NamePattern4) 583] Gardens [Location (un) 1411]. Son HCP. Requires [Name2 (NI) 77819] ADLs. ambulate independently risk falls. Family History: Noncontributory Physical Exam: ADMISSION EXAM VS arrival ED: 98.4, 100/70, 78, 24, 98% 2L NC VS arrival MICU: 98.6, 116/88, 116, 22, 99% 2L NC General: elderly male, pale, frail appearing; NAD HEENT: PERRL; dry mucous membranes LUNGS: diminished bilaterally CARDIO: tachycardic, m.r.g. appreciated ABD: midline abd scar EXTREMITIES: 1+ pedal pulses SKIN: skin tear L hand NEURO: sleepy arousable; oriented self (baseline per son); answers questions though non-specifically; intension tremor hands b/l; CN II - XII grossly tact; moving limbs; gait deferred. . EXAM transfer floor; . VS 97.8F 108/60 72 16 98% RA. General: elderly male, frail appearing; NAD HEENT: PERRL; dry mucous membranes, OP lesions LUNGS: nl breath sounds b/l, cracles left base. CARDIO: nl rate, [Last Name (un) 3526]/[Last Name (un) 3526], m.r.g ABD: midline abd scar, slightly distended, soft. EXTREMITIES: Trace pedal pulses, SKIN: skin tear L hand, dressed. edema. Hallux deformity b/l. warm LE. NEURO: Awake alert; oriented self (baseline per son); answers questions goal directed. intention tremor hands b/l, signficant cogwheeling rigidity UE b/l; CN III - XII grossly tact; moving extremities; gait deferred. Foley catheter place. Pertinent Results: Labs admission: . [2147-4-7] 05:30PM BLOOD WBC-15.4# RBC-3.09 Hgb-10.3* Hct-30.7* MCV-99* MCH-33.4* MCHC-33.6 RDW-16.4* Plt Ct-223 Neuts-84.1* Lymphs-11.6* Monos-4.0 Eos-0.1 Baso-0.1 [2147-4-7] 05:30PM BLOOD Glucose-123* UreaN-65* Creat-2.5# Na-143 K-4.4 Cl-110 HCO3-22 AnGap-15 [2147-4-7] 05:30PM BLOOD CK-MB-NotDone cTropnT-0.04* [2147-4-8] 01:05AM BLOOD CK-MB-NotDone cTropnT-0.05* [2147-4-7] 05:30PM BLOOD CK(CPK)-44 [2147-4-8] 01:05AM BLOOD CK(CPK)-50 [2147-4-8] 01:05AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.2 [2147-4-9] 03:45AM BLOOD Calcium-8.0* Phos-2.6* Mg-2.0 [2147-4-8] 01:05AM BLOOD TSH-2.1 [2147-4-7] 06:05PM BLOOD Lactate-2.8* [2147-4-8] 05:07PM BLOOD Lactate-0.8 [2147-4-8] 12:21AM BLOOD freeCa-1.13 IMAGING CHEST (PORTABLE AP) Study Date [2147-4-7] 6:11 PM Portable AP upright chest radiograph obtained. Cardiomegaly noted. known right upper lobe paraspinal mass clearly seen. remainder lungs appears unchanged without evidence overt CHF pneumonia. Patient slightly rotated left. Bones appear somewhat demineralized. Clips project left heart border. defects left posterior rib cage appear unchanged. IMPRESSION: Cardiomegaly without acute findings explain patient's symptoms. . Labs dischrge: . [2147-4-10] 07:35AM BLOOD WBC-9.9 RBC-2.94* Hgb-9.6* Hct-30.0* MCV-102* MCH-32.8* MCHC-32.2 RDW-16.3* Plt Ct-254 [2147-4-10] 07:35AM BLOOD Neuts-83.3* Lymphs-12.7* Monos-2.7 Eos-1.2 Baso-0.1 . [2147-4-10] 07:35AM BLOOD PT-14.6* PTT-28.6 INR(PT)-1.3* [2147-4-10] 07:35AM BLOOD Glucose-112* UreaN-32* Creat-1.4* Na-147* K-3.6 Cl-118* HCO3-19* AnGap-14 . [2147-4-8] 01:05AM BLOOD CK(CPK)-50 [2147-4-7] 05:30PM BLOOD CK(CPK)-44 [2147-4-8] 01:05AM BLOOD CK-MB-NotDone cTropnT-0.05* [2147-4-7] 05:30PM BLOOD CK-MB-NotDone cTropnT-0.04* . [2147-4-10] 07:35AM BLOOD Calcium-8.1* Phos-2.2* Mg-1.9 Iron-PND [2147-4-9] 03:45AM BLOOD TSH-2.2 [2147-4-8] 05:07PM BLOOD Lactate-0.8 . Urine Cx: . URINE CULTURE (Final [2147-4-10]): PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed MCG/ML _________________________________________________________ PROTEUS MIRABILIS \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 CEFAZOLIN------------- 8 CEFEPIME-------------- <=1 CEFTAZIDIME----------- <=1 CEFTRIAXONE----------- <=1 CEFUROXIME------------ <=1 CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 8 MEROPENEM-------------<=0.25 PIPERACILLIN---------- 8 PIPERACILLIN/TAZO----- <=4 TOBRAMYCIN------------ 2 TRIMETHOPRIM/SULFA---- =>16 R . Blood Cx - pending time discharge. . Brief Hospital Course: 85M AF RVR, setting fever urosepsis Afib RVR. # Sepsis: Upon admission, patient febrile leukocytosis, left shift, lactate 2.8. UA positive likely source. CXR obtained negative infiltrate. Additionally, abdomen soft, non-tender, guaiac negative. treated IV resuscitation 4L lactate normalized. Started Ceftriaxone 1g q24H plan add Vancomycin clinical deterioration. require pressors central line placement. BPs improved > 100mmHg systolic, patient transefered medical floor management. noted urine culture positive Proteus sensitive cephalosporins. initially started Cefpodoxime changed cefuroxime mirco-organism sensitive this. Per discussion family, mental status returned baseline HD#3. discharged 200mg [Hospital1 ] cefpodoxime additional 7 days, may switched 250mg [Hospital1 ] Cefuroxime additional 7 days permitted pharmacy supplies. Blood cultures require follow [Hospital1 18], pending time discharge. also require follow CBC LFTs due start cephalosporin. # Atrial Fibrillation RVR: setting sepsis fever, felt compensatory rather primary cardiac, although patient received Diltiazem 5 days due reported hypotension nursing home. Given IV fluids above. Started 30mg TID Diltiazem dosing Diltiazem gtt. Diltiazem uptitrated 60mg QID upon discharge ICU patient remained stable floor stay HR 70-90 range. may uptightrated back 75mg QID HR BP tolerate. . anticoagulation (stopped recent admission epistaxis per discussion PCP). Given CHADs score 3, readressed PCP noted frequent falls NH, thus would good candidate coumadin time. started 81mg ASA daily primary prevention CVA CAD. # Acute Renal Failure Mild Hypernatremia: Initially concern pre-renal pt appeared dry, vs possible ATN setting prolonged hypotension NH. Baseline creat 1.1. FeNa = 1.5 initially suggestive likely intrinsic renal pathology, however Fena 0.3% HD3, thus reliable. Cr improved 1.3 peak 2.5 HD#5. Patient provied IVF resuscitation D5W given hypernatremia 147. medications renally dosed. Na time discharge 141. # Anemia: Hct 30.7 baseline. Guaiac negative admission. Last Fe studies [2146], consistent w/ Fe defficiency anemia, however anemia macrocytic patient B12 supplementation. TSH wnl. require outpatient follow B12, Folate measurements. Patient continued iron. # Troponin leak: Patient troponins 0.07 past noted 0.04-0.05 setting ARF. Likely leak setting rapid rate. Enzymes trended rate control pursued above. # Aspiration risk. Patient noted bibasilar opacifications CXR preliminary read [2147-4-10] concerning possible aspiration. evaluated speech swallow, including video swallow, note overt aspiration, deemed high risk due penetration however recommended PO diet nectar thick liquids soft solids 1:1 supervision, crushed pills pure. CONTACT: [Name (NI) ] [Name (NI) ] [Name (NI) 77816] [Telephone/Fax (1) 77817] (HCP); [Location (un) 583] Gardens [Location (un) 1411] [Doctor Last Name ] [Telephone/Fax (1) 47057]; daughter [Name (NI) 41356] [Telephone/Fax (1) 77818] also HCP CODE: DNR/DNI (confirmed son, paperwork chart) Patient dicharged stable condition, normotensive afebrile. Medications Admission: (per NH list) Iron sulfate 325 mg Omeprazole 20 mg QD Lexapro 15 mg QD Vitamin B12 100 mg QD Folic acid 1 mg QD MVI Ensure TID Ropinerole 0.25mg one [Hospital1 ] Tylenol 1000 mg [Hospital1 ] + PRN Seroquel 200 mg [Hospital1 ] Aricept 10 mg QD Senna Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times day). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Lexapro 5 mg Tablet Sig: Three (3) Tablet PO day. 4. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO DAILY (Daily). 7. Diet Ensure TID 8. Ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice day. 10. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 11. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4 times day) 1 days. 12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times day). 14. Quetiapine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice day needed constipation. 16. Iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO day. 17. Outpatient Lab Work CBC, Chem 10 LFTs [2147-4-14], results forwarded PCP [Name9 (PRE) ],[Name9 (PRE) 77820], [Name9 (PRE) ] MEDICAL ASSOCIATES, INC., Phone: [Telephone/Fax (1) 8506], Fax: [Telephone/Fax (1) 77821] 18. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice day 7 days. Discharge Disposition: Extended Care Facility: Highgate Manor Discharge Diagnosis: Primary: Urosepsis, Atrial fibrillatin rapid ventricular response. Secondary: Alzhemier's disease, Atrial fibrillation, Anemia, Dysphagia Discharge Condition: Stable, normal heart rate normal blood pressure. Discharge Instructions: admitted [Hospital1 18] low blood pressure (hypotension), urinary tract infection (UTI) high heart rate (atrial fibrillation rapid ventricular response). hypotension felt due severe UTI (urosepsis). high heart rate felt due infection well received diltiazem nursing home. infection, treated intravenous fluids antibiotics intensive care unit. improved significantly medicaion switched taken mouth. blood pressure returned [Location 213]. high heart rate, treated fluids cardizem restarted. treatment, heart rate improved significantly. Due atrial fibrillation risk stroke, started low dose aspirin, 81mg daily. dementia, also evaluated speech swallow specialists. possible aspiration, advised diet nectar thick liquids soft solids, medications crushed puree. may take occasional regular soid foods supervision. following changes made medications: - Started Aspirin 81mg daily - Started Cefpodoxime 200mg twice daily 7 days, may switched Cefuroxime 250mg twice daily 7 days preferred rehabiliation staff. - Restarted Diltiazem 60mg four times daily. experience lower blood pressures, confusion, fevers, chills, changes urination, bleeding stool, shortness breath, symptom concerning you, please call primary care doctor go emergency room. Followup Instructions: Please call primary care doctor, [Doctor Last Name ],SREELEKHA [Telephone/Fax (1) 8506], make appointment within week. accomodate appointment whenever convenient you. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799] Completed by:[2147-4-11]	[ "311" ]
Admission Date: [2124-7-17] Discharge Date: [2124-7-26] Date Birth: [2048-6-14] Sex: Service: CHIEF COMPLAINT: Epigastric pain bloating. HISTORY PRESENT ILLNESS: patient 76-year-old gentleman history coronary artery disease (with history inferior wall myocardial infarction [2093]; status post coronary artery bypass graft [2093] redo coronary artery bypass graft [2111]) admitted [2124-7-17] three days persistent epigastric discomfort. point, patient denied chest pain, shortness breath, headaches, visual changes, nausea, vomiting, diarrhea, constipation, fevers, chills, sweats. patient complained increased bloating belching similar anginal pain experienced past. denied chest pain past 12 years. [2124-7-19], patient awoken sleep [10-13] anginal chest pain. Electrocardiogram without evidence ST segment elevations. Initial cardiac enzymes negative admission; however, significant troponin elevation 0.54 0.85. However, creatine phosphokinase 129 trending down. echocardiogram performed, patient found ejection fraction 25%, paced 58 (which elevated) new 4+ mitral regurgitation. patient referred cardiac catheterization. Catheterization Laboratory, angiography revealed 90% stenosis proximal saphenous vein graft right coronary artery 80% stenosis distal ramus. stent placed proximal region saphenous vein graft evidence residual stenosis resultant TIMI-III flow. patient started Integrilin milrinone transferred Coronary Care Unit. PAST MEDICAL HISTORY: 1. Coronary artery disease. (a) patient inferior myocardial infarction [2093]. (b) Status post coronary artery bypass graft left internal mammary artery first diagonal, saphenous vein graft left anterior descending artery, saphenous vein graft right coronary artery. (c) Status post redo coronary artery bypass graft [2111]. (d) patient also catheterization [2122-1-20] showing patent grafts 50% touchdown left internal mammary artery occlusion. Noted pressure gradient across left subclavian artery. 2. Peripheral vascular disease; status post coronary artery bypass graft [2124-6-13] left renal stent placed renal artery stenosis; [2124-6-14] bilateral iliac stents placed. 3. Hypercholesterolemia. 4. Hypertension. 5. Chronic obstructive pulmonary disease. 6. Gastroesophageal reflux disease. 7. Congestive heart failure; echocardiogram [2124-6-19] showed ejection fraction 25%, 4+ mitral regurgitation, 3+ tricuspid regurgitation, akinetic left ventricular wall motion, dilated right ventricle. 8. Bilateral carotid endarterectomies. MEDICATIONS ADMISSION: 1. Aspirin 81 mg mouth per day. 2. Lipitor 10 mg mouth per day. 3. Cardura 4 mg mouth per day. 4. Cardizem 240 mg mouth per day. 5. Toprol 200 mg mouth per day. 6. Diovan 160 mg mouth per day. 7. Lasix 40 mg mouth per day. 8. Potassium chloride 10 mEq mouth per day. 9. Niacin 1000 mg mouth per day. 10. Prilosec 20 mg mouth every day. 11. Fish oil 4000 units mouth every day. ALLERGIES: SOCIAL HISTORY: patient quit smoking approximately 20 years ago. Occasional alcohol use. drug use. FAMILY HISTORY: Mother deceased cerebrovascular accident 50 years age. Father deceased congestive heart failure age 80. PHYSICAL EXAMINATION PRESENTATION: Physical examination admission Coronary Care Unit revealed vital signs temperature 97 degrees Fahrenheit, blood pressure 95/39, heart rate 68, respiratory rate 20, oxygen saturation 100% 2 liters nasal cannula. Pulmonary artery diastolic pressure 10. Generally, patient lying bed calm. acute distress. Head, eyes, ears, nose, throat examination revealed pupils equal, round, reactive light accommodation. Positive bilateral carotid bruits. Elevated jugular venous pulsation. Cardiovascular examination revealed regular rate. Normal first heart sounds second heart sounds. [3-9] holosystolic murmur apex left sternal border. Lung examination revealed decreased breath sounds bilaterally. Crackles noted anterior bases bilaterally. Abdominal examination revealed positive bowel sounds. Soft, nontender, nondistended. Extremity examination revealed pulses 2+. edema. Right femoral line place. ASSESSMENT PLAN: patient 76-year-old male coronary artery disease elevated troponin levels occlusion saphenous vein graft right coronary artery, status post stent placement, evidence residual stenosis. patient started milrinone drip afterload reduction, fluid status monitored. HOSPITAL COURSE ISSUE/SYSTEM: patient continued milrinone drip afterload reduction understanding mitral regurgitation may decrease. 1. ISCHEMIA ISSUES: terms ischemia, patient denied chest pain. electrocardiogram changes noted. patient continued aspirin Plavix. patient noted ectopic beats milrinone drip. Therefore, drip titrated down, patient started captopril 6.25 mg three times per day. patient also received one unit packed red blood cells drop hematocrit 25.8 corrected 31.6. admission Coronary Care Unit, patient's chest x-ray showed pulmonary vasculature congestion. received 100 mg intravenous Lasix diuresis well continued captopril afterload reduction. patient initially high oxygen requirement, requiring nonrebreather face mask; however, patient diuresed afterload reduced, patient's oxygen requirement decreased patient 100% room air. 2. RHYTHM ISSUES: terms rhythm, patient converted atrial fibrillation normal sinus rhythm demonstrated evidence paroxysmal atrial flutter well premature atrial contractions. However, patient's rhythm corrected own. patient currently normal sinus rhythm. However, due current ischemia, dilated left atrium, patient started Coumadin prevent thrombus formation. 3. RENAL ISSUES: terms patient's renal function, creatinine elevated 2.2 admission Coronary Care Unit afterload reduction, increased perfusion kidneys, appropriate diuresis patient's creatinine trended 1.6 currently improving. patient also complained dysuria; however, urinalysis negative leukocyte esterase nitrites. patient started antibiotics given trial Pyridium symptomatic relief. patient started antibiotics unless urine cultures positive. Urine cultures currently pending. repeat echocardiogram showed dilated left atrium diameter 5.7 cm. left ventricular wall showed basal mid inferior akinesis, dilated left ventricular right ventricular (which larger previous examination), 4+ mitral regurgitation, 2+ tricuspid regurgitation, without significant change. Ejection fraction 20% 25%. PLANS PATIENT: 1. CARDIOVASCULAR: (a) Coronary artery disease; status post percutaneous coronary intervention saphenous vein graft right coronary artery. patient continued aspirin, Plavix, Lipitor. (b) Pump: Ejection fraction 25%, 4+ mitral regurgitation, dilated left ventricle right ventricle, dilated left atrium. patient increased risk atrial fibrillation given left atrial size ischemia. patient continued warfarin continued ACE inhibitor afterload reduction. (c) Rhythm: stated before, patient continued Coumadin risk atrial fibrillation atrial flutter sent home [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Hearts monitor discharge. 2. GOUT: patient episode pain consistent gout left big toe relieved colchicine 0.6 mg mouth needed. Currently, patient complaints pain. patient diagnosis gout past successfully treated Indocin; however, time treatment patient's kidney function baseline. Therefore, nonsteroidal antiinflammatory drugs could initiated. patient treated successfully colchicine treatment. 3. RENAL: Urinalysis negative leukocyte esterase nitrites. Dysuria likely secondary inflammation trauma Foley catheter. patient given prescription Pyridium dysuria, symptomatic relief noted. patient's creatinine decreased 2.2 1.6 (currently) trending down. patient started Lasix 40 mg per day may sent home medication patient likely dietary indiscretion outpatient. DISCHARGE DISPOSITION: patient sent home [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Hearts monitor. patient likely require home services. patient followed [Hospital3 ] frequent INR checks. patient follow Dr. [First Name8 (NamePattern2) 487] [Last Name (NamePattern1) ] approximately one month. patient scheduled echocardiogram prior Cardiology follow-up appointment. CURRENT CONDITION DISCHARGE: Condition discharge stable. CURRENT MEDICATIONS DISCHARGE: 1. Atorvastatin 10 mg mouth per day. 2. Coumadin 5 mg mouth per day. 3. Plavix 75 mg mouth every day. 4. Lisinopril 10 mg mouth twice per day. 5. Toprol-XL 100 mg mouth per day. 6. Colchicine 0.6 mg one tablet mouth q.1-2h. needed (for gouty pain). 7. Aspirin 81 mg mouth per day. 8. Prilosec 20 mg mouth every day. 9. Fish oil capsules. 10. Niacin 1000 mg mouth per day. 11. Lasix 40 mg mouth per day. 12. Potassium chloride 10 mEq mouth per day. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3184], M.D. [MD Number(1) 5211] Dictated By:[Dictator Info 21090] MEDQUIST36 D: [2124-7-26] 10:57 T: [2124-8-3] 08:26 JOB#: [Job Number 21091]	[ "496" ]
Admission Date: [2124-1-24] Discharge Date: [2124-3-8] Service: CARDIOTHORACIC Allergies: Percocet Attending:[First Name3 (LF) 165] Chief Complaint: Increasing SOB Major Surgical Invasive Procedure: [2124-1-27] cardiac catheterization [2124-2-3] Redo sternotomy, MVR (#31 [Company ] mosaic tissue valve), TV Repair (#32 CE band) [2-25] Trach/PEG [3-3] Tunneled Left subclavian HD Cath History Present Illness: HPI: 85 yo w/MMP including CAD s/p CABG, CRI, HTN presents SOB. Pt recently hospital [12-28] [1-14] mechanical fall. d/c sent rehab. rehab, pt states feeling well end last week felt "full fluid." described stop 40 feet walking b/c SOB (baseline >80 feet), requiring O2 night time (pt able sleep one pillow), sense increased abd distention, increased lower extremity edema. . EMED, received total 80 mg IV lasix total 1000 cc Uop noon. . denies, PND,denies cough, fever, fatigue, chest pain, dizziness, HA, sick contacts. . note, LLL PNA diagnosed [12-17], finished treatment augmentin 14 days. Past Medical History: 1. CAD s/p MI - CABG [2106] 2 vessel redo [2113]. - [10-16] PMIBI: anginal symptoms.No significant interval change. oderate fixed inferior wall defect moderate apical defect small amount reversibility. Inferior wall hypokinesis. Calculated ejection fraction 56%. 2. Ischemic cardiomyopathy - TTE [10-16] TTE: [Name Prefix (Prefixes) ] [Last Name (Prefixes) 5660] dilated, symm LVH, EF >55%, aortic root mildly dilated, trace AR, 3+ MR, mild PA sys HTN 2. Endocarditis [2114] Strep salivarius 3. 2:1 Wenckebach block s/p v-pacer 4. BPH 5. Pseudocyst L knee 6. s/p hernia repair, x3 surgeries 7. s/p appy 8. HTN 9. CRI (baseline 1.6-1.8) 10. LLE cellulitis 11. Gout 12. Emphysema 13. R colon cancer s/p colectomy 14. Parkinson's disease (followed Dr. [Last Name (STitle) ] 15. PVD w/ claudication symptoms 16. Chronic venous stasis 17. Hypercholesteroemia. Social History: Lives son although inpatient rehab facilities past 2 months. remote 1 year history cigar use, quit. Drinks occasional alcohol, 1 small glass wine per night, go days without drinking etoh. Denies drug use. Works 3hours/week insurance. . Family History: brother-80 YO deceased, MI two sisters CAD Physical Exam: PE: admission VS: Tm: 96.1 Tc 96.1 BP: 118/72 HR: 88 O2sat: 94% 2L Weight [1-24]: 251.1 lbs General: Aox3. NAD. Pulm: bibasilar crackles. Decreased breath sounds L>>R. CV: holosystolic murmur best heard apex. nl S1/S2. JVP jaw line ~ 11 cm. GI: distended. Nl BS+. tenderness. Ext: 3 + pitting edema. Redness lower extremities, consistent venous stasis. Skin: redness sacral region scrotum. Pt getting daily washing saline nystatin powder scrotum, xeroderm sacrum. PE prior leaving medicine floor: General: Aox3. NAD. Pulm: Bibasilar crackles. CTAB anteriorly CV: holosystolic murmur best heard apex. nl S1/S2. GI: soft non-tender. GU: 3+ scrotal edema. Foley place ([1-27]). Ext: 2 + pitting edema. Redness lower extremities, consistent venous stasis. Skin: redness sacral region scrotum. Pt getting daily washing saline nystatin powder scrotum, xeroderm sacrum. R femoral dressing intact, hematoma, drainage, pus, erythema (cath done [1-27]). Pertinent Results: [2124-3-8] 01:30AM BLOOD WBC-10.5 RBC-2.96* Hgb-8.8* Hct-27.7* MCV-94 MCH-29.8 MCHC-31.8 RDW-16.7* Plt Ct-237 [2124-3-7] 02:52AM BLOOD WBC-11.4* RBC-2.96* Hgb-8.9* Hct-27.8* MCV-94 MCH-30.1 MCHC-32.1 RDW-16.9* Plt Ct-267 [2124-3-8] 01:30AM BLOOD Plt Ct-237 [2124-3-8] 01:30AM BLOOD PT-14.3* PTT-30.7 INR(PT)-1.3* [2124-3-8] 01:30AM BLOOD UreaN-35* Creat-3.0# Na-143 K-3.6 Cl-105 HCO3-30 AnGap-12 [2124-3-7] 02:52AM BLOOD Glucose-115 UreaN-64* Creat-4.6* Na-138 K-4.7 Cl-103 HCO3-25 AnGap-15 [2124-3-1] 04:15AM BLOOD ALT-9 AST-18 LD(LDH)-210 AlkPhos-195* Amylase-104* TotBili-0.5 Portable chest [2-28] Tracheostomy tube remains standard position. Permanent pacemaker unchanged position, proximal coiling one leads right supraclavicular area. Heart enlarged stable size. Pulmonary vascular engorgement perihilar haziness unchanged. Multifocal areas atelectasis show slight improvement, particularly right lower lobe. Left retrocardiac opacity adjacent left pleural effusion unchanged. Small right pleural effusion also stable. [2-28] CT Head w/o contrast IMPRESSION: 1. hemorrhage mass effect. 2. Chronic microvascular ischemia. 3. Paranasal sinus mucosal disease. 4. Unchanged expansion diploic space left parietal bone may secondary Paget's disease. [3-2] EEG IMPRESSION: abnormal EEG due independent, times synchronous, frontocentral slowing broad-based phase reversals, well slow disorganized background bursts generalized slowing. suggests bilateral frontocentral subcortical dysfunction, well similar regions cortical irritability. slow disorganized background bursts generalized slowing suggest encephalopathy, may seen infections, toxic metabolic abnormalities, ischemia medication effect. Brief Hospital Course: Mr. [Known lastname ] admitted CHF exacerbation. diuresed began feeling better. CT surgery consulted MR TR. Cardiac cath [1-27] showed severe 3VD patent LIMA-LAD, severe disease SVG->OM occluded SVG->RCA. placed cipro UTI. Dental medicine cleared surgery. awaited improving creatinine going operating room [2124-2-3] underwent redo, redo-sternotomy, MVR #31 [Company ] mosaic tissue valve & TV Repair 32 mm CE band. transferred CSRU critical stable condition epinephrine, levophed, vasopressin, propofol. epi weaned started natrecor diuresis. extubated POD #2. remaining vasoactive drips weaned POD #3 diuresed lasix. continued followed cardiology. seen speech swallow recommended pureed solids thin liquids PO meds. transferred floor POD #5. cdiff positive [2-9] started flagyl. readmitted CSRU [2-9] respiratory distress decreased urine output. treated nebulizers little result required reintubation. seen mephrology later day anuria rising creatinine. started vasopressin neosynphrine hypotension. neo vasopressin weaned [2-11]. creaintine urine output continued improve. extubated [2-12]. [2-14], recurrent ATN, required reintubation suspected aspiration pressors again. also afib. started CVVH. seen ID started cefepime vanco. [2-21] extubated CVVH dc'd. dobhoff tube wsa placed started tube feeds. PICC line placed [2-22]. Antibiotics (vanco/cefepime) presumed hospital acquired pneumonia dc'd [2-23]. completed course flagyl. Urine output continued wax wane seen renal, repiratory status [Last Name (un) ] began deteriorate. seen thoracic surgery consideration trach PEG placed n [2-25]. seen neurology [2-27] stiffness ws thought metabolic. Head CT negative. restarted dialysis [3-1] HD cath placed [3-3]. last dialyzed [3-7] need HD [3-9]. Medications Admission: 1. Aspirin 81 mg Tablet2. 2. Allopurinol 100 mg 3. Simvastatin 40 mg Tablet QD 4. Ferrous Sulfate 325 (65) mg QD 5. Lisinopril 10 mg Tablet QD 6. Furosemide 80 mg Tablet [Hospital1 ] 7. Atenolol 25 mg Tablet QD Discharge Medications: 1. Acetaminophen 325 mg Tablet [Hospital1 ]: Two (2) Tablet PO Q4H (every 4 hours) needed. Tablet(s) 2. Bisacodyl 10 mg Suppository [Hospital1 ]: One (1) Suppository Rectal DAILY (Daily) needed constipation. 3. Simvastatin 40 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 4. Fluticasone 110 mcg/Actuation Aerosol [Hospital1 ]: Two (2) Puff Inhalation [Hospital1 ] (2 times day). 5. Aspirin 81 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO DAILY (Daily). 6. Ipratropium Bromide 0.02 % Solution [Hospital1 ]: One (1) Inhalation Q4H (every 4 hours). 7. Heparin (Porcine) 5,000 unit/mL Solution [Hospital1 ]: One (1) Injection TID (3 times day). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 9. Amiodarone 200 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 10. Nystatin 100,000 unit/g Cream [Last Name (STitle) ]: One (1) Appl Topical [Hospital1 ] (2 times day): periarea. 11. Albuterol Sulfate 0.083 % Solution [Hospital1 ]: One (1) Inhalation Q4H (every 4 hours). 12. B Complex-Vitamin C-Folic Acid 1 mg Capsule [Hospital1 ]: One (1) Cap PO DAILY (Daily). 13. Erythromycin 5 mg/g Ointment [Hospital1 ]: One (1) Ophthalmic QID (4 times day). 14. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift Discharge Disposition: Extended Care Facility: [Hospital ] Medical Center - [Hospital1 3597] Discharge Diagnosis: MR, TR, CAD Gout CRI (2.1) SBE 2:1 heart block s/p PPM BPH HTN LE cellulitis lipids emphysema colon ca parkinsons PVD claudication venoud stasis s/p CABG [2106], [2113] hernia repair colectomy Discharge Condition: stable Discharge Instructions: Call fever, redness drainage incisions weight gain 2 pounds one day five one week. baths, lotions, creams powders incisions. lifting 10 pounds. Followup Instructions: Please make appointments: Dr. [First Name (STitle) ] 4 weeks Dr. [Last Name (STitle) 1147] 2 weeks Already scheduled appointments: Provider: [Name10 (NameIs) 9894] [Name11 (NameIs) ] 4 PAIN MANAGEMENT CENTER Date/Time:[2124-5-5] 10:30 [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2124-3-8]	[ "486" ]
Admission Date: [2192-4-9] Discharge Date: [2192-4-16] Service: [Location (un) 259] FIRM HISTORY PRESENT ILLNESS: 77-year-old man history chronic obstructive pulmonary disease complaints increasing cough, dyspnea decreased intakes starting approximately three days prior admission. Per wife, temperature 100?????? morning shaking chills, cough productive copious yellow sputum. baseline, cough productive white sputum. homebound significant decline respiratory status past three months. becomes quite dyspneic even minimal ambulation. uses 2 liters oxygen home, 60 pack year history smoking quit [2187]. reports severity chronic obstructive pulmonary disease waxes wanes feel worse day admission chronic obstructive pulmonary disease exacerbations. reports history multiple chronic obstructive pulmonary disease examinations hospitals, never intubated before. Emergency Room, given 125 mg intravenous Solu-Medrol levofloxacin. Emergency Department, electrocardiogram initially showed sinus tachycardia, appeared atrial fibrillation 170s. given Diltiazem bolus started Diltiazem drip. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease, occasionally po steroids 2. PFTs revealing FEV1 FVC ratio 80%, FEV1 52% predicted asbestosis 3. Hypercholesterolemia 4. Head neck cancer status post surgery XRT [2178] 5. Anxiety 6. Pneumovax '[86] 7. Flu vaccine 8. Rheumatic fever child. known cardiac echocardiogram prior admission. HOME MEDICATIONS: 1. Serevent 2 puffs [Hospital1 ] 2. Azmacort 2 puffs qd 3. Albuterol Atrovent nebulizers 4. Librium 10 mg [Hospital1 ] prn anxiety 5. Tylenol #3 prn neck rib pain ALLERGIES: ERYTHROMYCIN SOCIAL HISTORY: Lives wife [Location (un) 538], 60 pack year history smoking, quit '[87], former merchant marine, question asbestosis exposure history toxic DM exposure, working antique furniture finisher. PHYSICAL EXAM: GENERAL: cachectic elderly man breathing pursed lips admission. VITAL SIGNS: Pulse 175, blood pressure 116/74, respiratory rate 40, 98% saturation nonrebreather. HEAD, EARS, EYES, NOSE THROAT: Pupils equal, round reactive light. Edentulous. Oropharynx dry. CHEST: Breathing accessory muscles. Breath sounds distant, scattered crackles posteriorly. HEART: Tachycardic heart sounds distant, unable assess sinus not. Unable assess murmurs. ABDOMEN: Thin, soft, nontender, nondistended, active bowel sounds. Stool guaiac negative. EXTREMITIES: Thin, edema. ADMISSION LABS IMAGING: Notable white count 13.1 77% segs, hematocrit 41.5. Chemistries unremarkable. C 79, troponin less 0.3. Urinalysis negative. Arterial blood gases 7.38, 46, 76 2 liters oxygen repeat 7.38, 47, 50 1.5 liters oxygen. Chest x-ray showed emphysema, pleural plaques, diffuse perihilar right apical opacities consistent acute pneumonia. HOSPITAL COURSE: patient admitted taken Medical Intensive Care Unit. Medical Intensive Care Unit, intubated. received antibiotics, levofloxacin pneumonia. received steroids tapered, chest physical therapy nebulizers improvement. heart rate controlled Lopressor Diltiazem able switched po cardiology felt treated pulmonary process aggressive treatment atrial fibrillation started. patient family decided comfort measures transferred floor. floor, remained stable occasional runs tachycardia, seemed related albuterol nebulizers. able tolerate nasal cannula oxygen [2192-4-16], rate gotten 172 decreased 120s receiving 50 mg intravenous Diltiazem. Repeat electrocardiogram showed atrial flutter continued po Lopressor Diltiazem. Lopressor dose increased 75 mg po bid. Palliative care consult called suggested switching sublingual morphine sulfate elixir, well adding Ativan prn Colace Senokot. DISCHARGE PLAN: patient stable transfer [Hospital3 2558] care. DISCHARGE MEDICATIONS: 1. Protonix 40 mg po qd 2. Levofloxacin 500 mg po qd, today day 7 10. stopped [4-19]. 3. Salmeterol 2 puffs [Hospital1 ] 4. Librium 20 mg po bid 5. Metoprolol 75 mg po bid 6. Diltiazem 90 mg po qid 7. Atrovent metered dose inhaler nebulizers q4h 8. Prednisone 20 mg po qd [4-17] 8th, 10 mg po qd [4-19] 10th discontinue prednisone. 9. Colace 100 mg po bid 10. Senna 2 tablets po q hs 11. Azmacort 2 puffs qid 12. Ativan 1 mg sublingual po q6h prn 13. Morphine sulfate elixir 20 mg per cc given 5 mg sublingual q4h 14. Morphine sulfate elixir 20 mg per cc given 5 10 mg sublingual q2h prn DIET: tolerated, supplement Boost. FINAL DIAGNOSES: 1. Chronic obstructive pulmonary disease 2. Asbestosis 3. Pneumonia 4. Hypercholesterolemia 5. Anxiety FOLLOW UP: Patient follow Dr. [Last Name (STitle) ]. Planned patient transfer 4 p.m. [First Name11 (Name Pattern1) 2671] [Last Name (NamePattern4) 2672], M.D. [MD Number(1) 2673] Dictated By:[Name8 (MD) 6069] MEDQUIST36 D: [2192-4-16] 13:05 T: [2192-4-16] 13:14 JOB#: [Job Number 10330] cc:[Hospital3 10331]	[ "486" ]
Admission Date: [2136-8-19] Discharge Date: [2136-8-23] Date Birth: [2101-10-31] Sex: F Service: MEDICINE Allergies: Ambien Attending:[Last Name (NamePattern1) 13159] Chief Complaint: DKA Major Surgical Invasive Procedure: None History Present Illness: History Present Illness: 34F history insulin-dependent diabetes, cardiomyopathy, hypomagnesemia blindness secondary mitrochondrial myopathy presents tachycardia full body pain. Patient states taking insulin 2 weeks visiting friend. refuses explain further, saying "didn't feel like taking it," despite admitted DKA past. chronic issues hypomagesemia results muscle pains, reports taht severe muscle pains thought likely low magnesium, came ER. also tachycardia past days, especially ambulation, began feel progressively weak tired, another cause seek care. complains pain entire body arms. Denies fevers, chills, chest pain, palpitations, abdominal pain, nausea, vomiting. urinating frequently. ED, initial VS were: 173 169/105 04:40 162 153/103 28 100% 05:14 130 135/77 32 100% 05:20 8 109 129/75 28 100% 06:21 108 124/75 18 99% 06:57 98.3 07:37 131 121/72 25 99% 08:30 7 108 122/72 18 98% 09:45 3 98.4 83 120/71 13 98% Rec'd 3050 (incl IL NS w 40 kcl) last K 2.8 D5NS 125/ hr; Insulin drip Drips: Insulin drip 100units/100cc 7 units per hour Rec'd Dilaudid 0.5mg IV x 3 last dose 0930 w good effect Initial Glu 400s- rec'd 16 Units Humalog. Fsbs prior drip 78. Given 1 amp Dextrose voided several times large amounts #18 Rac/ # 20 R ac outer aspect arrival MICU, patient says feels nauseous. says muscle pain arms, legs rib pain, describes bone pain. cannot pin whether abdominal pain alone. vomiting, says began feel nauseous began drink soda [Doctor Last Name ] ER. Past Medical History: Diabetes mellitus, type Hypertension Hypomagnesemia blindness Gait disorder Mitochondrial myopathy Insomnia Obstructive sleep apnea- CPAP Social History: Lives alone, enjoys [Location (un) 1131] books listening TV shows, sister apartment building (also blind mitochondrial disorder). Sister's husband recently passed away. independent ADLs, require walking assistance despite myopathy/vision deficit. Uses walking stick. Tobacco- denies Alcohol- denies Illicits- denies Family History: Father- unknown [Name (NI) 12237] [Name (NI) 2320] [Name (NI) 12408] mitochondrial myopathy [Name (NI) 61697] colon cancer Grandmother- breast cancer Father- unknown [Name (NI) 12237] [Name (NI) 2320] [Name (NI) 12408] mitochondrial myopathy [Name (NI) 61697] colon cancer Grandmother- breast cancer Physical Exam: ADMISSION [2136-8-19] Vitals: T: 98.2 BP: 129/68 P: 106 R: 18 O2: 100% RA General: Alert, oriented, acute distress HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear, edentulous. Eyes dilated pupils, focusing, often eyes closed. Neck: supple, JVP elevated, LAD CV: Regular rate rhythm, normal S1 + S2, murmurs, rubs, gallops Lungs: Clear auscultation bilaterally, wheezes, rales, ronchi Abdomen: soft, mild diffuse tenderness, obese, bowel sounds present 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 [2136-8-22] PHYSICAL EXAM: VS - Temp 97.9F, BP 104/67, HR 66, RR 18, O2-sat 99% RA FSBG 105 General: Alert, awake, oriented, acute distress, flat affect, laying bed, pleasant, cooperative, breakfast HEENT: Sclera anicteric, moist mucous membranes, oropharynx clear, edentulous. Eyes dilated pupils, focusing, often eyes closed, mild horizonatal nystagmus noted, Neck supple, JVP elevated, LAD CV: Regular rate rhythm, normal S1 + S2, murmurs, rubs, gallops Lungs: Clear auscultation bilaterally, wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, obese, bowel sounds present Ext: warm, well perfused, 2+ pulses, clubbing, cyanosis edema Neuro: CNIII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation light touch proprioception bilaterally, sensation light touch right heel Pertinent Results: ADMISSION LABS: [2136-8-19] 04:40AM WBC-5.1 RBC-5.47* HGB-15.9 HCT-46.1 MCV-84 MCH-29.1 MCHC-34.6 RDW-15.5 [2136-8-19] 04:40AM GLUCOSE-406* UREA N-11 CREAT-1.1 SODIUM-137 POTASSIUM-3.0* CHLORIDE-101 TOTAL CO2-13* ANION GAP-26* [2136-8-19] 07:03AM TYPE-[Last Name (un) ] PO2-150* PCO2-24* PH-7.26* TOTAL CO2-11* BASE XS--14 [2136-8-19] 01:13PM LACTATE-2.8* [2136-8-19] 12:06PM BLOOD Osmolal-292 [2136-8-19] 05:52PM BLOOD Glucose-125* UreaN-5* Creat-0.7 Na-138 K-3.5 Cl-110* HCO3-18* AnGap-14 [2136-8-19] 07:45PM BLOOD Glucose-84 UreaN-5* Creat-0.7 Na-138 K-3.7 Cl-109* HCO3-20* AnGap-13 MICROBIOLOGY URINE CULTURE (Final [2136-8-20]):MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT SKINAND/OR GENITAL CONTAMINATION BLOOD CULTURES [2136-8-19]: PENDING MRSA SCREEN (Final [2136-8-21]): MRSA isolated. IMAGING [2136-8-19]: PORTABLE AP CHEST RADIOGRAPH: lungs clear. confluent opacity identified. pulmonary edema pleural effusions. Cardiomediastinal hilar contours within normal limits. IMPRESSION: acute cardiopulmonary process EKG [2136-8-19]: Sinus tachycardia 160 beats per minute. Low voltage limb leads much baseline artifact. appears leftward axis. R wave progression abnormal consistent prior anterolateral myocardial infarction lead placement. Clinical correlation suggested. Compared previous tracing [2136-7-28] sinus tachycardia new abnormal R wave progression persists. DISCHARGE LABS: [2136-8-23] 09:05AM BLOOD WBC-2.8* RBC-4.71 Hgb-13.8 Hct-39.3 MCV-83 MCH-29.2 MCHC-35.1* RDW-16.2* Plt Ct-196 [2136-8-23] 09:05AM BLOOD PT-11.6 PTT-29.7 INR(PT)-1.1 [2136-8-23] 09:05AM BLOOD Plt Ct-196 [2136-8-23] 09:05AM BLOOD Glucose-102* UreaN-7 Creat-0.9 Na-139 K-3.3 Cl-105 HCO3-21* AnGap-16 [2136-8-23] 09:05AM BLOOD Calcium-9.1 Phos-4.6* Mg-1.2* Brief Hospital Course: 34 year old female significant PMH insulin-dependent diabetes, cardiomyopathy, hypomagnesemia blindness secondary mitochondrial myopathy presenting hypomagnesemia DKA likely secondary noncompliance. # DKA: Patient started insulin drip ED anion gap blood sugar resolved arrival MICU. Patient tolerated PO diet transitioned subq insulin. localizing symptoms concerning infectious ischemic causes DKA. Given patient's history poor control, DKA likely secondary non-compliance. Electrolytes monitored every 2 hours repleted. [Last Name (un) ] consulted saw patient MICU. Psychiatry consulted medication non-compliance likely [12-29] severe depression. # respiratory acidosis: likely secondary hyperventilation setting anxiety. Patient's CO2 resolved subsequent ABGs. # Whole Body Pain: patient reported baseline mitrochondrial myopathy pain except worsened, may related dehydration concomitant illness. localizing sx exam pain diffuse. given minimal doses PO dilaudid kept home doses NSAIDS tylenol. home carisprodol 350 mg continued. pain improved correction magnesium. # Depression/anxiety: Patient reporting intention self-harm taking insulin. maintained home dose fluoxetine lorazepam. refusing oral medication food intake [12-29] depression. Psychiatry consulted recomended inpatient psychiatric admission. agreeable discharge. # Lactic Acidosis: likely type acidosis related hypovolemia. 3.7 admission MICU normalized repeat labs fluid hydration. # Hypomagnesemia: Patient aggressive home repletion magnesium gluconate 27mg (500mg) 4 tablets [Hospital1 ] home. closely monitored repleted admission. carry formulary treated Magnesium oxide 400mg daily home equivalent. continued muscle pains improved IV Mg. # Type Diabetes: HgA1c 8.1 PCP's office [7-10], previously 6.4 [2136-3-1]. Pt reports HgA1C ranges [4-1]. Patient's home regimen insulin [Date Range ] 37u qHS Humalog sliding scale. [Last Name (un) ] consulted gap closed maintained [Last Name (un) ] 20 units humalog 5 units meal correction 1 unit every 50 150 sugars 120s-150s. # OSA/insomnia: patient continued CPAP @ 9 PEEP. # Code: Full (confirmed) TRANSITIONAL ISSUES: [ ] Please attempt keep patient home magnesium gluconate 27mg (500mg) 4 tablets [Hospital1 ]. formulary consider giving 400mg Magnesium oxide [Hospital1 ]. [ ] Trend magnesium levels [ ] Insulin sliding scale [First Name8 (NamePattern2) ] [Last Name (un) ] recommendations: [Last Name (un) ] 20 units humalog 5 units meal correction 1 unit every 50 150. [ ] Encourage CPAP 9 PEEP Medications Admission: Preadmission medications listed correct complete. Information obtained PatientwebOMR. 1. Atenolol 50 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Fluoxetine 60 mg PO DAILY 4. Glargine 37 Units Bedtime Insulin SC Sliding Scale using novolog Insulin 5. Lorazepam 1 mg PO BID:PRN anxiety 6. Pregabalin 200 mg PO TID 7. traZODONE 25 mg PO HS:PRN insomnia 8. magnesium gluconate NF [2123] mg Oral [Hospital1 ] 9. carisoprodol NF 350 mg Oral QHS 10. Lovaza NF (omega-3 acid ethyl esters) 1 gram Oral [Hospital1 ] 11. Acetaminophen 650 mg PO Q6H:PRN pain exceed 3000 mg 24 hours 12. Ibuprofen 400 mg PO Q8H:PRN pain exceed 1200 mg 24 hours 13. Amiloride HCl 5 mg PO DAILY hold SBP < 90 Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain exceed 3000 mg 24 hours 2. Amiloride HCl 5 mg PO DAILY hold SBP < 90 3. Aspirin 81 mg PO DAILY 4. Atenolol 50 mg PO DAILY 5. carisoprodol NF 350 mg Oral QHS 6. Fluoxetine 60 mg PO DAILY 7. Ibuprofen 400 mg PO Q8H:PRN pain exceed 1200 mg 24 hours 8. Glargine 20 Units Bedtime Insulin SC Sliding Scale using novolog Insulin 9. Lorazepam 1 mg PO BID:PRN anxiety 10. Pregabalin 200 mg PO TID 11. magnesium gluconate NF [2123] mg Oral [Hospital1 ] 12. Lovaza NF (omega-3 acid ethyl esters) 1 gram Oral [Hospital1 ] 13. Senna 1 TAB PO BID:PRN Constipation 14. Docusate Sodium 100 mg PO BID 15. traZODONE 25 mg PO HS:PRN insomnia Discharge Disposition: Extended Care Facility: [Hospital1 ] 4 Discharge Diagnosis: Diabetic ketoacidosis Severe Depression Hypomagnesemia Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent visually impaired requiring guidance. Discharge Instructions: Dear Ms. [Known lastname 29571]: pleasure taking care [Hospital1 18]. come ED severe muscle pain increased heart rate. ED sugar found high diagnosed diabetic ketoacidosis. transfered MICU given large amount IV fluids electrolytes repleted. diabetic ketoacidosis improved. also seen psychiatry felt depressed reason stopped taking medications. apetite, sugars, pain improved throughout stay. magnesium low stay gave oral IV medications make better. pain also improved administration magnesium. made following changes medications. Please CONTINUE taking home medications prescribed. Please START humalog [Hospital1 ] directed. Please START taking docusate sodium 100mg twice daily Senna twice daily constipation. Please follow-up appointments outlined below. Thank you, Followup Instructions: Department: [Hospital3 249] When: TUESDAY [2136-9-11] 8:40 With: [First Name8 (NamePattern2) 2878] [First Name8 (NamePattern2) 26] [Last Name (NamePattern1) 2879], MD [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: MEDICAL SPECIALTIES When: [Hospital Ward Name ] [2136-9-28] 7:40 With: DR. [First Name (STitle) ]/DR. [First Name (STitle) ] [Telephone/Fax (1) 612] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: ORTHOPEDICS When: MONDAY [2136-9-10] 8:30 With: [Name6 (MD) 13978] [Name8 (MD) ], MD [Telephone/Fax (1) 1228] Building: [Hospital6 29] [Location (un) 551] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "311" ]
