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Admission Date: [2159-6-12] Discharge Date: [2159-6-15] Date of Birth: [2077-11-19] Sex: F Service: MEDICINE Allergies: Lipitor / Tape Attending:[First Name3 (LF) 3561] Chief Complaint: s/p cardiac arrest Major Surgical or Invasive Procedure: cpr History of Present Illness: 81 yo F w/ CAD s/p CABGx4, HTN, DM, ESRD on HD (TUTHSAT), PVD, CHF (EF30%), PPM for SSS, NSCLC, admitted for elective angiography of the LE [1-6] to foot ulcerations (vanc/gent at dialysis). Now being transferred to the MICU s/p cardiac arrest. Pt. was taken down to angiography today but could not tolerate the procedure d/t back pain she was given approx 5mg of iv morphine throughout the day. At dialysis 3.5L were removed. On the floor, she was found slumped over and unresponsive although reportedly still breathing. A code blue was called. She was in PEA arrest for approximately 3 minutes during which time she received compression and bag ventilation. She did not receive any medications. The family was present during the arrest and the husband requested that resuscitation be held. Soon after stopping CPR, a femoral pulse was detected and the pt. was breathing spontaneously. She then awoke and was able to carry on a conversation, falling asleep intermittently. A discussion was held with the family regarding her code status and she was made DNR/DNI (documented in the chart by micu attending). However, she was transferred to the micu for close monitoring. Past Medical History: 1. Coronary artery disease - s/p NSTEMI ([10-6]) with resulting CABG x4 (bypass from the ascending thoracic aorta sequentially to the large diagonal and obtuse marginal with reversed vein and to the small posterior descending branch of the circumflex, with the second segment of vein and to the left anterior descending with the left internal mammary artery) 2. End-stage-renal disease, on HD 3. Congestive heart failure, ECHO ([2159-3-23]) with EF of 30% 4. Hypertension 5. Peripheral vascular disease 6. Sick sinus syndrome w/conduction abnormalities s/p DDD pacer placement [2159-3-28] 7. Hyperlipidemia 8. Diabetes 9. Cataracts 10. Osteoporosis 11. PMR 12. Gout 13. Basal Cell Carcinoma 14. Hypothyroidism Social History: At baseline the patient uses a walker and her mobility is limited. Her mobility typically is not limited by dyspnea but rather by claudiaction. Lives with husband. Social history is significant for the absence of current tobacco use, but she used to smoke cigarettes but quit 20 years ago. Approximately 60 pack year history. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death, but her mother had a CABG and died at age 86. Her father had diabetes and died at age 72. Her brother has prostate cancer. She has two children who are healthy. Physical Exam: VITALS - T 95.8 BP 82/13 HR 60 RR GEN - ill appearing thin elderly F laying in bed. somnolent, but follows directions. HEENT- nc in place. pupils 1mm bilaterally and reactive CV- distant heart sounds. regular PULM- CTA bilat ABD- soft, NT/ND, normoactive bs EXT- LE are cold, DP not dopplerable. skin- sacral decubitis erythema with palpable crepitus. NEURO- awakes to voice and is interactive, but then quickly falls asleep. Brief Hospital Course: cardiac arrest: unclear precipitant. could possibly be [1-6] to narcotics leading to respiratory depression, hypotension and cardiac arrest. CPR was started, however the husband asked for this to be stopped. There was spontaneous return of circulation and the pt. was transferred to the MICU. The Pt was given IVF. The family did not wish for any invasive procedures or further intervention. The pt. expired with the family at the bedside. Medications on Admission: tylenol prn asa 325 qdaily clonidine 0.1 [Hospital1 ] carvedilol 12.5mg [Hospital1 ] colace [Hospital1 ] hydrocort cream prn hemorrhoids RISS w/ lantus isosorbide mononitrate er 60mg po qdaily synthroid 37.5mg qdaily nephrocaps 1 cap qdaily nitroglycerin SL prn zofran 4mg q8hrs prn sevelamer 800mg po tid w/ meals senna prn tucks prn Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[2160-5-1]	[ "40391", "412", "41401", "4280", "2724", "2449", "V4581", "V5867", "V1582" ]