Admission Date: [2159-1-25] Discharge Date: [2159-2-8] Date Birth: [2114-8-15] Sex: Service: MICU HISTORY PRESENT ILLNESS: Patient 44-year-old gentleman history hypertension, diabetes, aortic root replacement x2 secondary abscess aortic valve presenting Emergency Department [1-25] upper gastrointestinal bleed. patient vomited blood, complaints low grade temperatures, admitted MICU. patient admitted prior [2158-9-24] [2159-1-23] workup aortic root abscess; subsequently discharged rehabilitation represented Emergency Department [1-25] upper gastrointestinal bleed. PAST MEDICAL HISTORY: 1. Hypertension. 2. Diabetes. 3. Seizure disorder. 4. Neuropathy. 5. Bilateral pleural effusion. 6. Disseminated fungemia. 7. Renal tubular acidosis x1. PAST SURGICAL HISTORY: 1. Status post coronary artery bypass graft. 2. PEG placement. 3. Right hemicolectomy. 4. Left thoracotomy. 5. Aortic valve surgery x2. ALLERGIES: patient known drug allergies. Upon presentation, patient's vital signs 99.5, blood pressure 100/53, heart rate 75, respiratory rate 20. SIMV mechanical ventilation pressure support. PHYSICAL EXAMINATION UPON ADMISSION: general, young man apparent distress, intubated. Pupils midline, equally reactive. Oropharynx moist. Neck supple, bruits. Lungs: Crackles diffusely, decreased breath sounds bilaterally. Heart: Regular, rate, rhythm. Abdomen soft, nontender, nondistended. Surgical incision midline stables clean, dry, intact. Extremities: 3+ pitting edema, significant scrotal edema. Foley intact. left subclavian intact. INITIAL LABORATORIES: White blood cell count 17.2, hematocrit 27, platelets 183. Chem-7: 144 sodium, potassium 3.7, chloride 114, bicarb 21, BUN 44, creatinine 1, sugar 154, lactate 1.8, INR 1.3, PTT 35.9. multiple blood cultures. [1-30], left subclavian central line culture showed growth. MRSA screen [2159-1-29] negative. Stool cultures negative [1-27]. Sputum culture [1-25] negative. Blood culture [1-15] negative. Urine culture [1-25] negative. ultrasound upper extremity showed deep venous thrombosis [2159-1-30]. hospital course terms issues: Gastrointestinal: upper gastrointestinal bleeding evaluated Gastroenterology Service. initially scope patient given hematocrit stabilized. last couple days prior discharge, scoped twice, times determined gastritis esophagitis lower [12-1] without focal hemorrhage. recommended supportive care. terms presentation, CT scan belly performed showed free air well bowel wall thickening around cecum. Surgery service consulted, elected right hemicolectomy secondary diverticular disease. postoperative CT scan several days later showed anastomotic leak. GI course unremarkable examination remained nontender, nondistended. terms pulmonary issue, patient getting Zosyn gentamicin presumptive pneumonia. blood cultures showed sparse growth Pseudomonas last month, treated 11 day course. terms mechanical ventilation, IMV pressure support, weaned pressure support PEEP, pressure support 20 PEEP 10. Chest x-rays already showed failure, i.e., pulmonary edema. However, saturations always remained stable. Cardiovascularly, always remained hemodynamically stable hypertension, Lopressor continued. Infectious Disease: never spiked fever, though white blood cell count elevated high 30s low 30s. Fever never spiked. Renal wise, given fluid status examination, anasarca, diffuse edema pitting upper lower extremities. Given diuresed 40 mg IV Lasix tid, put -1 2 liters negative last several days admission, continue diurese outpatient recommended. Heme wise, hematocrit stable, recently. Though hematocrit drop low 20s. transfused several units, stable q6 q12h hematocrit checks. Diabetes: stable. regular insulin-sliding scale. Seizure disorder: apparent seizures far. Neurologically, documented suffered anoxic brain event, brain damage, although continues oriented, occasionally appears able follow commands. track eyes, follow commands. Fluids, electrolytes, nutrition: tube feeds Peptamen 90 cc/hour, full code. DISPOSITION: Back nursing home. DISCHARGE DIAGNOSES: 1. Status post right hemicolectomy. 2. Status post upper gastrointestinal bleed. 3. Diabetes. 4. Hypertension. 5. Anoxic brain damage. 6. Status post aortic valve replacement x2. 7. Neuropathy. 8. History renal tubular acidosis. DISCHARGE MEDICATIONS: 1. Protonix 40 mg po bid. 2. Epogen 4,000 units subQ two times week Tuesday Friday. 3. Morphine sulfate 2-10 mg IV q2-4h prn pain. 4. Keppra 500 mg po bid. 5. Atrovent 1-2 puffs nebulizer q4h prn wheezing. 6. Bacitracin polymixin ophthalmic ointment apply eye q6h. 7. Tylenol 650 mg po q4-6h. 8. Metoprolol 25 mg po bid. 9. Tube feeds: Peptamen 90 cc/hour. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 968] Dictated By:[Last Name (NamePattern1) 19796] MEDQUIST36 D: [2159-2-7] 13:16 T: [2159-2-8] 08:02 JOB#: [Job Number 21700]	[ "486" ]
Admission Date: [2115-9-11] Discharge Date: [2115-9-21] Date Birth: [2037-10-7] Sex: F Service: MEDICINE [Company 191] HISTORY PRESENT ILLNESS: Ms. [Known lastname 96864] 77-year-old female history diabetes, hypertension, gastroesophageal reflux disease, peripheral neuropathy recently admitted [Hospital3 4527] found massive ascites abdominal carcinomatosis abdominal [Hospital ] transferred [Hospital1 18] gynecologic/oncology evaluation possible surgical staging debulking subsequently transferred Medicine Service right deep venous thrombosis management due allergy heparin. outside hospital, mentioned before, massive ascites abdominal carcinomatosis diffuse omental studding CA125 1,200. transfer Medicine Service, denying complaints including shortness breath, chest pain, fever, chills, nausea, vomiting, saying left leg less full several days prior. reports allergy heparin, although sure specifics allergy, told past given heparin. talking family, state denied seeing doctor many months complaining abdominal swelling right-sided abdominal pain months. also say points region liver source pain. [Hospital3 4527], vomited blood three transfusions admitted maintenance hematocrit. family also adamant full code, reported TAH/BSO done many years ago [Country 10363] specifics sure of. PAST MEDICAL HISTORY: 1. Diabetes. 2. Hypertension. 3. COPD. 4. Gastroesophageal reflux disease. 5. Depression. 6. Osteomyelitis. 7. Peripheral neuropathy. 8. Questionable history CVA past right-sided weakness. 9. Pneumonia two months ago. 10. History anemia Guaiac positive stools [Hospital3 4527] EGD colonoscopy negative. received three blood transfusions time. 11. TAH/BSO done [Country 10363] many years ago unclear specifics. SOCIAL HISTORY: Ms. [Known lastname 96864] lives [Hospital 1036] Nursing Home [Location (un) 620]. denied tobacco, alcohol, drug use. Per family, code status full. FAMILY HISTORY: one daughter breast cancer diagnosed age 45. denied family history ovarian cervical cancer. ALLERGIES: allergy aspirin causes rash hives. also allergy heparin unknown effects. ADMISSION MEDICATIONS: 1. Megace. 2. Nitroglycerin patch 0.1 grams q. 12 hours. 3. Zoloft 50 mg q.d. 4. Lasix 40 mg q.d. 5. Vitamin E. 6. Actos 30 mg q.d. 7. Glyburide 5 mg b.i.d. 8. Captopril 50 mg t.i.d. 9. Iron sulfate 325 mg t.i.d. 10. Ultram 50 mg t.i.d. 11. Atenolol 12.5 mg b.i.d. 12. Protonix 40 mg b.i.d. 13. Klonopin 0.5 mg t.i.d. 14. Zyprexa 2.5 mg q.h.s. 15. Lipitor 40 mg q.h.s. 16. Neurontin 300 mg q.h.s. 17. Trazodone 100 mg q.h.s. 18. Regular sliding scale insulin. PHYSICAL EXAMINATION ADMISSION: Vital signs: Temperature 98.6, blood pressure 142-176/60s-80s, pulse 80, respirations 20, oxygen saturation 98% room air. General: patient pleasant elderly female, appearing stated age, lying bed. HEENT: pupils equally round reactive light extraocular muscles intact. evidence scleral icterus. Heart: II/VI systolic ejection murmur heard throughout precordium radiation carotids. Pulmonary: decreased breath sounds left, audible wheezes rhonchi. Abdomen: Distended, tense. decreased bowel sounds. increased venous distribution periumbilical region. rebound guarding. Abdomen: Nontender palpation. Extremities: right lower extremity noted swollen left. palpable cords. 2+ dorsalis pedis pulses bilaterally, erythema evidence venostasis changes. LABORATORY/RADIOLOGIC DATA: admission, CBC revealed white count 11.7 differential showing 76.4% neutrophils, 11% lymphocytes, 8.8 monocytes. hematocrit 32.7 MCV 89, platelets 366,000. Coagulations revealed PT 13.8, PTT 22.9, INR 1.3. normal serum chemistries. ALT 13, AST 16, LD 306, alkaline phosphatase 57, amylase 80, bilirubin 0.3, lipase 36, albumin 3.4. admission [Hospital1 18], Doppler ultrasound right lower extremity showed nonocclusive thrombus right common femoral vein occlusive thrombus superficial femoral vein. thrombus also appeared extend greater saphenous vein. EKG well showed sinus tachycardia right bundle branch block, Q waves lateral limb leads. unchanged previous EKG compared [Hospital3 4527]. HOSPITAL COURSE: 1. HEMATOLOGIC: presumed felt likely Gynecology/Oncology well Hematology/Oncology mass patient's abdomen correlated elevated CA-125 1,200 probably consistent ovarian carcinoma. conveyed family offered surgical debulking surgical staging Gynecology/Oncology. felt necessary medically manage medical issues including deep venous thrombosis Medicine Team discussion later admission family regarding possibility surgery. medically managed discussions begun, family inconsistent indecisive plans wishes mother. became angry one point dissatisfied medical team talking patient without family present. explained them, however, Mrs. [Known lastname 96864] capacity make decisions own, health care needs discussed well. inconsistent well throughout admission whether wanted undergo surgery possible paracentesis analysis fluid cytology possible follow-up chemotherapy. beginning hospitalization, seemed wish undergo surgery, later throughout admission clear scared surgery feel best option, preferred paracentesis. Since conclusion could made decision made family, conveyed inappropriate extended hospital course hospital stay waited make decision decision could made outpatient. Hematology/Oncology consulted recommended three treatment options; first surgical debulking staging Gynecology/Oncology possible follow-up chemotherapy; second, abdominal paracentesis analysis fluid cytology pending results palliative chemotherapy; third hospice care Mrs. [Known lastname 96864]. options relayed family family meeting [2115-9-18], point still felt unable make decision. information also conveyed primary care physician. [Name10 (NameIs) ] [2115-9-23], patient decided proceed laparotomy staging debulking purposes. also noted admission right deep venous thrombosis, allergy heparin. Therefore, started lepirudin maintained lepirudin drip goal PTT 60-80. received one dose Coumadin prior consideration surgery, resulted elevated INR 5.6, subsequently came 2.5 range. unclear INR persistently elevated, possibly due malnutrition. LFTs checked, normal. Since therapeutic INR, started Coumadin need overlap Lepirudin. HIT antibody checked time. Mrs. [Known lastname 96864] also history anemia iron studies consistent anemia chronic disease. receiving iron supplementation admitted; however, discharged iron supplementation due inability iron supplementation help anemia chronic disease. hematocrit monitored closely. received 1 unit packed red blood cells [2115-9-18] hematocrit 25. hematocrit stable point. 2. CARDIOVASCULAR: Mrs. [Known lastname 96864] history hypertension good blood pressure control admitted Captopril 50 mg t.i.d., originally kept Atenolol 12.5 mg b.i.d., subsequently increased 25 mg b.i.d. better control blood pressure. questionable history coronary artery disease admission given Q waves lateral limb leads, right bundle branch block. underwent cardiac preoperative evaluation admission case possible surgical debulking also better convey risks benefits family. underwent echocardiogram showed mildly dilated left atrium, normal left ventricular cavity, normal ejection fraction, moderate pulmonary hypertension, mild aortic stenosis. also Persantine MIBI stress test revealed EKG changes, normal ejection fraction, reversible defect. felt cardiac postoperative risk death 10-15%. Mrs. [Known lastname 96864] also suffered fluid overload congestive heart failure admitted. oxygen desaturations maintained 3 liters oxygen nasal cannula. aggressively diuresed IV Lasix 80 mg b.i.d. two days, resolution symptoms. diuresed creatinine bumped 1.3 diuresis held, restarted next day dose 40 mg p.o. b.i.d. creatinine subsequently fell 1.0. 3. PULMONARY: Mrs. [Known lastname 96864] history COPD, originally started Albuterol nebulizer p.r.n., subsequently increased standing dose addition standing Atrovent nebulizers. also given Albuterol MDI p.r.n. audible wheezing evidence hypoxia, improvement nebulizer treatments. discharged Albuterol MDI p.r.n. strongly recommended respiratory treatments nebulizer treatments p.r.n. nursing home. also evidence increased sputum production several days admission poor quality chest x-ray. point, attempted get sputum induction; however, sample ever obtained. remained afebrile without clinical evidence pneumonia. 4. ENDOCRINE: Mrs. [Known lastname 96864] history type 2 diabetes maintained Actos Glyburide outpatient. admitted, decreased p.o. intake, Actos Glyburide held covered sliding scale regular insulin. time discharge, restarted Actos Glyburide. recommended close follow-up nursing home outpatient hypoglycemia given likely decreased p.o. intake malignancy. 5. INFECTIOUS DISEASE: Several days admission, noted Mrs. [Known lastname 96864] somnolent felt possibly developing infection, Tylenol; therefore, fever spike could detected. urine cultures, blood cultures, attempt sputum culture never obtained. U/A revealed signs urinary tract infection; however, urine culture times two came back fecal contamination. question whether might possible fistula rectum bladder malignancy. was, however, started levofloxacin, discharged five days complete total seven day course. Initial blood cultures grew one four bottles positive gram-positive cocci chains PICC line site. followed second day surveillance cultures time discharge never grown anything felt probably secondary contamination. 6. PSYCHIATRY: Mrs. [Known lastname 96864] history depression maintained nursing home Zoloft, Zyprexa 2.5 mg q.h.s., Klonopin 0.5 mg t.i.d. outpatient. continued admitted, several Klonopin doses held concern excessive sedation. withdrawn. also interactive periods. felt worried, anxious, fearful diagnosis, expected. DISPOSITION: yet determined. DISCHARGE DIAGNOSIS: 1. Presumed ovarian cancer. 2. Ascites. 3. Hypertension. 4. Diabetes. 5. Chronic obstructive pulmonary disease. 6. Depression. 7. Deep venous thrombosis. 8. Congestive heart failure. 9. Urinary tract infection. DR.[Last Name (STitle) 2511],[Doctor Last Name ] 12-AHZ Dictated By:[Last Name (NamePattern1) 14268] MEDQUIST36 D: [2115-9-20] 04:52 T: [2115-9-20] 21:06 JOB#: [Job Number 96865]	[ "496" ]
Admission Date: [2114-3-27] Discharge Date: [2114-3-29] Date Birth: [2091-12-16] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 330] Chief Complaint: Altered mental status, tylenol overdose Major Surgical Invasive Procedure: None History Present Illness: 22 F history ETOH abuse, IVDU heroin, cocaine, unknown street drugs, bipolar disorder, transferred [Location (un) ] hospital tylenol overdose. (The patient able give much history drowsiness, much history given mother.) took 15 tylenol pm last night, sometime evening midnight. usually takes 4 tylenol PM every night help sleep, last night sleep, took 15 tylenol PM. According mother, took klonepin yesterday well (her daughter told taken it), know amount. Patient take medications home regimen. . According patient mother, patient taking 15 tylenol PM suicide attempt. patient states wish hurt herself, took pills sleep rest. said usually takes Tylenol PM thought taking pills would increase effect helping sleep. reports abdominal pain, aching muscles "all over", sleepiness, "feel like flu". . mother actually taken [Hospital3 ] hospital 2 days ago, Sunday afternoon 2:30 pm, "acting funny", sitting floor, answering questions, looking disheveled, acting belligerent temperamental, uncharacteristic patient per mother. [Name (NI) ] mother states daughter "can really difficult, type never leave house without perfectly matched outfit makeup". boyfriend mother assumed "strung drugs". taken ambulance [Hospital3 ] hospital Sunday 2:30 pm returned home 7:30 pm hospital. mother know transpired ED visit Sunday. daughter hospital visit, returned hospital, daughter seemed back normal self per mother. . Late Monday night, mother called ambulance since patient seemed obtunded ill. OSH, vomiting, dry heaves, nausea, restlessness; given zofran 8 mg IV. EMS found BG 32, given D25; BG 162 arrival OSH; BG decreased 70 given D50 floor. AST >10,000, ALT >5,000, Cr 2.13, TBili 4.8, DBili 2.9, Alk phos 127. ABG: 7.32 / 24 / 121 / 12 2L nc. abdominal US found liver renal failure. received NAC 7g load plus 2.5g 4 Tuesday transferred [Hospital1 18] ED. . [Hospital1 18] ED, vitals 97.7, HR 132, 105/47, RR 26, 100% 3L nc admission. Hepatology consulted recommended 17 mg/kg/hr IV NAC infusion. Toxicology also consulted. INR 14.1, liver enzymes pending, acetaminophen level negative. Received 2250 ml NS ED, received [2106] ml NS OSH. transferred MICU Green. . subsequent information obtained patient's mother private: patient history bipolar disorder, tried slash wrists past suicide attempts, refuses treatment noncompliant medical recommendations medications, signed AMA psychiatry hospital, boyfriend Hepatitis C, takes heroin IV drugs whenever access. . REVIEW SYSTEMS: Patient cannot answer questions due obtundation. +abdominal pain. +generalized pain localize. fever, chills, vomiting, diarrhea, blood per rectum. Past Medical History: - ETOH abuse: 60 beers + 1 bottle rum + 1 bottle jagermeister per week - Hepatitis C - Chronic tylenol PM use: 4 pills per night least past years - IV drug use: heroin, cocaine, possibly drugs - Illicit drug use: unprescribed klonepin, percocet - Bipolar disorder: refuses medical treatment signed AMA psychiatric [Hospital1 ] - Previous suicide attempts: slashing wrists Social History: ETOH: Per mother, drinks 60 beers ("at least two 30-packs"), bottle rum, jagermeister per week. mother estimates amount that, since witnesses herself, see daughter drinks house. drinks beer every morning going work, often skips work inebriated. . IV drugs: Per mother patient, used heroin cocaine past. . drugs: history using percocet klonopin non-medical reasons without prescription. mother reports easy gain access drugs neighborhood. . ADLs: works roofer father. shows work approximately 10-15 days month ETOH drug use, able keep job works father. lives home mother, works nights. mother states "it's impossible keep track her" feels since adult 22, lead life. boyfriend hepatitis C. tested HIV hepatitis. Family History: liver disease first degree relative. [Name (NI) ] family member frequenter house currently ill. Physical Exam: VS: 97.7 / HR 125-135 / 107/47 / 20 / 98% 4L nc (85% RA) GEN: Drowsy, irritable, restless, cannot answer questions. Falls asleep middle history-taking exam. move around bed without limited pain. Tachypneic. HEENT: Subtle ecchymoses eyelids bilaterally, ecchymoses behind ears. PERRL, scleral icterus, cannot perform EOM exam due lack concentration, cannot assess nystagmus. Nasal turbinates clear normal nasal septum. Dry mucous membranes. NECK: LAD, soft, supple. carotid bruits heard. thyroid masses thyromegaly. CV: Regular, tachy. [1-2] flow SEM heard best apex, rub gallop, clear S1 S2 S3 S4 LUNGS: Quiet rhonchi bibasilar rales, wheezing. ABD: Soft, normoactive BS, nondistended. Diffusely tender mild palpation, especially right quadrant epigastrium, rebound, moderate guarding. bruits heard. BACK: Mild costovertebral tenderness. Ext: track marks arms. Asterixis present bilaterally. cyanosis, clubbing, edema. Neuro: Oriented person, place, year. CN 2-12 intact tested. 5 motor arms legs. 2+ reflexes triceps, biceps, patellar, Achilles. Toes downgoing. assess gait. Pertinent Results: [2114-3-27] 08:37PM TYPE-[Last Name (un) ] TEMP-36.9 PO2-32* PCO2-31* PH-7.30* TOTAL CO2-16* BASE XS--10 INTUBATED-NOT INTUBA [2114-3-27] 08:37PM LACTATE-5.2* [2114-3-27] 08:37PM freeCa-0.88* [2114-3-27] 08:17PM GLUCOSE-120* UREA N-30* CREAT-2.6* SODIUM-139 POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-15* ANION GAP-26* [2114-3-27] 08:17PM CALCIUM-8.0* PHOSPHATE-5.1* MAGNESIUM-2.4 [2114-3-27] 08:17PM URINE HOURS-RANDOM [2114-3-27] 08:17PM URINE UCG-NEGATIVE [2114-3-27] 08:17PM WBC-12.3* RBC-2.08* HGB-6.9* HCT-19.6* MCV-94 MCH-33.3* MCHC-35.4* RDW-13.5 [2114-3-27] 08:17PM PLT COUNT-108* [2114-3-27] 08:17PM PT-42.5* PTT-57.0* INR(PT)-4.8* [2114-3-27] 12:36PM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.025 [2114-3-27] 12:36PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-TR [2114-3-27] 12:36PM URINE RBC-0-2 WBC-0 BACTERIA-0 YEAST-MOD EPI-0 [2114-3-27] 12:33PM LACTATE-6.8* [2114-3-27] 12:28PM GLUCOSE-134* UREA N-32* CREAT-2.5* SODIUM-136 POTASSIUM-5.3* CHLORIDE-99 TOTAL CO2-15* ANION GAP-27* [2114-3-27] 12:28PM LD(LDH)-8210* DIR BILI-2.5* [2114-3-27] 12:28PM CALCIUM-8.2* PHOSPHATE-5.4* MAGNESIUM-2.8* [2114-3-27] 12:28PM HAPTOGLOB-37 [2114-3-27] 12:28PM WBC-19.0* RBC-2.62* HGB-8.5* HCT-24.8* MCV-95 MCH-32.5* MCHC-34.3 RDW-13.5 [2114-3-27] 12:28PM PLT COUNT-118* [2114-3-27] 12:28PM PT-31.6* PTT-46.8* INR(PT)-3.4* [2114-3-27] 12:28PM PT-31.6* PTT-46.8* INR(PT)-3.4* [2114-3-27] 12:15PM AMMONIA-69* [2114-3-27] 12:09PM TOT PROT-5.3* IRON-224* CHOLEST-88 [2114-3-27] 12:09PM calTIBC-229* FERRITIN-GREATER TH TRF-176* [2114-3-27] 12:09PM TRIGLYCER-89 HDL CHOL-50 CHOL/HDL-1.8 LDL(CALC)-20 [2114-3-27] 12:09PM OSMOLAL-308 [2114-3-27] 12:09PM TSH-0.40 [2114-3-27] 12:09PM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc Ab-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [2114-3-27] 12:09PM Smooth-NEGATIVE [2114-3-27] 12:09PM [Doctor First Name ]-NEGATIVE [2114-3-27] 12:09PM TSH-0.40 [2114-3-27] 12:09PM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc Ab-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [2114-3-27] 12:09PM Smooth-NEGATIVE [2114-3-27] 12:09PM [Doctor First Name ]-NEGATIVE [2114-3-27] 12:09PM AFP-<1.0 [2114-3-27] 12:09PM HIV Ab-NEGATIVE F [2114-3-27] 12:09PM HCV Ab-POSITIVE [2114-3-27] 11:38AM TYPE-ART TEMP-36.3 PO2-120* PCO2-29* PH-7.33* TOTAL CO2-16* BASE XS--9 INTUBATED-NOT INTUBA [2114-3-27] 11:38AM LACTATE-6.7* [2114-3-27] 11:38AM O2 SAT-97 [2114-3-27] 11:38AM freeCa-0.85* [2114-3-27] 10:14AM TYPE-ART TEMP-36.1 RATES-/24 O2 FLOW-2 PO2-51* PCO2-31* PH-7.30* TOTAL CO2-16* BASE XS--9 INTUBATED-NOT INTUBA COMMENTS-NASAL [Last Name (un) 154] [2114-3-27] 10:14AM LACTATE-8.3* [2114-3-27] 09:07AM PO2-78* PCO2-34* PH-7.30* TOTAL CO2-17* BASE XS--8 [2114-3-27] 09:07AM GLUCOSE-172* LACTATE-9.5* NA+-133* K+-5.2 CL--100 [2114-3-27] 08:45AM GLUCOSE-180* UREA N-34* CREAT-2.5* SODIUM-133 POTASSIUM-5.2* CHLORIDE-93* TOTAL CO2-12* ANION GAP-33* [2114-3-27] 08:45AM estGFR-Using [2114-3-27] 08:45AM ALT(SGPT)-9260* AST(SGOT)-[Numeric Identifier 29620]* ALK PHOS-122* AMYLASE-108* TOT BILI-4.2* [2114-3-27] 08:45AM LIPASE-186* [2114-3-27] 08:45AM CALCIUM-8.7 PHOSPHATE-5.8* MAGNESIUM-3.0* [2114-3-27] 08:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2114-3-27] 08:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2114-3-27] 08:45AM URINE HOURS-RANDOM UREA N-263 CREAT-92 SODIUM-17 [2114-3-27] 08:45AM URINE UCG-NEGATIVE OSMOLAL-396 [2114-3-27] 08:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS amphetmn-NEG mthdone-NEG [2114-3-27] 08:45AM WBC-23.1* RBC-3.37* HGB-11.2* HCT-32.0* MCV-95 MCH-33.3* MCHC-35.0 RDW-13.3 [2114-3-27] 08:45AM NEUTS-91* BANDS-0 LYMPHS-1* MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2114-3-27] 08:45AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2114-3-27] 08:45AM PLT SMR-LOW PLT COUNT-148* [2114-3-27] 08:45AM PT-102.0* PTT-53.7* INR(PT)-14.2* [2114-3-27] 08:45AM URINE COLOR-Amber APPEAR-Hazy SP [Last Name (un) 155]-1.020 [2114-3-27] 08:45AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2114-3-27] 08:45AM URINE RBC-[1-29]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [2114-3-27] 08:45AM URINE AMORPH-FEW . EKG: Sinus tachycardia Low QRS voltage - clinical correlation suggested Since previous tracing [2114-3-28], axis less rightward Intervals Axes Rate PR QRS QT/QTc P QRS 123 148 90 284/357.28 47 64 29 . CXR [2114-3-29]: ET tube tip 6 cm carina. left internal jugular line tip terminating low SVC. pneumothorax apical hematoma identified. NG tube tip terminates stomach. significant change bilateral perihilar lower lobe consolidations. Small bilateral pleural effusion cannot excluded though evidence large pleural fluid. . CT Head/Chest/Abd/Pelv [2114-3-29]: NON-CONTRAST HEAD CT: diffuse edema brain parenchyma loss [Doctor Last Name 352]- white matter differentiation obliteration ventricular system. also obliteration basilar cisterns. Obliteration pre- mesencephalic space suggests bilateral uncal herniation. Complete obliteration ambient cistern suggests transtentorial herniation. also complete obliteration CSF space foramen magnum suggesting tonsillar herniation. focal mass lesion seen. major minor vascular territorial infarct detected. shift normal midline structure seen. surrounding bony soft tissue structures unremarkable evidence fracture. maxillary sinuses normal.The ethmoid sinuses , frontal sinuses Sphenoid sinuses demonstrate mucosal thickening. IMPRESSION: Severe diffuse brain edema obliteration CSF spaces uncal, downward transtentorial tonsillar herniation. . CT chest [2114-3-29]: IMPRESSION: 1. evidence acute bleeding seen within chest, abdomen pelvis explain patient unresponsiveness. 2. Small bilateral pleural effusions, prominent left side. 3. Bilateral ground-glass opacities consolidations, centered bronchovascular bundle, may suggest aspiration pneumonitis. 4. Anasarca ascites. . TTE [2114-3-27]: Conclusions: left atrium normal size. Left ventricular wall thicknesses cavity size normal. Regional left ventricular wall motion normal. Left ventricular systolic function hyperdynamic (EF>75%). Tissue Doppler imaging suggests normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size free wall motion normal. aortic valve leaflets appear structurally normal good leaflet excursion. valvular aortic stenosis. increased transaortic gradient likely related high cardiac output. aortic regurgitation seen. mitral valve prolapse. mitral regurgitation seen. pulmonary artery systolic pressure could determined. pericardial effusion. IMPRESSION: Hyperdynamic left ventricular function. Resting tachycardia. obvious structural valvular disease evaluation limited due marked tachycardia. . Abdomen US [2114-3-27]: IMPRESSION: 1. Normal-appearing liver without focal lesion identified. 2. Diffuse bilateral renal cortical echogenicity consistent diffuse parenchymal disease. 3. Gallbladder wall edema without evidence acute cholecystitis may seen liver disease hypoalbuminemia. Brief Hospital Course: 22 F history heavy ETOH abuse, HCV, IVDU heroin, cocaine, unknown street drugs, bipolar disorder, transferred [Hospital3 ] Hospital admitted MICU tylenol overdose, renal failure, altered mental status, improved first 3 days, evolved brain death due brain herniation. . # Acute fulminant liver failure: Patient history heavy ETOH abuse, HCV, fulminant liver failure precipitated tylenol overdose. MELD 50 98% predicted mortality admission. Acetaminophen level negative, AST [Numeric Identifier 29620], ALT 9260, INR 14.1, TB 4.2 admission. loaded N-acetylcysteine IV infusion [Location (un) 21541] Hospital, transferred [Hospital1 18] ED. Hepatology consult Toxicology consult called gave initial recommendations NAC dosing. . MICU, 17 mg/kg/hr NAC per hour started time admission. initial workup covered viruses, toxins, drugs, autoimmune, shock liver, hemochromatosis, liver cancer, sepsis alternative impetus liver failure. HBV immune (HBsAb positive), HCV Ab positive, HIV negative, CMV negative, Monospot negative, [Doctor First Name ] negative, AFP negative, TIBC low (229), ferritin >[2106] (inflammation). Urine toxin screen positive cocaine. Serum toxin screen negative (included opiates, cocaine, benzodiazepines). TTE ordered assess possibility shock liver, addition assessment flow murmur exam; TTE showed hyperdynamic LV systolic function EF > 75%. EKG showed sinus tachycardia. Patient guaiac positive brown stool vault. Free calcium 0.85 aggressively repleted. Normal serum glucose maintained D50 slow D5W infusion. . Hepatology consult assessed patient would liver transplant candidate, due continued heavy ETOH abuse, continued illicit IV drug use, nonprescribed heavy klonepin percocet use, previous consistent refusal medical treatment recommendations (history signing medical advice hospitals). plan discussed mother, father, aunt, family, understood agreed. . MICU hepatology team discussed intracranial pressure monitoring using bolt, agreed bolt would placed, patient liver transplant candidate. Neurologic exam performed every hour. neurologic exam admission showed pupils constricting briskly 4 3 mm right 4 3 mm left, drowsy oriented person, place, year. required high dose propofol maintain proper sedation. [3-28], sedation turned test mental status, withdrew appropriately painful stimuli, pupils briskly reactive. . patient episode vomiting concern airway protection aspiration, sedated, intubated, LIJ central line arterial line placed [3-28]. noted diffuse ecchymoses eyelids, behind ears, bilateral abdomen, thought secondary coagulopathy. elicited concern retroperitoneal bleed, since patient candidate surgical repair time, since patient's clinical status tenuous safe leave ICU, CT performed time. . [3-29] AM, sedation turned test mental status, withdrew slowly painful stimuli, pupils still equally reactive. Ecchymoses expanded anteriorly abdomen, abdomen soft bowel sounds hematocrit maintained > 21 pRBC transfusions. [3-29] AM, change medications sedation past hour, noted sudden spike BP >200/>110 HR 150s. given ativan 1 mg IV labetalol 10 IV BP immediately returned 110/60 HR 70s. Neurologic exam performed vitals measured every hour change. . [3-29] early afternoon, neurologic exam suddenly showed right pupil 5 mm nonreactive left pupil slow react 4 3 mm. Sedation turned patient longer reacted painful stimuli. Mannitol CT head, chest, abdomen, pelvis ordered. Within minutes, patient's pupils became fixed dilated. CT head showed uncal, transtentorial, tonsillar herniation. Neurology reported brain death [3-29]. Organ bank assessed patient candidate heart donation due hepatitis C. patient subsequently given support cardiac care organ donation [3-29] [3-30]. . # Coagulopathy/bleeding: Since admission, hematocrit continued decrease INR continued increase. received total 4 pRBC, 12 FFP, 1 cryoprecipitate transfusions 3 days death. INR initially 14.1 maintained goal INR < 4.0; cryoprecipitate given fibrinogen < 100; RBC transfusion given hematocrit < 21 acute drop. . # Respiratory insufficiency: patient hyperventilating large tidal volumes. intubated AC episode vomiting, airway protection. CXR showed bilateral basilar infiltrates concerning early acute lung injury versus aspiration, patient started levofloxacin cover possible aspiration pneumonia. . # ETOH/opiate withdrawal: propofol gtt controlled withdrawal well. [3-29] AM, one episode BP 200/110, HR 150s. given ativan 1 mg IV labetalol 10 IV immediate resolution. . # Renal failure: received several boluses NS IVF prerenal azotemia Cr 2.5 admission Cr baseline. renal function worsened renal consulted [3-28]. Urine output sufficient, require HD CVVH. placed phosphate binder. possible renal failure occurred conjunction liver failure and/or associated cocaine-induced vasoconstriction. . # Hematemesis: Patient small coffee ground gastric fluid orogastric tube placed low suction. placed pantoprazole IV BID. . # Leukocytosis: WBC 23.1 admission resolved 6.3 one day. Antibiotics started [3-28] due CXR infiltrates. Blood cultures [3-27] showed positive gram stain, [3-31] [4-2] grew Corynebacterium species Fusobacterium nucleatum, beta lactamase negative. Surveillance blood cultures [3-28] [3-29] showed growth still pending (no growth yet) [4-3]. Sputum cultures [3-28] grew Streptococcus pneumoniae MSSA [4-2], sensitive levofloxacin. Urine culture showed 1000 organisms gram positive organism, likely staphylococcus. . # Hypoglycemia: Patient one episode fingerstick glucose 32, given D50. D5W infusion continued subsequent normal fingerstick glucose readings, checked every hour. . # Prophylaxis: placed pneumoboots subcutaneous heparin. given PPI IV BID hematemesis. . # Code: code full death [3-29]. Medications Admission: Tylenol PM 4 pills per night . ALLERGIES: PCN Discharge Medications: Patient expired [2114-3-29]. Discharge Disposition: Expired Discharge Diagnosis: Patient expired [2114-3-29]. Discharge Condition: Patient expired [2114-3-29]. Discharge Instructions: Patient expired [2114-3-29]. Followup Instructions: Patient expired [2114-3-29]. Completed by:[2114-4-10]	[ "570" ]
Admission Date: [2199-9-1] Discharge Date: [2199-9-19] Date Birth: [2128-3-9] Sex: Service: NEUROSURGERY Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1271] Chief Complaint: Headache Major Surgical Invasive Procedure: Right Craniotomy SDH [2199-9-3] Redo Right craniotomy SDH [2199-9-10] History Present Illness: 71 year old man presents approx 1 month left sided weakness speech difficulty. worsened gradually, initially felt may neuropathy acting up. also feeling headaches, describes bifrontal headaches helped motrin. days presentation, daughter noted left arm becoming clumsy turning lamp using spoon. also noted left leg dressing. denied history trauma head. Past Medical History: pituitary tumor s/p resection, DMII, neuropathy, obesity s/p gastric bypass surgery, melanoma removal face OSA Social History: lives wife, nonsmoker, EtOH, 3 kids Family History: non-contributory Physical Exam: Admission: Gen: WD/WN, comfortable, NAD. HEENT: scar melanoma rsxn left face Pupils: [3-30] EOMs full, nystagmus Neck: Supple. Extrem: Warm well-perfused. Neuro: Mental status: Awake alert, cooperative exam, normal affect. Orientation: Oriented person, place, date. Recall: [2-28] objects 5 minutes. Language: Speech fluent good comprehension repetition. Naming intact. slight dysarthria, paraphasic errors. Cranial Nerves: I: tested II: Pupils equally round reactive light, 4to2 mm bilaterally. Visual fields full confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength sensation intact symmetric. VIII: Hearing intact voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk tone bilaterally. abnormal movements, tremors. Strength full power [5-2] except 4+/5 left deltoid IP. pronator drift Sensation: Intact light touch bilaterally. Toes downgoing bilaterally Handedness: Right discharge: Pertinent Results: [9-1] CT Head- IMPRESSION: Complex heterogeneous right subdural collection suggestive mostly subacute subdural hematoma areas hyperdensity may indicate acute component. Right-to-left subfalcine herniation. 9 mm rightward shift septum pellucidum. [2199-9-1] CXR AP lateral views chest demonstrate clear lungs without effusion pneumothorax. heart size normal. mediastinal contours unremarkable. IMPRESSION: Normal chest. CT head [2199-9-3] Post-surgical changes recent right frontoparietal craniotomy right-sided drainage catheter surgical bed. degree subfalcine herniation, sulcal effacement local mass effect appears slightly improved compared recent examination. CXR [2199-9-3] comparison study [9-1], placement endotracheal tube tip approximately 5.5 cm carina. Nasogastric tube tip appears extend upper portion stomach side hole within lower esophagus. Low lung volumes may account prominence transverse diameter heart. CT head [2199-9-4] Slight increase size previously noted acute subdural hematoma, change midline shift. CT Head [9-5] change compared previous scan [9-4] LENIs [9-9] - negative DVT. CT Head [9-10] (post op) 1. Decreased size right subdural hematoma decreased mass effect. 2. New subarachnoid hemorrhage right sylvian fissure right frontal sulci. CT Head [9-12] Slight increase right frontal wedge-shaped hypodensity mild increase size likely related evolution without significant increase mass effect. Decrease previously noted right sided subdural fluid collection dense foci. new hemorrhage. Carotid US [2199-9-17] evidence significant carotid artery stenosis bilaterally. Echocardiogram [2199-9-18] left atrium normal size. right atrium markedly dilated. mild symmetric left ventricular hypertrophy normal cavity size regional/global systolic function (LVEF>55%). Right ventricular chamber size free wall motion normal. ascending aorta mildly dilated. aortic valve leaflets (3) mildly thickened. minimally increased peak transvalvular velocity consistent minimal aortic valve stenosis. mitral valve leaflets mildly thickened. Mild (1+) mitral regurgitation seen. pericardial effusion. IMPRESSION: cardiac source embolism identified. Preserved global regional biventricular systolic function. Minimal aortic valve stenosis. Compared prior study dated [2193-6-5] (images unavailable review), minimal aortic valve stenosis appreciated. Brief Hospital Course: [9-1] Mr. [Known lastname 45777] admitted neuro ICU started Keppra seizure prophylaxsis. remained stable neurologically radiologically cleared transfer floor [9-2]. Surgery scheduled [9-3] craniotomy evacuation hematoma. Preop consent obtained. proceeded [2199-9-3] right craniotomy subdural evacuation. JP drain left place. remained intubated post-op went CT scan showed acute blood. left sided weakness. transfered NICU. [2199-9-4], extubated strength slowly improving. CT head showed small amount acute blood given platelets. total received 2 units platelets platelet count remained 100k. repeat CT head [9-5] showed change compared previous scan. subdural drain remained place removed late afternoon. transferred step-down bed SICU evening. morning [9-6] patient repeat Head CT demonstrating change right frontoparietal hyperdensity new hemorrhage. patient mental status waxed waned course day. Patient failed speech swallow recommended keep patient NPO. NG tube placed order get medications nutrition. [9-9] LENIs obtained rule DVT essentially negative. repeat Head CT showed slight increase right Frontoparietal collection. result, Brain MRI Stroke protocol obtained improved neurologically demonstrated brainstem hemorrhage. [9-10] MRI head demonstrated right frontoparietal subdural subarachnoid hemorrhage mass effect midline shift unchanged compared prior CT scan. taken [9-10] redo right craniotomy SDH evacuation. post-op CT showed improvement decreased size right subdural hematoma decreased mass effect new subarachnoid hemorrhage right sylvian fissure right frontal sulci. patient taken SICU-B surgery intubated. remained intubated morning [9-11] reported seizure activity (right arm right downward gaze fixation) treated increased keppra continuous EEG. patient also pan cultured fever. CT-scan re-ordered demonstrating right frontal infarct. Dilantin added seizure prophylaxis. Vancomycin, tobramycin, cefepime added Bronch cx returned positive gram positive rods cocci gram negative rods. Urine cultures returned positive Enterococcus. patient remained intubated change neuro exam overnight. Patient continued febrile temperatures overnight. morning [9-12], patient continued seizure episodes. Neuroepilepsy consulted seizure work-up recommendations, endocrine service consulted work-up endocrine issues recommendations, repeat head CT ordered. Patient overnight without seizures afebrile throughout [9-13]. Urine cultures bronchalveolar lavage cultures returned antibiotic sensitivities; antibiotics tailored per sensitivity testing. patient continued progress physical exam increased movement right upper lower extremit, minimal movement left upper extremity withdrawal pain left lower extremity, following commands, opening eyes voice. plan begin considering possible extubation. [9-14], patient continued Surgical intensive care unit. ventilator weaned patient extubated. patient weak, opened eyes voice oriented person place time. patient able move four extremities antigravity command. patient moves left arm leg delay. left side weakner right. patient bowel movement. [9-16] pt well. AOx3 interactive staff family. transferred SDU stable condition. abx narrowed Cefepime plan continue total fo 14 days. [9-17] carotid US done per Neuro-Vascular service significant stenosis. changed floor status. [9-18] calcium repleted. neurologically stable. Cefepime changed Bactrim oral therapy. IV meds discontinued. approved PT. Central line discontinued. Patient taking oral intake without issues. Overnight, patient complaints. Patient take dobbhoff tube despite restraints. echo without source embolus. [9-19] patient without complaints. neurologic exam stable strength left upper lower extremities progressed. Patient's restraints discontinued. Lasix given signs fluid overload lower extremities. staple removed routine fashion. DOD, afebrile, VSS, himproved neurologically. tolerating oral diet without issues. evaluated pt/ot/speech recommended rehab. [2199-9-19], stable discharge rehab f/u accordingly. Medications Admission: bromocritine/clobentasol/lasix40'/hydrocortisone /levothyroxine/testosterone/vit D/multivitamin Discharge Medications: 1. bromocriptine 2.5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. clotrimazole 1 % Cream Sig: One (1) Appl Topical DAILY (Daily). 3. testosterone cypionate 200 mg/mL Oil Sig: One (1) Intramuscular Q2WK (). 4. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times day). 7. levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. codeine sulfate 30 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) needed pain, ha. 9. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times day) needed constipation. 10. levetiracetam 100 mg/mL Solution Sig: 1000 (1000) mg PO BID (2 times day). 11. phenytoin 125 mg/5 mL Suspension Sig: One [Age 90 1230]y (150) mg PO Q8H (every 8 hours). 12. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [Hospital1 ] (2 times day) needed pruritis. 13. hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO QAM (once day (in morning)). 14. hydrocortisone 20 mg Tablet Sig: 0.5 Tablet PO QPM (once day (in evening)). 15. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once day (at bedtime)). 16. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 17. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times day): cont [9-25]. 18. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) needed fever, pain. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: subdural hematoma obstructive sleep apnea pituitary insufficiency Thrombocytopenia Recurrent SDH anemia right frontal infarct Post-op fever Seizures malnutrition dysphagia Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - requires assistance aid (walker cane). Discharge Instructions: General Instructions ?????? friend/family member check incision daily signs infection. ?????? Take pain medicine prescribed. ?????? Exercise limited walking; lifting, straining, excessive bending. ?????? may wash hair sutures and/or staples removed. ?????? 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. ?????? medication Coumadin (Warfarin), Plavix (clopidogrel), Aspirin, prior injury, may safely resume taking follow us ??????You discharged Keppra (Levetiracetam), require blood work monitoring. ?????? Clearance drive return work addressed post-operative office visit. ?????? Make sure continue use incentive spirometer home, unless instructed to. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([Telephone/Fax (1) 88] schedule appointment Dr. [Last Name (STitle) 739], seen 4 weeks. ??????You need CT scan brain without contrast. [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2199-9-19]	[ "430" ]
Admission Date: [2148-8-4] Discharge Date: [8-11] /[2148] Date Birth: [2148-8-4] Sex: Service: NB interim summary covering [2148-8-4] [8-11]. [Hospital ] transferred Neonatology Service development medical necrotizing enterocolitis. HISTORY PRESENT ILLNESS: Baby baby [Name (NI) 4549] [2049] gram product 31 6/7 weeks twin gestation born 28- year-old G3, P0, 2 woman. Prenatal screens - positive, antibody negative, hepatitis surface antigen negative, rubella immune, RPR nonreactive, GBS unknown. pregnancy remarkable [Last Name (un) 5153] fertilization, dichorionic, diamniotic twin complicated preterm labor cervical shortening 24 weeks. mother treated bed rest magnesium sulfate. Betamethasone given [2148-6-10]. remained bed rest [Doctor First Name ]- [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] one month discharged home PO terbutaline. presented night delivery spontaneous labor spontaneous rupture membranes 37 minutes prior delivery. Vertex, vertex presentation, prompting cesarean section delivery. Per parents' wished, want try labor. infant emerged initially good tone cry, however developed apnea, large amount oropharyngeal secretions suctioned. baby required bag, mask ventilation suctioning orogastric fluid. Apgars 5, 7, 8. PHYSICAL EXAMINATION: Weight [2048], 75th percentile; length 44 cm, 75th percentile; head circumference 32 cm, 90th percentile; anterior fontanel soft flat. Palate intact. Nondysmorphic facies. Breath sounds coarse fair air entry intubation. S1 S2 normal intensity. murmurs. Perfusion fair. Soft abdomen organomegaly. Three-vessel cord. Normal male genitalia. Appropriate gestational age. Tone appropriate gestational age. Hips stable. HOSPITAL COURSE SYSTEMS: RESPIRATORY: [Known lastname ] continued respiratory distress. infant intubated, received 2 doses Surfactant extubated nasal cannula oxygen 24 hours age. remains stable nasal cannula oxygen, 13 cc. occasional apnea bradycardia currently received methylxanthine therapy. CARDIOVASCULAR: issues. FLUIDS, ELECTROLYTES NUTRITION: Birth weight [2048] grams. Initially started 80 cc per kg per day D10W. Enteral feedings initiated day life No. 1. currently 140 cc per kg per day, 50 cc per day breast milk - premature Enfamil 20 calorie. GASTROINTESTINAL: Bilirubin day life 2 7.9/0.3. placed phtx current bili HEMATOLOGY: Hematocrit admission 47.8. required blood transfusions. INFECTIOUS DISEASE: CBC blood cultures obtained admission. CBC benign. Blood cultures remained negative 48 hours time ampicillin gentamycin discontinued. [8-11] infant developed bloody stools abdominal film consistent NEC. made NPO placed Vanc/Gent/Clinda switched 48 hours Amp/Gent/Clinda treated 14 days time kept NPO. NEUROLOGIC: Appropriate gestational age. Screening HUS done [8-14] DISCHARGE DIAGNOSES: Premature twin No. 1, 31 6/7 weeks gestation. Respiratory distress syndrome. Rule sepsis antibiotics. Hyperbilirubinemia Necrotizing enterocolitis DR.[Last Name (STitle) ],[First Name3 (LF) ] 50-393 MEDQUIST36 D: [2148-8-11] 21:59:57 T: [2148-8-11] 23:05:54 Job#: [Job Number 63961]	[ "769" ]
Admission Date: [2119-4-2] Discharge Date:[2119-5-19] Date Birth: [2119-4-2] Sex: Service: NB HISTORY: Baby [Name (NI) ] [Known lastname 46082] number 1 former 1585 gram product 29 week twin gestation pregnancy, born 40 year old G2 P1-3 woman whose pregnancy apparently uncomplicated admitted [Hospital1 190] [3-30] vaginal bleeding preterm labor. Spontaneous rupture membranes occurred day delivery. day prior delivery, morning delivery, labor progressed, breech presentation one twin prompted delivery via cesarean section. PRENATAL SCREENS: positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, GBS status unknown. risks factors sepsis noted time delivery. delivery, infant emerged vigorous noted mild moderate respiratory distress. given blow- O2, stim CPAP. Apgars 7 1 minute, 8 5 minutes. Baby transferred newborn intensive care unit visiting briefly parents delivery room. PHYSICAL EXAMINATION ADMISSION: Pink, active, non dysmorphic infant, well saturated perfused. Increasing work breathing noted early part NICU course. Skin notable scattered petechiae upper trunk neck. Bruising noted flank buttocks. 5 mm superficial laceration left buttock noted. HEENT within normal limits. Normal regular rate rhythm. S1 S2. murmur. Lungs crackly, shallow bilateral breath sounds. Abdomen benign. hepatosplenomegaly. Normal premature genitalia, male. testes canal. Hips normal. Back blind ending sacral dimple. Neurologic nonfocal age appropriate. HOSPITAL COURSE SYSTEM: 1. RESPIRATORY. Infant required intubation received 2 doses surfactant. conventional ventilator day life 3. time, loaded caffeine citrate, transition CPAP 5 cm, less 30 percent O2. Remained CPAP day life 27, required re-intubation increased apnea bradycardia. time, noted positive blood culture. See "infectious disease," below. remained ventilator day life 33, transitioned CPAP. remained prong CPAP day life 37, transitioned nasal cannula O2. currently nasal cannula O2 100 percent, 25-75 cc. Baseline breath sounds 40-60, clear equal. Caffeine discontinued day life 15 due episodes supraventricular tachycardia (see "cardiovascular," below). baby occasional episode desaturations point time. baby require pressor support admission. 2. CARDIOVASCULAR. baby noted large PDA day life 2 echocardiogram. received first course indomethacin. day life 15, noted episodes supraventricular tachycardia. cardiovascular instability episode. received 2 doses adenosine break supraventricular tachycardia. day life 18, recurrence SVT. point time, caffeine discontinued several days. lasted [1-1] minutes. broke without intervention. Cardiology consultation obtained rule congenital heart disease assist ectopy management. Ultimate disease probable premature atrial contractions wandering atrial pacer. junctional beats. Plan discuss Cardiology followup plan time discharge, probable return see Cardiology discharge Holter monitor, determine whether ectopy continues discharge. time dictation, baby irregular heartbeat intermittently. supraventricular tachycardia. baby showed symptoms patent ductus arteriosus. echocardiogram [4-28], day life 26. echo showed moderate PDA left right flow. [5-3], received second course indomethacin. [5-4], echo showed PDA. baby current baseline heart rate 130-160's. murmur, baseline blood pressures 60-70's systolic, diastolic 30-40's, means 40-50's. 3. FLUID ELECTROLYTES. Birth weight 1590 grams, 90th percentile. Current weight 2625, 50th, greater 50th percentile. Admission length 40 cm, greater 50th percentile. Current length 44 cm, greater 25th percentile. Admission head circumference 28.5 cm, 75th percentile. Current head circumference 32 cm, 50th percentile. baby initially NPO double lumen UVC line inserted. Received parenteral nutrition enteral lipids respiratory status stabilized. day life 5, enteral feedings introduced. achieved full enteral feedings day life 12. currently feeding 130 cc/kg/day breast milk 26. achieved adding 4 calories/oz HMF 2 cal/oz MCT. also receiving supplemental FeSO4 25 mg/ml, 0.2 ml daily, equals 2 mg/kg/day. voiding stooling requiring gavage feedings. Last electrolytes [5-6] showed sodium 140, potassium 4.9, chloride 105, CO2 22. AST time 20, ALT 9, alkaline phosphatase 301. due nutrition labs [5-23]. BUN creatinine [5-2] BUN 13, creatinine 0.6. 4. GASTROINTESTINAL. Baby peak bilirubin day life 3 7.2/0.4/6.8. Responded double phototherapy. rebound bilirubin day life 8 5/0.3/4.7. 5. HEMATOLOGY. blood type positive. received 2 transfusions far admission, last one [5-4]. Last hematocrit [5-13] 37.2. 6. INFECTIOUS DISEASE. Upon admission, blood culture CBC sent started 48 hours ampicillin gentamicin. 48 hours, baby clinically well antibiotics discontinued. day life 20, another CBC blood culture sent increase apnea bradycardia. within normal limits, white count 13.6, 31 polys, 6 bands, 37 lymphocytes platelet count 563, hematocrit 30. placed back positive airway pressure, resolved increase apnea bradycardia. urine sent CMV sibling's diagnosis urine positive CMV. baby's urine remained negative. day life 26, baby increase apnea bradycardia CPAP. blood culture CBC sent. white count 14.8, 75 polys, 5 bands, platelets 484, hematocrit 29. Blood culture grew Staph aureus. started vancomycin gentamicin. Culture sent. Lumbar puncture ultimately done. showed 1 red cell, 2 white cells, protein 87, glucose 50. Cultures remained negative. transitioned oxacillin received 14 days treatment Staph aureus negative culture. Oxacillin discontinued [5-17]. treatment oxacillin, serial liver function tests CBC's drawn, stated above. 7. NEUROLOGY. [Known firstname ] serial head ultrasounds, within normal limits, last one [5-3] 33- 3/7 weeks gestation. neurologically appropriate gestational age. 8. SENSORY. Audiology screening done time dictation. Ophthalmology - Eye exam [5-1] showed immature retina, zone 2, plan follow 2 weeks. 9. INTEGUMENTARY. noted strawberry hemangioma scrotum. 10. PSYCHOSOCIAL. Parents visiting frequently, look forward transitioning home [Known firstname ] brother [Name (NI) ] join sister, [Name (NI) 3608]. CONDITION TIME TRANSFER: Stable. Transfer [Hospital1 35174] service. Primary pediatrician Dr. [First Name4 (NamePattern1) 449] [Last Name (NamePattern1) ], [Location (un) 2274]. CARE RECOMMENDATIONS: 1. Continue breast milk 26, 130 kg/day p.o. p.g. 2. Medications - FeSO4 above, 0.2 ml p.o. daily 25 mg/cc, equals 2 mg/kg/day. 3. Car seat screening done time dictation. 4. State newborn screening - Serial screens done. Last one [4-16], within normal range. 5. Immunizations received - None date. 6. Immunizations recommended: Synergist RSV prophylaxis considered [Month (only) ] [Month (only) 958] infants meet following three criteria: 1) Born less 32 weeks. 2) Born 32-35 weeks two following: day care RSV season, smoker household, neuromuscular disease, airway abnormalities school age siblings. 3) chronic lung disease. Influenza immunization recommended annually fall infants reach six months age. age, first 24 months child's life, immunization influenza recommended household contacts home caregivers. 7. Followup appointment primary care pediatrician per routine. Early intervention, VNA, cardiology. DISCHARGE DIAGNOSES: 1. Former 29 week twin #1 2. 2. Status post respiratory distress syndrome. 3. Status post rule sepsis antibiotics. 4. Status post Staph aureus bacteremia. 5. Status post PDA treated indomethacin. 6. Supraventricular tachycardia, ectopic beats. 7. Strawberry hemangioma. 8. Immature retinas. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2119-5-19] 00:45:02 T: [2119-5-19] 03:09:13 Job#: [Job Number 61015]	[ "769" ]
Admission Date: [2120-2-26] Discharge Date: [2120-2-28] Date Birth: [2034-8-16] Sex: Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 30] Chief Complaint: Pleuritic chest pain Major Surgical Invasive Procedure: Heimlich valve [Hospital3 3765] PTX History Present Illness: 85M PMh s/f severe COPD chronic O2, complete heart block s/p PMP [7-21], PVD s/p bilateral carotid endarterectomies [2111], HTN, HLD presents presented [Hospital3 7569] w/chief complaint chest pain shortness breath since AM. recent hospitalization MI PNA, completed 2 week course PNA Sunday. home, denied F, C, N/V, endorsed pleureitic L sided chest pain shortness breath. . initally taken [Hospital3 ], given nitro gtt, briefly heparin gtt, given Levofloxacin worsening LLL PNA. plan transfer [Hospital1 ] since receives cardiology care, sats 70's-80's facemask prior switching nrb, improved low 90s cards evalulation. ambulance, radiology [Location (un) ] stat notified ED finding 30% left PTX. ambulance thus directed nearest hospital, turned [Hospital1 ]. [Hospital1 ], left PTX relieved Heimlich valve device, repeat CXR shows resolution. patient reported improved SOB, still mild L CP inspiration. . ED, initial VS were: 99.0 110 170/91 20 98% cont neb . Labs notable HCT 36.2, INR 1.4. . given Aspirin 325mg, 4 mg Morphine Sulfate. . CXR notable interval resolution PTX. . arrival MICU, AAOx3, surrounded family, comfortable. family says slightly worse cough,a lthough chronic cough baseline, although denies cough worse. Past Medical History: Severe COPD chronic oxygen treatment Complete heart block, status post pacemaker implantation [7-/2116], peripheral vascular disease, status post bilateral carotid endarterectomies [2111]. Hyperlipidemia HTN Social History: married. wife lives home. former 40 pack-year history smoking; smoked 19 years. rare alcohol intake. Family History: Mother father passed CAD. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T:afebrile BP:142/63 P:90 R:20 O2:96% 2L General: Alert, oriented, acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition, R eye corneal scar, L lower eye lid scar prior surgery Neck: supple, LAD Lungs: Clear auscultation bilaterally, wheezes, rales, ronchi CV: distant heart sounds, Regular rate rhythm, normal S1 + S2, murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, rebound tenderness guarding, organomegaly Ext: Warm, well perfused, 2+ pulses, clubbing, cyanosis edema GU:foley place . DISCHARGE PHYSICAL EXAM Vitals: T:96.2 BP:90s-110s/40s-60s P:70s-80s R:18 O2:95% 2L General: Alert, oriented, acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition, R eye corneal scar, L lower eye lid scar prior surgery Neck: supple, LAD Lungs: Clear auscultation bilaterally, wheezes, rales, ronchi CV: distant heart sounds, Regular rate rhythm, normal S1 + S2, murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, rebound tenderness guarding, organomegaly Ext: Warm, well perfused, 2+ pulses, clubbing, cyanosis edema GU:foley place Pertinent Results: [2120-2-26] 08:35PM GLUCOSE-133* UREA N-18 CREAT-0.9 SODIUM-137 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-26 ANION GAP-15 [2120-2-26] 08:35PM cTropnT-<0.01 [2120-2-26] 08:35PM ALBUMIN-4.0 [2120-2-26] 08:35PM WBC-11.0 RBC-4.23* HGB-12.1* HCT-36.2* MCV-86 MCH-28.7 MCHC-33.5 RDW-14.5 [2120-2-26] 08:35PM NEUTS-85.6* LYMPHS-9.1* MONOS-4.5 EOS-0.6 BASOS-0.2 [2120-2-26] 08:35PM PLT COUNT-259 [2120-2-26] 08:35PM PT-14.5* PTT-37.2* INR(PT)-1.4* CXR [2-26]: IMPRESSION: Bibasilar opacities, left greater right, raises concern infection/pneumonia and/or aspiration. Blunting left costophrenic angle may due small pleural effusion. Bibasilar atelectasis. tubular structure/catheter extending left lung apex possible tiny left apical pneumothorax remaining. However, suggest followup removal external artifact better evaluation. Upright PA lateral views may helpful evaluation when/if patient able. CHEST (PORTABLE AP) Study Date [2120-2-28] left pigtail place. left lower lobe consolidation substantially improved. Heart size mediastinum overall unchanged. assessment lung bases still demonstrate bilateral pleural effusion, small right likely small moderate left. Brief Hospital Course: 85M PMh s/f severe COPD chronic O2, complete heart block s/p PMP [7-21], PVD s/p bilateral carotid endarterectomies [2111], HTN, HLD presents pleuritic pain found L PTX. # PTX/Chest Pain: remained hemodynamically stable since arrival hosptial. Heimlich valve device place, oxygenating well, without new development PTX. likely pt developed PTX bursting bleb complication severe COPD. pt ruled MI CE. weaned 2L O2 NC home O2 requirement. Interventional pulmonology removed Heimlich valve without complication. . # LLL infiltrate: CXR hospitalization shows LLL opacity. pt completed two week course antibiotics prescribed PCP treatment pneumonia. pt afebrile, without leukocytosis cough. evidence infection currently likely radiographic reminence resolving prior pneumonia. antibiotics given hospitalization. . # Acute Urinary Retention: pt known BPH Terazosin home. claims prior hospitalizations required urinary catheterization obstruction well. difficulty voiding hospitalization. bladder scan revealed >1L urine bladder. foley catheter placed relieve obstruction. removed repeat voiding trial obtained showed retaining 600cc urine bladder. foley catheter re-inserted follow appointment made Urology removal. increased dose Terazosin 2mg 5mg daily prior discharge. . # Severe COPD chronic oxygen treatment: Patient quickly weaned back home O2 requirements (2-3L 02 NC), without extra wheezing exam. continued home Advair, Tiotroprium nebulizers prn. . # Elevated INR: Chronic problem noted pt seen labs [2111] INR also noted 1.4. Pt warfarin currently. albumin wnl active signs bleeding. . # Hyperlipidemia/PVD: continued aspirin 81 mg Daily Plavix 75 mg Daily Zocor 10 mg Daily Lisinopril 10 mg Daily . # Chronic Lower Extremity Edema- continued Lasix 20 mg QAM Lasix 10 mg QPM . # Restless Leg Syndrome: continued Mirapex 0.5 mg QHS . # Transitional- Prior discharge urinary catheter placed relieve urinary obstruction BPH. follow appointment urology removed. also follow appointment PCP well. Medications Admission: Oxygen 3-liters/hr aspirin 81 mg Daily Alphagan 0.15% Eye dropps 1 [Hospital1 ] Plavix 75 mg Daily Advair 250-50 1 inh [Hospital1 ] Lasix 20 mg QAM Lasix 10 mg QPM Prinivil 10 mg Daily Multivitamin 1 capsule Mirapex 0.5 mg QHS Zocor 10 mg Daily Atenolol 50 mg PO/NG DAILY Tiotropium Bromide 1 CAP IH DAILY Terazosin 2.5 mg PO DAILY Discharge Medications: 1. Home Oxygen 3L / hr 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times day). 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. fluticasone-salmeterol 250-50 mcg/dose Disk Device Sig: One (1) Disk Device Inhalation [Hospital1 ] (2 times day). 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO QAM (once day (in morning)). 7. furosemide 20 mg Tablet Sig: 0.5 Tablet PO QPM (once day (in evening)). 8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO day. 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. pramipexole 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once day (at bedtime)). 11. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 13. terazosin 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:2 14. atenolol 50 mg Tablet Sig: One (1) Tablet PO bedtime. 15. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). Disp:1 bottle Refills:2 Discharge Disposition: Home Service Facility: [Location (un) ] Nursing Services Discharge Diagnosis: Primary Diagnosis: Pneumothorax Urinary Retention Secondary Diagnosis: Hyperlipidemia Peripheral Vascular Disease Lower Extremity Edema Chronic Obstructive Pulmonary Disease Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname ], pleasure taking care [Hospital1 827]. admitted hospital chest tube placed [Hospital3 ] collapsed lung. chest tube removed lung remained inflated. also discovered completely empyting bladder urination. placed urinary catheter help relieve obstruction. made follow appointment urology regarding matter. following changes made medications: INCREASE Terazosin 5mg daily START Fluticasone Propionate 1 spray per nostril daily nasal congestion Please see follow appointments made behalf. Please call Dr. [Last Name (STitle) 1911] schedule follow up. Followup Instructions: Name: [Last Name (LF) ],[First Name8 (NamePattern2) 2515] [Last Name (NamePattern1) ] JR. Location: [Name2 (NI) ] FAMILY MEDICINE Address: [Apartment Address(1) 17034], [University/College ],[Numeric Identifier 17035] Phone: [Telephone/Fax (1) 17030] When: Wednesday, [2119-3-7]:30 Department: SURGICAL SPECIALTIES When: WEDNESDAY [2120-3-6] 4:30 PM With: [First Name8 (NamePattern2) 161] [Name6 (MD) 162] [Name8 (MD) 163], MD [Telephone/Fax (1) 164] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "496" ]
Admission Date: [2142-4-25] Discharge Date: [2142-4-29] Date Birth: [2079-6-8] Sex: Service: MEDICINE Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4095] Chief Complaint: Chief Complaint: shortness breath Reason MICU transfer: tachypnea Major Surgical Invasive Procedure: Thoracentesis History Present Illness: 62-year-old gentleman HIV (not compliant HAART, recent CD4 220), DM2 nephropathy (baseline Cr 1.8-2.0), Hodgkin's Burkitt's lymphoma (s/p doxorubicin, vinblastine, dacarbazine remission), CHF (EF 22% [1-/2142]) recent admission [Hospital1 18] [Date range (1) 39579] RLL pneumonia treated 10 days levofloxacin (end date [2142-4-26]). discharged rehab. presented PCP today SOB orthopnea (needs sit chair sleep). Denies chest pain. Continues non-productive cough, anorexia fatigue. Denies fever. also notes increased abdominal distention regular non-bloody bowel movements regular urination. CXR [Hospital 3390] clinic today revealed large right sided effusion. ED, initial vitals 98.5 90 136/96 24 100% 4L. Labs notable WBC 9.1 1% band, 3% myelo, 3% meta, Cr 1.8 (baseline ~2), BUN 36, Na 132, K 5.3, lactate 2.8, ALT 105, AST 83, AP 605. UA 100+ protein, WBCs. Blood urine cultures sent. CT torso contrast showed simple large right pleural effusion RLL collapse abdominal free fluid. received cefepime, vancomycin metronidazole. Zofran given nausea. Paracentesis attempted due poorly identified effusion. ED course, dyspnea increased 30-40, sats 92% RA 94% 2L admitted MICU. IP [Name (NI) 653], planning thoracentesis AM. recent vitals: 82 130/82 20 94% 2L. MICU, patient reports feeling better, breathing comfortable. states dry weight 149lb. weighs 154lbs today. received Torsemide 40 mg IV 1x got diagnostic thoracentesis revealed transudative effusion. Cultures fluid pending. CXR tap revealed resolution effusion. also found somewhat hyperkalemia 5.5 torsemide given concern regarding renal function due chronic DM related renal disease well recent contrast administration. Currently, reports feels much better SOB sitting lying down. denies pain says abdomen continues feel distended. Past Medical History: - NSTEMI [9-/2140] medically managed - HIV (CD4 198 [2142-1-17] VL 84,000 [2140-12-14]) - HIV cholangiopathy - DM, type II, uncontrolled (most recent HA1c 9.0 [2142-1-17]) - CKD - Cardiomyopathy EF 20% [2140-2-11] likely secondary doxorubicin, although HIV and/or ischemia may contributed - Pleural effusions - Burkitt's lymphoma ([2134]) - Hodgkins lymphoma (last cycle [8-5], stable disease) Social History: Came rehab. Denies smoking, prior smoker. Occasional EtOH. drug use. Originally [Country ]. Family History: Mother alive gastric cancer. Father died Alzheimer's ?cancer. Physical Exam: ADMISSION EXAM: Vitals: 97.7 84 132/93 25 98%2L 70kg General: Alert, oriented, acute distress, using neck accessory muscles respiration HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP elevated mid neck sitting upright, LAD CV: Regular rate rhythm, normal S1 + S2, 3/6 SEM heard best LLSB, rub/gallop Lungs: Decreased breath sounds right base ([11-27] way up), W/R/R Abdomen: distended, soft, non-tender, +ascites, bowel sounds hypoactive Ext: warm, well perfused, 2+ pulses, edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation . DISCHARGE EXAM: VS - Temp 97.9F, BP 110/62, HR 86 , RR 18, O2-sat 98% RA GENERAL - NAD, comfortable, appropriate HEENT - sclerae anicteric NECK - supple, JVD ~6 cm. HEART - RRR, nl S1-S2, 2/6 systolic murmor base LUNGS - decreased breath sounds right base, otherwise CTA. ABDOMEN - Mild distended, non tender, normal bowel sounds EXTREMITIES - Feet shiny without hair, pulses 1+, 2+ pitting edema NEURO - awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: Admission labs: [2142-4-25] 04:50PM BLOOD WBC-9.1 RBC-3.39* Hgb-11.3* Hct-35.4* MCV-104* MCH-33.3* MCHC-32.0 RDW-17.8* Plt Ct-402 [2142-4-25] 04:50PM BLOOD Neuts-59 Bands-1 Lymphs-23 Monos-11 Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-3* [2142-4-25] 05:05PM BLOOD PT-14.2* PTT-33.0 INR(PT)-1.3* [2142-4-25] 04:50PM BLOOD Glucose-197* UreaN-36* Creat-1.8* Na-132* K-5.3* Cl-98 HCO3-24 AnGap-15 [2142-4-25] 04:50PM BLOOD ALT-109* AST-83* CK(CPK)-74 AlkPhos-605* TotBili-0.7 [2142-4-25] 04:50PM BLOOD CK-MB-2 cTropnT-<0.01 [2142-4-26] 04:38AM BLOOD CK-MB-2 cTropnT-<0.01 [2142-4-26] 04:38AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.1 [2142-4-25] 04:50PM BLOOD Osmolal-294 Radiology CXR ([2142-4-26]) FINDINGS: compared previous radiograph, patient undergone right thoracocentesis. extent right pleural effusion substantially decreased. opacity right lung base, likely reflecting reexpansion lung edema. evidence pneumothorax. change appearance left lung cardiac silhouette. Cytology - pleural fluid Pleural fluid: NEGATIVE MALIGNANT CELLS. Mesothelial cells, histiocytes lymphocytes. [2142-4-28] 6:11 pm STOOL CONSISTENCY: APPLICABLE Source: Stool. FINAL REPORT [2142-4-29] C. difficile DNA amplification assay (Final [2142-4-29]): Negative toxigenic C. difficile Illumigene DNA amplification assay. (Reference Range-Negative). [2142-4-26] 6:45 PLEURAL FLUID GRAM STAIN (Final [2142-4-26]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. MICROORGANISMS SEEN. concentrated smear made cytospin method, please refer hematology quantitative white blood cell count.. FLUID CULTURE (Final [2142-4-29]): GROWTH. ANAEROBIC CULTURE (Preliminary): GROWTH. FUNGAL CULTURE (Preliminary): FUNGUS ISOLATED. ACID FAST SMEAR (Final [2142-4-27]): ACID FAST BACILLI SEEN DIRECT SMEAR. ACID FAST CULTURE (Preliminary): BLOOD CULTURES: GROWTH DATE [2142-4-29] 05:08AM BLOOD WBC-6.7 RBC-3.30* Hgb-10.7* Hct-34.4* MCV-104* MCH-32.4* MCHC-31.0 RDW-18.2* Plt Ct-387 [2142-4-29] 05:08AM BLOOD Glucose-131* UreaN-40* Creat-1.9* Na-136 K-4.6 Cl-99 HCO3-28 AnGap-14 [2142-4-29] 05:08AM BLOOD Calcium-9.0 Phos-3.8 Mg-1.9 Brief Hospital Course: 62-year-old gentleman HIV CD4 220, DM2, CKD, Hodgkin's/Burkitt's lymphoma, CHF (LVEF 22%) recent RLL pneumonia interval development right pleural effusion. emergency department, patient respiratory rates 30 - 40s admitted ICU tachypnea. # RIGHT PLEURAL EFFUSION: Patient presented PCP's office worsening dyspnea, found increased pleural effusion. Patient sent ED subsequently admitted MICU tachypnea. effusion drained IP. fluid appear pustular thoracentesis patient felt much improved fluid removal. CHF exacerbation seems probable given recently reduced torsemide, abdominal distention free fluid, simple appearing effusion, weight gain. Patient initially treated vancomycin cefepime, vancomycin stopped plerual fluid gram stain showed microorganisms. Cefepime also later discontinued. Pleural culture cytology returned negative. # ACUTE CHRONIC CHF EXACERBATION: Suspected secondary torsemide held since recent admission recent pneumonia. Patient received IV torsemide arrival MICU. received 80mg lasix IV transfer floor HD2. transitioned home dose PO torsemide 20mg [Hospital1 ] good response. # DIARRHEA: C.diff negative. Likely setting recent antibiotics. # CHRONIC RENAL FAILURE: Suspected secondary DM2, creatinine currently baseline. # TRANSAMINITIS: Likely congestive hepatopathy, vs HIV cholangiopathy. LFTs trended remained stable. . # HIV: Last CD4 count 220 [2142-3-27] HIV PCR VL 780. CD4 nadir 70s; patient recently initiated HAART therapy, compliance uncertain. Last admission team suspected [Female First Name (un) ] esophagitis potentially HIV encephalopathy. admission, patient continued Abacavir, Atazanavir, Lamivudine Ritonavir. Continued atovaquone PCP [Name Initial (PRE) 1102]. continue fluconazole 2 weeks [2142-5-9]. repeat viral loa # DM2: HBA1C 8.4 recently, compliance difficult. admission, patient maintained insulin sliding scale QID fingerstick checks glargine 15 units qHS. Held glipizide admission. restarted home dose medications discharge. # HYPONATREMIA: Mild, suspect hypervolemic secondary heart failure. Patient diuresed toresemide sodium remained stable. Na 136 discharge. Medications Admission: 1. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO day. 4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 5. glipizide 10 mg Tablet Sig: 1.5 Tablets PO day. 6. Epivir 150 mg Tablet Sig: One (1) Tablet PO day. 7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO day. 8. nystatin 100,000 unit/mL Suspension Sig: Five (5) mL PO three times day. 9. ritonavir 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three times day needed pain. 11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Ensure Liquid Sig: One (1) shake PO three times day. 13. Eucerin Cream Sig: One (1) application Topical twice day needed rash. 15. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours): started [2142-4-17], ending [2142-4-26]. 16. fluconazole 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours) 7 days: started [2142-4-18], ending [2142-4-24]. 17. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) drop right eye Ophthalmic QID (4 times day) 5 days: started [2142-4-18], ending [2142-4-22]. 18. insulin glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous bedtime. 19. insulin lispro 100 unit/mL Solution Sig: per sliding scale units Subcutaneous directed: see insulin sliding scale. Discharge Medications: 1. Abacavir Sulfate 600 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atazanavir 300 mg PO DAILY 4. Atovaquone Suspension 1500 mg PO DAILY 5. Fluconazole 200 mg PO Q24H 6. Gabapentin 300 mg PO Q12H 7. Glargine 15 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 8. LaMIVudine 150 mg PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Nystatin Oral Suspension 5 mL PO TID 11. RiTONAvir 100 mg PO DAILY 12. Torsemide 20 mg PO BID 13. GlipiZIDE XL 10 mg PO DAILY 14. Acetaminophen [Telephone/Fax (1) 1999] mg PO TID pain Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) 1820] [Last Name (NamePattern1) ] [Location (un) 1821] Discharge Diagnosis: Congestive Heart Failure Exacerbation, Pleural Effusion Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Last Name (Titles) 39580], pleasure taking care hospitalization. admitted shortness breath swelling legs. initially place medical ICU fluid lungs drained. given diuretic medications (Toresemide Furosemide) decrease swelling. Please take Torsemide 20mg mouth twice day every day. Please weigh every morning, call doctor weight goes 3 lbs. important continue taking antiretroviral medications HIV. Please also take Fluconazole 200 mg day treatment fungal esophagitis [2142-5-9] following changes made medications: -- START taking Torsemide 20mg twice day Followup Instructions: Department: [Hospital3 249] When: WEDNESDAY [2142-5-16] 10:30 With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: WEST PROCEDURAL CENTER When: MONDAY [2142-5-21] 8:30 With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6543], MD [Telephone/Fax (1) 7769] Building: [Hospital Ward Name 121] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: WEST PROCEDURAL CENTER When: MONDAY [2142-5-21] 8:30 [Telephone/Fax (1) 5072] Building: [Hospital Ward Name 121] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage	[ "042" ]