Admission Date: [2145-10-16] Discharge Date: [2145-10-25] Date of Birth: [2125-8-16] Sex: M Service: SURGERY Allergies: morphine / Penicillins / Latex Attending:[First Name3 (LF) 371] Chief Complaint: s/p Motorcycle crash Major Surgical or Invasive Procedure: [2145-10-16] ELEVATION OF LEFT SKULL FRACTURE; CRANIOPLASTY WITH TITANIUM MESH; REPAIR OF FRONTOBASILAR FRACTURE, FRONTAL SINUS MUCOSECTOMY, LEFT ORBITAL RECONSTRUCTION, REPAIR OF SCALP/FOREHEAD DEFECT. [2145-10-18] IRRIGATION AND DEBRIDEMENT OPEN SKULL FRACTURE, SYNTHESIS LOW PROFILE PLATE EXCHANGE [2145-10-22] ORIF left zygomatic maxillary fracture History of Present Illness: 20 M unhelmeted MCC vs tree. Questionable LOC. On initial presentation GCS 15,verbal, following commands, and moving all extremities with full strength. However left pupil midriatic, non reactive. Degloving injury of the forehead with open skull fracture. Electively intubated in ED due to emesis. Past Medical History: PMH: pectus excavatum, R humeral fracture from bike accident at age 15 PSH: R humeral fracture repair at age 15 Social History: unknown Family History: non-contributory Pertinent Results: IMAGING: [10-16] CTA head: 3 cm left frontal calvarial depression into the left frontal lobe with adjacent small intraprenchymal hematoma. No large mass effect or vascular territorial infarction seen. Mild pneumocephalus [12-23] open left frontal fracture/avulsion. CTA: Patent anterior and posterior circulation, COW, ACA, MCA, and PCA with no dissection, flow limiting stenosis, or vascular malformations detected. Active extravasation seen within the superficial soft tissues next to the avulsed frontal bone (4:157). No intracranial active extravasation. [10-16] CT max-face: 1.Large avulsion fracture of the left frontal bone, resulting in exposure of the left frontal lobe and pneumocephalus. 2. Extensively comminuted and displaced fractures of the left frontal bone with depression of fracture fragments approximately 3 cm into the left frontal lobe, with a small amount of adjacent intraparenchymal hemorrhage. No shift of intracranial midline structures. 3. Extensively comminuted and displaced fractures involving the left face as noted above. 4. Proptosis of the left globe, with stretching of the left optic nerve and left lateral rectus muscle secondary to marked lateral and posterior rotation of the orbital plate. A fracture fragment impinges upon the left inferior rectus muscle. Left lens is dislocated. 5. Blood products within the ethmoid, left maxillary, and sphenoid sinuses. [10-16] CT C-spine prelim: No acute fx or traumatic malalignment of the cervical spine [10-16] CT torso prelim: NO acute intrathoracic, intraabdominal, or intrapelvic process [10-17] CT head w/o contrast: Post-surgical changes in the left frontal region with mild post-operative hemorrhage and pneumocephalus. Minimal local mass effect. Persistent left frontal lobe contusion. Assessment for subtle cerebral edema can be limited given the noisy iamges- correlate clinically. No intracranial osseous fragments. No evidence of subfalcine or transtentorial herniation. No new hemorrhage or acute large territorial infarction. CT sinus/mandible/maxillofacial: Post-surgical repair of the left frontal bone fractures. No osseus fragments remain in the intracranial structures. Mass effect upon the left extra-ocular muscles appears decreased. Persistent lateral stretch of the left optic nerve. Stable multiple fractures of the left orbit and maxillary sinus. Hemorrhagic fluid remains in the paranasal sinuses. [10-18] CXR: Right lower lobe opacity worrisome for infectious process is noted, although it could represent atelectasis. [10-18] MRI C spine: 1. No focal signal abnormality noted in the cord. 2. No marrow edema noted in the cervical vertebrae. 3. No evidence of subluxation. 4. Hyperintense signal noted on STIR images in the interspinous soft tissues from C1-C2 to C6-C7 levels which likely represent edema or injury to the interspinous ligament which is less likely. 5. Hyperintense signal noted on STIR images in the posterior paraspinal soft tissues from C2 to C7 level which may represent edema. Brief Hospital Course: Mr. [Known lastname ] was transferred to the TICU after going to the operating room with Neurosurgery for elevation of the left frontal bone & cranioplasty with titanium mesh as well as ORIF of the left orbit. DIlantin prpohylaxis was initiated. He remained intubated post-operatively. Left globe pressures were monitored but were not felt to be elevated. His anti-seizure propylaxis was recommended to continue after discharge until follow up as outpatient with Neurosurgery. On POD 2 he retuned to OR with plastics for washout and plate replacement. Postoperatively he spiked a fever to 101.5 and a full workup was perfomed. His hematocrit was 20 and he was