Admission Date: [2149-10-9] Discharge Date: [2149-10-17] Date Birth: [2073-7-6] Sex: F Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 21990] Chief Complaint: bright red blood stool Major Surgical Invasive Procedure: Colonoscopy History Present Illness: 76F prior history GI bleed, HTN, Sciatica rehab back pain, past 2 weeks constipation & crampy abdominal pain associated increased belching, flatus. Patient written narcotics pain control sciatica unaware whether taken them. morning admmission 4 episodes blood per rectum initial bowel movements, relieved abdominal discomfort, described dark maroon blood mixed stool progressing BRBPR. Patient denies associated lightheadedness, dizziness, CP, SOB, change vision, hematuria, epistaxis, ASA, NSAID, EtOH use. Patient never colonoscopy family history colon cancer. Patient denies weight change change appetite. says staff rehab disagreed bowel regimen, may receiving one regularly. Past Medical History: HTN Sciatica, L4/5 lumbar spondylolisthesis--seen ortho. Shoulder injury--associated weakness. OA--knees, bilat. Cervical Joint Disease Depression Narrow angle glaucoma Social History: Patient emigrated [Location (un) ] > 50 yrs ago. Used work translator. Currently lives senior housing JP 12 yr old granddaughter. Lives elder housing 12 year old grandaughter. Per OMR, DSS get involved given granddaughter school: "complicated family dynamics". Per pastor friend patient, child school issue resolved now. denies EtoH, tobacco, illicit drug use. Family History: Patient denies family history colon cancer. patient one living relative [Age 90 ] years age. Physical Exam: Vitals - T:98.7 BP:155/66 HR:62 RR:16 02 sat:94 RA GENERAL: laying bed, NAD SKIN: 8cm vertical old, small multiple subcentimeter hypopigmented macules lower extremities, well healed incision scar mid abdomen, warm well perfused, excoriations rashes HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pale conjunctiva, patent nares, dry mucus membranes, good dentition, supple neck, LAD, JVD CARDIAC: RRR, S1/S2, soft SEM @ RUSB LUNG: CTAB ABDOMEN: nondistended, +BS, nontender quadrants, rebound/guarding, hepatosplenomegaly M/S: moving extremities well, cyanosis, clubbing edema, obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact Pertinent Results: [2149-10-9] 12:15PM PT-12.4 PTT-31.3 INR(PT)-1.1 [2149-10-9] 12:15PM PLT COUNT-327 [2149-10-9] 12:15PM NEUTS-68.9 LYMPHS-22.7 MONOS-6.3 EOS-2.0 BASOS-0 [2149-10-9] 12:15PM WBC-4.2 RBC-3.39* HGB-10.9* HCT-31.3* MCV-92 MCH-32.1* MCHC-34.8 RDW-13.2 [2149-10-9] 12:15PM CALCIUM-9.4 PHOSPHATE-3.5 MAGNESIUM-2.2 [2149-10-9] 12:15PM GLUCOSE-105 UREA N-10 CREAT-0.9 [Month/Day/Year 11516]-123* POTASSIUM-4.7 CHLORIDE-87* TOTAL CO2-26 ANION GAP-15 [2149-10-9] 12:39PM HGB-11.0* calcHCT-33 [2149-10-9] 03:45PM PLT COUNT-287 [2149-10-9] 03:45PM NEUTS-69.9 LYMPHS-23.7 MONOS-4.2 EOS-2.1 BASOS-0.1 [2149-10-9] 03:45PM WBC-4.4 RBC-3.58* HGB-11.6* HCT-33.5* MCV-94 MCH-32.4* MCHC-34.6 RDW-13.4 [2149-10-9] 07:06PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2149-10-9] 07:06PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.002 [2149-10-9] 07:06PM URINE OSMOLAL-113 [2149-10-9] 09:36PM HCT-28.3* . [2149-10-10] 04:57AM BLOOD WBC-8.7# RBC-3.77* Hgb-11.9* Hct-34.9* MCV-93 MCH-31.5 MCHC-34.1 RDW-13.5 Plt Ct-288 [2149-10-10] 07:04PM BLOOD Hct-34.5* [2149-10-11] 05:55AM BLOOD WBC-8.0 RBC-3.50* Hgb-11.0* Hct-33.0* MCV-94 MCH-31.5 MCHC-33.4 RDW-13.9 Plt Ct-273 [2149-10-11] 05:55AM BLOOD Glucose-71 UreaN-5* Creat-0.6 Na-139 K-3.6 Cl-102 HCO3-25 AnGap-16 [2149-10-17] 05:40AM WBC 5.4 Hgb 10.3* HCT 30.9* MCV 95 Plt 256 [2149-10-17] 09:55AM HCT 33.3* . [10-10] Colonoscopy: Findings: Excavated Lesions Multiple diverticula medium openings seen whole colon.Diverticulosis appeared severe. single diverticulum signs inflammation seen ascending colon.Diverticulosis appeared mild severity. Impression: Diverticulosis whole colon. Diverticulum ascending colon . [10-15] Tagged RBC Findings: Negative GI bleeding study. . [10-13] MRI L-spine: alignment lumbar spine demonstrate minimal anterolisthesis L4-L5. signal intensity vertebral bodies slightly heterogeneous, likely consistent degenerative changes. intervertebral disc space L1-L2 appears unremarkable. L2-L3 significant neural foraminal narrowing spinal canal stenosis identified. L3-L4 demonstrates disc desiccation mild posterior diffuse disc bulge producing mild bilateral neural foraminal narrowing, frank evidence nerve root compression detected. Bilateral hypertrophy articularjoint facets well ligamentum flavum observed level. L4-L5, evidence disc desiccation, mild posterior broad-based disc bulge producing bilateral neural foraminal narrowing, right greater left possible contact right [Name (NI) 5774] nerve root, please correlate specifically finding, bilateral articular joint facet hypertrophy also noted associated bilateral ligamentum flavum thickening. level, evidence significant spinal canal stenosis, thecal sac measures approximately 6 mm anterior, posterior diameter. L5-S1, evidence disc desiccation, posterior broad-based disc bulge producing bilateral neural foraminal narrowing significant spinal canal stenosis, left greater right possible contact [Name (NI) 13032] nerve root. Bilateral articular joint facet hypertrophy ligamentum flavum thickening noted level. also evidence irregular contour inferior endplate L5 consistent Schmorl's node bone marrow replacement fat endplates. Vacuum phenomena also detected intervertebral disc space. sacroiliac joints, visualized aspect retroperitoneum vascular structures appear grossly normal. IMPRESSION: Multilevel degenerative changes lumbar spine described detail above. L4-L5, evidence disc desiccation posterior broad-based disc bulge producing right side neural foraminal narrowing possible contact right nerve root [Name (NI) 5774]. L5-S1, evidence left paracentral disc protrusion producing left side neural foraminal narrowing possible contact left [Name (NI) 13032] nerve root, moderate-to-severe spinal canal stenosis identified level. Brief Hospital Course: 76 year old female history HTN sciatica presented 4x BRBPR setting 2 weeks intermittent constipation. Brief hospital course problem: 1.Diverticular bleed - patient presented BRBPR x4 gassy abdominal pain setting intermittent constipation several weeks duration. GI consulted, NG lavage ED negative, patient treated fluid resucitation systolic pressure running baseline 110s. Hematocrit admission 31.3 stable first 12 hours. white count, temperature acute abdominal pain. transferred MICU observation overnight prep colonoscopy am. one episode hypotension 90s associated lightheadedness one bloody BM overnight. hct dropped 28.3 early [10-10] transfused 2 u PRBCs increase back 34.9. went colonoscopy numerous diverticula seen throughout colon, least one evidence inflamation. Though source acute bleeding seen, diverticuli felt etiology bleed. transferred floor remained hemodynamically stable. [10-12] however, experienced renewed melanotic stools transferred MICU observation. hematocrit remained >30, returned floor [10-13]. Late [10-14] first bowel movement since MICU stay streaked bright red blood, sent tagged red blood cell scan demonstrate bleeding. remained hemodynamically stable passed another stool difficulty [10-16] formed, brown, streaked bright red blood, thought likely secondary hemorrhoids. HCT stable baseline (33.3) morning discharge. need continue aggressive bowel regimen prevent constipation may aggravated surely underlying silent diverticular disease. . 2.HTN: patient history hypertension HCTZ CCB. held [10-9] [10-10] secondary bleeding, restarted [10-11] patient hemodynamically stable. . 3.Sciatica - patient continued complain lower back pain radiating leg consistent well documented hx sciatica L4/5 disease. seen orthopaedics, recommended medical treatment physical therapy followup ortho-spine symptoms persist. comes [Hospital1 18] [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] receiving rehabilitation condition. continued Tylenol opioids breakthrough pain. appears Amitryptiline recently discontinued. Opioids initially used cautiously low doses given constipation role potentially instigating bleed, minimal requests. Pain control adequate rest, unable ambulate. complained increased left lower extremity weakness sent MRI lumbar spine. MRI demonstrated following findings: 1. Multilevel degenerative changes lumbar spine; 2. L4-L5, evidence disc desiccation posterior broad-based disc bulge producing right side neural foraminal narrowing possible contact right nerve root [Name (NI) 5774]; 3. L5-S1, evidence left paracentral disc protrusion producing left side neural foraminal narrowing possible contact left [Name (NI) 13032] nerve root, moderate-to-severe spinal canal stenosis identified level. examined spine team felt would likely benefit inpatient pain consult outpatient work-up spine findings. deferred surgical intervention point given unresolved GI bleeding issues. chronic pain team consulted deferred steroid injection, saying might aggrevate GI bleeding. recommendation started neurontin 300mg TID assist pain. follow orthopedics chronic pain clinics outpatient. . discharged [First Name4 (NamePattern1) 2299] [Last Name (NamePattern1) ] standing Tylenol neurontin oxycodone breakthrough pain. reinforced importance continuing bowel regimen continues narcotic pain medication. . 4. Hyponatremia: Patient serum Na 123 presentation. Per PCP, [Name10 (NameIs) ] 138 [9-24]. Hyponatremia thought likely secondary volume depletion context blood loss +/- cathartic diarrhea. urine paradoxically dilute Uosm =113. serum [Month/Year (2) ] post-fluid repletion 140. . 5. Social: Patient distressed [10-11] regarding situation non-biological 12 year old granddaughter [Name (NI) 17976], care. estranged biological daughter [Name (NI) 107509] threatening call DSS remove [Last Name (un) 17976] friend's apartment staying. DSS involved past, patient's pastor confirms helped resolve issue enrolling [Last Name (un) 17976] school. daughter additionally came hospital convey message patient drug seeking. patient denied overuse medications, accusation verified pastor primary care physician. . Dispo: patient discharged back rehabilitation center stable condition instructions return hospital another bowel movement significant blood loss (more bright red blood streaking) becomes hemodynamically unstable. Code: FULL. Medications Admission: Tylenol Valium 5 mg prn Oxycodone 5mg prn Timolol ophth Verapamil 240 mg qd HCTZ 25 mg qd Ibuprofen 600mg QID Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day). Disp:60 Tablet(s) Refills:0 2. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 3. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours): Hold SBP <100; HR <55. 4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold SBP<95. 5. Docusate [Last Name (un) ] 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). Disp:60 Capsule(s) Refills:2 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours needed pain 1 weeks: Take breakthrough pain. Avoid possible constipated. Disp:28 Tablet(s) Refills:0 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) needed constipation. 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times day). Discharge Disposition: Extended Care Facility: [Hospital3 1186] - [Location (un) 538] Discharge Diagnosis: Primary Diagnoses: 1)Diverticular bleeding 2)Sciatica lumbar degenerative disease disc compression nerve roots Secondary Diagnoses: 1)Hypertension Discharge Condition: Hemodynamically stable. HCT 33.3 (baseline). large bloody stool since [10-12]. Since 2 formed stools small amount blood streaking outside. Discharge Instructions: diagnosed diverticular bleeding, condition abnormal outpouchings wall intestines cause rapid bleeding via rectum. treated fluids blood transfusion support completed colonoscopy locate specific sources bleeding. test showed diverticula (outpouchings). Constipation may cause diverticula cause bleed. important continue regimen we've outlined keep bowels moving regularly. outpatient doctors [Name5 (PTitle) ] [Name5 (PTitle) 9004] adjust pain medications, since opioid narcotics (oxycodone, morphine, etc.) aggravate constipation, especially taking agents keep bowels moving. continued treat sciatica pain medication. obtained MRI lumbar spine showed disc protrusion possible compression lumbar nerve roots would explain symptoms. evaluated orthopedics deferred surgical intervention point given medical issues. recommendation evaluated chronic pain clinic decided give steroid injection point, recommended adding neurontin medications pain management. started medication well. discharged [First Name4 (NamePattern1) 2299] [Last Name (NamePattern1) ] physical therapists doctors [Name5 (PTitle) ] [Name5 (PTitle) ] treat condition. recommending take tylenol four times day oxycodone needed breakthrough pain. also added new medication (protonix) help prevent stomach forming ulcers may bleed. Please take medication prescribed. Please call primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 6924], schedule follow-up visit leave rehab. also modify diet include adequate fiber may help prevent constipation diverticular disease. experience blood stools (more blood streaks), black stools, maroon-colored stools, change bowel movements, contact primary care physician go emergency room. Please also seek medical attention experience chest pain, shortness breath, dizziness, lightheadedness weakness. Followup Instructions: - Please contact Dr. [Last Name (STitle) 6924] [Hospital3 4262] Group schedule followup visit discharged [First Name4 (NamePattern1) 2299] [Last Name (NamePattern1) ] Rehabilitation. - Please keep previously scheduled appointment eye testing eye doctor, [Name6 (MD) 251] [Last Name (NamePattern4) 252], M.D. [2149-10-20] 10:30 11:00. need reschedule, please call office [Telephone/Fax (1) 253]. - Please also follow-up neurologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [2149-11-6] 12:00. need reschedule, please call office [Telephone/Fax (1) 541]. - Please also follow-up chronic pain clinic appointment [2149-12-3] 1:40pm. located pain management center [Hospital Ward Name 1950] Building Fth Floor. - also follow-up appointment Dr. [Last Name (STitle) ] orthopedics [2149-11-6] 1:40 pm. Completed by:[2149-10-17]	[ "311" ]
Admission Date: [2119-6-7] Discharge Date: [2119-7-18] Date Birth: [2063-7-15] Sex: F Service: SURGERY Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 695] Chief Complaint: Unresponsive Major Surgical Invasive Procedure: evacuation abdominal wall hematoma paracentesis re-exploration abdominal wall hematoma surgicel packing History Present Illness: 55yoF alcoholic cirrhosis s/p TIPS [1-/2118] found husband. patient history depression husband, [Name (NI) ], reports exacerbated lately several stressful situations including chronic back pain, finances, etc. last seen interactive appropriate 06:00am morning husband. [Name (NI) ] son saw 11am, thought patient asleep attempt wake her. subsequently found floor husband 3pm, 9 hours last seen, describes fetal position eyes rolled back head mouth wide open. husband began lift patient floor bit shoulder appear recognize him. take [Hospital6 33] found responsive verbal stimuli unable interact appropriately. intubated. Coffee grounds returned OGT hypotensive 80's/40's. FS 22 received glucose, 94.6, placed bear hugger. pH 6.8, lacate 25, creatine 3.2, bicarb 4. received 2 amps bicarb, 1 amp D50, blood cultures drawn central line. started bicarb drip, levophed gtt SBP 80's. making urine 6L IVF. transferred [Hospital1 18] management. R IJ placed OSH 2 peripheral IVs. . Per husband's report, patient history surreptitious alcohol ingestion occasion noticed detected alcohol use recently. denies likelihood illicit drug use prescription drug overdose, stating medication access Tramadol, taking. denies recent vocalizations patient regarding suicidal ideation. . [Hospital1 18] ED, initial VS: 123 113/29 27 100% patient noted 150cc dark coffee ground output OGT, stool guiac negative. Hepatology consulted, patient started Octreotide gtt Pantoprazole gtt, aggressive flushing OGT recommended. ordered transfused 1 unit PRBC. empirically treated Vanc/Levo/Flagyl CT torso obtained, showed evidence infection acute bleed. received 8L IVF ED, increased Levophed 0.4mcg/kg/hr. Renal consulted patient poor UOP acidotic, CVVH vs hemodialysis discussed. patient given Calcium gluconate 2gm, Bicarb gtt @150cc/hr, prepared possible CVVH tomorrow. Transfer VS were: 112/47, HR 117, 99% 60% PEEP 5, TV 450 . arrival MICU, patient intubated opening eyes verbal stimuli following commands. husband available give brief history, detailed above. Past Medical History: - Alcoholic cirrhosis s/p TIPS placement [1-/2118] (per GI OSH neg hepatitis serology, pos Anti-SMA neg [Doctor First Name ]) - h/o GIB [11/2117] s/p banding esophageal varices - h/o myomectomy Social History: - Tobacco: smoked since 20s. - EtOH: History heavy alcohol use x 20 years, sober since [8-25]. - Illicit Drugs: Remote cocaine history. - Lives husband. Family History: Father CAD. Otherwise non-contributory. Physical Exam: Admission physical exam VS: 98.9 126 -> 110 139/55 -> 92/49 24 99% GEN: Intubated, NAD HEENT: Pupils small (<1mm) equal reactive light, sclear anicteric, MMM, jvd, intubated ETT place CV: Tachycardic, regular rhythm, normal S1/S2, GII holosystolic murmer LSB, S3 heard best LSB RESP: CTAB anteriorly laterally good air movement throughout, wheezes/rales/rhonchi ABD: Soft, mild abdominal distension without appreciable fluid wave, diffuse tenderness palpation RUQ LUQ without rebound guarding grimacing exam. +b/s EXT: c/c/e, 2+ DP pulses b/l SKIN: rashes/no jaundice NEURO: Responds verbal stimuli follow commands Pertinent Results: [2119-6-6] 10:50PM BLOOD WBC-10.7 RBC-2.80* Hgb-9.9* Hct-30.2* MCV-108* MCH-35.2* MCHC-32.7 RDW-14.6 Plt Ct-47* [2119-6-6] 10:50PM BLOOD PT-19.0* PTT-41.5* INR(PT)-1.7* [2119-6-6] 10:50PM BLOOD Glucose-170* UreaN-24* Creat-3.2* Na-146* K-4.1 Cl-98 HCO3-14* AnGap-38* [2119-6-6] 10:50PM BLOOD ALT-204* AST-1699* CK(CPK)-1496* AlkPhos-145* TotBili-4.2* DirBili-3.2* IndBili-1.0 [2119-6-6] 10:50PM BLOOD Albumin-2.8* Calcium-6.0* Phos-8.1* Mg-1.7 [2119-6-6] 10:43PM BLOOD Glucose-148* Lactate-14.6* Na-142 K-4.3 Cl-101 calHCO3-14* [2119-7-5] 05:00PM BLOOD WBC-11.1* RBC-3.29* Hgb-10.1* Hct-26.6* MCV-81* MCH-30.8 MCHC-38.0* RDW-17.6* Plt Ct-115* [2119-7-5] 11:26AM BLOOD PT-19.2* PTT-43.1* INR(PT)-1.7* [2119-7-5] 11:26AM BLOOD Glucose-125* UreaN-24* Creat-2.0* Na-140 K-3.7 Cl-106 HCO3-19* AnGap-19 [2119-7-5] 03:09AM BLOOD ALT-16 AST-60* AlkPhos-45 TotBili-11.9* [2119-7-18] 06:04AM BLOOD WBC-17.2* RBC-3.54* Hgb-11.1* Hct-32.4* MCV-92 MCH-31.3 MCHC-34.2 RDW-20.9* Plt Ct-215 [2119-7-18] 06:04AM BLOOD Glucose-92 UreaN-8 Creat-0.6 Na-140 K-3.8 Cl-112* HCO3-19* AnGap-13 [2119-7-18] 06:04AM BLOOD ALT-12 AST-42* AlkPhos-85 TotBili-5.4* [2119-7-18] 06:04AM BLOOD Calcium-8.0* Phos-2.1* Mg-1.6 Imaging summary: - [6-7] liver u/s: 1. TIPS patent. prior ultrasound available compare velocities. High velocities suggest interval hyperplasia TIPS. 2. Cholelithiasis. 3. Diffuse symmetric thickening wall gallbladder, likely related chronic liver disease. 4. Fatty liver. forms advanced liver disease fibrosis cirrhosis cannot excluded. 5. Liver vessels patent. Reverse flow seen left right anterior portal vein. right posterior portal vein visualized due breathing artifact - [6-15] fluid study: negative malignancy - [6-22]: Flexsig active bleeding - [6-23]: endoscopy: active bleeding - [6-25]: CT abdomen: 15-cm left anterior abdominal/pelvic wall hematoma correlation trauma intervention suggested. free intraperitoneal air extensive ascites cirrhotic liver before. Unchanged hepatic hypodensities, small characterized. Unchanged multiple vertebral body compression fractures - [6-26]: GIB study: active GI bleeding imaged time period - [2119-6-27] EGD active bleeding - [2119-7-4] CT ab/pelv LLQ abdominal wall hematoma - [2119-7-4] Colonoscopy active bleeding - [2119-7-5] Paracentesis 2+PMNs, microorg. . - [2119-7-6] Paracentesis 2+PMNs, microorg. - [7-8] CXR: Moderate bilateral pleural effusions, edema lower lobe atelectasis/pneumonia - [7-9] CXR: Minimal improvement pulmonary edema still severe - [2119-7-12] paracentesis - [2119-7-12] ucx 10-100,000 VRE - [2119-7-11] UA bac, 19 RBC, 9 WBC Brief Hospital Course: 55yoF alcoholic cirrhosis s/p TIPS [1-/2118] found husband admitted MICU GIB resp failure. Improved MICU extubated [6-14]. floor, Ms. [Known lastname 696] noted AMS likely [1-18] Korsakoff's amnesia. 1. Abdominal wall hematoma: pt began complain pain site originally though ventral hernia LLQ. abd protrusion palpated crepitus could reduced, action taken mass thought hernia time. Pt supposed go colonoscopy K+ low, delayed [2119-7-4]. pt felt diarrhea improved day. Creatinine elevated 2.1 thought [1-18] poor renal perfusion. pt started albumin 100mg. Renal u/s negative obstruction. hct 17.5 midnight pt received 2 units PRBC, repeat hct 24.8. Pt's abdominal protrusion approx doubled size tender. Pt went GI suite colonoscopy, show source bleeding. colonoscopy, abdominal protrusion twice large continued progress rapidly throughout day. developed bluish appearance - surgery consulted pt sent non con CT showed hematoma. Repeat Hct CT 21.0, pt given another unit PRBC also transfused 1 unit FFP, 100mg cryoprecipitate. Cr 2.0 albumin jumped PM 2.3, likely [1-18] ongoing blood loss. 2. post-operative course: Patient taken evacuation hematoma [2119-7-5] [7-6] intraop 2L paracentesis. Intraop: 1u prbc, 1u FFP, albumin. Patient extubated responsive postop. Patient transfused 2u PRBC's Hct 25 setting active bleeding. Additional 7u PRBC next 2 nights. JP putting sanguineous fluid, Hct decreasing. Transfused 2u PRBC, 2 FFP, 1 cryo. Direct pressure applied LLQ. JP Hct sent. Ceftriaxone started SBP per Hepatology recs. [7-7] U PRBC given, started 1/2cc per cc replacement JP output. UOP adequate. Pain control adequate. [7-8], 2u FFP given INR 1.7. High JP output continued, NS repletion increased cc per cc. Pt later became acutely dyspneic desaturation high 70s. CXR consistent flash pulmonary edema. IVF discontinued, pt responded well BiPAP 40 IV Lasix. Pt later weaned nasal cannula. IVF repletion JP output resumed 1/2cc per cc ratio. Remained persistently tachycardic throughout. Increasing PVCs improved K repletion. Regular diet started. Overnight, burst tachycardia 170s, EKG unchanged troponin negative. transferred ICU floor [7-10]. complained shortness breath day sitting also component anxiety. ambulated, tolerating regular diet, making good urine. continued ceftriaxone. [7-12], underwent diagnostic therapeutic paracentesis, 3L taken sent studies, showed clearance SBP. switched ciprofloxacin. ambulated physical therapy. Tolerating regular diet. 3. Mental status: transfer floor MICU, patient noted confused AMS. Differential initially anoxic brain injury vs. hepatic encephalopathy vs. delerium vs. withdrawal. Psych neuro consulted. Benzos weaned. Lactulose provided MRI brain revealed evidence anoxic brain injury. Given prominence patient's confabulations absence memory loss, suspected neurology patient suffering Korsakoff's amnesia. patient's family informed diagnosis. 4. GIB: Patient coffee grounds NG tube admission noted bright red blood coming NG tube first several days admission. started Octreotide Pantoprazole gtt's. given 1u plts, 3u FFP, 3u PRBC's, 10 mg IV Vitamin K admission. Liver consulted, felt since imaging showed patent TIPS UGIB portal HTN unlikely. Pt eventually scoped showed 2cm non-bleeding ulcer clot overlying given NG tube holiday prevent irritation allow healing. Also showed mild portal gastropathy. Hct stable call MICU. floor, patient HD stable. [6-23], noted patient tachycardic 140s. HCT fell 34.4 28.7 BRBPR noted. patient undergone sigmoidoscopy evaluate ?ischemic colitis day prior without bleeding source noted. [6-23] underwent endoscopy also without evidence bleeding source. patient transfused appropriate HCT response remained stable without BRBPR afterward. Source bleeding likely hemorrhoidal. [6-27] - [6-29] transfused 4u pRBCs total. 5. Hypotension: Fluid resuscitated crystalloid colloid. Started Levophed gtt. Arterial line placed. given broad spectrum ABx (Vanc/Zosyn) culture grew MSSA sputum. Echo normal. note, weaned pressors stabilized, necessitated diuresis volume overload/pulmonary edema. 6. Renal failure: Felt ATN due hypotension vs HRS vs mild rhabdomyolysis given mildly elevated CK's. initially HCO3 gtt, fluid resuscitated. Electrolytes abnormal (K, Phos, Ca) repleted aggressively normalized. never needed dialysis renal function improved. 7. Alcoholic Cirrhosis s/p TIPS: Patient US ED showing patent TIPS. received IV thiamine IV Folate. started Lactulose Rifaxamin extubation; liver recommended starting Pentoxyfyline x30 days pt able. Repeat U/S [2119-7-15] showed patent TIPS 8. AFib: episode AFib RVR flipped back NSR IV Metoprolol. issues. Medications Admission: - Folic Acid 1 mg daily - Thiamine HCl 100 mg daily - Ciprofloxacin 250 mg daily SBP prophylaxis - Pantoprazole 40 mg EC daily - Simethicone 80 mg qid - Furosemide 20 mg daily - Spironolactone 100 mg daily - Docusate Sodium 100 mg [Hospital1 ] prn - Senna 8.6 mg Tablet: 1-2 Tablets [Hospital1 ] prn - Tramadol 25 mg q12h prn pain: 50 mg/day. Discharge Medications: 1. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO BID (2 times day). 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 4. pentoxifylline 400 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO TID (3 times day). 5. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES DAY MEALS). 6. loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 7. insulin lispro 100 unit/mL Solution Sig: follow sliding scale units Subcutaneous ASDIR (AS DIRECTED). 8. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () needed hypoglycemia protocol. 9. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times day) needed itching. 10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush 10mL Normal Saline followed Heparin daily PRN per lumen. 12. MagOx 400 mg Tablet Sig: One (1) Tablet PO day. 13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Outpatient Lab Work Labs twice weekly chem 10 fax results [Telephone/Fax (1) 697] attention [First Name4 (NamePattern1) 698] [Last Name (NamePattern1) 699], RN coordinator 16. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice day. 18. potassium chloride 20 mEq Packet Sig: Two (2) Packet PO BID (2 times day). Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: abdominal wall hematoma alcoholic cirrhosis ascites Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - requires assistance aid (walker cane). Discharge Instructions: admitted hepatobiliary service [Hospital1 18] evacuation abdominal wall hematoma. 2 JP drains used hematoma cavity, put serosanguinous ascites fluid. Drain care: drains left place output minimal seen [Hospital 702] clinic. Please continue drain dressings emptying drains daily. Diet: continue regular diet supplements increase caloric intake. Activity: Please ambulate tolerated multiple times per day. Medications: Continue discharge medications home medications. increased lasix 40 mg [Hospital1 ] home 20 mg daily dose. Followup Instructions: Provider: [Name10 (NameIs) 703] [Location 704] [Location 705] / IOUS [Location 706] Phone:[Telephone/Fax (1) 327] Date/Time:[2119-7-24] 9:00 Provider: [Name10 (NameIs) 706] CARE,FIVE [Name10 (NameIs) 706] CARE UNIT Phone:[Telephone/Fax (1) 446] Date/Time:[2119-7-26] 8:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2119-7-26] 3:00 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2119-7-18]	[ "570" ]
Admission Date: [2122-3-28] Discharge Date: [2122-3-31] Date Birth: [2041-6-29] Sex: F Service: MEDICINE Allergies: Morphine / Motrin / Levaquin Attending:[First Name3 (LF) 689] Chief Complaint: shortness breath Major Surgical Invasive Procedure: None History Present Illness: 80yo female multiple medical problems including hypertension, recent ICU admission pulmonary edema ARDS, previous admission septic hip treatment admitted shortness breath chest pain. . several recent admissions [Hospital1 18] within last 3 months. - [Date range (1) 44958] - admitted right septic hip underwent washout repair. discharged complete 6 week course nafcillin - [Date range (1) 44959]/09 - hospitalized shortness breath. admission, found bilateral infiltrates consistent multifocal pneumonia superimposed pulmonary edema, well diffuse alveolar hemorrhage. pneumonia, treated broad spectrum antibiotics vancomcyin, zosyn, azithromycin. pulmonary edema, treated aggressively diuretics, nitroglycerin, beta blockers. diffuse alveolar hemorrhage, treated short time steroids complicated delirium underwent extensive autoimmune work-up negative. discharged rehab 2L O2 furosemide 40mg PO bid. . Rehab, developed multiple complications, including delirium, acute renal failure, fever, chest pain, shortness breath. delirium thought likely related medications (received short course baclofen), infection, renal failure. Regarding acute renal failure, creatinine increased 2.6 1.5 within 2 days discharge, furosemide anti-hypertensives discontinued, started IVF. Regarding fever, febrile high 102 rehab. Regarding chest pain shortness breath, evaluated pulmonary consultant day transfer thought CHF exacerbation. . Upon arrival ED, temp 100.2, HR 86, BP 133/50, RR 18, Pulse ox 77% room air. ED, remained afebrile, normotensive, 96-10% NRB. received SL NG x 3 started nitro drip chest pain. blood cultures drawn received zosyn. also received zosyn pneumonia, started heparin drip treatment presumed pneumonia, also given fentanyl 25mcg IV x 1 treatment chest pain. . Upon arrival floor, initially reported [7-24] chest pain, describes located across left anterior chest, character pleuritic, duration intermittent, worsened deep inspiration movement, reliever hydromorphone rest. Additional review systems notable following: shortness breath, fatigue, back pain (chronic unchanged), lower extremity swelling, neck pain (chronic unchanged). delirium markedly improved according daughters. . review systems, denies prior history stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding time surgery, myalgias, cough, hemoptysis, black stools, red stools. denies shaking chills, rigors. dysuria, diarrhea, abdominal pain, cough, sputum production. denies exertional buttock calf pain. review systems negative. . Cardiac review systems notable absence dyspnea exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope presyncope. . Past Medical History: 1. Coronary Artery Disease s/p CABG bioprosthetic AVR [2119] 2. Diastolic Heart Failure 3. Type 2 Diabetes Mellitus complicated neuropathy 4. Chronic Renal Insufficiency 5. Hypertension 6. Diverticulitis 7. Hyperlipidemia 8. Hypothyroidism 9. Endometriosis . PAST SURGICAL HISTORY: 1. s/p R Hip hemiarthroplasty fracture [2111]. 2. Right hip washout head replacement [2122-1-17] 3. s/p b/l TKR 4. s/p appendectomy, 5. s/p TAH-BSO, 6. status post right carpal tunnel release, status post tonsillectomy. 7. s/p Nissen 8. s/p CABG [5-20] . Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension . Cardiac History: CABG, [2119] anatomy follows: LIMA --> LAD . Percutaneous coronary intervention: applicable Social History: - Home: previously lived independently [Location (un) ]; living daughter / health care proxy preparation upcoming right hip revision multiple, recent hospitalizations; currently [Hospital 100] Rehab - Tobacco: Denies - Alcohol: previous history alcohol abuse > 30 years ago Family History: Non-contributory Physical Exam: VS: 96.7 / HR 75 / BP 126/42 / RR 27 / Pulse ox 100% 15L NRB Gen: WDWN elderly female mild respiratory distress requiring NRB. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, pallor cyanosis oral mucosa. xanthalesma. Neck: Supple elevated JVP earlobe. CV: PMI located 5th intercostal space, midclavicular line. RR, normal S1, S2. [3-20] mechanical systolic murmur LUSB. thrills, lifts. S3 S4. Chest: chest wall deformities, scoliosis kyphosis. Resp unlabored, accessory muscle use. Well-healed anterior midline sternotomy scar. bibasilar crackles right middle lung crackles well Abd: Obese, Soft, NTND. HSM tenderness. Abd aorta enlarged palpation. abdominial bruits. Ext: trace - 1+ bilateral lower extremity edema. femoral bruits. Right hip without evidence inflammation - erythema, tenderness, pain, swelling Skin: stasis dermatitis, ulcers, scars, xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Admission Labs [2122-3-28] 02:00PM BLOOD WBC-15.3* RBC-2.84# Hgb-9.0 Hct-25.1* MCV-88 MCH-31.7 MCHC-35.9* RDW-15.6* Plt Ct-227 [2122-3-28] 02:00PM BLOOD Neuts-88.7* Lymphs-8.4* Monos-2.3 Eos-0.4 Baso-0.2 [2122-3-28] 02:00PM BLOOD PT-14.1* PTT-31.7 INR(PT)-1.2* [2122-3-28] 02:00PM BLOOD Glucose-126* UreaN-17 Creat-1.5* Na-135 K-4.7 Cl-103 HCO3-21* AnGap-16 [2122-3-28] 02:00PM BLOOD CK-MB-NotDone proBNP-9713* [2122-3-28] 02:00PM BLOOD cTropnT-0.27* [2122-3-28] 10:28PM BLOOD Calcium-8.8 Phos-4.5 Mg-1.9 [2122-3-29] 05:18AM BLOOD calTIBC-185* VitB12-564 Folate-3.8 Ferritn-661* TRF-142* [2122-3-28] 02:16PM BLOOD Lactate-1.2 [2122-3-28] 10:28PM BLOOD CK-MB-NotDone cTropnT-0.20* [2122-3-29] 05:18AM BLOOD CK-MB-NotDone cTropnT-0.15* [2122-3-28] 10:28PM BLOOD CK(CPK)-55 [2122-3-29] 05:18AM BLOOD CK(CPK)-28 [2122-3-28] 10:28PM BLOOD Glucose-123* UreaN-19 Creat-1.7* Na-138 K-5.6* Cl-104 HCO3-22 AnGap-18 [2122-3-29] 05:18AM BLOOD Glucose-97 UreaN-20 Creat-1.8* Na-134 K-4.7 Cl-101 HCO3-23 AnGap-15 [2122-3-29] 01:58PM BLOOD Glucose-123* UreaN-22* Creat-1.7* Na-136 K-4.2 Cl-99 HCO3-24 AnGap-17 [2122-3-29] 05:18AM BLOOD WBC-10.6 RBC-2.74* Hgb-8.5* Hct-24.6* MCV-90 MCH-31.0 MCHC-34.5 RDW-15.8* Plt Ct-208 . Discharge labs: [2122-3-31] 05:55AM BLOOD WBC-7.8 RBC-2.90* Hgb-9.1* Hct-25.4* MCV-88 MCH-31.3 MCHC-35.7* RDW-15.7* Plt Ct-310 [2122-3-31] 05:55AM BLOOD Plt Ct-310 [2122-3-31] 05:55AM BLOOD Glucose-117* UreaN-26* Creat-1.9* Na-133 K-4.3 Cl-93* HCO3-27 AnGap-17 [2122-3-31] 05:55AM BLOOD CK(CPK)-12* [2122-3-31] 05:55AM BLOOD Calcium-8.9 Phos-4.7* Mg-2.2 [2122-3-29] 05:18AM BLOOD calTIBC-185* VitB12-564 Folate-3.8 Ferritn-661* TRF-142* . [2122-3-29] CXR: fluctuating appearance parenchymal opacities consistent recurrent pulmonary edema. Compared recent chest radiograph [2122-3-28], interval progression parenchymal opacities involving entire lungs worrisome interval worsening pulmonary edema. appreciable pleural effusions seen, although small amount pleural fluid cannot excluded. changes sternotomy wires position well cardiomediastinal contour demonstrated. fluctuating character parenchymal opacities consistent pulmonary edema infection, although underlying foci infection ARDS cannot completely excluded. . [2122-3-29] LENIs: IMPRESSION: evidence DVT seen either lower extremity. . [2122-3-29] Renal US : IMPRESSION: evidence hydronephrosis although right kidney appears smaller left. Brief Hospital Course: 80yo female history multiple medical problems including recent right hip infection, diastolic dysfunction, recent hospitalization intubation, Type 2 Diabetes Mellitus admitted shortness breath. . 1. Shortness Breath: Etiology shortness breath likely multifactorial. Differential diagnosis includes congestive heart failure exacerbation related recent medication changes fluid administration, pneumonia setting rehab stay / recent hospitalization / recent intubation, splinting secondary chest pain. additional possibility includes pulmonary embolism given recent hospitalization immobilization. Unfortunately candidate CTA time due renal failure, VQ scan would likely helpful due diffuse patchy infiltrates. briefly started heparin gtt admission. Bilateral LENI's negative [3-29]. Pulm consulted thought CHF likely PE unlikely heparin gtt stopped, vanco/zosyn HAP started [3-28] continued. pt diuresed initially lasix gtt transitioned [Hospital1 ] lasix prior transfer. time transfer, continues c/o inability take deep breath EKG without changes pt slight crackles exam. Would recommend pt kept slightly negative OSH Cr remains baseline 1.9. . 2. Chest Pain: Etiology chest pain unclear. Differential includes pain related pneumonia, GERD esophageal irritation s/p intubation NGT placement prior admission. Pt c/o odynophagia evidence aspiration. Pericarditis, pulmonary embolism, costochondritis considered unlikely. description pain also consistent acute coronary syndrome, ECG also unremarkable ACS. treated HAP given dilaudid PRN poor control pain baseline. future, GI ENT could consulted evaluate odynophagia. PPI continued here. . 3. Fever Leukocytosis likely [2-16] pneumonia. time transfer OSH, blood urine cultures remain without growth rapid viral testing negative. pt continued vanco/zosyn HAP. pt needs bactrim s/p osteo 6 months hold pt vanco/zosyn. restarted current abx finished. . 4. Acute Renal Failure Etiology acute renal failure likely secondary dehydration aggressive diuresis. Avoided nephrotoxins, held ACEI NSAIDs. future, would recommend gentle diuresis. . 5. Coronary Artery Disease Continued aspirin statin. CP thought c/w ACS. Elevated trops setting unremarkable CK MB thought [2-16] renal failure. ECG unchanged. Beta blocker held setting CHF exacerbation ACEI held setting ARF. . 6. Anemia Patient's hematocrit decreased 33 last discharge 25 admission. Hct remained stable discharge. Iron studies d/w anemia chronic disease. Retic count elevated 2.4 prior discharge. Would recommend continuing trend Hct guaiac stools. . 7. Hypothyroidism Stable, continued levothyroxine . #. Code: FULL CODE, confirmed patient daughter #. Communication: Patient; Daughter HCP [Name (NI) ] [Name (NI) ] [Telephone/Fax (1) 44960] Medications Admission: REHAB MEDICATIONS: 1. Levothyroxine 100 mcg PO Qday 2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, 3 patches 12hrs on, 12 hours 3. Omeprazole 20mg PO daily 4. Simvastatin 40 mg PO Qday 5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet PO BID 6. Bisacodyl 10mg PR daily prn 7. Tylenol 975mg PO tid 8. Aspirin 81 mg PO Qday 9. Calcium Carbonate 350 mg PO TID 10. Cholecalciferol (Vitamin D3) 800 unit PO Qday 11. Vitamin B12 500mcg PO daily 12. Conjugated Estrogens 0.3 mg PO Qday 13. Ferrous Sulfate 325 mg (65 mg Iron) PO Qday 14. Gabapentin 200mg PO tid 15. Heparin 5000 units SC bid 16. Insulin humalog sliding scale Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Insulin Lispro 100 unit/mL Solution Sig: One (1) sliding scale Subcutaneous ASDIR (AS DIRECTED). 9. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times day). 11. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) needed. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times day). 15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times day). 16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times day) needed. 18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush 3 mL Normal Saline every 8 hours PRN. 19. Vancomycin 1000 mg IV Q48H Day 1 - [2122-3-28] 20. Piperacillin-Tazobactam Na 2.25 g IV Q6H Day 1 - [2122-3-28] 21. HYDROmorphone (Dilaudid) 0.25 mg IV Q4H:PRN Please hold RR < 12 and/or sedation. Thanks. 22. Ondansetron 4 mg IV Q8H:PRN Discharge Disposition: Extended Care Discharge Diagnosis: Hospital acquired Pneumonia diastolic CHF Acute Chronic renal failure CAD Anemia Discharge Condition: stable. O2 sat mid 90's 2L NC. Afebrile. tachycardic. BP stable Discharge Instructions: admitted CHF exacerbation. here, diuresed. also treated hospital acquired pneumonia. briefly started heparin drip possible pulmonary embolism stopped pulmonary consult thought diagnosis unlikely. continue complain chest pain despite EKG changed think could due mechanical trauma recent intubation NG tube. . Please follow below. . Please see attached medications transfer. . Please call doctor return ED chest pain, increasing shortness breath, vomitting, blood stools concerning symptoms. Weigh every morning, [Name8 (MD) 138] MD weight > 3 lbs. Adhere 2 gm sodium diet Fluid Restriction: Followup Instructions: [Hospital ] clinic: [First Name4 (NamePattern1) 8495] [Last Name (NamePattern1) 8496], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2122-4-23] 10:00 CAT SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2122-4-29] 1:30 Please follow Dr. [Last Name (STitle) ] directed staff [Hospital1 ] [Location (un) 620] Completed by:[2122-3-31]	[ "486" ]