transfused 2u PRBC's. He was not extubated due to significant facial swelling. On [10-19] a spine consult was called given possible interspinous ligament injury and it was determined that he did not have ligamentous injury and the hard collar was then removed. He extubated on POD 4 and a code purple was called given severe agitation. He then stabilized over the course of the next several days with zyprexa and was transferred to the floor. Once transferred to the regular surgical floor he continued to progress. His mental status improved significantly during his floor course and there were no further issues with agitiation and/or aggressive behaviors for the remainder of his stay. His Zyprexa dose was decreased. He was seen by Opthmaology for the shattered left orbit with left blowout fracture traumatic mydriasis and for evaluation before undergoing repair of his facial fractures by Plastics. Several eye drops were recommended and clearance to proceed with his Plastics procedure was given. He was taken to the operating room on [10-22] by Plastics for open reduction and internal fixation of left zygomatic-malar complex fracture. There were no complications. He was left with many facial sutures which were treated with Bacitracin ointment. He will follow up with Plastics for removal of the sutures after discharge. He participated with Physical and Occupational therapy and intially the thought was that he would require [Hospital 91373] rehab stay. Given his significant improvement and after discussions with his family the decison was made that he was safe to transition home with 24 hour supervision that his family was able to provide. Medications on Admission: none Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical TID (3 times a day): apply to facial wounds. 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 5. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. Disp:60 Tablet(s) Refills:1 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 8. bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic TID (3 times a day): apply to OS. Disp:1 tube Refills:2 9. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic SIX TIMES A DAY (): left eye. Disp:1 bottle Refills:2 10. scopolamine HBr 0.25 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day): left eye. Disp:1 bottle Refills:2 11. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). Disp:180 Tablet, Chewable(s) Refills:1 12. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:1 Discharge Disposition: Home With Service Facility: [Location (un) 2203] VNA Discharge Diagnosis: s/p Motorcycle crash Injuries: Depressed left skull fracture Degloving injury to left forehead Shattered left orbit with left blowout fracture Traumatic mydriasis Left maxillary sinus fractures Delirium Acute blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital on [2145-10-16] after a motorcyle crash where you sustained a traumatic brain injury and injury to your left eye - both of which required an operation to repair. You will likely need to undergo further surgery and this will be determined when you return to the hospital for your follow up appointments. Please follow these discharge instructions: . AVOID any activities that may cause injury to your head - do not ride any motorcycles, bicycles or other modes of transportation other than in a car or bus. . Medications: * You have been prescribed an anit-seizure medication called Keppra to continue for at least a month. You will then follow up with these specilaist to determine how much longer this medication is needed. * Resume your regular medications unless instructed otherwise. * You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. * Take prescription pain medications for pain not relieved by tylenol. * Do not drive or operate heavy machinery while taking any narcotic pain medication. * Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softener if you wish. . Call the office IMMEDIATELY if you have any of the following: * Signs of infection: fever with chills, increased redness, swelling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). * A large amount of bleeding from the incision(s). * Fever greater than 101.5 oF * Severe pain NOT relieved by your medication. . Activities: * No strenuous activity * Exercise should be limited to walking; no lifting, straining, or excessive bending. * It is recommended that you wear a soft collar when out of bed for 4 weeks. * Unless directed by your physician, [Name10 (NameIs) ] not take any medicines such as Motrin, Aspirin, Advil or Ibuprofen etc . Comments: * Please sleep on several pillows and try to keep your head elevated to help with drainage. * Please maintain SOFT diet until your follow up clinic visit and you can ask your surgeon whether you can advance your diet at that time. Avoid soft diet foods with 'little pieces' (ie; oatmeal) that can get stuck in surgical wounds. * Please avoid blowing your nose. * Sneeze with your mouth open * Try to avoid sipping liquids through a straw * Use your oral rinse as directed. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2477], MD Phone:[Telephone/Fax (1) 31444] Date/Time: [2145-10-29] 1:30 Dr.[Name (NI) 2989] clinic is located on the [Hospital Ward Name ], [Hospital Ward Name 23] building, [Location (un) 470], Surgical Specialties. . Name: [First Name11 (Name Pattern1) 275] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], MD Specialty: Internal Medicine Location: PMG PHYSICIAN ASSOCIATES Address: [Location (un) 88267] [Apartment Address(1) 40744], [Location (un) ],[Numeric Identifier 88268] Phone: [Telephone/Fax (1) 36604] We are working on a follow up appointment with Dr. [Last Name (STitle) 39360] for within the next 2 weeks. You will be called at home with the appointment. If you have not heard within 2 business days or have questions, please call the number listed above. Department: [Hospital3 1935] CENTER When: MONDAY [2145-11-1] at 2:15 PM With: [Name6 (MD) 6131] [Name8 (MD) ], MD [Telephone/Fax (1) 253] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Name: [Name6 (MD) ] [Name8 (MD) 739], MD Specialty: Neurosurgery Location: [Hospital1 18]-DIVISION OF NEUROSURGERY Address: [Doctor First Name ], STE 3B, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 1669] We are working on a follow up appointment with Dr. [Last Name (STitle) 739] for within the next 30 days. You will be called at home with the appointment. If you have not heard within 2 business days or have questions, please call the number listed above. Department: COGNITIVE NEUROLOGY UNIT When: THURSDAY [2145-12-9] at 9:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 6403], MD [Telephone/Fax (1) 1690] Building: Ks [Hospital Ward Name 860] Building ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage We are working to have you seen by Dr. [First Name (STitle) ] for within the next 2 weeks, sooner than the appointment booked above. You will be called at home with the appointment. If you have not heard within 2 business days or have questions, please call the number listed above. Completed by:[2145-10-27]	[ "2851" ]
Admission Date: [2143-2-16] Discharge Date: [2143-2-25] Date of Birth: [2073-7-25] Sex: F Service: MEDICINE Allergies: Lipitor / Zocor Attending:[First Name3 (LF) 3276] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Please see admission note for full details of history. Ms. [Name14 (STitle) 102143] is a 69 year old female with past medical history of right lower lobe squamous cell carcinoma, status-post resection in [2141], treated with chemotherapy and thoracentesis in [11/2142], who brain radiation in [12/2141], and recent admission for pneumonia in [12/2142] treated with levofloxacin. Likely leptomeningeal spread. . She presented to the ED [2-16] with dyspnea and increasing home O2 requirement. Her home nurse had also recently noted low BP, causing her to miss her daily amiodarone and metoprolol. Her dyspnea progressed from exertional to at rest over days. She also had a chest discomfort, nonpleuritic. No fevers, chills, or change in chronic productive cough. ROS otherwise negative. . Her initial vital signs were a temperature of 97.0, [Month/Year (2) ] pressure of 110/59, heart rate of 132, respiratory rate of 20, and 91% on room air. She was given 2 mg of morphine, 4 mg of zofran, 150 mg bolus of amiodarone IV, 200 mg of PO amiodarone, 5 mg of roxicet, 325 mg of tylenol, amiodarone drip, fentanyl 50 mcg, and 750 mg of levofloxacin. In the ED, she was initially tachycardic with a heart rate as high as 140, but this converted to sinus at a rate of 70 after administration of amiodarone. There was concern for worsening metastatic disease or PE, so she underwent a chest CT. It was negative for a pulmonary embolism, however it did demonstrate a worsening multifocal pneumonia and worsening metastatic disease as compared to PET/CT from [2143-1-21]. During the time in the ED, her systolic [Year (4 digits) ] pressure ranged from 70-90's. She was given one liter of IVF. She