Admission Date: [2163-10-14] Discharge Date: [2163-10-17] Service: CCU CHIEF COMPLAINT: Substernal chest pain. HISTORY PRESENT ILLNESS: 85 year-old female known coronary artery disease status post inferior myocardial infarction [2161], hypertension, increased cholesterol, tobacco, presented three days substernal chest pain. went primary care physician found electrocardiogram changes (deepened wave inversions V1 V6, 2, 3, AVL). chest pain free throughout primary care physician's visit. sent [Hospital1 190] Emergency Room, increasing chest pressure 7 10 substernally associated diaphoresis, sinus bradycardia 45 beats per minute, systolic blood pressure dropped 70s electrocardiogram notable 2 [Street Address(2) 1755] elevations V1 V6 additionally reciprocal wave inversions 2, 3, AVF. received half dose Integrilin, heparin, aspirin, beta blocker, taken directly cardiac catheterization laboratory. found left main coronary artery disease short, left anterior descending artery proximal tubular lesion 80% prior diagonal, mild moderate diffuse disease, mid left anterior descending coronary artery, TIMI two flow slowly distally. left circumflex diffuse disease 40% involving CX obtuse marginal, collateral right coronary artery. right coronary artery mildly calcified, tubular 80 90% proximal mid stenoses, competitive flow seen RPL, diffuse disease mid right coronary artery. proximal left anterior descending coronary artery dilated 2.5 15 mm open sail 6 atmospheres stented. residual stenosis, TIMI two fast flow observed. cardiac catheterization also notable cardiac output 2.7, cardiac index 1.8, wedge pressure 29, elevated filling pressures PA diastolic pressure 26. left ventriculogram performed. patient received intravenous Lasix transferred Coronary Care Unit. hemodynamically stable throughout catheterization. PHYSICAL EXAMINATION: Vital signs admission, temperature 96.5. Blood pressure 108/38. Heart rate 56. Respiratory rate 15 20 sating 95 97% 2 liters. general, patient talkative acute distress. oropharynx clear without lesions. JVD. carotid bruits. regular rate rhythm mild 2 6 early systolic ejection murmur bilateral sternal borders well positive S3. lungs clear auscultation. without wheezes. abdomen soft, nontender, nondistended. normoactive bowel sounds organomegaly. right groin small hematoma without bruit. 1+ pedal pulses bilaterally edema. PAST MEDICAL HISTORY: 1. patient history coronary artery disease myocardial infarction [2163]. 2. Increased cholesterol. 3. Hypertension. 4. Osteoporosis. CARDIAC MEDICATIONS ADMISSION: Aspirin 325 mg po q.d., Digoxin 0.25 mg po q.d., Atenolol 25 mg po q.d., Lipitor 20 mg po q.d. SIGNIFICANT LABORATORY FINDINGS ADMISSION: white blood cell count 11.3, hematocrit 41.3, platelets 239. Chemistries sodium 140, potassium 5.3, BUN 24, creatinine 0.9, glucose 125, CK admission 136, MB fraction 8, troponin 6.3. ALT 24, AST 19. Electrocardiogram admission stated history present illness. HOSPITAL COURSE: 1. Cardiac: Ischemia; patient finished course Integrilin heparin. maintained aspirin, Plavix Lipitor. remained chest pain free subsequent initial presentation Emergency Department. peak CKs 260, peak MB 28 peak cardiac index 10.8. dynamic electrocardiogram changes throughout stay. Given minimal CK leak presumably patient interrupted acute myocardial infarction amenable angioplasty proximal left anterior descending coronary artery. Pump; patient noted high filling pressures intracath. diuresed adequately started ace inhibitor well beta blocker pressures tolerated it. outpatient Digoxin continued admission, included outpatient regimen. patient echocardiogram performed [2163-10-17]. ejection fraction notably 30 35%. moderate symmetric left ventricular hypertrophy, moderate global left ventricular hypokinesis, inferior severe hypokinesis. Overall left ventricular systolic function moderately decreased. 2+ aortic insufficiency. Also ascending aorta noted mildly thickened. Rhythm; patient episodes sinus bradycardia sleep low 40 beats per minute. sinus bradycardic episodes asymptomatic resolved awakening activity. 2. Pulmonary: patient supplemental oxygen requirements hospitalization well pulmonary standpoint. patient seen physical therapy hospitalization able ambulate back baseline level function. patient also advised repeatedly admission quit smoking cigarettes. patient ready quit time. FOLLOW APPOINTMENTS: patient follow Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 111570] Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] clinic. patient called [2163-10-18] appointment time place. patient also instructed call primary care physician, [First Name4 (NamePattern1) 401] [Last Name (NamePattern1) 410], set follow appointment ensuing weeks. FOLLOW ISSUES: 1. patient provided visiting home nurse services order obtain medication teaching. ALLERGIES DISCHARGE: patient known drug allergies. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg po q day. 2. Plavix 75 mg po q.d. complete thirty day course patient written prescription additional 26 days complete thirty days. 3. Lipitor 20 mg po q day. 4. Zestril 2.5 mg po q.d. 5. Atenolol 25 mg po q day. 6. Miacalcin 2200 IU per ml. 7. Multivitamin. 8. Calcium carbonate. 9. Vitamin taking before. 10. patient's Digoxin discontinued resuming medication. CODE STATUS: Full code. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1013], M.D. [MD Number(1) 1014] Dictated By:[Doctor Last Name 111571] MEDQUIST36 D: [2163-10-18] 15:22 T: [2163-10-21] 09:04 JOB#: [Job Number 7070]	[ "496", "412" ]
Admission Date: [2137-8-16] Discharge Date: [2137-8-29] Service: MEDICINE Allergies: Atenolol Attending:[First Name3 (LF) 3984] Chief Complaint: Hypoxia Major Surgical Invasive Procedure: endotracheal intubation tracheotomy tube placement placement PEG (feeding) tube History Present Illness: 86 year old male pmh COPD, CAD, HTN, DMII feeling weak difficulty standing [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] found O2 sat 46% 2L NP, marginal improvement 63% 5L NP. placed NRB transported [Hospital1 18]. Full vitals prior transfer 98.4, BP 149/84, P121, RR22. Allergies atenolol Tylenol #3. . [Hospital1 18] ED, able state name, though appeared distressed. moving extremities. Intial vitals were: T: 100.5 BP 133/68, HR 114, Sat 100% NRB RR 30s. rectal temperature 101 F. intubated sedated fentanyl Versed. CXR showed multifocal pneumonia. given 1g tylenol, 750mg IV levofloxacin 750cc NS. EKG showed, sinus tach 111, LAD, NI, TWF aVL, poor baseline. transfer vitals: 98.3 HR 101 BP 110/61 Sat 98% CMV mode, TV 500, FiO2 50%, RR 24 PEEP 5. . transfer MICU, intubated completely sedated. responding commands. Past Medical History: (Per OMR) DM (DIABETES MELLITUS) LUNG DISEASE, CHRONIC OBSTRUCTIVE HYPERTENSION, ESSENTIAL LOW BACK PAIN FTT (Failure Thrive) Adult Hypotension BLINDNESS - LEGAL HISTORY CORNEA TRANSPLANT GLAUCOMA - PRIMARY OPEN ANGLE DEPRESSIVE DISORDER CANCER PROSTATE TUBERCULOSIS BRONCHIECTASIS CORONARY ARTERY DISEASE RECTAL BLEEDING Social History: Former truck driver, prior worked defense factory. Currently residing [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ]. HCP [Name (NI) ] [Name (NI) ], daughter [Name (NI) 40477] [Name (NI) ]. Also, granddaughter area, involved care. - Tobacco: Quit smoking 20 years ago, smoked 18 - 65; used smoke 1PPD - Alcohol: Heavy drinker smoker - Illicits: Unknown Family History: DM father mother. [Name (NI) ] cancers. Physical Exam: Admission Exam: Vitals: T: 98.5 BP: 119/63 P: 101 R: 20 O2: 100% CMV, 500, 50%, 14 5. General: Intubated, sedated responding commands HEENT: Sclera anicteric, Cataracts bilterally, non-responsive pupils (blind) mildly dry MM, oropharynx clear Neck: supple, JVP elevated, LAD Lungs: Mechanical breath sounds minimal wheezing. Rhonchi right upper lung zone CV: Normal rate Regular rate, II/VI holosystolic murmur obscuring S1 rubs, gallops Abdomen: soft, mildly distended, non-distended, bowel sounds present, rebound tenderness guarding, organomegaly GU: foley place Ext: warm, + clubbing right hand, missing 4 digits left hand, chronic venous stasis changes bilateral lower extremities, multiple 1cm areas ulceration, edema Neuro: Non-responsive sedation Discharge physical exam General Appearance: Thin Eyes / Conjunctiva: cataracts, nonresponsive pupils b/l Head, Ears, Nose, Throat: Normocephalic, Poor dentition Peripheral Vascular: (Right radial pulse: assessed), (Left radial pulse: assessed), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : , No(t) Rhonchorous: ) Abdominal: Soft, Non-tender, Bowel sounds present, Peg site intact Musculoskeletal: Muscle wasting Skin: assessed Neurologic: Responds to: assessed, Movement: assessed, Tone: assessed Pertinent Results: Admission Labs: [2137-8-16] 08:05AM BLOOD WBC-8.8# RBC-3.43* Hgb-9.9* Hct-29.2* MCV-85 MCH-28.9 MCHC-34.0 RDW-14.0 Plt Ct-217 [2137-8-16] 08:05AM BLOOD Neuts-81.1* Lymphs-12.5* Monos-5.6 Eos-0.4 Baso-0.4 [2137-8-16] 08:05AM BLOOD PT-13.0 PTT-25.3 INR(PT)-1.1 [2137-8-16] 08:05AM BLOOD Glucose-234* UreaN-19 Creat-1.1 Na-141 K-4.9 Cl-103 HCO3-31 AnGap-12 [2137-8-16] 08:05AM BLOOD proBNP-754 [2137-8-16] 08:05AM BLOOD cTropnT-0.01 [2137-8-16] 08:05AM BLOOD Triglyc-64 [2137-8-16] 09:27AM BLOOD Type-ART Temp-38.6 Rates-/28 PEEP-5 pO2-53* pCO2-67* pH-7.28* calTCO2-33* Base XS-2 Intubat-INTUBATED Vent-CONTROLLED [2137-8-16] 08:12AM BLOOD Lactate-1.1 . Discharge labs: [2137-8-29] 05:41AM BLOOD WBC-10.4 RBC-2.85* Hgb-8.2* Hct-24.7* MCV-87 MCH-28.6 MCHC-33.1 RDW-13.9 Plt Ct-462* [2137-8-29] 05:41AM BLOOD PT-14.0* PTT-26.7 INR(PT)-1.2* [2137-8-29] 05:41AM BLOOD Glucose-123* UreaN-20 Creat-1.0 Na-140 K-3.9 Cl-102 HCO3-33* AnGap-9 [2137-8-29] 05:41AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.5 [2137-8-28] 03:38AM BLOOD Vanco-15.3 [2137-8-29] 06:08AM BLOOD Type-ART Temp-37.2 Rates-[10-9] Tidal V-500 PEEP-5 FiO2-40 pO2-97 pCO2-53* pH-7.43 calTCO2-36* Base XS-8 Intubat-INTUBATED Vent-CONTROLLED [2137-8-26] 02:01PM BLOOD Lactate-0.7 K-3.9 [2137-8-21] 05:10PM BODY FLUID Polys-44* Lymphs-19* Monos-0 Mesothe-17* Macro-20* . CXR [2137-8-16] 1. Multifocal opacities confluent opacity right upper lung field. findings worrisome multifocal pneumonia. 2. Bilateral small pleural effusions. 3. Mild moderate pulmonary edema. . Echo [2137-8-16] Normal biventricular cavity size normal regional low normal global left ventricular systolic function. Pulmonary artery hypertension. Mild-moderate mitral regurgitation. findings suggestive primary pulmonary process (OSA, COPD, etc.). . CT Chest [2137-8-22] 1. Multifocal pneumonic consolidation predominantly involving right upper lobe. 2. Moderate loculated effusion along right minor fissure minimal simple effusion bilaterally. 3. Borderline enlarged mediastinal lymph nodes. Prominent right hilar appearance could due enlarged lymph node enlarged vessles, however defining cause limited due lack intravenous contrast administration. 4. Bilateral pleural calcifications. Please correlate clinical history asbestos exposure. history established, follow-up imaging surveillance recommended. . Dishcarge Chest xray [2137-8-29]: interval prior examination, endotracheal tube removed tracheostomy placed standard position. Right-sided PICC unchanged tip reaching low SVC. significant change multifocal opacities, greatest right base. Trace pleural effusions may present. pneumothorax seen. cardiomediastinal silhouette significantly changed. . Microbiology: BAL RESPIRATORY CULTURE (Final [2137-8-24]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. ~[2125]/ML. Oxacillin RESISTANT Staphylococci MUST reported also RESISTANT penicillins, cephalosporins, carbacephems, carbapenems, beta-lactamase inhibitor combinations. Rifampin used alone therapy. _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 TETRACYCLINE---------- <=1 TRIMETHOPRIM/SULFA---- <=0.5 VANCOMYCIN------------ 1 Brief Hospital Course: 86 year old male history COPD, DMII, CAD HTN admitted respiratory failure multifocal pneumonia. . # Respiratory failure: History COPD, found hypoxic [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] 46% 2L. CXR showed multifocal pneumonia. given levofloxacin ED intubated. Febrile 101 rectally ED. Failed extubation due respiratory fatigue, tachypnea, worsening shortness breath. re-intubated underwent bronchocopy. BAL revealed MRSA. IP consulted tracheotomy tube/PEG performed [8-27]. Pt continue vanco total 14 days end [9-4]. may continue require Oxycodone needed pain related tracheostomy tube. discharge chest xray showed increased opacities attribute de-recruitment higher ventilator settings. Would recommend monitoring respiratory status, fever curve (currently afebrile) ventilator requirements would re-image consider antibiotics clinical status changes. Plan wean ventilator tolerated. . # DMII: oral hypoglycemics home. insulin SS house. started tube feeds goal discharge. Home metformin glipizide held- would restart time discharge home. . # HTN: diltiazem home (ER). started lisinopril 40mg. initially required IV hydral, transitioned amlodipine 10mg daily. . # CHF/Venous stasis: furosemide. Chronic venous stasis changes. EF 50-55% admission, echo showed pulmonary HTN. diuresed, ultimately put standing dose [Hospital1 ] Lasix remain euvolemic. Lytes checked K replaced aggressively. furosemide 40mg daily discharge. Would recommend checking [Hospital1 ] electrolytes replete necessary. Goal diuresis 500 cc negative daily following in/outs. . # Glaucoma: Legally blind due acute angle glaucoma, also bilateral cataracts. Continued home eye drops. . # Anemia: Unclear baseline. MCV normal. monitor. signs bleeding, Hct stable. . Full Code Medications Admission: ([First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 1188] [Last Name (NamePattern1) ] Med Rec) Metformin 1000mg PO BID Dorzolemide/Timolol 2%-0.5% 1gtt eyes, [Hospital1 ] Erythromycin opth, 5mg/gm, apply left eye HS Lumigam 0.03% gtt, 1 gtt eye HS glipizide 10mg PO BID [Last Name (un) 7139] 128; 5% gtts - 1 gtt eye Q6H Famciclovir 500mg; 0.5 tabs PO daily Omeprazole 20mg PO daily Citalopram 10mg PO daily Diltiazem CR 180mg PO daily fluticasone nasal spray 1 spray nostril daily furosemide 20mg PO daily Spiriva 18mcg 1 cap, daily Artificial tears [Hospital1 ] Bromide Tartrate 0.2% 1 gtt eye [Hospital1 ] Calcium cab w/ 600mg-400IU 1 tab [Hospital1 ] Guaifenesin 100mg/5ml; 30mls PO BID Trazadone 50mg PO HS Tylenol 650mg PO prn Bisacodyl 10mg PR prn constipation milk mag 30mls daily prn compazine 10mg TID prn nausea fleet enema daily prn albuterol nebs Q6H prn SOB Discharge Medications: 1. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [Hospital1 ]: [12-30] Drops Ophthalmic PRN (as needed) needed dry eyes. 2. acetaminophen 325 mg Tablet [Month/Day (2) ]: 1-2 Tablets PO Q6H (every 6 hours) needed pain/fever: exceed 3 grams daily. 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [Month/Day (2) ]: Six (6) Puff Inhalation Q4H (every 4 hours) needed sob/wheeze. 4. acyclovir 200 mg Capsule [Month/Day (2) ]: Two (2) Capsule PO Q12H (every 12 hours). 5. amlodipine 5 mg Tablet [Month/Day (2) ]: Two (2) Tablet PO DAILY (Daily). 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Month/Day (2) ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) needed Constipation. 7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable [Month/Day (2) ]: One (1) Tablet, Chewable PO BID (2 times day). 8. citalopram 20 mg Tablet [Month/Day (2) ]: 1.5 Tablets PO DAILY (Daily). 9. chlorhexidine gluconate 0.12 % Mouthwash [Month/Day (2) ]: Fifteen (15) ML Mucous membrane [Hospital1 ] (2 times day): Use patient mechanical ventilation. 10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 11. glucagon (human recombinant) 1 mg Recon Soln [Hospital1 ]: One (1) Recon Soln Injection Q15MIN () needed hypoglycemia protocol. 12. dorzolamide-timolol 2-0.5 % Drops [Hospital1 ]: One (1) Drop Ophthalmic [Hospital1 ] (2 times day). 13. docusate sodium 50 mg/5 mL Liquid [Hospital1 ]: Ten (10) ml PO BID (2 times day). 14. erythromycin 5 mg/gram (0.5 %) Ointment [Hospital1 ]: 0.5 gram gram Ophthalmic QHS (once day (at bedtime)). 15. fluticasone 50 mcg/Actuation Spray, Suspension [Hospital1 ]: One (1) Spray Nasal DAILY (Daily). 16. furosemide 40 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 17. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush 10mL Normal Saline followed Heparin daily PRN per lumen. 18. heparin (porcine) 5,000 unit/mL Solution [Hospital1 ]: One (1) injection Injection TID (3 times day). 19. insulin regular human 100 unit/mL Solution [Hospital1 ]: One (1) sliding scale Injection ASDIR (AS DIRECTED): following enclosed humalog sliding scale. . 20. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [Hospital1 ]: Six (6) Puff Inhalation QID (4 times day). 21. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 22. latanoprost 0.005 % Drops [Last Name (STitle) ]: One (1) Drop Ophthalmic HS (at bedtime). 23. Lorazepam 0.5-1 mg IV Q4H:PRN aggitation 24. lisinopril 20 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO DAILY (Daily). 25. lactulose 10 gram/15 mL Syrup [Last Name (STitle) ]: Thirty (30) ML PO Q8H (every 8 hours) needed constipation. 26. cholecalciferol (vitamin D3) 400 unit Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 27. oxycodone 5 mg/5 mL Solution [Last Name (STitle) ]: Ten (10) ml PO Q6H (every 6 hours) needed pain: hold sedation. 28. vancomycin 500 mg Recon Soln [Last Name (STitle) ]: 1250 (1250) MG Intravenous Q 24H (Every 24 Hours) 7 days. Discharge Disposition: Extended Care Facility: [Hospital6 459] Aged - MACU Discharge Diagnosis: Pneumonia Discharge Condition: Mental Status: Confused - sometimes. Level Consciousness: Alert interactive. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [Known lastname ] pleasure taking care [Hospital1 18]. admitted pneumonia required IV antibiotics. continued rehab. Due respiratory distress, intubated placed ventilator ("life support") lungs fully recovered. continued show improvement benefit longer weaning ventilator, thus trachestomy tube placed. removed fully able breathe own. peg tube (feeding tube stomach) also placed facilitate feeding able eat fully. need continue IV antibiotics another week. following changes made medications. STARTED Albuterol inhaler 6 puffs prn SOB STARTED acyclovir 400mg Q12 STARTED amlodipine 10mg daily hypertension STARTED Docusate sodium constipation STARTED Heparin subcutaneous TID STARTED ipratropium bromide inhaler STARTED lansoprazole reflux STARTED lorazepam anxiety STARTED lisinopril hypertension STARTED lactulose constipation STARTED oxycodone pain related tracheostomy STARTED Vancomycin (IV antibiotic) pneumonia, complete [9-4] total 14 day course. STARTED insulin coverage INCREASED furosemide/lasix dose 40mg daily INCREASED citalopram 30mg daily STOPPED glipizide STOPPED omeprazole STOPPED diltiazem STOPPED metformin STOPPED trazodone STOPPED compazine STOPPED famciclovir Followup Instructions: need follow primary care doctor discharged rehab. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438]	[ "496", "311" ]
Admission Date: [2111-4-16] Discharge Date: [2111-5-15] Date Birth: [2068-11-7] Sex: F Service: MEDICINE Allergies: Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 7591] Chief Complaint: Pneumonia, New Leukemia Major Surgical Invasive Procedure: Central Line Placement History Present Illness: Ms. [Known lastname ] 42 yo woman PMH significant morbid obesity gastric bypass 3 years ago well HTN hyperlipidemia, presents acute leukemia. . Ms. [Known lastname ] describes feeling unwell past four weeks; describes normal state health this. Four weeks ago started developing pain thighs describes achy, bony pain, associated trauma swelling. saw PCP [Name9 (PRE) 78036] increased ESR, decreased platelets abnormal electrolytes recommended followup Rheumatology. seen Rheumatologist put 10 day taper Prednisone, starting 40 mg daily. pain improve regimen instead spread arms lower back. visited [Hospital1 1474] ED discharged Percocet instructions followup rheumatologist. subsequent Rheumatology visit platelets decreased. sent back PCP referred hematology thrombocytopenia. Around time (5 days prior admission) also started notice L sided chest pain, worse taking deep breaths. unable make appointment hematology yesterday morning went [Hospital6 33] ED. denies fever, chills, difficulty breathing, diarrhea symptoms past weeks. . ED [Hospital3 ], found CBC significant WBC 15.0 7% bands, 2% atypical lymphocytes. Also ESR 113, LDH 1600, indicating acute leukemia; treated allopurinol. . Chest CT showed multiple bilateral prominent axillary lymph nodes air trapping, ground glass opacities consolidations L lung. largest L axilla measuring 1.1 cm. evaluated Infectious Disease concerned atypical PNA v. viral illness gave Levaquin. transiently desated 86% RA walking bathroom placed nasal cannula. given Percocet Toradol leg pain. Vitals transfer 98.5 103 90/58 98% 2L. . floor, comfortable pain. anxious initate diagnosis possible treatment. Past Medical History: Gastric bypass 3 years ago Hypertension Gestational diabetes Hypercholesterolemia History C-section s/[Initials (NamePattern4) ] [Last Name (NamePattern4) 8509] Social History: [Known firstname ] married 2 children, age 13 15. works ophthalmic technician [1-30] mornings week, 3-4 hours. drinks occasionally weekend last month, never smoked, use illicit drugs. Mother ALL, Breast Cancer, Lung Cancer. Family History: See Physical Exam: Admission Exam: Genera: Diaphoretic, young woman NAD HEENT: Anicteric, EOMI, Atraumatic CV: RRR, murmurs, rub Pulmonary: Decreased breath sounds bases bilaterally mild rhonchi L lung base. Ab: Normoactive BS, Soft, NT, ND Extremities: rashs, LE edema Neuro: CNII-XII intact. Strength intact four exteremities. Cerebellar testing (finger nose heel shin testing) intact. Pertinent Results: ADMISSION LABS: ============== [2111-4-16] 09:47AM BONE MARROW IPT-DONE [2111-4-16] 09:47AM BONE MARROW CD34-DONE CD3-DONE CD4-DONE CD8-DONE [2111-4-16] 09:47AM BONE MARROW CD33-DONE CD41-DONE CD56-DONE CD64-DONE CD71-DONE CD117-DONE CD45-DONE HLA-DR[Last Name (STitle) 7735] [Name (STitle) 31151] A-DONE KAPPA-DONE CD2-DONE CD7-DONE CD10-DONE CD11C-DONE CD13-DONE CD14-DONE CD15-DONE CD19-DONE CD20-DONE LAMBDA-DONE CD5-DONE [2111-4-16] 05:05PM FIBRINOGE-904* [2111-4-16] 05:05PM PT-15.0* PTT-26.0 INR(PT)-1.3* [2111-4-16] 05:05PM PLT SMR-LOW PLT COUNT-83# [2111-4-16] 05:05PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL [2111-4-16] 05:05PM I-HOS-AVAILABLE [2111-4-16] 05:05PM NEUTS-55 BANDS-0 LYMPHS-30 MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1 OTHER-15* [2111-4-16] 05:05PM WBC-10.1 RBC-2.67# HGB-8.4# HCT-24.5# MCV-92 MCH-31.3 MCHC-34.0 RDW-14.3 [2111-4-16] 05:05PM calTIBC-169 VIT B12-211* FERRITIN-[Numeric Identifier ]* TRF-130* [2111-4-16] 05:05PM ALBUMIN-3.0* CALCIUM-7.8* PHOSPHATE-2.3* MAGNESIUM-2.1 URIC ACID-4.4 IRON-60 [2111-4-16] 05:05PM ALT(SGPT)-58* AST(SGOT)-72* LD(LDH)-1681* ALK PHOS-169* TOT BILI-0.5 [2111-4-16] 05:05PM GLUCOSE-96 UREA N-18 CREAT-1.2* SODIUM-133 POTASSIUM-3.5 CHLORIDE-95* TOTAL CO2-29 ANION GAP-13 . ANC Trend ========== [2111-4-18] 12:01AM BLOOD Gran Ct-2432 [2111-4-19] 03:15AM BLOOD Gran Ct-3274 [2111-4-21] 12:00AM BLOOD Gran Ct-1748* [2111-4-22] 12:00AM BLOOD Gran Ct-870* [2111-4-23] 12:00AM BLOOD Gran Ct-152* [2111-4-25] 06:00AM BLOOD Gran Ct-0* [2111-4-26] 12:00AM BLOOD Gran Ct-0* [2111-4-27] 12:00AM BLOOD Gran Ct-0* [2111-4-28] 06:00AM BLOOD Gran Ct-40* [2111-4-29] 08:50AM BLOOD Gran Ct-30* [2111-4-30] 05:50AM BLOOD Gran Ct-0* [2111-5-1] 12:30AM BLOOD Gran Ct-0* [2111-5-2] 03:56AM BLOOD Gran Ct-0* [2111-5-4] 12:50AM BLOOD Gran Ct-0* [2111-5-5] 06:00AM BLOOD Gran Ct-0* [2111-5-6] 06:15AM BLOOD Gran Ct-0* [2111-5-7] 06:15AM BLOOD Gran Ct-0* [2111-5-6] 06:15AM BLOOD Gran Ct-0* [2111-5-7] 06:15AM BLOOD Gran Ct-0* [2111-5-8] 06:00AM BLOOD Gran Ct-0* [2111-5-9] 06:30AM BLOOD Gran Ct-9* [2111-5-10] 06:00AM BLOOD Gran Ct-11* [2111-5-11] 05:27AM BLOOD Gran Ct-39* [2111-5-12] 06:20AM BLOOD Gran Ct-195* [2111-5-13] 12:45AM BLOOD Gran Ct-209* [2111-5-13] 02:30PM BLOOD Gran Ct-524* [2111-5-14] 12:00AM BLOOD Gran Ct-503* [2111-5-14] 01:45PM BLOOD Gran Ct-1180* [2111-5-15] 12:00AM BLOOD Gran Ct-792* . DISCHARGE LABS: ================== [2111-5-15] 12:00AM BLOOD WBC-2.7* RBC-3.25* Hgb-9.5* Hct-28.6* MCV-88 MCH-29.1 MCHC-33.1 RDW-13.9 Plt Ct-823* [2111-5-15] 12:00AM BLOOD Neuts-26* Bands-0 Lymphs-31 Monos-37* Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-2* Blasts-3* [2111-5-15] 12:00AM BLOOD Glucose-131* UreaN-4* Creat-0.6 Na-136 K-3.5 Cl-98 HCO3-25 AnGap-17 [2111-5-15] 12:00AM BLOOD ALT-63* AST-46* LD(LDH)-315* AlkPhos-235* TotBili-0.4 [2111-5-15] 12:00AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.8 BONE MARROW [2111-4-16]: PATHOLOGY: BONE MARROW EXTENSIVE INVOLVEMENT ACUTE MONOCYTIC LEUKEMIA (FAB M5). CYTOGENETICS Karyotype: 54,XX,+X,+1,[Doctor Last Name ](1)t(1;16)(q11;p11),+3,+4,+8,+14,+20,+21[20] 20/20 cells show hyperdiploid karyotype described . BONE MARROW [2111-5-3]: Markedly hypocellular marrow features consistent myeloablative chemotherapy effect . BONE MARROW [2111-5-8] PATHOLOGY Variably cellular, overall hypocellular bone marrow megakaryocytic clustering, left-shifted myelopoiesis increased blasts (see note). . Note: Circulating blasts seen peripheral blood (7%). aspirate paucispicular, however increased blasts monocytic precursors noted. core biopsy variably cellular trilineage hematopoiesis, megakaryocytic clustering left shifted myelopoiesis. immunostaining CD34 immunoreactive blasts increased (~10% cellularity), however present singly without clusters. CD117 highlights early myeloid precursors clusters comprising 30% marrow cellularity. Overall, morphologic differential includes regenerating marrow versus residual disease correlation cytogenetic findings recommended . CYTOGENETICS KARYOTYPE: 46,XX[20] . INTERPRETATION: karyotype characteristic chromosomally normal female. . BRONCHIAL LAVAGE [4-18]: Bronchial lavage: NEGATIVE CARCINOMA, (see note.) Bronchial cells, macrophages small lymphocytes. . Pericardial fluid [5-4]: . ATYPICAL. . Numerous mature lymphocytes occasional atypical cells (see note). . Note: Occasional larger cells identified; differential diagnosis includes reactive lymphocyte vs. leukemic blast. definitive distinction difficult preparation, although reactive lymphocyte favored. . . MICROBIOLOGY: ============== - Parvovirus IgG IgM negative - Mycoplasma IgG IgM negative - Anaplasma IgG IgM negative - Beta glucan/galactomanin negative - EBV PCR negative - HHV8, HHV6, HSV1, HSV2, DNA PCR negative - Adenovirus PCR negative . [2111-5-14] STOOL CLOSTRIDIUM DIFFICILE TOXIN & B TEST-FINAL NEGATIVE [2111-5-13] STOOL CLOSTRIDIUM DIFFICILE TOXIN & B TEST-FINAL NEGATIVE [2111-5-12] STOOL CLOSTRIDIUM DIFFICILE TOXIN & B TEST-FINAL NEGATIVE [2111-5-10] BLOOD CULTURE Blood Culture, Routine-PENDING NEGATIVE [2111-5-10] BLOOD CULTURE Blood Culture, Routine-PENDING NEGATIVE [2111-5-10] URINE URINE CULTURE-FINAL NEGATIVE [2111-5-9] URINE URINE CULTURE-FINAL NEGATIVE [2111-5-9] URINE URINE CULTURE-FINAL NEGATIVE [2111-5-8] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [2111-5-8] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [2111-5-8] Immunology (CMV) CMV Viral Load-FINAL NEGATIVE [2111-5-7] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [2111-5-5] STOOL ACID FAST CULTURE-PRELIMINARY; VIRAL CULTURE-PRELIMINARY [2111-5-4] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [2111-5-4] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [2111-5-2] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [2111-5-2] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [2111-5-2] URINE URINE CULTURE-FINAL NEGATIVE [2111-5-2] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY INPATIENT [2111-5-1] Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture-FINAL; Respiratory Viral Antigen Screen-FINAL NEGATIVE [2111-5-1] MRSA SCREEN MRSA SCREEN-FINAL NEGATIVE [2111-5-1] FLUID,OTHER GRAM STAIN-FINAL; FLUID CULTURE-FINAL; ANAEROBIC CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY; VIRAL CULTURE-PRELIMINARY [2111-5-1] URINE URINE CULTURE-FINAL NEGATIVE [2111-5-1] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [2111-4-30] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [2111-4-28] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [2111-4-28] URINE URINE CULTURE-FINAL NEGATIVE [2111-4-27] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [2111-4-27] CATHETER TIP-IV WOUND CULTURE-FINAL NEGATIVE [2111-4-26] URINE URINE CULTURE-FINAL NEGATIVE [2111-4-26] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [2111-4-25] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [2111-4-25] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [2111-4-23] SWAB WOUND CULTURE-FINAL NEGATIVE [2111-4-23] URINE URINE CULTURE-FINAL NEGATIVE [2111-4-23] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [2111-4-23] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [2111-4-18] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [2111-4-18] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [2111-4-18] Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture-FINAL; Respiratory Viral Antigen Screen-FINAL NEGATIVE [2111-4-18] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL; LEGIONELLA CULTURE-FINAL NEGATIVE; POTASSIUM HYDROXIDE PREPARATION-FINAL NEGATIVE; Immunoflourescent test Pneumocystis jirovecii (carinii)-FINAL NEGATIVE; FUNGAL CULTURE-FINAL NEGATIVE; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY; VIRAL CULTURE: R/O CYTOMEGALOVIRUS-PRELIMINARY INPATIENT [2111-4-18] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [2111-4-17] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE [2111-4-17] URINE URINE CULTURE-FINAL NEGATIVE [2111-4-17] Blood (CMV AB) CMV IgG ANTIBODY-FINAL; CMV IgM ANTIBODY-FINAL NEGATIVE [2111-4-17] SEROLOGY/BLOOD MONOSPOT-FINAL NEGATIVE [2111-4-17] URINE URINE CULTURE-FINAL NEGATIVE [2111-4-16] BLOOD CULTURE Blood Culture, Routine-FINAL NEGATIVE IMAGING: ================= [4-16] ECHO: left atrium right atrium normal cavity size. Left ventricular wall thickness, cavity size regional/global systolic function normal (LVEF >55%). Right ventricular chamber size free wall motion normal. diameters aorta sinus, ascending arch levels normal. aortic valve leaflets (3) appear structurally normal good leaflet excursion aortic stenosis aortic regurgitation. mitral valve appears structurally normal trivial mitral regurgitation. mitral valve prolapse. estimated pulmonary artery systolic pressure normal. trivial/physiologic pericardial effusion. . IMPRESSION: Normal global regional biventricular systolic function. pulmonary hypertension clinically-significant valvular disease seen. . [5-1] ECHO estimated right atrial pressure 10-20mmHg. Left ventricular wall thicknesses normal. left ventricular cavity small. right ventricular free wall appears thickened depressed/paradoxical free wall contractility. markedly abnormal/paradoxical septal motion/position. aortic valve well seen. mitral valve appears structurally normal trivial mitral regurgitation. mitral valve prolapse. Tricuspid regurgitation present cannot quantified. large pericardial effusion subtending primarily right atrial right ventricular free walls. right ventricular diastolic collapse, consistent impaired fillling/tamponade physiology. . right atrial free wall right ventricular free wall appear markedly thickened marked acoustic enhancement impaired contractile function, suggestive inflammatory infiltrative process. . Compared findings prior study (images reviewed) [2111-4-20], large pericardial effusion cardiac tamponade present. . IMPRESSION: large pericardial effusion subtending right atrial right ventricular free walls; cardiac tamponade present . [5-8] ECHO Regional left ventricular wall motion normal. Overall left ventricular systolic function normal (LVEF>55%). abnormal septal motion/position. trivial/physiologic pericardial effusion. echocardiographic signs tamponade. Pericardial constriction cannot excluded. . Compared prior study (images reviewed) [2111-5-4], findings similar. presence abnormal septal motion seen shortly effusion drained ("effusive-constrictive" physiology). often resolves time (several months). Brief Hospital Course: Ms. [Known lastname ] 42 yo woman PMH significant morbid obesity gastric bypass presented OSH ED acute monocytic leukemia, treated 7+3 course complicated pericardial tamponade febrile neutropenia. . # Acute Leukemia: Ms. [Known lastname ] diagnosed acute monocytic leukemia initiated 7+3 induction chemotherapy daunorubicin cytarabine tolerated well. Cytogenetics initial bone marrow biopsy showed 54,XX,+X,+1,[Doctor Last Name ](1)t(1;16)(q11;p11),+3,+4,+8,+14,+20,+21[20]. Day 14 bone marrow biopsy delayed due pericardial tamponade. Day 16 bone marrow biopsy showed hypocellular marrow report however review slides, early forms seen. Patient continued nightly fevers blasts seen pheripheral smear. Bone marrow bx performed early day 21 showed early forms, cytogenetics showed normal karyotype 20/20 cells. Bone marrow biopsy repeated [5-14], results pending time discharge. ANC began rise day 21, recovery sluggish reached 792 day discharge. Given complex cytogenetics AML, plan undergo transplant. . # Pulmonary Infiltrates: CT scan obtained admission showed bilateral pulmonary opacitities interestitial pattern concerning infection vs. leukemic involvement. Pulmonology consulted bronchoscopy performed culture negative reveal malignant cells. patient's hypoxia resolved simultaneous treatment antibiotics (see below) chemotherapy. Repeat CT scan showed resolution pulmonary opacities. . # Pericardial Effusion: patient developed dramatic friction rub day admission concern effusion. initial ECHO showed small perical cardial effusion subsequent ECHO described effusion trivial. patient hemodynamically stable. [2111-5-1] friction rub absent, EKG showed low voltage across precordium. Pulsus 8mmHg repeat ECHO demonstrated tamponade physiology. hemodynamically stable. Cardiology performed pericardiocentesis dropped right atrial pressure 15 1 draining 85 cc pericardial fluid sent viral, bacterial, mycobacterial fungal culture. pericardial drain placed removed next day little drainage noted overnight. Repeat TTE [2111-5-2] showed resolution tamponade physiology normal systolic function. study also showed possible thickening posterior parietal pericardium, tethering visceral parietal surfaces consistent constrictive pericarditis. cardiac MRI showing constrictive pericarditis, small circumfrential effusion, normal RV function though RV hypertrophy noted. Repeat ECHO showed evidence pericardial tamponade findings consistent constrictive pericarditis. Constrictive pericarditis expected resolve without intervention coming months, specific cause effusion identified however malignancy vs viral etiology considered likely. . # Febrile Neutropenia: patient developed fever day+5 chemotherapy. initially treated Vancomycin developed rash pre-medicated subsequent doses tolerated without issue. treated Vancomycin cefepime continued low grade fevers. Micafungin added low grade fevers continued. Antibiotics broadened include vancomycin, cefepime, voriconazole, metronidazole. Potential sources included central line (removed tip culture negative) pulmonary, pericaridal fluid malignancy. ID consulted recommended sending pericardial fluid fungal, bacterial viral (EBV, Coxackie, Enterovirus, adenovirus) culture Acid fast (TB) culture & smear; Cytologic exam; Cell Count Differential; Enterovirus RNA, Qualitative, RT-PCR; EBV PCR, Coxackie PCR, Adenovirus PCR, negative. CT Abd/Pelvis [5-2] performed infectious workup showed bilateral pleural effusions presacral soft tissue thickening without fluid collection unclear significance. Antibiotics changed Voriconazole, meropenem, vancomycin nad metronidazole. continued fevers 101 repeat CT scan showed resolution soft tissue thickening fluid collections pulmonary findings. Antibiotics held fevers resolved. Given previous reaction vancomycin, medication may source prolonged fevers. time discharge, afebrile >36 hours. . # Menses: Patient treated Provera chemotherapy prevent menses. failed prevent menstrual cycle discontinued lower thrombotic risk. . # HTN: Held HCTZ admission. . # Hyperlipidemia: Held statin admission. . . Medications Admission: ATORVASTATIN 10 mg daily (STOPPED PRIOR ADMISSON PCP) HYDROCHLOROTHIAZIDE 12.5 mg daily (STOPPED PRIOR ADMISSON PCP) Multivitamin Vitamin Discharge Medications: 1. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours needed nausea. Disp:60 Tablet, Rapid Dissolve(s) Refills:0 2. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours needed nausea. Disp:60 Tablet(s) Refills:0 3. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every six (6) hours needed nausea. Disp:30 Tablet(s) Refills:0 4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours 10 days: drive taking medication. Disp:40 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Acute monocytic leukemia . Constrictive pericarditis Febrile neutropenia Discharge Condition: Mental Status: Clear coherent. Level Consciousness: Alert interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [Known lastname ], pleasure taking care hospital. admitted leg pain, pneumonia abnormal blood counts. found acute myelogenous leukemia treated chemotherapy repeat bone marrow biopsy prior discharged results pending. . course complicated fluid accumulation around heart (pericardial tamponade) admitted intensive care unit fluid removed. repeat ultrasound cardiac MRI heart showed fluid reaccumulated. white blood cell count low, developed fevers treated antibiotics, source fever identified antibiotics stopped. . important eat balanced diet following chemotherapy. important increase intake red meat foods high protein phosphorous (meat, grains, nuts) body makes new cells replace cells destroyed chemotherapy. . medication list changed substantially since admission. Please see attached list medications taking. . Please see follow appointments. Followup Instructions: Department: BMT/ONCOLOGY UNIT When: MONDAY [2111-5-18] 3:00 PM [Telephone/Fax (1) 447] Building: Fd [Hospital Ward Name 1826] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) 3971] Campus: EAST Best Parking: Main Garage	[ "486" ]