was transfered to the ICU for further management given her hypotension and high oxygen requirement. . In the [Hospital Unit Name 153], there was concern for amiodarone pulmonary toxicity, so this medication was stopped. Cardiology followed her and recommended continuation of low-dose beta blocker. Antibiotics were broadened to Bactrim (for possible PCP given chronic steroid use) and levofloxacin. There was consideration of broncoscopy for the purpose of BAL for culture, but the patient declined. Currently she is on a non-rebreather with good O2 Sats. She is also on stress-dose steroids given chronic prednisone. She was given 2 units of pRBC. . Goals of care were addressed and revised to include DNR and no invasive measures. Palliative care is following. She will be transferred to the OMED team given no desire for ICU-level aggressive measures. . HR 60 110/53 16 97% NRB. Got levoflox already today. 1L positive. Also given 2u pRBC's. . Main goal at this time is for hospice, palliative care on board. Not bronched per patient request. Will accept abx, but nothing invasive. . Past Medical History: Oncology History: T2 N1 squamous cell lung cancer in the right lower lobe s/p resection [2142-6-11]. Pathology notable for a positive margin, lymphatic, and venous invasion. She is s/p chemo radiation and resection of the right-sided lesion. She is s/p four cycles of carboplatin and paclitaxel with the fourth cycle of chemotherapy on [2142-10-16]. [2142-11-27] [Year (4 digits) 4338] of head with concern for metastatic disease with a 5-mm enhancing lesion in the left frontal lobe and a new 6 x 6 x 5 mm enhancing lesion in the right parietal lobe with mild associated edema concerning for cortical or leptomeningeal metastatic disease. . [2142-12-7] thoracentesis to drain left pleural effusion given symptomatic cough. No evidence of malignancy with resolution of cough but continued shortness of breath with exertion. CXR on [2142-12-11] showed a persistent small left pleural effusion. . [2142-12-18] whole brain radiation therapy and radiation therapy to her sacral metastasis with intermittent pain requiring dilaudid, nausea and dry heaves requring compazine. She continued to have chronic lower extremity weakness which has not changed in severity. . [2142-12-31] Patient completed course of radiation to C2 Whole Brain and Sacrum. She received a total dose of 3000 cGy to each site. Of note she has had increased sacral pain and worsening nausea and dry heaves. She was attempting Zofran, and dilaudid 2 mg Q6 as needed for pain. She also reported slight worsening of her shortness of breath. No pleuritic chest pain. At that time o2 sat 94%RA. Social History: Married. Smoked in the past but quit 25 years ago, denies alcohol or illicit drug use. Family History: The patient's father died of CAD as did her mother. Two brothers have CAD. A sister has had multiple TIAs. Physical Exam: Vital Signs BP 110/53, HR 76, O2 Sat 96% on NRB GENERAL: pleasant woman, appears comfortable HEENT: slopecia, pupils small but reactive, no scleral icterus NECK: supple, JVP not appreciated LUNGS: decreased breath sounds and dullness to percussion over left base, diffuse bronchial breath sounds over b/l lung fields CARDIAC: regular, no murmurs ABDOMEN: soft, nontender, nondistended EXTR: warm, no edema, ecchymoses over right tibia. NEURO: alert and oriented PSYCH: pleasant, appropriate . Pertinent Results: [2143-2-16] CTPA 1. No evidence of pulmonary embolism. 2. Persistent diffuse ground-glass opacity in the right upper lobe and worsened ground-glass within the lingula are concerning for worsening multifocal infection. 3. Increased size of pulmonary nodules concerning for worsening metastatic disease. [2143-2-18] Echo The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with severe hypo/akinesis of the basal half of the inferiorseptum, inferior, and inferolateral walls. The remaining segments contract normally (LVEF = 50 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. At least moderate (2+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a fat pad. IMPRESSION: Suboptimal image quality. Normal left ventricular cavity size with regional systolic dysfunction c/w CAD. At least moderate mitral regurgitation suggestive of papillary muscle dysfunction. Compared with the prior study (images reviewed) of [2142-6-13], the severity of mitral regurgitation has increased. Brief Hospital Course: Ms. [Known lastname 94074] is a 69 year old female with past medical history of squamous