Admission Date: [2199-12-6] Discharge Date: [2199-12-13] Date Birth: [2120-4-15] Sex: Service: MEDICINE Allergies: Pneumococcal Vaccine Attending:[First Name3 (LF) 338] Chief Complaint: hemoptysis Major Surgical Invasive Procedure: s/p bronchial artery embolization History Present Illness: 79-year-old male history NSCLC s/p chemotherapy radiation [2191] local recurrence diagnosed [4-10] developed hemoptysis transferred bronchial artery embolization. . patient well couple months ago. time developed intermittent hemoptysis. scant intermittent [5-6] day ago. time noted increased hemoptysis totaling couple teaspoons presented [Hospital3 3765] [2199-12-4]. noted Hct 28, bronchoscopy 90% obstructing mass proximal right bronchus orifice RML RLL. Per note, mass fungating polypoid. Electrocautery coagulation done reduction amount bleeding. evidence mets RML RLL. transferred [Hospital1 18] bronchial artery embolization. . [Hospital1 18] hct noted 28.2. breathing comfortably 4L NC. monitored floor procedure. underwent right bronchial artery embolization (330-550 microns) uncomplicated. procedure patient transferred angio table stretcher developed tachypnea 40s, desaturation low 80s 2L NC significant work breathing. switched 8L simple face mask saturation 90. 15L NRB saturation 95. given 1mg morphine albuterol treatment ease breathing. CXR done apparent change prior description (although comparison CXR). ABG 7.42/47/23 SaO2 95%. next 5-10 minutes patient became comfortable patient longer respiratory distress. NRB weaned simple face mask. Request made patient observed MICU overnight. . Upon transfer, initial vitals were: BP 154/65, HR 115, RR 35, SaO2 94% 50% FM. patient denies pain, fevers, chills, nausea, vomiting, diaphoresis, diarrhea, constipation. endorses intermittent shortness breath notes occassionally productive cough, sometimes blood clots. Past Medical History: 1. Stage IIIB NSCLC, s/p radiation chemotherapy [2191]. Cancer originally distal trachea near right bronchus. Patient [4-10] noted local recurrence admission pneumonia. Patient started late [2199-10-2] palliative chemo Gemcitabine five cycles. 2. COPD 3. h/o Seizures secondary brain injury 4. Hyperlipidemia 5. h/o pseudomonas pneumonia Social History: Widower, quit smoking [2199-4-1], denies EtOH. Family History: Noncontributory. Physical Exam: Vitals: 99.5, BP 135/61, HR 108, RR 26, SaO2 97% 40% FM General: Alert, oriented, cachectic, acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP elevated Lungs: Decreased breath sounds throughout, decreased RLL RML. Anterior exam only. crackles wheezes appreciated. Cardiovascular: Decreased heart sounds, difficult assess. RR, tachycardia. murmurs rubs. Abdomen: soft, non-tender, non-distended, bowel sounds present, rebound tenderness guarding, organomegaly Ext: Warm, well perfused, 2+ pulses, cyanosis edema, mild clubbing, hematoma/bruit groin. Pertinent Results: Labs: [2199-12-6] 04:53PM BLOOD WBC-7.4 RBC-3.34* Hgb-10.0* Hct-29.1* MCV-87 MCH-29.8 MCHC-34.2 RDW-20.0* Plt Ct-209 [2199-12-7] 05:11PM BLOOD WBC-15.5# RBC-3.20 Hgb-9.3* Hct-28.0* MCV-88 MCH-29.1 MCHC-33.3 RDW-20.4* Plt Ct-341 [2199-12-10] 04:15AM BLOOD WBC-13.3* RBC-2.98* Hgb-8.9* Hct-26.1* MCV-88 MCH-29.7 MCHC-33.9 RDW-20.0* Plt Ct-669* [2199-12-11] 04:00AM BLOOD WBC-11.0 RBC-2.84* Hgb-8.2* Hct-24.7* MCV-87 MCH-28.9 MCHC-33.3 RDW-19.6* Plt Ct-890* [2199-12-12] 04:32AM BLOOD WBC-10.3 RBC-2.68* Hgb-8.0* Hct-23.0* MCV-86 MCH-29.9 MCHC-34.8 RDW-19.9* Plt Ct-901* [2199-12-13] 03:59AM BLOOD WBC-11.5* RBC-3.15* Hgb-9.0* Hct-27.1* MCV-86 MCH-28.7 MCHC-33.2 RDW-19.5* Plt Ct-1208* [2199-12-6] 04:53PM BLOOD Glucose-105* UreaN-15 Creat-0.6 Na-136 K-3.5 Cl-99 HCO3-29 AnGap-12 [2199-12-8] 04:46AM BLOOD Glucose-127* UreaN-21* Creat-0.9 Na-132* K-4.0 Cl-99 HCO3-25 AnGap-12 [2199-12-11] 04:00AM BLOOD Glucose-147* UreaN-12 Creat-0.7 Na-129* K-4.1 Cl-95* HCO3-31 AnGap-7* [2199-12-12] 04:32AM BLOOD Glucose-159* UreaN-11 Creat-0.6 Na-132* K-4.2 Cl-96 HCO3-31 AnGap-9 [2199-12-13] 03:59AM BLOOD Glucose-132* UreaN-9 Creat-0.7 Na-127* K-4.6 Cl-91* HCO3-32 AnGap-9 [2199-12-6] 04:54PM BLOOD PT-13.7* PTT-26.4 INR(PT)-1.2* [2199-12-12] 04:32AM BLOOD PT-16.2* PTT-37.9* INR(PT)-1.4* [2199-12-6] 04:53PM BLOOD Calcium-8.2* Phos-2.5* Mg-2.2 [2199-12-13] 03:59AM BLOOD Calcium-8.1* Phos-2.4* Mg-2.1 [2199-12-6] 11:16PM BLOOD Type-ART pO2-23* pCO2-47* pH-7.42 calTCO2-32* Base XS-3 [2199-12-7] 12:45AM BLOOD Type-[Last Name (un) ] Temp-37.8 pO2-43* pCO2-46* pH-7.39 calTCO2-29 Base XS-1 Intubat-NOT INTUBA [2199-12-10] 04:15AM BLOOD Vanco-17.0 . Blood cx [2198-12-9] pending, blood cx earlier admission negative Urine cx: negative . [2199-12-9] 8:31 pm SPUTUM Source: Expectorated. GRAM STAIN (Final [2199-12-9]): <10 PMNs >10 epithelial cells/100X field. Gram stain indicates extensive contamination upper respiratory secretions. Bacterial culture results invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [2199-12-9]): TEST CANCELLED, PATIENT CREDITED. . CXR [2199-12-11]: FINDINGS: Right middle lower lobe post-obstructive combination collapse consolidation volume loss rightward shift midline structures unchanged. Increased opacity within right upper lobe entire left lung reflects vascular congestion mild-to-moderate pulmonary edema. Cardiac silhouette significantly obscured. pneumothorax left effusion. IMPRESSION: Mild-to-moderate pulmonary edema within left lung right upper lobe unchanged right pleural effusion post-obstructive atelectasis consolidation right middle lower lobes. . LENIs [2199-12-9]: FINDINGS: Grayscale, color Doppler images obtained bilateral common femoral, superficial femoral, popliteal tibial veins. normal flow, compression augmentation seen vessels. IMPRESSION: evidence deep vein thrombosis either leg. . CT chest contrast [2199-12-8]: CT CHEST CONTRAST: pathologically enlarged supraclavicular, axillary lymph nodes present. small 8-mm left hilar node seen. loss normal fat plane along right mediastinal surface 2 inferior paraesophageal nodes measuring 6 10 mm short axis (2:29). Volume loss noted involving right lung paramediastinal fibrosis seen bilaterally, predominantly right upper lobe poorly enhancing. aerosolized secretions noted within distal trachea extending proximal main stem bronchi right complete occlusion bronchus intermedius proximal segmental branches right middle right lower lobe soft tissue mass. right upper lobe bronchus secretions within origin patent distally. overall size right hilar mass difficult delineate conjunction surrounding post-obstructive collapse large portion right lower lobe vasculature remaining patent coursing atelectatic lung. scattered centrilobular nodules noted within right upper lobe conjunction regions bronchiolectasis bronchial/bronchiole wall thickening (4:64). aerated portions right middle right lower lobe display bronchiectasis, interstitial septal thickening surrounding ground-glass opacities. Mild thickening noted along pleural surface right major minor fissures. Mild enhancement noted along right pleural surface conjunction moderate-sized pleural effusion fissural components. left lung displays apical scarring paramediastinal fibrotic changes well tubular 4 x 6-mm nodule within lingula (4:95), without suspicious pulmonary nodules. Underlying traction bronchiectasis noted adjacent post-radiation changes remaining airways appearing otherwise unremarkable. Moderate background centrilobular emphysema better appreciated within normal-appearing left lung. Mild-to-moderate atherosclerotic calcification noted involving aortic arch, ascending/descending aorta, coronary arteries. Atherosclerotic calcification also noted involving aortic valve. Incidentally noted independent takeoff left vertebral artery aortic arch. Included portions upper abdomen display scattered small cardiophrenic lymph nodes. suspicious masses within liver, spleen, kidneys, pancreas, visualized bowel. adrenal glands appear hypertrophied prominent left side. BONE WINDOWS: malignant-appearing osseous lesions noted. IMPRESSION: 1. Poorly defined mass region right hilum complete opacification bronchus intermedius proximal segmental branches right middle right lower lobe bronchi. right upper lobe bronchus opacified orifice likely fluid present within distal right mainstem bronchus. extensive post-obstructive post radiation changes involving right lung resultant volume loss. Lymphangitic spread disease excluded. 2. Moderate-sized right pleural effusion pleural enhancement suggesting complex fluid. Effusion surrounds large portion right lower lobe fissural components. Left lobe contains single lingular nodule mild post-radiation changes Note: Please note assessment superimposed pneumonia, pulmonary hemorrhage, worsening post-obstructive changes possible absence prior exams available review. [2199-12-6] s/p embolization: PROCEDURE: 1. Right common femoral arterial access. 2. Aortogram. 3. Bronchial artery embolization. DETAILS: explaining risks, benefits, alternatives procedure, written informed consent obtained. patient brought angiographic suite placed supine table. timeout huddle performed per [Hospital1 18] protocol. right groin prepped draped sterile fashion. continuous fluoroscopic palpatory guidance, right common femoral artery access obtained using micropuncture system, exchanged 5 French vascular sheath, sidearm connected continuous heparin flush. 5 French pigtail catheter advanced aorta [Initials (NamePattern4) ] [Last Name (NamePattern4) 7648] wire aortogram performed. Next, multiple different catheters wire tried cannulate common bronchial trunk arising aorta. Due tortuous acute orientation origin common bronchial trunk, cannulation advancement catheter difficult. However, extreme care, Renegade catheter angled Glidewire advanced common bronchial trunk. Arteriograms performed confirm location. advancement catheter Glidewire possible due extreme tortuous anatomy vessels. Hence, decided perform embolization location. 300-500 micron Embospheres used embolize intermittent saline flushes. Care taken avoid anyreflux. Intermittent hand angiograms performed rule filling anterior spinal artery. embolization stopped stagnancy antegrade flow noted. catheter wires removed followed vascular sheath manual pressure held arterial puncture site 15 minutes good hemostasis achieved. FINDINGS: 1. Aortogram performed demonstrating common bronchial trunk. right bronchial artery relatively hypertrophied compared left. active extravasation noted. 2. contribution anterior spinal artery bronchial arteries noted. IMPRESSION: Successful Embosphere embolization common bronchial trunk preferential flow right bronchial artery. Far distal embolization selectively right bronchial artery possible stage due difficult angle origin tortuousity. Brief Hospital Course: 79-year-old male history NSCLC s/p chemo XRT [2191] local recurrence developed hemoptysis s/p right bronchial artery embolization developed hypoxic respiratory distress. . # Hypoxic respiratory distress: patient developed hypoxemic respiratory distress turned right side procedure. differential broad includes airway obstruction tumor, mucous plugging, intermittent bronchospasm, pulmonary embolus. likely etiology original hypoxia secondary airway obstruction tumor mucous plugging causing temporary shunt physiology. likely occurred patient turned right side, temporary, relieved coughing. Interval CXRs showed worsening opacifiation right lung suggesting complete tumor mucous occlusion bronchus versus post obstructive pneumonia process. started continued IV vanocmycin (day 1 [12-7]) cefepime (day 1 [12-7]) cultures remained negative. spiked fever flagyl started [12-9]. plan total 14 day course antibiotics. patient given nebulizations ease possible bronchospastic response. peripheral signs DVT, including negative LENIs although pt mildly tachycardic PE entirely excluded CTA done PE protocal. However, cancer PNA explain oxygen requirement anticoagulation treatment would risky given recent arterial access, embolization, hemoptysis. generally requires 4-5L oxygen maintain sats low 90s (has h/o hypercarbia COPD) intermittent needs facemask ventilation setting coughing fits. started morphine 5mg po prn SOB. regularly self suctions. also lot anxiety receives lorazepam 0.5mg po needed. also standing tylenol suppress fever. . # Goals care: patient wanted second opinion oncology [Hospital1 18]. Oncology consult called previous oncology records obtained Dr. [Last Name (STitle) 87663] Dr. [Name (NI) 88182]. Oncology suggested possible 3rd line chemotherapy, patient said would want "get better" trying it. Palliative care also consulted code status changed DNR/DNI. patient expressed wishes die home, family able organize 24 hour home care preferred patient discharged [Hospital1 1501] complete IV antibiotics course making decision approach care home. follow appointment thoracic oncology [12-31] 10:30 discuss chemo options. discussions abbout home hospice implemented time. . # Hemoptysis: patient stable hematocrit s/p bronchial artery embolization. procedure went well, desatted 80s procedure layed right side transferred stretcher. desaturation improved nonrebreather, resolved within hours weaning nasal cannula, likely ssecondary mucous plugging. LENIs checked negative DVT. minimal hemoptysis procedure twice week following. heparin sc stopped remain given risk bleeding. HCT trend 23 29 admission 27 discharged without transfusion. . # Metastatic NSCLC: patient undergoing palliative chemotherapy Gemcitabine. hold chemo pending oncology input. See goals care section above. . # Hypothyroidism: Continued levothyroxine . # Hyperlipidemia: Continued statin . #. Constipation: Pt constipation report us initially. moved bowels senna, colace, miralax. monitored constipation. . # h/o Seizures secondary brain injury: Continue home phenytoin. . # Hypophosphatemia: repeatedly low phos hospital. phos monitored regularly. . #.Hyponatremia: SIADH also likely hypovolemic component given decreased pos. Trend hyponatremia. . # Thrombocytosis: Likely secondary suboptimally tx post obstructive pneumonia . # Insomnia setting respiratory issues: Pt well trazodone 25mg qhs. . # Code: DNR/DNI outlined Medications Admission: Simvastatin 20mg daily Levothyroixine 75mcg daily Dilantin 100mg QID Phenobarb 60mg daily Albuterol neb q4hrs prn Spiriva 18mcg daily Temazapam 30mg qHS Discharge Medications: 1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO day. 2. levothyroxine 75 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) needed SOB. 4. phenobarbital 60 mg Tablet Sig: One (1) Tablet PO day. 5. phenytoin 100 mg/4 mL Suspension Sig: Two Hundred (200) mg PO twice day. 6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation Q4H (every 4 hours) needed shortness breath wheezing. 7. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): day 1 [12-9] total 14 day course last day [12-23]. 8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) needed anxiety, discomfort: hold sedation. 9. lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous membrane TID (3 times day) needed sore throat. 10. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) needed cough. 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times day) needed constipation. 12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) needed pain/fever. 13. morphine concentrate 20 mg/mL Solution Sig: Five (5) mg PO Q4H (every 4 hours) needed shortness breath. 14. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 15. sodium chloride 0.65 % Aerosol, Spray Sig: [2-2] Sprays Nasal QID (4 times day) needed dry nose. 16. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) needed constipation. 17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice day: hold loose stool. 18. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) needed insomnia. 19. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush 3 mL Normal Saline every 8 hours PRN. 20. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush 10mL Normal Saline followed Heparin daily PRN per lumen. 21. CefePIME 2 g IV Q12H day 1=[12-7] 22. vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q 12H (Every 12 Hours): day 1 [12-7] total 14 day course last day [12-21]. 23. Outpatient Lab Work Chem 10, CBC daily 1st 3 days discretion MD facility 24. Pneumoboots Discharge Disposition: Extended Care Facility: highlands Discharge Diagnosis: Primary diagnosis: 1. Stage IIIB NSCLC, s/p radiation chemotherapy [2191]. Cancer originally distal trachea near right bronchus. Patient [4-10] noted local recurrence admission pneumonia. Patient started late [2199-10-2] palliative chemo Gemcitabine five cycles. 2. s/p bronchial artery embolization 3. Post obstructive PNA 4. COPD . Seondary diagnosis: 1. h/o Seizures secondary brain injury 2. Hyperlipidemia 3. h/o pseudomonas pneumonia Discharge Condition: & x3, able get chair assistance oxygen reserve more, 4-5L oxygen maintain o2 sats 89-92% occasionally needs fase mask short periods Discharge Instructions: admitted bronchial artery embolization increased oxygen requirement. lung cancer worse taken almost entire part right lung. addition developed fever post obstructive PNA cefepime, flagyl, vancomycin take 14 days. also started morphine ipratropium albuterol nebs. saw oncology follow appointment Dr. [Last Name (STitle) ] [12-31]. Followup Instructions: Thoracic oncology working appointment later month. please call ([2199] 1-2 days discharge find time appointment. Completed by:[2199-12-13]	[ "486" ]
Admission Date: [2164-1-23] Discharge Date: [2164-2-20] Date Birth: [2102-3-25] Sex: Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 99] Chief Complaint: shortness breath Major Surgical Invasive Procedure: multiple bronchoscopies [1-30]: CT guided lung biopsy [1-31]: Chest tube (left) placed; removed [2-10] [2-7]: started chemoradiation (stopped [2-13]) d/w family [2-8]: PEG placement, Trach placement, VATS, pleurodesis History Present Illness: 61 Cantonese-speaking only, former smoker quit 10 yrs ago, admitted Mon [Location ] service workup L lung mass likely malignant, dysphagia x 2 months, hemoptysis x 2 months, weight loss [5-10] lbs, reduced PO intake, became acutely SOB today 2 pm. well yesterday, SOB all, RR 14, comfortable. isolation getting r/o TB (due hemoptysis), bronch planned tomorrow PM. Throughout today, developed worsening SOB, O2 sats ranging 95-98% RA 2 pm, 92% RA 5 pm, 87% 2L nc 9 pm, 85% 100% FM 11 pm. . became severely SOB, rales, wheezing, first ABG 7.35/60/68, O2 sat 95-98% RA. ENT consulted SOB, found normal vocal cords, normal posterior pharynx, lesions vocal cords, +mediastinal lymph nodes. CXR shows cardiomegaly, pleural effusions, infiltrate. Earlier today, patient sitting straight side bed drooling, severe SOB, RR 30. EKG showed mild STD lateral leads, previous comparison. Patient failed bedside video swallow study. . Patient one AFB negative, one AFB pend. Bronch planned IP tomorrow r/o TB. Past Medical History: stomach ulcer- ?of partial gastrectomy (30 years ago) . Social History: Previous smoker, quit 10 yrs ago. Lives son home, worked dishwasher restaurant. Family History: noncontributory Physical Exam: VS: 95.5 / 154/81 / 30 / 87% 5L nc GEN: Cachectic, SOB speak, akathisic, fatigued HEENT: JVD flat, LAD, OP clear, anicteric sclerae LUNGS: CTA B HEART: RRR, m/r/g ABD: Soft, thin, +BS, ND NT EXTR: c/c/e NEURO: exam performed SKIN: rash Pertinent Results: Admission labs: 136 99 14 -------------< 99 4.9 28 0.8 . 14.5 7.3 >---< 551 42 N:79.6 L:15.4 M:2.9 E:1.5 Bas:0.5 . Trends: Discharge CBC: [2164-2-16] 04:33AM BLOOD WBC-15.2* RBC-3.37* Hgb-10.1* Hct-29.7* MCV-88 MCH-29.9 MCHC-33.9 RDW-14.5 Plt Ct-386 Discharge coags: [2164-2-15] 05:56AM BLOOD PT-12.2 PTT-40.9* INR(PT)-1.1 Discharge Chem panel: [2164-2-17] 02:50AM BLOOD Glucose-127* UreaN-32* Creat-0.6 Na-142 K-3.6 Cl-103 HCO3-36* AnGap-7* [2164-2-17] 02:50AM BLOOD ALT-27 AST-30 LD(LDH)-207 AlkPhos-76 Amylase-92 TotBili-0.2 . CE: [2164-1-25] 03:45PM BLOOD CK-MB-5 cTropnT-<0.01 [2164-1-26] 12:25AM BLOOD CK-MB-11* MB Indx-4.4 cTropnT-0.9* [2164-1-26] 06:13AM BLOOD CK-MB-10 MB Indx-5.5 cTropnT-0.23* [2164-1-28] 09:54AM BLOOD CK-MB-3 cTropnT-0.09* [2164-1-31] 02:43AM BLOOD CK-MB-2 cTropnT-0.01 . [2164-1-29] 05:27AM BLOOD calTIBC-170* VitB12-449 Folate-9.8 Ferritn-55 TRF-131* [2164-1-25] 03:32PM BLOOD Lactate-1.3 [2164-2-4] 03:34PM BLOOD Lactate-0.8 . Micro: Multiple blood, sputum, urine, BAL cultures negative. BAL [1-25]: RESPIRATORY CULTURE (Final [2164-2-2]): >100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA. BETA STREPTOCOCCI, GROUP A. 10,000-100,000 ORGANISMS/ML.. SENSITIVITY PER DR [First Name (STitle) ] #[Numeric Identifier 70374]. UNABLE ISOLATE WORK UP. Thought contaminant. . Cytology: Pleural fluid negative x3 malignancy CT guided bx positive adenoca lung . Imaging: [1-24]: CT Abd: 1. Focal liver lesions peripheral enhancement, likely representing hemangiomas. 2. 2 cm left adrenal nodule enhancement, worrisome metastasis patient lung mass. PET CT may help staging. 3. Small free fluid lower pelvis. . [1-23]: CT chest: Chest CT [2164-1-23]: (1) Mass mass-like consolidation two segments left upper lobe. (2) Small left adrenal mass. Extensive heterogeneity liver texture. (3) Esophageal distention, probably functional. . [1-26]: ECHO: 1.The left atrium normal size. 2. Left ventricular wall thicknesses normal. left ventricular cavity size normal. mild regional left ventricular systolic dysfunction mid septal hypokinesis. Overall left ventricular systolic function low normal (LVEF 50-55%). 3. Right ventricular chamber size normal. Right ventricular systolic function normal. 4.The aortic valve leaflets mildly thickened. aortic regurgitation seen. 5.The mitral valve leaflets mildly thickened. mitral regurgitation seen. 6.The estimated pulmonary artery systolic pressure normal. 7.There pericardial effusion. . CXR upon admission: 1. New left upper lobe consolidation occupying predominantly upper portion lobe addition known left upper lobe/lingular consolidation/mass. finding may represent massive aspiration hemorrhage 2. New retrocardiac left lower lobe atelectasis. . CXR upon discharge: Tracheostomy tube G-tube seen relatively stable position. Cardiac mediastinal contours appear stable. improved aeration left lung persistent atelectasis consolidation air bronchograms noted. Left-sided PICC seen tip region cavoatrial junction. IMPRESSION: Improved aeration left lung persistent atelectasis consolidation Brief Hospital Course: 61 yo former smoker admitted workup L lung mass presenting w/ c/o dysphagia, hemoptysis, weight loss x 2 months, admitted ICU acute SOB. Hospital course problem: . # Hypoxemic respiratory failure: Likely [2-3] mucus plugging L upper lung field complicated ? postobstructive pneumonia. Bronchoscopy performed x4 time evidence mucus plugging thick secretions. Sputum cultures not, however, yield growth order guide antibiotic coverage. continued zosyn vancomycin x14 days switched meropenem 1 week treat possible ESBLs. Following 4th bronchoscopy, tolerating trials PS. Thereafter, placed trach [2-8] tolerated well. aggressively diuresed. [2-16] well trach collar remained vent >24 consecutive hours. recommend continued lasix 40mg PO daily approx 1-2 weeks quite volume overloaded admission. . # Adenoca lung: CT guided biopsy showed adenoca lung. negative head CT mets adrenal met noted abdominal CT scan. pleural fluid neg x3 malignancy. unable accurately stage without PET scan. Given poor respiratory status extensive disease burden, heme/onc service feel would benefit surgical resection high dose chemo. however treat 5 day course chemoradiation help decrease size mass attempt assist weaning vent. may helped subsequently vent several days therapy. family patient longer interested treating malignancy. . # Cards Vasc: setting hypoxia hemoptysis, patient troponin peak 0.9. CKs negative. echo showed mid-septal hypokinesis. thought demand ischemic event issues hospitalization. .. # Left pneumothorax: Patient PTX s/p CT guided biopsy. chest tube placed left. remained place approx one week. Thereafter PTX resolved. undergo VATS pleurodesis [2-8] given signifant pleural effusion. . # fib: [2-10], went afib rvr 160s. BP stable. - lopressor 37.5 tid achieved good rate control . # HTN- Consistently elevated BP, especially becomes agitated. -continue lopressor 37.5 tid, -lorazepam 0.5 prn . # Hemodynamic instability: Originally hypotensive. appeared combination sedation intubation hypovolemia. did, however, remain largely levophed dependent. BP would rise >170s systolic agitation. However, least 10 days prior discharge, blood pressure well controlled metoprolol 37.5 tid. . # FEN: peg placed [2-8]. Tube feeds started. tolerated well. . # Anxiety: ambien and/or ativan prn . # Code: DNR per discussion family. final discussion revealed patient DNR would hooked ventilator respiratory distress. . # Communication: Son = [Name (NI) ] [Name (NI) 3443]: speaks English. [Telephone/Fax (1) 70375] Medications Admission: unknown, ? antihypertensives Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [Telephone/Fax (1) ]: One (1) Injection TID (3 times day). 2. Albuterol 90 mcg/Actuation Aerosol [Telephone/Fax (1) ]: 6-8 Puffs Inhalation Q4H (every 4 hours). 3. Ipratropium Bromide 17 mcg/Actuation Aerosol [Telephone/Fax (1) ]: 6-8 Puffs Inhalation Q4H (every 4 hours). 4. Senna 8.6 mg Tablet [Telephone/Fax (1) ]: One (1) Tablet PO BID (2 times day). 5. Docusate Sodium 50 mg/5 mL Liquid [Telephone/Fax (1) ]: One (1) PO BID (2 times day). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Telephone/Fax (1) ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Chlorhexidine Gluconate 0.12 % Mouthwash [Telephone/Fax (1) ]: Fifteen (15) ML Mucous membrane [Hospital1 ] (2 times day). 8. Zolpidem 5 mg Tablet [Hospital1 ]: One (1) Tablet PO HS (at bedtime) needed insomnia. 9. Metoprolol Tartrate 25 mg Tablet [Hospital1 ]: 1.5 Tablets PO TID (3 times day). 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 11. Furosemide 40 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily): recommend continuing another 5-7 days correct positive fluid balance. 12. Lorazepam 0.5 mg Tablet [Last Name (STitle) ]: 1-2 Tablets PO HS (at bedtime). 13. Morphine 2 mg/mL Syringe [Last Name (STitle) ]: One (1) mg Injection Q4H (every 4 hours) needed. 14. Albuterol Sulfate 0.083 % Solution [Last Name (STitle) ]: One (1) treatment Inhalation Q4H (every 4 hours) needed. treatment 15. Ipratropium Bromide 0.02 % Solution [Last Name (STitle) ]: One (1) treatment Inhalation Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary: - Adenocarcinoma lung - hypoxic respiratory failure - postobstructive pneumonia - atrial fibrilation - hypertension - left pneumothorax (now resolved) - prolonged intubation requiring trach placement - s/p VATS, pleurodesis - s/p PEG placement Discharge Condition: fair, breathing trach collar. Discharge Instructions: admitted shortness breath coughing blood. mass lung consistent adenocarcinoma lung. treated prolonged course ventilator ultimately extubated well trach. briefly received chemotherapy radiation. However, given severity disease, continue measures. . Please contact PCP questions. Please take medications instructed. Followup Instructions: please followup PCP within next month	[ "486", "496" ]
Admission Date: [2120-3-10] Discharge Date: [2120-4-18] Date Birth: [2120-3-10] Sex: Service: NEONATOLOGY HISTORY PRESENT ILLNESS: Baby boy [Known lastname 46197] 1080 gram product 27 [5-20] week twin gestation born 36 year-old G7P5 mother. Serologies negative, hepatitis surface antigen negative, hepatitis C positive, RPR nonreactive, antibody negative, rubella immune, GBS unknown. living children. spontaneous twin pregnancy. Mother reports normal amniocentesis normal second trimester ultrasound. pregnancy going well without complications morning [2120-3-9] 7:30 mother reported spontaneous rupture membranes (twin two). presented Labor & Delivery Emergency Room. mother noted early Ampicillin Erythromycin given one dose betamethasone 1300 [2120-3-9]. later transferred floor. Early a.m. [2120-3-10] mother found progressive cervical dilatation decision made deliver twins cesarean section. Mother unable get effective spinal anesthesia placed general anesthesia. infant's membranes ruptured time delivery. infant emerged decreased activity spontaneous respirations. bulbed suctioned, dried, stimulated give positive pressure ventilation. responded well, progressive respiratory distress consistent respiratory distress syndrome. patient's CPAP started intubated prior transfer MICU improvement aeration color. Apgars 5 7. PHYSICAL EXAMINATION ADMISSION: Weight 1080 (50th percentile). Length 37 cm (25 50th percentile). Head circumference 26 cm (50 75th percentile). Anterior fontanel open flat, pink well perfuse, rashes. Skin intact. Positive red reflexes bilaterally. Equal chest excursion retractions, poor aeration consistent respiratory distress. Skin extensive bruising throughout. Normal S1 S2. murmurs. 2+ pulses. Abdomen without hepatosplenomegaly, three vessel cord. Normal external genitalia preterm male. Spine straight intact. Patent anus. Infant tone appropriate gestational age. HOSPITAL COURSE: Respiratory: patient increased respiratory distress requiring intubation treatment Surfactant times two. extubated CPAP 24 hours age continued CPAP brief periods trials day 47, [2120-4-16] time extubated room air. stable without increase apnea bradycardia spells. started caffeine citrate management apnea bradycardia day life one continues caffeine citrate currently good management. average one three apnea bradycardia spells per day. Cardiovascular: Initially required normal saline boluses times two Dopamine 7.5 micrograms per kilogram per minute management hypotension. weaned Dopamine 24 hours age cardiovascularly stable throughout remainder hospital course history cardiac murmur. Fluid electrolytes: birth weight 1080. initially started 80 cc per kilo per day D10W. required D10 bolus admission hypoglycemia. issues hypoglycemia. started enteral feedings day life number one, advanced full enteral feedings day life eight stable 150 cc per kilogram per day, max PE 30 ProMod. currently receiving 150 cc per kilogram per day PE 26 demonstrating good weight gain. discharge weight 2055. recent nutrition laboratories obtained [2120-4-18], sodium 139, potassium 5.7, chloride 107, total CO2 26, BUN 14, creatinine .3 alkaline phosphatase 432, phosphorus 6.3. Gastrointestinal: Initially treated phototherapy peak bilirubin 6.5/0.4 likely secondary extensive bruising delivery process. received double phototherapy times three days, decreased single phototherapy phototherapy discontinued day life eight rebound bilirubin 3.1/0.3. issue resolved. Hematology: Hematocrit admission 54.6. recent hematocrit [2120-4-18] 30.8. required blood transfusions hospital course. Infectious disease: CBC blood culture obtained admission. CBC benign. culture remained negative 48 hours Ampicillin Gentamicin discontinued. day life five infant increased apnea bradycardia spells, temperature 101. time CBC obtained. CBC benign. Blood cultures positive staph aureus. infant treated Vancomycin Gentamicin total three days changed Penicillin Oxacillin total seven day course. Antibiotics discontinued [2120-3-23] issues sepsis hospital course. Neurological: Head ultrasound performed day life one, four 30 days within normal limits. appropriate gestational age. Sensory: Audiology screened. Recommended prior discharge. Ophthalmology: patient seen ophthalmology [2120-4-17] revealing stage 1 zone 2 10 o'clock hours right eye 11 o'clock hours left eye recommended follow one week. Psycho/social: [Hospital1 69] social worker involved family. Mom agoraphobia visits infrequently. Dad visits fairly frequent basis. DISCHARGE CONDITION: Stable. DISCHARGE DISPOSITION: [Hospital3 ] level two facility. Name primary pediatrician process. Mom trying identify pediatrician [Hospital1 ] system. CARE RECOMMENDATIONS: Continue 150 cc per kilogram per day PE 26 calorie iron wean appropriate. Medications, continue caffeine citrate. Car seat position screening performed. State newborn screens sent per protocol within normal limits. Immunizations received: received immunizations. Immunizations recommended: hepatitis B vaccine consent obtained. Synagis RSV prophylaxis considered [Month (only) 359] [Month (only) 547] infants meet following three criteria: born less 32 weeks, born 32 35 weeks plans day care RSV season, smoker household preschool sibling chronic lung disease. Influenza immunizations considered annually fall preterm infants chronic lung disease reach six months age. age family care givers considered immunization influenza protect infant. DISCHARGE DIAGNOSES: 1. Former 27 [5-20] week twin B 39 days old, 32 1/7 weeks gestation. 2. Status post respiratory distress syndrome treated Surfactant, rule sepsis antibiotics. 3. Hypoglycemia, transient. 4. Hypotension, transient. 5. Staph aureus bacteremia. 6. Hyperbilirubinemia, resolved. 7. Anemia prematurity. 8. Apnea bradycardia prematurity. 9. Retinopathy prematurity. Reviewed By: [Doctor Last Name ] [Last Name (NamePattern5) 36094], M.D. [MD Number(1) 36250] Dictated By:[Last Name (NamePattern1) 46198] MEDQUIST36 D: [2120-4-18] 11:14 T: [2120-4-18] 11:26 JOB#: [Job Number 46199]	[ "769" ]
Admission Date: [2145-9-4] Discharge Date: [2145-9-7] Service: MED Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 99] Chief Complaint: hypoxia & hypotension Major Surgical Invasive Procedure: Expired History Present Illness: [Age 90 ] y/o woman DM2, CAD, CHF EF 40% recurrent pneumonias, DNR/DNI, presented Heb Reb persistent cough/SOB, hypoxia/tachypneic 3d keflex azithromycin [8-26], started MUST protocol presumed pneumonia. Became progressively hypoxic hypotensive 24 hours ED, Got one dose levaquin, flagyl, vanco, ceftazidine, levophed weaned 4L IVF. Past Medical History: CAD, CHF EF35-40%, pulm HTN, LVH, 1+MR mod-severe AS, HTN, DM2, h/o atrial tach/A fib/flutter rate controlled coumadin, known recurrent pleural effusions-transudative, recurrent pna aspirations, CVA R hemiparesis, parkinsons, depression, spinal stenosis, LBP Social History: Lives [Hospital 100] Rehab Family History: n.c. Physical Exam: 97.7, 97% NRB, 24, 96, 109/47, . General:pleasant, elderly woman, looking fatigued conversant Heent:anicteric, mmm, supple neck CV:prominent JVD JVP 12 cm, tachy rate, quiet s1 s2, hear s2 split, 3/6 systolic LSB, [12-25] late-peaking systolic murmur base, R/G Resp:accessory mm use, tachypneic NRB, I:E 1:2, crackles throughout respiratory cycle Abd:soft, distended, nontender, organomegaly, bruits, cherry angiomata Extrem:no c/c/edema, radial 2+ b/l delayed upstroke, dp 1+ b/l Neuro:CN 2-12 grossly intact, alert, oriented self, location, situation Skin: warm, rashes, evaluate back/sacral area yet Access: R IJ TLC considerable oozing, foley . Pertinent Results: EKG: irreg ectopic atrial, 110, nl axis, st depressions v5/v6, I,L, TWI v4 [9-4] rate 95 near-resolution ST/TW changes noted . CXR:R pleural effusion, distinct infiltrate . Brief Hospital Course: Pt admitted [Hospital Unit Name 153] MUST protocol RIJ pressors. patient respiratory distress hypoxia. patient started levaquin/vanco/cefipime nosocomial pneumonia. Pressors weaned patient transferred floor gentle diuresis. Within one day, patient hypoxic hypotensive transferred [Hospital Unit Name 153]. time, discussion daughter, health care proxy, patient made "CMO" (comfort measures only) morphine drip started. 5:58pm, patient expired. Medications Admission: Discharge Medications: Discharge Disposition: Home Discharge Diagnosis: Pneumonia Pneumonia Discharge Condition: Expired Expired Discharge Instructions: Pt expired Pt expired Followup Instructions: Expired	[ "486" ]
Admission Date: [2159-7-28] Discharge Date: [2159-8-13] Date Birth: [2106-12-11] Sex: Service: HISTORY PRESENT ILLNESS: patient 52-year-old man woke day admission worst headache life. fell floor unconscious. neurologic deficits. taken [Doctor Last Name 40277] Hospital, head CT revealed subarachnoid [Hospital ] [First Name (Titles) ] [Last Name (Titles) ] management. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: 1. Umbilical hernia repair. 2. Status post knee surgery. MEDICATIONS: None. ALLERGIES: None. HOSPITAL COURSE: patient taken angio upon arrival, revealed ACOM aneurysm taken operating room underwent clipping aneurysm. tolerated procedure well intraoperative complications. VITAL SIGNS: Heart rate 57, blood pressure 113/60, respiratory rate 17, saturations 98%. Postoperatively, alert, oriented times three. Sensation grossly intact. Pupils equal, round, reactive light. Cranial nerves II XII intact. CARDIOVASCULAR: Regular rate rhythm. RESPIRATORY: Clear auscultation bilaterally. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: clubbing, cyanosis edema. patient status post craniotomy clipping ACOM aneurysm. stable condition. patient also vent drain placed time surgery. [7-30], patient somewhat sleepy. patient received 500 cc fluid bolus. also question right drift. patient taken angio evaluation vasospasm, negative. [2159-8-2], patient went back angio, showed residual aneurysm minimal vasospasm. treatment done tine. patient transferred back Intensive Care Unit close monitoring. [2159-8-4], patient spiked 102. CSF sent culture. patient continued high rate IV fluid monitored vasospasm. alert, oriented times three slight right pronator drift. patient remained neurologically stable drain, eventually raised 20 cm tragus [2159-8-7]. cultures date negative. patient continued low grade temperature. Vital signs stable. afebrile. CSF negative. [2159-8-9], patient neurologically awake, alert, oriented times three. Face symmetrical drift moving extremities good strength. ventriculostomy drain discontinued. [2159-8-10], patient LP check opening pressure, 22. Ventriculostomy drain discontinued 26th. patient transferred regular floor [2159-8-10] stable condition. patient seen Departments Physical Therapy Occupational Therapy. [8-13]/2902 patient repeat head CT, showed increased size ventricles. LP, show significant opening pressure. patient discharged home stable condition followup Dr. [Last Name (STitle) 1132] one two weeks. MEDICATIONS DISCHARGE: 1. Dilantin 100 mg PO t.i.d. 2. Nimodipine 60 mg q.4h. 3. Senna one tablet PO b.i.d. 4. Colace 100 mg PO b.i.d. 5. Zantac 150 mg PO b.i.d. CONDITION DISCHARGE: Stable discharge. FOLLOW-UP CARE: patient followup Dr. [Last Name (STitle) 1132] two weeks' time. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 1133] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2159-11-14] 11:38 T: [2159-11-14] 11:49 JOB#: [Job Number 43164]	[ "431" ]
Admission Date: [2139-7-22] Discharge Date: [2139-8-6] Date Birth: [2069-8-5] Sex: F Service: MEDICINE Allergies: Captopril / Neurontin / Shellfish / Nsaids / Promethazine / Valproate Sodium Attending:[First Name3 (LF) 1990] Chief Complaint: Altered Mental Status Major Surgical Invasive Procedure: None History Present Illness: Ms. [Known lastname ] 69 year old female history DM, COPD, ventilator dependent, hypertension, rectus sheath hematoma [6-/2139] brought [Hospital 8] Hospital altered mental status abdominal pain. Abdominal CT done outside hospital showed partial SBO. CT head OSH negative intracranial process. transferred [Hospital1 18] work given recent admission here. . ED, vital signs BP 115/50, HR 90, RR 16, O2 sat 100% trach collar. Labs notable positive UA, WBC count 12.9 (73% neutrophils), creatinine 6.2 last d/c 4.2, troponin 1.51 (CKMB normal), hct 30.2 (up b/l 24-25 last admission). Blood urine cultures sent ED. given 1L NS, Cipro 400mg x1, Aspirin 600mg PR, Tylenol 1g. also given ?????? amp D50 low BG. seen surgery evaluation partial SBO. Decision surgical intervention NGT placed. patient recently admitted [Hospital Unit Name 153] [4-25] urosepsis treated Linezolid, MRSA RLL PNA treated Ceftazadime Cipro. Also noted RUE edema last admission, UE US negative DVT. . ROS: Patient unable provide . Past Medical History: 1. Recent admission [6-/2139] -ICU MRSA highly resistant pseudomonal pneumonias. Sputum culture data indicates multiple colonies pseudomonas without overlapping sensitivities -Rectal sheath hematoma, s/p embolization [4-/2139] -Tracheostomy placed chronic ventilator dependence 2. Diabetes Mellitus type 2 3. GERD 4. COPD -On home Oxygen 5. Obstructive sleep apnea 6. Depression 7. HTN 8. s/p TAH 9. s/p PE [2135], -with IVC filter, -not anticoagulated developed abdominal wall hematoma 10. Focal seizures 11. Diastolic CHF, -ECHO [6-17] EF >55%, mild pulm artery hypertension 12. s/p CVA x 2 right facial droop 13. CKD -baseline Cr 1.3-1.5 . Surgical History: s/p coil embo L inf epigastric ([4-18] [Doctor Last Name ]) s/p hematoma evacuation debridement ([Date range (1) 15051] [Doctor Last Name ], [Doctor Last Name ], [Doctor Last Name ]) s/p repair incarc ventral hernia repair c mesh ([6-17] [Doctor Last Name ]) s/p ex lap, LOA, omentectomy ([6-14] [Doctor Last Name ]) ex-lap, ventral hernia repair, rigid sig ([4-14] [Doctor Last Name ]) CDiff. Social History: Resides [Hospital1 ], chronically ventilator dependent since last hospitalization. Retired seamstress, waitress. Daughter [Name (NI) ] HCP. Pt former smoker, 3ppd x 30 years, quit [2128], per records pt distant history ETOH abuse ([2091]), current ETOH drug use. . . Family History: FH:Malignancy (pancreas, larynx), CAD, HTN, DM, asthma; daughter recently diagnosed leukemia Physical Exam: General Appearance: acute distress, Overweight / Obese, No(t) Thin, Anxious, Diaphoretic Eyes / Conjunctiva: PERRL, No(t) Conjunctiva pale, No(t) Sclera edema Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, Endotracheal tube, NG tube, OG tube, teeth Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic), HD line place right upper chest Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : anterior lateral, Crackles : , Wheezes : ) Abdominal: Soft, Non-tender, Bowel sounds present, Obese, tender right flank/lateral mid right back Extremities: 2+ peripheral edema Musculoskeletal: Unable stand Skin: two dressed wounds right leg. C/D/I dressings non-tender around area Neurologic: Somnolent arousable, follows simple commands, A&Ox1 Guaiac: negative ED Pertinent Results: EKG: Sinus arrhythmia, left axis deviation, nl intervals, Q waves II, III, TWF III, avF, I, aVL, V1-V3, ST changes. Compared EKG dated [6-27] new Q wave aVF, TWF V1-V3. . [2139-7-22] 11:52AM WBC-12.0* RBC-3.09* HGB-9.0* HCT-27.7* MCV-90 MCH-29.1 MCHC-32.5 RDW-17.3* [2139-7-22] 11:52AM PLT COUNT-465* [2139-7-22] 10:29AM GLUCOSE-66* UREA N-53* CREAT-6.3* SODIUM-138 POTASSIUM-2.7* CHLORIDE-108 TOTAL CO2-15* ANION GAP-18 [2139-7-22] 10:29AM CK(CPK)-328* [2139-7-22] 10:29AM CK-MB-12* MB INDX-3.7 cTropnT-1.42* [2139-7-22] 10:29AM CALCIUM-8.8 PHOSPHATE-5.9* MAGNESIUM-1.8 [2139-7-22] 10:29AM PT-14.8* PTT-30.4 INR(PT)-1.3* [2139-7-22] 04:32AM LACTATE-1.3 K+-3.6 [2139-7-22] 04:15AM GLUCOSE-53* UREA N-55* CREAT-6.2# SODIUM-141 POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-15 ANION GAP-23* [2139-7-22] 06:08PM GLUCOSE-80 UREA N-54* CREAT-6.1* SODIUM-139 POTASSIUM-3.3 CHLORIDE-109* TOTAL CO2-14* ANION GAP-19 [2139-7-22] 06:08PM CK(CPK)-424* [2139-7-22] 06:08PM CK-MB-14* MB INDX-3.3 cTropnT-1.30* [2139-7-22] 06:08PM CALCIUM-8.8 PHOSPHATE-6.3* MAGNESIUM-1.6 [2139-7-22] 04:15AM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.012 [2139-7-22] 04:15AM URINE BLOOD-LG NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [2139-7-22] 04:15AM URINE RBC-[12-31]* WBC->50 BACTERIA-MANY YEAST-MOD EPI-[4-15] RENAL EPI-0-2 [2139-7-22] 04:15AM URINE CA OXAL-MOD . Micro: [2139-7-22] 4:15 BLOOD CULTURE Blood Culture, Routine (Pending): [2139-7-22] 4:15 URINE Site: CATHETER URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. . TTE [7-22] LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness, cavity size, global systolic function (LVEF>55%). Suboptimal technical quality, focal LV wall motion abnormality cannot fully excluded. resting LVOT gradient. AORTA: Normal aortic diameter sinus level. AORTIC VALVE: Normal aortic valve leaflets. AS. AR. MITRAL VALVE: Normal mitral valve leaflets trivial MR. Mild mitral annular calcification. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Moderate PA systolic hypertension. PERICARDIUM: anterior space likely represents fat pad, though loculated anterior pericardial effusion cannot excluded. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Right pleural effusion. Conclusions left atrium mildly dilated. Left ventricular wall thickness, cavity size, global systolic function normal (LVEF>55%). Due suboptimal technical quality, focal wall motion abnormality cannot fully excluded. aortic valve leaflets appear structurally normal good leaflet excursion. aortic valve stenosis. aortic regurgitation seen. mitral valve appears structurally normal trivial mitral regurgitation. moderate pulmonary artery systolic hypertension. anterior space likely represents fat pad. Compared prior study (images reviewed) [2139-6-29], moderate pulmonary artery systolic pressure identified. Biventriclar systolic function similar. Brief Hospital Course: # Altered mental status: admission patient somnolent responding commands. According team slightly somnolent prior baseline. Head CT negative evidence bleed. AMS likely due infection Acute renal failure. . #. Acute Chronic Renal Failure - Baseline creatinine 1.5-1.8 prior last admission, however last discharge Cr 4.2 (felt new baseline secondary ATN. admission pt found Cr 6.2. received 1L NS ED, additional 1-2L NS bolus ICU little subsequent improvement renal function. Urine lytes obtained FeNa 9%. Renal team consulted family expressed desire proceed aggressive care (dialysis). family meeting extensive discussion patients multiorgan system failure continued worsen despite medical management, family medical team agreed dialysis indicated chose make patient CMO. . #. Chronic Respiratory Failure - s/p trach 03/[2139]. Evidence COPD exacerbation expiratory wheezes prolonged expiratory phase [7-24]. Prednisone increased 60 mg po qday nebulized albuterol scheduled. patient required support mechanical ventilation prednisone changed solu-medrol taper. Current dose 30mg daily plan taper Q4 days. pt's respiratory status improved increased steroids weaned ventilator continued trach collar. family agreed hold mechanical ventilation become necessary focus comfort. . # Lower GI bleed - patient episode significant lower gi bleeding setting coagulopathy related poor nutritional status. Given patient's worsening multiorgan system failure medical team family agreed hold blood transfusions possible procedures may lead discomfort. . # UTI: patient history multiple UTIs highly resistant organisms. Recently completed course linezolid cipro VRE cefepime resistant nonfermenter nonpseudomonas. admission pt found positive UA mod leuk, pos nit. Elevated WBC count, currently afebrile. BP stable. Lactate within normal limits. Given previous culture data pt started linezolid cipro pending repeat culture. Linezolid discontinued [7-24] culture grew gram negative rods. Final speciation sensitivities demonstrated resistance cipro patient transitioned meropenem. 7 day course meropenem completed [7-30]. . # Small bowel obstruction/ileus: Partial SBO noted CT scan outside hospital. seen surgery ED - nonoperative candidate, NG tube placed. Abdominal exam notable distension, nontender, diminished BS. Plan continue serial abdominal exams, continue NGT manage conservatively. Improved quickly, large bowel movements second day admission. . # NSTEMI: Troponin 1.51 admission ED setting increased creatinine. Case discussed cardiology feel intervention necessary time. point timing event unclear. [Name2 (NI) ] echo [6-29] showed EF 50-55%. Repeat TTE unchanged prior. continued medical management aspirin, beta blocker, statin. Aspirin discontinued pt developed lower GI bleed. . # Goals Care: Dr. [Last Name (STitle) ], primary physician, [Name10 (NameIs) ] active discussion goals care family, recent hospitalizations complicated. Intially family requested consideration continued aggressive care including mechanical ventilation, PEG placement dialysis necessary. However patient continued worsen despite maximal medical therapy given overall poor prognosis due multi-organ system failure family decided hold dialysis, reinstating mechanical ventilation. transferred ICU medical floor goal maintaining comfort care only. . maintained morphine IV, titrated comfort. died peacefully 1900 hours [2139-8-6]. son present, attending physician. # PPx: PPI, heparin subq, bowel regimen . # Code: DNR/DNI, CMO Medications Admission: Meds: (per OMR) Atorvastatin 20mg daily Acetaminophen 160mg/5mL q8H PRN Albuterol NEB q4H PRN Aspirin 81mg daily Diltiazem 90mg QID Colace 100mg [Hospital1 ] Fentanyl 50mcg patch q72h Fluticasone 50mcg [2-11] sprays daily Heparin subq Hydralazine 25mg q6H Ipratroprium 17mcg 2 puffs QID Reglan 5mg tab TID w/ meals, hs Metoprolol 50mg TID Prednisone 2.5mg tab daily Protonix 40mg daily Multivitamin daily Nystatin suspension Oxcarbazepine 300mg [Hospital1 ] Percocet 5/325 q6H prn pain Senna 8.6mg tab [Hospital1 ] prn Advair diskus 250/50 IH [Hospital1 ] Insulin SS Nortriptyline 50mg hs Sucralfate 1g QID Discharge Disposition: Expired Discharge Diagnosis: COPD ARF Discharge Condition: expired Discharge Instructions: Expired Followup Instructions: Expired	[ "311" ]
Admission Date: [2198-2-11] Discharge Date: [2198-3-14] Date Birth: [2150-10-21] Sex: Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 3624] Chief Complaint: Shortness breath Major Surgical Invasive Procedure: 1. Intubation/extubation 2. Bronchoscopy 3. PICC placement 4. Right internal jugular placement 5. Blood transfusions 6. [Last Name (un) 1372]-intestinal feeding tube placement 7. Arterial line placement History Present Illness: Mr. [Known lastname 931] 47 yo male h/o DM, kidney/pancreas transplant [2183] recent STEMI medically managed late [12-18] transferred OSH SOB. Hx obtained mostly notes pt quite somnolent exam. Pt presented OSH today c/o 2 weeks progressive dyspnea pedal edema. sats 70% RA 92% NRB RR 40. placed Bipap sats 94-95% CXR showed whiteout lungs. treated Rocephin,solumedrol 125 mg, 80 mg IV lasix, ativan nitro gtt. Additionally, troponin noted 1.17, proBNP 70,000 (baseline 30,000), WBC 21.8 left shift. ABG 7.39/32/71. transferred [Hospital1 ]. . Upon arrival ER blood pressures stable. sats 98% 15L NRB. Since appeared using ascessory muscles switched BIPAP sats 95%. additional 80 IV lasix administered time put 1.1L past 6 hours. CXR done showed evidence PNA. Additionally ER troponin noted elevated ST elevations seen EKG. d/w cards determined trop trending previous STEMI ST changes residual previous STEMI. . Currently patient BIPAP answering questions periodically falling back asleep. Past Medical History: STEMI (admitted [Date range (1) 26574]) decided medically manage setting renal failure Cr 6 fact event likely occurred several days prior. MIBI showed EF of18%. DM1 x 12 yo- pt insulin longer checks BS R toe amputation Osteopenia Urethral stricture Penile implant Sleep apnea history bilateral IVH [2195] Kidney/pancreas transplant [2183]: kidney transplant present RLQ, pancreas transplant LLQ (enteric conversion performed pancreas moved bladder GI). Rejection [2183] Recent admit elevated Cr thought [3-16] lasix ACEI well recent STEMI Social History: ETOH, 20 pky smoker, quit [2183] transplant, smokes marijuana rarely, heroin, cocaine. Married 2 children, works [Company 11293]. Family History: Brother - deceased MI age 52, also diabetes s/p transplant Father - deceased MI age 53 Physical Exam: VS:T 97.7 BP 125/83 HR 79 RR 23 O2 94% bipap 8/10 Fio2 0.5 GEN: somnolent arousable male, NAD HEENT: bipap place, unable open eyes, limited BIPAP mask Neck: supple, JVP 6 cm Cardio: RRR, 2/6 systolic murmur loudest LUSB, nl S1 S2 Pulm: CTA b/l ant Abd: soft, NT, ND, hypoactive BS Ext: 3+ pitting edemal b/l Neuro: somnolent arousable, withdraws painful stimuli, cooperative exam Pertinent Results: EKG: NSR LAD; TWI I,AVL,V2-V6 (new V2,V3) q v2-v5; persistent ST elevations V3-V5 (present previously V3,V4). . CXR [2198-2-10] prelim read: Worsening airspace opacities likely representing consolidation element edema; pneumonia. effusions. . Exercise MIBI [12-18]: 1. Moderate, predominantly fixed perfusion defect involving mid-distal anterior wall, apex, distal septum. 2. Marked left ventricular enlargement. 3. Severe global hypokinesis, superimposed apical dyskinesis. LVEF=18%. . ECHO [2198-1-1]: Moderate aortic valve stenosis, AoV area 0.8 cm2. Mild symmetric left ventricular hypertrophy regional systolic dysfunction c/w CAD (mid-LAD territory), EF 30%. Moderate pulmonary artery systolic hypertension, PASP 48mm Hg. . LENI [2198-2-13]: Possible old, nonocclusive thrombus within duplicated left superficial femoral vein. Remainder deep veins lower extremities bilaterally unremarkable. . RENAL U/S [2198-2-13]: 1) Tardus parvus waveforms within segmental arteries supplying renal parenchyma decreased resistive indices suggestive parenchymal hypoperfusion. 2) hydronephrosis. . TTE [2198-2-13]: left atrium moderately dilated. estimated right atrial pressure >20 mmHg. left ventricular cavity moderately dilated. Overall left ventricular systolic function severely depressed. Transmitral Doppler tissue velocity imaging consistent Grade II (moderate) LV diastolic dysfunction. Right ventricular chamber size free wall motion normal. ascending aorta mildly dilated. aortic valve leaflets moderately thickened mild moderate aortic stenosis. Trace aortic regurgitation seen. mitral valve leaflets mildly thickened. Mild (1+) mitral regurgitation seen. moderate pulmonary artery systolic hypertension. Significant pulmonic Regurgitation seen. end-diastolic pulmonic regurgitation velocity increased suggesting pulmonary artery diastolic hypertension. small pericardial effusion. echocardiographic signs tamponade. . CT HEAD [2198-2-28]: 1. evidence acute intracranial hemorrhage. Stable appearance brain compared [2195-9-2]. 2. New opacification mastoid air cells bilaterally right middle ear cavity intubated patient. . RENAL U/S [2198-3-11]: Overall stable appearance renal transplant tardus-parvus waveforms within parenchymal segmental arteries suggestive parenchymal hypoperfusion. Brief Hospital Course: A/P: 47 yo male h/o DM, kidney/pancreas transplant [2183] recent STEMI medically managed late [12-18] transferred OSH SOB, likely PNA CHF exacerbation. . 1) Respiratory failure: Patient's sats 70s RA OSH. CXR showed whiteout c/w bilateral patchy PNA +/- CHF exacerbation. Following admission, patient initially maintained BiPAP appeared increased work breathing, though sats stable time. transfer [Hospital1 18], patient failed improve clinically diuresis, making CHF seem less likely etiology respiratory failure. Bilateral patchy infiltrate visualized; atypical pattern community-acquired pneumonia raised concerns PCP [Last Name (NamePattern4) ]. fungal vs. multifocal bacterial pneumonia chronically immunosuppressed host. HD#2, intubated respiratory distress. Diagnostic bronchoscopy BAL performed unrevealing culture data. initially treated empirically PCP, [Name10 (NameIs) ] Bactrim discontinued due nephrotoxicity highly sensitive BAL negative PCP. [Name10 (NameIs) ] treated 10-day course levaquin vancomycin broad spectrum coverage organism isolated. Serum fungal markers negative aspergillus, equivocal beta-glucan. Patient remained ventilator-dependent [2-12] - [3-1], CPAP + PS ongoing high ventilatory requirements likely due fluid overload compounded acute oliguric chronic renal failure. Course complicated MSSA ventilator-acquired pneumonia treated 8 days vancomycin zosyn. Following improvement renal function, diuresed aggressively lasix gtt lasix boluses. [3-1], extubated despite poor prognostic indicators due chronicity vent-dependence, plan tracheostomy tolerate non-invasive respiratory support. transitioned face-mask O2 ultimately require planned tracheostomy. . 2) Cardiac: (a) Pump - Patient s/p STEMI [12-18] resultant CHF, last EF measured 30% [Month (only) ], 25% admission. admission, heart failure service consulted. clinical status early admission improve diuresis, feel though heart failure predominant precipitating factor initial respiratory failure. However, poor pump function poor renal function compounded course significantly led protracted course ventilator due worsening pulmonary edema. tried trial nitroglycerin drip afterload reduction, later discontinued favor hydralazine. beta-blockade therapy uptitrated tolerated BP. Throughout hospital course, diuresed tolerated, careful monitoring tenuous renal function. (b) Vessels - Per cards, persistent troponin elevation likely residual prior STEMI, CKMB elevated. Continued medical management ASA, plavix, statin, BB. ACEI held setting ARF. (c) Rhythm - Previously NSR new onset paroxysmal atrial fibrillation hospitalization. initially started beta-blocker rate control ICU. [3-3] went afib without resolution Lopressor, dropping blood pressure. amiodarone drip started, loading bolus 150 mg, improvement. Coumadin initiated [3-5] CVA prophylaxis relatively young man [Name (NI) 16064] score 3 (1 point DM, HTN, CHF); Goal INR [3-17]. difficulty regulation coumadin dosing patient became supratherapeutic likely secondary renal failure. dose held days restarted. However, patient refused take coumadin reinitiation recommended concerned elevated INR again. Multiple attempts made encourage take medications recommended. eventually started discharged daily oral amiodarone irregular rhythm. . 4) Anemia: NG lavage gastroccult positive. Stools reported guiac-negative. GI consulted [2-24] ? UGIB EGD deferred. Consider stress ulcer vs. OG trauma. Iron studies c/w anemia chronic disease. transfused periodically setting low output state. hematocrit stable medicaly floor. . 5) ARF: setting acute pulmonary illness, patient developed acute chronic renal insufficiency s/p renal transplant x 14 years. Suspect initially pre-renal picture precipitant ARF, given intravascular volume depletion. Renal ultrasound transplant kidney shows hypoperfusion hydronephrosis (which queried acute setting post-renal obstruction, resolved). Likely overall picture c/w prerenal azotemia, resolved throughout hospitalization improving Cr improving UOP. Renal service followed throughout stay felt acute HD needs despite poorly functioning renal graft. continued Vitamin analogue Calcitriol secondary hyperparathyroidism (PTH 225). received Epo 10,000 units 3x/week anemia chronic disease. aAceI setting acute renal failure. maintained prednisone tacrolimus chronic immunosuppression. tacrolimus dose decreased direction Nephrology service. . 6) Urinary retention: Patient also unusual phallic anatomy penile implant, stricture, ? prostatic enlargement, possible post-renal obstruction also contributed onset ARF. Following multiple nursing house officer attampts foley placement, Urology consulted ultimately able place 12 french Coude catheter. difficulties urinary retention foley discontinued. restarted flomax hemodynamics stable tolerated well. . 7) FEN: Nutrional support tube feeds provided patient ventilator-dependent. S&S evaluation demonatrated possible delayed signs aspiration. video swallow study ultimately performed revealed moderate silent aspiration nectar-thick consistencies multiple episodes laryngeal penetration, able cleared cued cough. underwent repeat swallow evaluaiton [3-14] improved swallowing mechanics. diet advanced regular tolerated well. medical floor, patient remained stable monitored mainly return renal function baseline medication management. recommended patient initially discharged rehabilitation facility PT/OT. However, patient wife felt strongly would safe home. worked PT throughout admission felt improving appropriate home PT. discharged home home PT VNA medication teaching. follow Renal Diabetic physicians. Medications Admission: Tacrolimus 2 mg qAM Tacrolimus 1 mg qPM Atorvastatin 80 mg qd Aspirin 325 mg Tablet qd Ferrous Sulfate 325 [Hospital1 ] Cholecalciferol (Vitamin D3) 400 unit qd Prednisone 12.5 mg qhs Metoprolol Succinate 150 mg qd Calcium Acetate 667 mg 2 tabs PO TID Sodium Citrate-Citric Acid Thirty ml TID Clopidogrel 75 mg Tablet qd Hydralazine 10 mg Tablet q8hours Lasix Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 5. Prednisone 5 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). Disp:15 Tablet(s) Refills:1 6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times day). Disp:90 Tablet(s) Refills:1 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times day). Disp:60 Tablet(s) Refills:1 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:120 Tablet(s) Refills:1 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:1 11. Tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO BID (2 times day). Disp:120 Capsule(s) Refills:1 12. Epogen 10,000 unit/mL Solution Sig: Three (3) Injection week. Disp:10 Refills:1 Discharge Disposition: Home Service Facility: VNA Assoc. [Hospital3 ] Discharge Diagnosis: 1. Congestive Heart Failure 2. Diabetes Mellitus 3. Pneumonia 4. non-St elevation myodardial infarction 5. Atrial Fibrillation Discharge Condition: Stable. Able walk safely walker. Tolerating general diet. Discharge Instructions: weight every day. weight 3 pounds, call doctor. Adhere low sodium diet. tacrolimus level changed. taking 1.5 mg tacrolimus twice day. change made Renal doctors. also started amiodarone atrial fibrillation (irregular heart rate). continue take medication seen primary care physician. Contact physician fever > 101.5, nausea, vomiting, loss conciousness, abdominal pain, persistent diarrhea, concerns. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 5003] Date/Time:[2198-3-27] 11:40 Provider: [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2198-6-12] 10:10 Provider: [Name10 (NameIs) ], [Name11 (NameIs) ] MD Phone: [Telephone/Fax (1) 26575] [Telephone/Fax (1) 2378]. Follow-up within 2 weeks. must call make appointment. [First Name4 (NamePattern1) 971] [Last Name (NamePattern1) 970] MD [MD Number(1) 3629]	[ "486" ]
Admission Date: [2177-2-14] Discharge Date: [2177-2-17] Date Birth: [2128-7-1] Sex: Service: [Company 191] EAST CHIEF COMPLAINT: Lethargy. HISTORY PRESENT ILLNESS: 48-year-old HIV positive African-American male history polysubstance abuse, hepatitis C, cirrhosis hypertension admitted [Hospital 10073] Hospital [2177-2-10], detox following recent binge using crack cocaine (about one gram per day), alcohol (one pint wine per day) Xanax Klonopin Methadone maintenance. [2177-2-12], noted fluctuating mental status (somnolence, disorientation) found beside bed confused, bloody nose blood pressure 170/130, presumed seizure. given 1 mg Ativan brought [Hospital1 1444] Emergency Department. Following negative head CT, seizures stable vital signs, patient discharged back Bornwood Ativan taper. [2177-2-13], patient reported lethargic ataxic, blood pressure 150/100. EMT brought patient back [Hospital1 188] Emergency Department, vital signs included blood pressure 190/90, pulse 88 respiratory rate 4, satting 94% room air. patient barely responsive sternal rub, constricted pupils started Narcan, receiving dose 0.06 mg/hour good effect. admitted MICU early a.m. [2177-2-14]. difficult obtain additional history patient time. Subsequently learned patient received OxyContin 40 mg friend detox, remembers taking prior admission hospital, although unclear day took it. PAST MEDICAL HISTORY: 1. HIV positive since [2162-3-12]. CD4 count 78 undetectable viral load noted [2176-9-10] per patient's primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 8271]. patient history thrush per previous dictation summaries. question history PCP past. patient HAART, discontinued fall last year decompensating liver disease setting hepatitis C. 2. Multisubstance abuse including intravenous drug abuse. patient long-standing history multisubstance abuse going back 25 years includes intravenous heroin cocaine abuse, benzodiazepine use including Xanax Klonopin, ethanol. patient rehabilitation facilities past, stays long term Methadone maintenance. patient admit recent use cocaine, ethanol, benzodiazepines, denies use heroin several months, stating crave heroin Methadone. 3. Hepatitis C positive. patient active hepatitis C disease high viral load candidate therapy time considering current treatment depression. albumin low 2.5 past improved since holding HAART therapy. history ascites gastrointestinal bleed. patient falls Child Class B C cirrhosis. 4. Pan cytopenia likely secondary HIV ethanol abuse. 5. Hypertension. 6. Depression. 7. History tuberculosis exposure. 8. History bacterial endocarditis, Staph positive past ([2161] [2168] hospitalizations). 9. History sternoclavicular septic arthritis [2167]. 10. Status post motor vehicle accident head trauma. 11. Bilateral leg pain numbness secondary peripheral neuropathy. 12. Status post appendectomy. 13. Status post inguinal hernia repair. 14. Question distant history seizure. MEDICATIONS PRIOR ADMISSION: 1. Methadone 55 mg q. day. 2. Prozac 20 mg q. day. 3. Ativan 1 mg t.i.d. taper. 4. Thiamine. 5. Folate. 6. Clonidine 0.2 t.i.d. p.r.n. 7. Motrin 400 mg q. 4h. p.r.n. 8. Mylanta 30 cc q. 4h. p.r.n. 9. Ativan 1 mg p.o. q. 4h. p.r.n. SOCIAL HISTORY: patient lives wife [Location (un) 686] five children several grandchildren. retired since [2172] working American Airlines ramp worker. lives SSI Mass Health Veterans benefits cover medications. previously mentioned, extensive history intravenous drug abuse includes intravenous heroin cocaine abuse extends back decades. recent binge attributed increased depression recent time inability stay clean, cirrhosis chronic illnesses, recent fight wife, multiple deaths family, upcoming court date next week DUI arrested [Month (only) 404] year. patient one pack per day smoking history and, denies extensive abuse alcohol, admit recently drinking one pint one bottle wine per day. ALLERGIES: patient allergy Bactrim causes rash. patient allergy nafcillin also given exfoliative dermatitis palms soles past. FAMILY HISTORY: patient's mother healthy age 83. patient's father 82 years old, suffering diabetes mellitus. patient two sisters died cancer, one age 58 one passed away 20's. family history substance abuse. question history depression patient's mother. REVIEW SYSTEMS: admission patient denied complaints headache, chest pain, shortness breath, nausea, vomiting, fevers chills. complaints diarrhea, constipation abdominal pain time. dysuria increased urinary frequency. PHYSICAL EXAMINATION PRESENTATION: physical examination presentation Intensive Care Unit floor patient following vital signs: afebrile heart rate 75, blood pressure 139/101, respiratory rate 18 saturating 100% room air. General appearance: patient somnolent, responsive questions without tremulousness. examination head, eyes, ears, nose throat, patient normocephalic, atraumatic. Mucus membranes dry. Pupils 4 mm reactive light bilaterally. patient's neck supple without lymphadenopathy. pulmonary examination lungs clear auscultation bilaterally without wheezes crackles. cardiovascular examination, normal rate rhythm normal S1, S2. systolic murmur appreciated apex. abdominal examination normal bowel sounds present. abdomen soft, non-tender non-distended. extremities without edema cyanosis. neurological examination, patient alert oriented times three. Cranial nerves II XII intact. focal motor deficits appreciated. PERTINENT LABORATORY DATA PRESENTATION: patient following laboratories admission: complete blood count revealed white blood cell count 1.9 ANC 700, hematocrit 32.5 platelet count 53,000. Chem-7 (hemolyzed) showed sodium 137, potassium 4.8, chloride 103, bicarbonate 31, BUN 13, creatinine 0.8 glucose 118. serum tox screen aspirin, ethanol, acetaminophen, benzodiazepines, barbiturates, TCA negative. RADIOLOGY/STUDIES ADMISSION: 1. Electrocardiogram: Sinus rhythm, left ventricular hypertrophy left atrial abnormality. Nonspecific ST changes observed. Q2 prolongation new EKG observed compared previous [2170-12-16] EKG. 2. Chest x-ray: Mild moderate cardiac enlargement prominent left ventricle contour. Wide thoracic aorta. evidence pulmonary congestion infiltrates. 3. Head CT: Head CT [2177-2-12] Emergency Department visit showed mild focal dilatation, normal ventricular system. midline shift, mass, mass effect, hemorrhage observed. Chronic paranasal sinus disease noted. IMPRESSION ADMISSION: 45-year-old African-American male history polysubstance abuse, HIV hepatitis C came Emergency Department stuporous mental status changes detox facility. felt likely opiate overdose, patient appeared respond Narcan Emergency Department. Infection possible etiology mental status changes could completely ruled HIV positive patient last CD4 count 78. However, patient recall taking extra 40 mg OxyContin prior admission top maintenance Methadone dose 55 mg per day benzodiazepine taper started [2177-2-12] Emergency Department visit, making overdose likely. HOSPITAL COURSE INTENSIVE CARE UNIT: [Unit Number ]. Neurological: Patient's mental status changes included increased lethargy stuporousness, pinpoint pupils decreased respiratory rate setting Methadone, benzodiazepine opiate use make opiate overdose likely cause patient's presentation. patient showed good response naloxone throughout stay Intensive Care Unit continued drip [2177-2-15], dramatic improvement patient's state alertness. causes change mental status included withdrawal benzodiazepines alcohol, electrolyte abnormalities, infection, intracranial processes, well renal hepatic disease. reason, electrolytes followed, calcium, magnesium, phosphate levels sent. LP also performed. patient pan cultured, including cultures blood, urine cerebrospinal fluid. patient's history alcohol benzodiazepine use last alcohol use likely [2177-2-10], possibility withdrawal patient, CIWA protocol diazepam q. 4h. score greater 10. Clonidine p.r.n. also continued possibility developing opiate withdrawal. patient depression, Prozac held Intensive Care Unit. Neurology consult felt seizure [2177-2-12], likely secondary combination withdrawal alcohol benzodiazepines. recent cocaine evident urine tox screen, concern cerebral infarct, negative CT nonfocal neuro examination made less likely. Liver function tests ammonia also sent patient history hepatitis C. Patient's laboratory values Intensive Care Unit [2177-2-14], included calcium 8.0, magnesium 1.4 phosphate 3.1. patient's PT 13.7, INR 1.2 PTT 37.7. patient elevated AST 101, ALT 52, alkaline phosphatase 129, total bilirubin 0.8. albumin 2.7 repeated day found 3.1. Amylase 98 lipase 63. patient ammonia elevated 95 history previous baseline ammonia recorded past. urine tox screen positive cocaine Methadone negative benzodiazepines. LP performed [2177-2-14], showed 0 white blood cells, 6 red blood cells, protein 37, glucose 57. Gram stain negative PMNs, microorganisms seen. Cryptococcal antigen detected, fluid, acid fast, viral, fungal cultures sent. 2. Infectious Disease: patient HIV positive hepatitis C positive, possible infection could also underlying cause mental status changes. mentioned pan cultured, including blood, urine, CSF stool cultures. Tests CD4 count viral load sent. patient reported retrovirals since fall last year. Liver function tests ordered follow status cirrhosis, elevated previously mentioned dictation. Throughout patient's duration Intensive Care Unit, complain fevers, shortness breath productive cough, dysuria, complaints suggestive infectious process. 3. Pulmonary: patient's respiratory rate improved Narcan drip Intensive Care Unit need intubate. 4. Cardiac: patient history hypertension used beta blockers past. hypertensive medication past several days detox. pressures remained elevated Intensive Care Unit. evening [2177-2-14], hypertensive 206 given dose hydralazine control pressure. Subsequently, lisinopril 5 mg q. day hydrochlorothiazide 25 mg q. day begun better control pressure. patient's EKG showed increased QT prolongation prior EKG, setting potassium 3.4 upon repeat Chem-7 [2177-2-14]. unclear medicines patient taking associated causing QT prolongation. patient's potassium repleted. 5. Hematology. patient's pan cytopenia noted CBC. stable throughout stay Intensive Care Unit. 6. Renal/Fluids, Electrolytes Nutrition. patient given maintenance fluids one-half normal saline 100 cc per hour. maintained patient's mental status improved. began tolerating p.o.'s [2177-2-15]. patient's elevated ammonia, placed low protein diet able tolerate p.o.'s. Electrolytes followed daily repleted necessary, potassium magnesium requiring repletion. patient placed thiamine, folate multivitamin considering patient's history alcohol abuse. 7. Gastrointestinal: patient history cirrhosis setting HAART use discontinued [2176-9-10] history ethanol abuse. elevated transaminases, PT albumin 3.1 elevated ammonia. Lactulose started 30 cc t.i.d., titrated less two stools per day treat elevated ammonia. Hepatitis C serologies sent time likely followed outpatient. 