cell carcinoma and atrial fibrillation who presented with dyspnea and was found to have multifocal pneumonia. . #) Multifocal pneumonia: Likely related to underlying cancer, possibly post-obstructive. O2 Sats were mostly in the upper 90s on nonrebreather. Patient initially wanted like to continue antibiotics, but has declined elective intubation for BAL cultures after sputum cx contaminated. Thus she was transferred to OMED given no desire for aggressive measures. There goals of care were further revised ot include comfort measures only. Antibiotics were stopped. Stress dose steroids were quickly tapered. She was given nebulizer treatments as needed for comfort. Because there was a question of mild volume overload, she was also given lasix 20 mg IV as needed, which seemed to help. A foley was placed to improve comfort of urination given that she was becoming short of breath with any transfer. . #) Atrial fibrillation: Patient presented to ED in AF with RVR in the setting of missing amiodarone. Converted to NSR with amiodarone and beta blocker. She was not anticoagulated secondary to history of GI bleed. Cardiology followed her. When goals of care were revised to comfort, metoprolol PO was continued to prevent recurrence of atrial fibrillation with RVR. Prior to discharge she again developed atrial fibrillation but was not uncomfortable. Metoprolol was continued. . #) Squamous cell lung carcinoma: Followed by Dr. [Last Name (STitle) 3274] as an outpatient. Brain metastases have responded to XRT, but worsening pulmonary disease burden. Patient is followed by Drs. [Last Name (STitle) 3274] and [Name5 (PTitle) ] here at [Hospital1 18]. There were no plans for further chemotherapy, as the cancer was considered end-stage. . #) Anemia: She received 2 units pRBC in the ICU. When goals of care were revised no futher labs were drawn. . #) Chronic renal insufficiency: Creatinine was initially below baseline 1.1-1.2. Lab tests were stopped . #) Polymyalgia rheumatica: On 10 mg prednisone daily at home. Received stress-dose steroids here in the setting of infection. This was quickly tapered back to her home dose, which may be continued to prevent recurrence of PMR. . #) Coronary artery disease: Aspirin, [Last Name (un) ] were stopped after goals of care were revised. . #) Gout: No active symptoms. Allopurinol was stopped. . #) Contact: [Name (NI) ], daughter # [Telephone/Fax (1) 102144] . #) Code: Code status at discharge was DNR, DNI, no ICU transfers or aggressive measures, with primary goal of care being comfort. Medications on Admission: per outpatient OMR note from [2143-1-29], reconcilled at that time) - ALLOPURINOL 100 mg daily - AMIODARONE 200 mg daily - CANDESARTAN 16 mg once a day - HYDROMORPHONE 2 mg, [11-23] Tablet every 6 hours as needed for pain - METOPROLOL TARTRATE 12.5 mg twice a day - NITROGLYCERIN - 0.3MG PRN - NYSTATIN 100,000 unit/mL Suspension, 5 ml QID - ONDANSETRON 4 mg Tablet, QID - PREDNISONE 10 mg Tablet daily - PROCHLORPERAZINE EDISYLATE [COMPAZINE] 10 mg Tablet TID PRN - ASPIRIN 81 mg - CALCIUM 600 + D, 1 Tablet three times a day - DOCUSATE SODIUM PRN - SENNOSIDES-DOCUSATE SODIUM PRN Discharge Disposition: Extended Care Facility: [Hospital1 656] House Discharge Diagnosis: primary: metastatic squamous cell carcinoma of the lung, atrial fibrillation with rapid ventricular response secondary: coronary artery disease, chronic kidney disease, Discharge Condition: with facemask oxygen requirement Discharge Instructions: You came to the hospital because you were short of breath. You were treated with oxygen. Your heart was also in an irregular fast rhythm and you were given medications to control this. You and your family decided to transisition to hospice care. Please follow the attached medication list which may be adjusted at the [Hospital1 656] House as needed. Followup Instructions: Please follow up at your hospice facility. [First Name8 (NamePattern2) 251] [Name8 (MD) ] MD [MD Number(1) 3282] Completed by:[2143-2-26]	[ "486", "42731", "V4581", "V4582", "412", "40390", "5859", "2724", "V1582" ]