8. Prophylaxis. patient placed subcu heparin Pepcid IV q. day. SUMMARY INTENSIVE CARE UNIT STAY: patient's mental status continued improve Narcan drip weaned 12 hours respiratory rate greater 11. Cultures remained negative ICU stay. patient able tolerate p.o.'s prior transfer. Vital signs stable, although blood pressures remained elevated prior transfer. patient transferred [Hospital Ward Name 8559] [Company 191] Service [2177-2-15]. HOSPITAL COURSE FLOOR ([2177-2-15] [2177-2-17]): 1. Neurological: arrival floor, patient breathing comfortably acute distress alert oriented depressed mood. complain symptoms nausea, chills, diaphoresis, aches pains, diarrhea, thought consistent typical withdrawal symptoms. continued CIWA protocol p.r.n. diazepam, clonidine continued complaints opiate withdrawal. Methadone begun floor dose 55 mg q. day. Lactulose also considered light elevated ammonia, although encephalopathy appeared unlikely patient asterixis additional changes mental status. continued follow daily labs showed white blood cell count 1.7, hematocrit 32.6 platelet count 47,000, ANC 740. Electrolytes showed sodium 137, potassium 3.3, chloride 107, bicarbonate 22, BUN 8, creatinine 0.5 glucose 98. Calcium 7.5, magnesium 1.8 phosphate 3.0. PT INR normal, PTT remained slightly elevated 39. patient offered nicotine patch nicotine addiction declined. patient's mental status continued stable stay floor, signs overt anxiety, hallucinations, instability, patient somewhat depressed nervous, admitted primarily due worry personal stressors. symptoms opiate withdrawal also negligible second third days floor. Prozac restarted last day admission depression. appeared patient symptoms ethanol withdrawal, however, blood pressure remain elevated throughout stay without tachycardia. patient's symptoms opiate withdrawal seemed well controlled Methadone maintenance dose although patient receive one two doses benzodiazepine per day, requested clonidine final day admission p.r.n. However, patient admit feels better years physically admits psychological problems depression make feel concerned time. several discussions patient regarding seriousness hospital admission risk poor outcome continues risky behaviors, overdose might life threatening. patient actually quite thoughtful clearly depressed current health situation, living environment ("my neighborhood full drugs"), life stressors (several deaths recent past family). 2. Infectious Disease. patient's CD4 count found 48 admission viral load still pending. patient remained afebrile throughout admission, without complaints fever, productive cough, dysuria, abdominal pain, clinical signs concerning infection. Blood, stool cerebrospinal fluid cultures negative date. Prophylaxis begun PCP dapsone fluconazole also started patient history thrush. However, fluconazole discontinued prior __________ prophylaxis indicated routinely HIV positive patients. patient's CD4 count 50, toxoplasmosis titers also sent, followed possible toxoplasmosis prophylaxis well [Doctor First Name ] prophylaxis outpatient. 3. Cardiovascular. patient's EKG repeated [2177-2-16], found unchanged admission EKG, suddenly prolonged QT interval. Potassium also 3.2 [2177-2-16], repleted. patient's blood pressure continued elevated throughout stay floor, 150's 180's 90's 100's. dose lisinopril increased 10 q. day, decided prior discharge change patient's blood pressure regimen 10 mg lisinopril b.i.d., discontinue hydrochlorothiazide, begin Norvasc 5 mg p.o. q. day. 4. Pulmonary. patient breathing comfortably normal respiratory rate saturating well room air throughout stay floor. patient complained runny nose transfer floor, developed symptoms suggestive serious respiratory infection. patient previous hospitalizations pneumonia question PCP pneumonia past. 5. Renal. patient normal creatinine throughout hospital stay. urinalysis negative except negative urobilinogen patient advanced liver disease. Urine culture positive group B Strep endogenous organism considered needing treated. 6. Fluids, Electrolytes Nutrition. patient's lytes followed repleted floor. Potassium remained slightly low throughout repleted 40 mEq KCl stays floor increased 60 mEq [2-17]. maintained low protein diet light elevated ammonia 148 day discharge. continued thiamine, folate multivitamin additional B12 folate studies sent still pending. tolerated p.o. liquids solids well throughout stay floor. complaints nausea vomiting. 7. Gastrointestinal. patient hepatitis C positive cirrhosis albumin came back 2.8 [2177-2-16]. continued follow ammonia 148 prior discharge, lactulose poorly tolerated patient discontinued final day admission. patient requesting therapy options liver disease seemed concern health issues. Unfortunately, Interferon therapy may contraindicated patient Zoloft clear symptoms depression. outpatient would recommended receive vaccination hepatitis light liver disease. patient prior history gastrointestinal bleed, began Imdur GI prophylaxis, recommended esophagogastroduodenoscopy outpatient. 8. Hematology. patient's pan cytopenia stable floor. patient complain nose bleed one morning setting low platelet count described robust, stopped easily recur. light patient's pan cytopenia may likely due ethanol use, HIV, liver disease, thought B12 folate also checked. 9. Prophylaxis. patient remained heparin subcu b.i.d. ranitidine 150 mg p.o. b.i.d. throughout stay floor. CONDITION DISCHARGE: patient good condition discharge. complaining symptoms alcohol withdrawal, maintained CIWA protocol greater 8 last three days floor. Methadone maintenance restarted good effect. primarily concerned psychosocial issues maintaining sobriety, safe drug-free environment, chronic health issues, family stressors, tomorrow's pending court appearance. Depression, reasons, concern patient appears overdosed narcotics leading admission. DISCHARGE STATUS: patient discharged back [Hospital 10073] Hospital, first admitted last Monday ([2177-2-10]) begin detox program prior hospitalization. wishes return Bornwood continue detox safe environment try address recurrent urges polydrug abuse. [Hospital 10073] Hospital located [Street Address(2) 10074] [Location (un) ], [Numeric Identifier 10075]. DISCHARGE MEDICATIONS: 1. Thiamine 100 mg q. day. 2. Folic acid 1 mg q. day. 3. Multivitamin. 4. Dapsone 100 mg q. day. 5. Methadone 55 mg q. day. 6. Fluoxetine 20 mg q. day. 7. _____ 10 mg b.i.d. 8. Ativan 1 mg q. 4h. p.r.n. 9. Clonidine 0.2 mg t.i.d. p.r.n. 10. Potassium chloride 20 mEq b.i.d. 11. Norvasc 2.5 mg p.o. q. day. 12. Magnesium oxide 400 mg p.o. q. day. 13. Imdur 30 mg q. day. DISCHARGE INSTRUCTIONS FOLLOW UP: 1. patient instructed call primary care physician, [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 8271], discharge set follow-up appointment one week desired continue involved care. 2. patient mentioned desire transfer care V.A. Hospital, negative experiences past, set appointment Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Associates, [Hospital1 1444], Thursday, [2-20], 2:00 p.m., [Hospital Ward Name 23] Building. appointment patient able follow pending laboratory studies include pending cultures, viral load, toxoplasmosis cultures. Also potassium ammonia levels checked time. patient's blood pressures elevated hospital stay blood pressure control medications still optimized, blood pressure checked visit modification medical regimen considered. Pending results toxoplasmosis titers, patient considered toxo [Doctor First Name ] prophylaxis, considering CD4 count 48. Also consider hepatitis vaccine confirm hepatitis B status patient. patient noted slightly prolonged QT interval EKG, would also useful recheck EKG visit. patient complaints gastrointestinal bleed past, sent endoscopy look varices outpatient. patient also requesting psychiatric and/or social work support numerous psychosocial stressors needs support network help depression numerous issues involving drug abuse health care problems. patient also set followed [Hospital3 ]. 3. patient also scheduled visit Pain Clinic [Hospital1 69] Thursday Dr. [Last Name (STitle) ] [2-20] 12:40 p.m. visit important light chronic back pain peripheral neuropathy, patient states factor persistent drug use. 4. Continue Methadone maintenance program previous admission. 5. Consider contacting [Name (NI) 10076] acupuncture treatments patient requested therapy worked past. DISCHARGE DIAGNOSES: 1. Opioid benzodiazepine intoxication. 2. Polysubstance abuse. 3. HIV positive. 4. Hepatitis C positive. 5. Hypertension. 6. Depression. [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) 1775] [Last Name (NamePattern1) ], M.D. [MD Number(1) 1776] Dictated By:[Name8 (MD) 10077] MEDQUIST36 D: [2177-2-17] 16:59 T: [2177-2-17] 16:15 JOB#: [Job Number 10078]	[ "042" ]
Admission Date: [2176-11-4] Discharge Date: [2176-11-8] Service: CARDIOTHORACIC HISTORY PRESENT ILLNESS: patient 77 year-old female status post myocardial infarction [11-2] substernal chest pain shortness breath. arrival Emergency Room electrocardiogram changes increased CK. Diagnosis coronary artery disease, unstable angina. taken Operating Room coronary artery bypass graft times three Dr. [Last Name (STitle) ]. PAST MEDICAL HISTORY: Hypertension, hypercholesterolemia, peripheral vascular disease, hypothyroidism. CATHETERIZATION REPORT: Left main normal. Left anterior descending coronary artery 90% stenosis. Left circumflex 20%. Obtuse marginal two 30% stenosis. Obtuse marginal three 60% stenosis. Right coronary artery 80% stenosis. MEDICATIONS HOME: Hyzaar 125, Synthroid .112 mcg po q day, Pletal 100 mg po b.i.d., Lipitor 10 mg po q day. HOSPITAL COURSE: patient taken Operating Room coronary artery bypass graft times three, left internal mammary coronary artery left anterior descending coronary artery, saphenous vein graft posterior descending coronary artery, saphenous vein graft obtuse marginal. Postoperatively, patient well. Chest tube extubated promptly Intensive Care Unit. Chest tube taken postop day number one. patient subsequently transferred floor postop day number one. Upon arriving floor patient able work physical therapy ambulate. Upon discharge patient able ambulate approximately 300 feet assistance. patient discharged rehab facility [2176-11-9]. DISCHARGE MEDICATIONS: Lopressor 50 mg po b.i.d., Synthroid .112 mcg po q day, Lasix 20 mg po b.i.d. times ten days, K-Ciel 20 milliequivalents po b.i.d. times ten days ASA 81 mg po q day, Lipitor 10 mg po q.d., iron sulfate 325 mg po t.i.d. CONDITION DISCHARGE: Stable. sinus rhythm. pulse 95 blood pressure 126/67. patient sating 98% 2 liters. hematocrit 25.3. PHYSICAL EXAMINATION DISCHARGE: Lungs clear auscultation. heart regular rate rhythm. Incision clean dry. drainage. Sternum stable. patient discharged rehab facility [2176-11-9]. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Name8 (MD) 33515] MEDQUIST36 D: [2176-11-8] 12:16 T: [2176-11-8] 13:02 JOB#: [Job Number 111135]	[ "412" ]
Admission Date: [2148-10-6] Discharge Date: [2148-12-30] Date Birth: [2148-10-6] Sex: Service: HISTORY PRESENT ILLNESS: [Known lastname ] [Known lastname ] former 936 gram product 26 [3-8] week gestation, twin pregnancy, born 45 year old, Gravida II, Para II woman. PRENATAL SCREENS: Blood type 0 negative, antibody negative, Rubella immune; rapid plasma reagent nonreactive; hepatitis B surface antigen negative; hepatitis C negative; HIV negative, group beta strep status unknown. maternal pregnancy notable hypothyroidism Synthroid, ureteral reflux, status post repair; fibroids, status post resection HSV last lesion [2148-9-2]. in-[Last Name (un) 5153] fertilization pregnancy donor eggs. donor 26 years old. pregnancy remarkable dichorionic, diamniotic twins concordant growth. Cervical shortening diagnosed 21 weeks, treated bed rest home admitted [9-17]. mother beta complete [9-20]. premature labor treated Terbutaline magnesium [9-21]. questionable premature rupture membranes [9-21]. date delivery, mother noted advanced cervical dilatation breech/breech presentation. Intrapartum antibiotics given mother received cesarean section spinal anesthesia. Twin 1 emerged initial cry poor respiratory effort, requiring bagged mask ventilation. intubated delivery room. Apgar scores six one minute seven five minutes. child brought Neonatal Intensive Care Unit. PHYSICAL EXAMINATION: Physical examination notable premature male, orally intubated poor perfusion. Birth weight 936 grams, 50th percentile; length 35.5 cm (50th percentile); head circumference 24.5 cm (50 percentile). infant non dysmorphic male overall appearance consistent gestational age. anterior fontanel soft, open flat. Palate intact. Fair aeration crackly breath sounds, murmur, soft abdomen. hepatosplenomegaly. 1+ pulses throughout. Normal male genitalia testes high canal, patent anus, sacral dimple, hip click; mild bruising arms 1.5 5 cm birth mark/versus bruise back mid thoracic region. HOSPITAL COURSE: 1.) Respiratory: patient initially intubated settings 20/5 rate 25. received three doses Surfactant. day life #3, weaned C-pap 6 cm room air. also started caffeine day life three. weaned C-pap room air day life #20. remained caffeine mild apnea prematurity. caffeine discontinued day life 45. remained apnea free and, time discharge, breathing comfortably room air good saturations, evidence apnea prematurity two weeks. 2.) Cardiovascular: initially required two normal saline boluses started Dopamine. weaned Dopamine day life number two. continued stable blood pressures. never patent ductus arteriosus. time discharge, stable blood pressures good perfusion. 3.) Fluids, electrolytes nutrition: infant initially made n.p.o. started intravenous nutrition. Feeds started day life 6 gradually advanced. reached full feeds day life 13 calories gradually increased maximum 30 calories per ounce. growth continued good started orally feeding. time discharge, tolerating full feeds breast milk Enfamil supplement 24 calories per ounce. discharge weight 3.525 kg. 4.) Gastrointestinal: infant developed unconjugated hyperbilirubinemia prematurity treated phototherapy day life #1 day life #8. maximum total bilirubin level 4.9 0.3 day life number one. 5.) Hematology: infant receive one blood transfusion day life #12 low hematocrit. 6.) Infectious disease: Initial complete blood count showed neutropenia subsequent CBC day life one impressive left shift. started Ampicillin Gentamycin day life one completed 7 day course. cultures remained negative. lumbar puncture performed day life number four revealed zero red blood cells three white blood cells. Cultures spinal fluid also negative. time discharge, patient remained antibiotics negative cultures. 7.) Neurology: Head ultrasounds performed day life number 3, day life number 10 day life number 31. head ultrasounds remained within normal limits. 8.) Ophthalmology: Ophthalmology examination performed [11-18] Mid- [Month (only) 1096] revealed immaturity bilaterally zone three. Follow-up ophthalmology required. DISCHARGE STATUS: Discharged home. PRIMARY PEDIATRICIAN: [First Name8 (NamePattern2) 50100] [Last Name (NamePattern1) 10132] [Hospital 3146] Pediatrics. CARE RECOMMENDATIONS: Feedings: Continue breast milk Enfamil 24 calories per ounce monitor growth. MEDICATIONS: Ferrous sulfate 0.2 cc p.o. q. day. Poly-Vi-[Male First Name (un) ] 1 cc p.o. q. day. Eye examination performed 2 3 weeks. State newborn screen sent. Results pending. Automated auditory brain stem response screen prior discharge. Car seat position screening: passed. IMMUNIZATIONS: patient received hepatitis B vaccine [11-22]. received DTAP HIB vaccines [12-6]. received IPV pneumococcal conjugant vaccine [12-5]. Prior discharge, dose Synagis vaccine given. IMMUNIZATIONS RECOMMENDED: Synagis-RSV prophylaxis considered [Month (only) 359] [Month (only) 547] infants meet following three criteria: 1.) Born less 32 weeks. 2.) Born 32 35 weeks two three following: Day care RSV season, smoker household, neuromuscular disease, airway abnormalities preschool siblings. 3.) chronic lung disease. Influenza immunization considered annually Fall preterm infants chronic lung disease reach six months age. age, family caregivers considered immunization influenza protect infant. DISCHARGE DIAGNOSES: Prematurity 26 3/7 weeks gestation. Sepsis ruled out. Respiratory distress, resolved. Apnea prematurity, resolved. Unconjugated hyperbilirubinemia, resolved. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 35940], M.D. [MD Number(1) 35941] Dictated By:[Name8 (MD) 50101] MEDQUIST36 D: [2148-12-13] 02:31 T: [2148-12-13] 15:32 JOB#: [Job Number 50102]	[ "769" ]
Admission Date: [2154-5-2] Discharge Date: [2154-5-11] Date Birth: [2090-9-9] Sex: Service: MEDICINE Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 6169] Chief Complaint: CC:[CC Contact Info 25337] Major Surgical Invasive Procedure: Stereotactic brain biopsy History Present Illness: HPI:Pt 63 yo CAD s/p MI stents, DM2, NASH cirrhosis, recent diagnosis lymphomatoid granulomatosis presents OSH GTC seizure. diagnosed [Month (only) 404] large B-cell lymphoma, review, diagnosed probable lymphomatoid granulomatosis. received Rituxan-CHOP, diagnosis changed, switched Rituxan weekly only, last dose 6 days prior admission. told definitive treatment require bone marrow transplant. suffering diarrhea 2 months 10 days unknown med home. PET scan apparently showed disease mainly lungs possibly liver. never head imaging apparently. home today took temp. 103.2 fever wife brought OSH. En route, stopped talking apparently started GTC activity. got ED either stopped briefly continued convulse, unclear. Ativan 3 mg given resolution. intubated. ? left gaze preference. CT showed 2 cm round left temporal lobe mass mild local edema. shift brainstem involvement. temp 101.7. got vanco, CTX, acyclovir, 1 g cerebyx. transferred here. Past Medical History: Large B-cell lymphoma, changed lymphatoid granulomatosis, large B-cell lymphoma per Dr. [First Name (STitle) 1557]. iron deficiency anemia- Long standing per patient. recently treated IV iron. Recent colonoscopy negative bleeding source Hypertension Coronary Artery Disease s/p MI 2 setnts placed [Hospital1 18] Type II Diabetes Mellitus retinopathy, neuropathy, nephropathy Non-Alcoholic Steatorrheic Hepatitis cirrhosis - verified liver bx 5 years ago per pt report s/p cholecystectomy psoriasis vitiligo Social History: SH: Lives wife. [Name (NI) ] EtOH. smoking. Exposed [Doctor Last Name 360] [Location (un) 2452] [Country 3992]. Family History: FH: Sister metastatic colon CA Physical Exam: Exam:100.3, 112/50->97/48, RR=14-19, O2=99% vent Medications received prior exam: See above. propofol Mental Status:Intubated sedated. Pt lightly sedated, pull restraints times. CN: Pupils: 3 2 sluggishly reactive. Nasal Tickle: Grimaces equally turns away briskly. Gag/Cough: Coughs tube Corneal Reflex:Present bilaterally OCRs: Sluggish, intact. Motor:Some spontaneous movement exts. Withdraws UE LE briskly equally painful stimulus(nailbed pressure). Toes:Upgoing bilaterally DTRs: [Name2 (NI) ] Tri Br Pa [Doctor First Name ] R L Respiration:Pt overbreathing ventilator. Pertinent Results: Labs/Radiology/Procedure: OSH: CBC:15/38.7\91 Chems:138/3.5/105/14/14/0.7/195 Ca=8.5 UA neg nit, neg LE, 0-5 wbcs, 1+ bact. Coags: PTT=30, INR=1.3, PT=12.7 CT head [5-1]: 2 cm left medial temp lobe mass ? vague ring hyperdensity. Slight edema, shift brainstem involvement. CXR [5-1]: 1. Endotracheal tube 3.3 cm carina. Nasogastric tube good position. 2. Low lung volumes bibasilar consolidations - atelectasis pneumonia. 3. 1cm rounded opacity left lung base. Bilateral hilar fullness proportion vasculature. Evaluation via contrast enhanced CT recommended. 4. Stones surgical clips right upper quadrant. Correlation patient's surgical history requested. MRI Head [5-2]: 1. Left temporal lobe mass likely represents focus infection. Rim enhancement edema suggests abscess, though restricted diffusion. Demyelinating process neoplasm also possible, though lesion enhancing. 2. lesions within brain parenchyma. 3. Probable developing hydrocephalus. Echocardiogram [5-6]: LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Dynamic interatrial septum. LEFT VENTRICLE: Normal LV wall thickness, cavity size, systolic function (LVEF>55%). False LV tendon (normal variant). RIGHT VENTRICLE: Normal RV chamber size free wall motion. AORTA: Normal aortic diameter sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. 2D Doppler evidence distal arch coarctation. AORTIC VALVE: Normal aortic valve leaflets (3). AS. AR. MITRAL VALVE: Normal mitral valve leaflets trivial MR. MVP. [Male First Name (un) ] mitral chordae (normal variant). resting LVOT gradient. TRICUSPID VALVE: Normal tricuspid valve leaflets trivial TR. Normal PA systolic pressure. PERICARDIUM: pericardial effusion. Conclusions: left atrium mildly dilated. Left ventricular wall thickness, cavity size, systolic function normal (LVEF>55%). Right ventricular chamber size free wall motion normal. aortic valve leaflets (3) appear structurally normal good leaflet excursion aortic regurgitation. mitral valve appears structurally normal trivial mitral regurgitation. mitral valve prolapse. estimated pulmonary artery systolic pressure normal. pericardial effusion. IMPRESSION: valvular pathology pathologic flow identified. Brief Hospital Course: Mr. [Known lastname 25338] admitted seizures, fevers left temporal lobe mass. placed Dilantin planning tissue biopsy begun. placed Flagyl concern C. dificile. extubated HD2, subsequently transferred floor. underwent radiographic studies, may reviewed inthe results section. underwent cardiac echocardiogram part infectious etiology workup. HD7, underwent stereotactic brain biopsy, preliminary diagnosis lymphoma. tissue biopsy obtained, begun decadron. postoperative CT scan unremarkable. dilantin levels difficult maintain, converted Keppra. HD7, received 500 mg [Hospital1 ]. goal dose 1500 mg [Hospital1 ], wean dilantin. transferred medicine oncology service care Dr. [First Name (STitle) 1557]. Mr. [Known lastname 25338]' staples removed [2154-5-17]. still inpatient point, Neurosurgery service would happy remove them. Medications Admission: Meds(list may old per daughters bring meds soon possible): Immodium metoprolol 50mg daily norvasc 5mg daily lisinopril 10mg daily aspirin PRN recently d/c'd insulin glucophage HCTZ isosorbide Discharge Disposition: Home Service Facility: care VNA Discharge Diagnosis: CNS lymphoma B cell lymphoma Generalized tonic Clonic Seizures Diarrhea __________________________ Diabetes Cirrhosis Discharge Condition: good, tolerating pos, satting well RA, ambulating without assistance Discharge Instructions: Please seek medical attention develop headache, nausea, vision changes, dizziness, weakness, numbness tingling. Also seek medical attention develop fever, chest pain, shortness breath, concerning symptoms. Please follow below. Take medications exactly prescribed. stopped aspirin, heart medications currently started dexamethasone take twice day keppra also take 1500mg twice day. finish course flagyl three days. also started lomotil diarrhea pantoprazole take long taking dexamethasone. Followup Instructions: Folllow directed Dr. [First Name (STitle) ] [Name (STitle) 3929] radiation oncology next week. office number ([Telephone/Fax (1) 8082]. also follow Dr. [First Name (STitle) 1557] next friday Provider: [First Name11 (Name Pattern1) 1730] [Last Name (NamePattern4) 6175], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2154-5-17] 12:30 Follow [2158-5-17]:00 Dr. [Last Name (STitle) ] suture removal [Last Name (NamePattern1) 439]. ([Telephone/Fax (1) 88]. also following appointment attend. Provider: [First Name11 (Name Pattern1) 1730] [Last Name (NamePattern4) 6175], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2154-6-21] 10:30 Please also make follow appointment opthamologist within 3 months follow diabetic retinopathy	[ "412" ]
Admission Date: [2174-11-25] Discharge Date: [2174-12-5] Service: MEDICINE Allergies: Nsaids / Ace Inhibitors Attending:[First Name3 (LF) 7934] Chief Complaint: shortness breath hemoptysis Major Surgical Invasive Procedure: - History Present Illness: [Age 90 ]y/o female history COPD, hypertension, gastroespohageal reflux presented shortness breath dyspnea exertion X 3 days. Per nursing home records, patient reported 10cc hemoptysis. O2 sat 92%. Patient reports substernal chest pain radiating back, lasting seconds. history pain pleuritic, coughing makes worse. . presentation peak flow 140; improved 240 1st neb ED. Chest X-ray showed multilobular consolidation. CT-A showed PE obstructive bronchial lesion, central bilateral consolidation secondary pneumonia CHF noted. EKG showed TWI avL, V4-V6, unchanged previous. Trop 0.10 setting renal insufficiency. Past Medical History: COPD Rash back neck GERD HTN Social History: Lives [Hospital 100] Rehab Denies alcohol ciggarette smokine Family History: Non-contributory Physical Exam: VS t98.8, hr82, bp, r26, 99%on2lNC Gen elderly petite Caucasian female sitting upright stretcher, mod distress, using accessory muscles breath HEENT MMM, OP, -JVD, bruits Heart nl rate, S1S2, unable assess due breathing Lungs coarse, rhonchorous breath sounds Abdomen round, soft, nt, nd, +bs Extremities [1-2]+pitting edema, posterior aspect legs bilaterally Neuro: A&O X3, II-XII grossly intact Pertinent Results: Labs Admission [2174-11-25] 11:30AM BLOOD WBC-17.1# RBC-3.86 Hgb-11.2* Hct-34.6* MCV-90 MCH-29.0 MCHC-32.4 RDW-14.0 Plt Ct-290 [2174-11-25] 11:30AM BLOOD Plt Ct-290 [2174-11-25] 11:30AM BLOOD Glucose-119* UreaN-47* Creat-1.9* Na-142 K-4.4 Cl-101 HCO3-31 AnGap-14 [2174-11-25] 11:30AM BLOOD CK(CPK)-48 [2174-11-25] 11:30AM BLOOD CK-MB-3 cTropnT-0.10* . Chest X-ray [2174-11-25] 1. Multilobar consolidation, could reflect asymmetrical edema and/or multilobar pneumonia. postobstructive process right middle lobe cannot excluded. report, patient scheduled undergo CTA, helpful complete characterization findings. 2. Bilateral pleural effusions, right greater left. . CT-A [2174-11-25] 1. parenchymal mass lesion mediastinal lymphadenopathy. acute pulmonary embolus. 2. Central bilateral consolidation mainly along inferior hilar regions patchy areas consolidation upper lower lobes. Enlargement central arterial pulmonary vasculature mild cardiac enlargement suggestive background pulmonary hypertension. Small bibasilar pleural effusions. findings may due cardiac failure pulmonary hypertension. Infective consolidation also considered depending current clinical correlation. Interval followup post-treatment initially chest x-ray advised. Brief Hospital Course: 1. Pneumonia patient initially maintained ceftriaxone azithromycin community acquired pneumonia. patient came rehabilitation, decision made change antibiotic coverage Levaquin. treatment also consisted Q2 nebulizer treatments, oxygen home dose prednisone. morning HD #2, patient's course complicated transient desaturation 88% 6L NC shovel mask. exam patient rhonchorous breath sounds, difficulty mobilizing secretions. O2 sats improved coughing 91%. Despite improvement O2 sats, patient continued labored breathing. received 10 IV lasix nebulizer treatments. O2sats improved 95-99% amount O2. Respiratory therapy recommmended humidified air help loosen secretions. Patient course deteriorated morning HD #3. 02sats initially stable 90s. patient became tachypneic breathing average rate 30. Antibiotic coverage changed Ceftazadine prelim sputum cultures grew gram negative rods. Despite lasix, morphine frequent nebulizer treatments, patient's O2sats decreased 86% 6LNC 100%NRB. decision made transfer [Hospital Unit Name 153] management. . [Hospital Unit Name 153], pt continued desaturate 80s NC FM. one episode desaturation 80s resolve one minute. CXR showed mucus plugging entire left lung. Pt placed right side rigorous chest PT, saturations improved low 90s. Family called in. several days pt's respiratory status improving, pt's status discussed family, decided make CMO. Pt placed morphine gtt died [2174-12-5] surrounded family. . 2. Leukocytosis: Pt's leukocytosis likely [2-2] pneumonia UTI. Pt afebrile throughout admission. Pt placed levaquin, blood cultures negative. . 3. Hemoptysis: Pt episodes hemoptysis floor, [Hospital Unit Name 153]. likely [2-2] pneumonia. Pt's Hct stayed stable, stool guaiac negative. . 4. Chest pain: Pt episodes fleeting, pleuritic chest pain floor, Trop 0.10, likely due renal insufficiency. family patient agreed intervention possible cardiac issues. . 5. Acute renal failure: Pt's acute renal failure likely due dye load CT. Cr improved fluids. . 6. HTN: Pt continued Isordil norvasc. . 7. CHF: Pt evidence CHF CXR, trace edema posterior aspect legs. continued daily lasix prn. Medications Admission: Acetaminophen Aluminum Hydroxide Suspension Albuterol 0.083% Neb Soln Amlodipine Bicitra Calcium Carbonate Cyanocobalamin Fexofenadine Fluticasone-Salmeterol (250/50) Furosemide Hydrocortisone Cream 1% Hyoscyamine Ipratropium Bromide Neb Isosorbide Dinitrate Pantoprazole Prednisone Simethicone Sorbitol Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnoses: pneumonia non ST elevation myocardial infarction congestive heart failure, EF 15-20% COPD Secondary Diagnoses: Hypertension GERD Discharge Condition: expired Discharge Instructions: None. Followup Instructions: None Completed by:[2175-3-26]	[ "486" ]
Admission Date: [2117-3-30] Discharge Date: [2117-4-7] Date Birth: [2052-1-15] Sex: Service: CARDIOTHORACIC Allergies: Patient recorded Known Allergies Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Chest Pain Major Surgical Invasive Procedure: CABG x 3 [2117-4-1] History Present Illness: Mr. [Known lastname 102632] 65-year-old man HIV, HTN, ^Chol, type II diabetes mellitus chest pain past 2 years. initially found ROS cardiac evaluation planned dorsocervical fat pad removal. Pt initially thought CP indigestion. experiencing resting chest pain. Cardiac cath performed [2117-3-31] revealed 3 vessel disease left main disease EF 49%. Referred CABG. Past Medical History: PAST MEDICAL HISTORY HIV ([2102]) - CD4 866, viral load undetectable HAART [2-23] Type II diabetes mellitus ([2112]) Hypertension Hypercholesterolemia Lightheadedness LOC ([2113]) Recurrent perirectal herpes ([2099]) Lipodystrophy Varicose veins Erectile dysfunction Diverticulae sigmoid descending colon ([2114]) Left ankle subacute cellulitis, venous stasis ulcer ([2110]) Left tibia fracture fall ([2092]) Posterior vitreous detachment OD Right arm fracture ([2055]) PAST SURGICAL HISTORY Facelift ([2113]) Left inguinal herniorraphy gortex mesh ([2108]) Arthroscopic surgery Hemorrhoidectomy ([2092]) Esophageal ring dilation Appendectomy ([2055]) Tonsillectomy/adenoidectomy ([2055]) Social History: Denies smoking. Drinks socially occasion. Born raised [Location (un) 86], currently lives horse farm [Location (un) ] Fall, N.H. Works cosmetologist, used salon [Location (un) 102633]. trains, breeds, sells horses. Family History: Notable uterine cancer (mother), CAD (mother), lupus (sister), stroke (grandmother 70's), diabetes (two aunts). [Name2 (NI) ] history hypertension. Physical Exam: Tm 98, Tc 97.1, BP 110/70, P 80, RR 20, O2Sat 97 RA, weight 68.0 kg General: NAD Skin: 2cm x 2cm discolored patch area L medial malleolus. Tanned skin exposed areas. HEENT: Mucous membranes dry; mildly icteric sclerae; PERRLA; large dorsocervical fat pad; oral mucosa without lesions. carotid bruits. Pulm: CTAB, wheezes, rales, ronchi. Symmetric expansion chest cavity inspiration. Diaphragmatic excursion 2cm. Cor: II/VI blowing, mid-systolic crescendo-decrescendo murmur auscultated best LLSB. Abd: Soft, distended, nontender. Active BS x4. hepatomegaly, splenomegaly appreciated. Ext: peripheral edema. varicosities. Neuro/Psych: CNII-XII intact screen. AOx3. Walking gait, heel-to-toe performed without difficulty. Slight tremor left 5th digit rest. Pertinent Results: Cardiac catheterization ([2117-3-31]): 1. Coronary angiography right dominant circulation revealed severe three vessel disease. LMCA 60% narrowing origin pressure damping noted engagement artery. LAD serial 80-90% lesions mid vessel diffuse luminal irregularities narrowed 30-40% distal vessel. RCA also diffuse luminal irregularities focal 70% lesion distal vessel. RCA supplied moderate sized PDA 50% lesion. 2. Resting hemodynamics revealed mildly elevated left ventricular filling pressures LVEDP 18 mmHg mean PCWP 13 mmHg setting normal systemic arterial blood pressure. evidence mild pulmonary artery hypertension PA pressures 38/17/26 mmHg. gradient across aortic valve detected. 3. Left ventriculography demonstrated mild anterolateral hypokinesis calculated LVEF 49%. Mild (1+) mitral regurgitation seen. [2117-3-30] 05:17PM BLOOD WBC-8.8 RBC-4.49* Hgb-15.3 Hct-44.9 MCV-100* MCH-34.1* MCHC-34.0 RDW-15.0 Plt Ct-307 [2117-4-2] 07:23PM BLOOD WBC-11.4* RBC-3.13* Hgb-10.1* Hct-28.8* MCV-92 MCH-32.2* MCHC-35.0 RDW-16.5* Plt Ct-147* [2117-4-7] 05:50AM BLOOD WBC-11.9* RBC-3.00* Hgb-9.2* Hct-29.0* MCV-97 MCH-30.8 MCHC-31.9 RDW-16.4* Plt Ct-353 [2117-3-30] 05:17PM BLOOD PT-12.0 PTT-21.1* INR(PT)-1.0 [2117-4-5] 05:30AM BLOOD PT-13.4* PTT-21.5* INR(PT)-1.2 [2117-3-30] 05:17PM BLOOD Glucose-267* UreaN-26* Creat-1.0 Na-138 K-4.5 Cl-101 HCO3-24 AnGap-18 [2117-4-5] 05:30AM BLOOD Glucose-148* UreaN-23* Creat-0.9 Na-139 K-4.3 Cl-101 HCO3-25 AnGap-17 [2117-3-30] 05:17PM BLOOD Calcium-9.9 Phos-3.3 Mg-2.2 [2117-3-31] 06:45PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.015 [2117-3-31] 06:45PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [2117-3-31] 06:45PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-<1 Brief Hospital Course: mentioned HPI, Mr. [Known lastname 102632] presented Cardiac Surgery service following Cardiac Cath HD #2 revealed severe 3VD. following day, [2117-4-1], pt brought operating room underwent Coronary Artery Bypass surgery. Please see op note full details. Pt. tolerated procedure well total byoass time 93 minutes cross clamp time 75 minutes. transferred CSRU stable condition MAP 76, CVP 12, PAD 15, [Doctor First Name 1052] 22, HR 92 SR titrated Neo, Propofol, Insulin. Pt transfused 1 unit pRBC cryo x 2 CSRU. Later op day pt weaned propofol mechanical ventilation extubated without incidence. awake, alert, mae, following commands. POD #1 pt still requiring Neo BP support. Lasix started. [Last Name (un) ] consult today cont. see pt. throughout hosp. course help managed diabetes. Chest tubes removed. Transfused 1 unit pRBCs. POD #2. pt better. weaned Neo. Pacing wires removed. Lopressor started. HIV meds started. POD #3 Pt remained CSRU, transferred telemetry floor today. POD #[2-24] Pt improved steadily throughout 3 days ready discharge POD #6. seen PT throughout post-op course level 5. Labs stable exam unremarkable. Pt slightly pre-op wt d/c'd lasix. Medications Admission: 1. ACTOS 30MG--One tablet daily. 2. ACYCLOVIR 400MG--Two tablets (800 mg) mouth twice day 3. ANDROGEL 1%(50MG)--Use contents one packet daily. apply skin. 4. ASPIRIN 81MG--One daily cardiovascular prophylaxis. 5. ATAZANAVIR SULFATE 150MG--Two capsules mouth daily, one capsule ritonavir. 6. ATENOLOL 25MG--One tablet daily. 7. ATORVASTATIN CALCIUM 10MG--One tablet daily control cholesterol. 8. EFFEXOR XR 75MG--One tablet daily depression 9. GLYBURIDE 5MG--2 tablets (10 mg) mouth twice day control type ii diabetes mellitus. 10. LAMIVUDINE 150MG--One tablet mouth twice day 11. LEVITRA 5MG--One tablet per day prn. 12. LISINOPRIL 2.5MG--One tablet daily. 13. NITROGLYCERIN 0.3MG--One tablet tongue needed chest pain. repeat 5 minutes pain persists. pain persists 5 minutes 2nd dose, seek medical attention. 14. OXANDRIN 10MG--Take one tablet mouth twice day 15. PROSCAR 5MG--[11-25] tablet daily hair growth. 16. RANITIDINE HCL 300MG--One tablet daily chronic esophageal reflux. 17. RITONAVIR 100MG--One capsule mouth daily, two capsules atazanavir. 18. STAVUDINE 15MG--One capsule mouth twice day 19. TENOFOVIR 300 MG (VIREAD)--Take one tablet mouth daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times day). Disp:60 Capsule(s) Refills:2 3. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times day). Disp:60 Tablet(s) Refills:2 4. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 6 hours) needed 21 days. Disp:40 Tablet(s) Refills:0 5. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:60 Capsule(s) Refills:2 6. Atazanavir Sulfate 100 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). Disp:90 Capsule(s) Refills:2 7. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 8. Stavudine 15 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Disp:60 Capsule(s) Refills:2 9. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 10. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). Disp:60 Capsule, Sust. Release 24HR(s) Refills:2 11. Zantac Maximum Strength 150 mg Tablet Sig: Two (2) Tablet PO day. Disp:60 Tablet(s) Refills:2 12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times day). Disp:90 Tablet(s) Refills:2 13. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). Disp:120 Capsule(s) Refills:2 14. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice day. Disp:60 Tablet(s) Refills:2 15. Proscar 5 mg Tablet Sig: one fifth Tablet PO day: one fifth tablet hair growth. Disp:30 Tablet(s) Refills:1 16. Insulin Glargine 100 unit/mL Solution Sig: Seventy (70) units Subcutaneous bedtime. Disp:22 vials Refills:2 17. Insulin Lispro (Human) 100 unit/mL Solution Sig: see sliding scale units Subcutaneous four times day: Sliding scale: BS Units 120-140 2 141-160 4 161-180 6 181-200 8 [Telephone/Fax (2) 102634]1-240 12 241-260 14 261-280 16 [Telephone/Fax (2) 102635]1-320 20 greater 300 call doctor . Disp:2 vials Refills:2 18. Insulin Syringe Ultra Fine II Syringe Sig: One (1) needle Miscell. five times day. Disp:qs 1 month supply Refills:2 19. Ultra TLC Lancets Misc Sig: One (1) lancet Miscell. five times day. Disp:qs 1 month supply Refills:2 20. ultra one glucose test strips 1 5x per day 1 month supply refills: 2 Discharge Disposition: Home Service Facility: [Location (un) 8300],NH VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 HIV ([2102]) - CD4 866, viral load undetectable HAART [2-23] Type II diabetes mellitus ([2112]) Hypertension Hypercholesterolemia Lightheadedness LOC ([2113]) Recurrent perirectal herpes ([2099]) Lipodystrophy Varicose veins Erectile dysfunction Diverticulae sigmoid descending colon ([2114]) Left ankle subacute cellulitis, venous stasis ulcer ([2110]) Left tibia fracture fall ([2092]) Posterior vitreous detachment OD Right arm fracture ([2055]) PAST SURGICAL HISTORY Facelift ([2113]) Left inguinal herniorraphy gortex mesh ([2108]) Arthroscopic surgery Hemorrhoidectomy ([2092]) Esophageal ring dilation Appendectomy ([2055]) Tonsillectomy/adenoidectomy ([2055]) Discharge Condition: good Discharge Instructions: may drive 4 weeks may lift greater 10 pounds 2 months shower only, let water flow wounds, pat dry Followup Instructions: make appt. follow Dr. [Last Name (STitle) 2148] [11-22] weeks make appt. follow Dr. [Last Name (STitle) 1445] (card) [12-24] weeks Make appt. ([Telephone/Fax (1) 26721]) follow Dr. [Last Name (STitle) ] 4 weeks make appt. ([Telephone/Fax (1) 2384]) follow [Hospital ] Clinic [11-22] weeks Completed by:[2117-4-26]	[ "412" ]

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