Admission Date: [2115-6-4] Discharge Date: [2115-6-10] Date of Birth: [2063-9-29] Sex: M Service: C-MED HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old male with ankylosing spondylosis, but no prior cardiac history who presented with a history of worsening and more frequent shortness of breath, dizziness, and palpitations both on exertion and at rest. This started two months ago when climbing up stairs. On the day prior to admission, the patient experienced this five to eight times and was brought to the [Hospital3 3583] Emergency Department. There, his heart rate went from 140 to 250, and the patient experienced shortness of breath and chest heaviness. A total of 30 mg of adenosine was given and had no affect and 50 mg of diltiazem. The patient was electively cardioverted back to a normal sinus rhythm and then received 400 mg of amiodarone and was started on Lopressor 25 mg twice per day. An echocardiogram at the outside hospital revealed an ejection fraction of 20% and global hypokinesis. The patient was brought to [Hospital1 69], and a cardiac catheterization was performed. The catheterization revealed clean coronary arteries but increased pressures; including a wedge pressure of 30, and an ejection fraction of 20%, and confirmed global hypokinesis. That evening the patient had atrial fibrillation with a rapid ventricular response, and was started on amiodarone. He spontaneously reverted to sinus rhythm. The following day, the patient was taken for an elective electrophysiology study and for atrial flutter ablation. The ablation was successful, but the patient went into atrial fibrillation. Ibutilide was started with an increase QTc noted on electrocardiogram of greater than 700 milliseconds. A temporary pacing wires were was left in the coronary sinus. In retrospect it was noted that the patient's QT interval had prolonged significantly even prior to ibutilide, after only a few doses of amiodarone. Amiodarone and ibutilide were discontinued, and the patient was transferred to the Coronary Care Unit for monitoring. PAST MEDICAL HISTORY: (Past medical history is significant for) 1. Ankylosing spondylolysis since the age of 23. 2. Hypercholesterolemia (which the patient denies). [First Name4 (NamePattern1) 610] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3812] Dictated By:[Last Name (NamePattern1) 6006] MEDQUIST36 D: [2115-6-10] 16:35 T: [2115-6-15] 01:19 JOB#: [Job Number 52053]	[ "4240", "4280", "42731" ]
Admission Date: [2163-9-19] Discharge Date: [2163-9-19] Date of Birth: [2163-9-19] Sex: F Service: NB HISTORY OF PRESENT ILLNESS: Baby Girl [Known lastname 56982] was born at 38 and 6/7 weeks gestation by cesarean section for breech presentation and known meningomyelocele. She was born to a 44 year old gravida III, para 0, now I, woman who prenatal screens were blood type A positive, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, and GBS status unknown. Mother had been taking Folate 1.8 mg p.o. daily. Mother had a previous spontaneous loss and a therapeutic loss. This pregnancy was complicated by prenatal diagnosis of myelocele and bilateral clubfeet at 18 weeks gestation. A prenatal ultrasound at 23 and 6/7 weeks gestation showed a single well defined cyst overlying the posterior at approximately L4. It measured 0.9 by 0.9 centimeters. There were also bilateral clubfeet. She had a fetal magnetic resonance imaging which supported the finding of the ultrasound. There was no hydrocephalus, no Chiari malformation or other fetal anomalies. She was followed by the Fetal Care Clinic at [Hospital3 1810]. An amniocentesis showed normal chromosome 46XX. She also had a negative FISH for chromosomes 13, 18, and 21. The family also was followed by Dr. [Last Name (STitle) ] at [Hospital3 1810], neurosurgery. The infant emerged with spontaneous cry and good tone. Apgar eight at one minute and nine at five minutes. Rupture of membranes occurred at the time of delivery. There was no intrapartum sepsis suspected. Her birth weight was 3365 grams (75th percentile), birth head circumference 35.5 centimeters (90th percentile), her length estimated at 53 centimeters, difficult to measure due to her flexed hip position. PHYSICAL EXAMINATION: Her admission physical examination revealed an active, nondysmorphic, term appearing infant. Anterior fontanelle soft, open and flat. Positive bilateral red reflexes. Neck supple without masses. Lungs clear, respirations comfortable. Heart was regular rate and rhythm, no murmur. Abdomen soft, nondistended, nontender, with present bowel sounds. Spine with approximate 2.0 centimeter by 2.5 centimeter outpouching with cystic areas present with open myelocele. Patent anus but no anal wink. Extremities warm and well perfused. No obvious spontaneous movement of the lower extremities with bilateral clubfeet. Decreased reflexes at the knees. Normal genitourinary examination. Normal tone in the upper extremities. HOSPITAL COURSE: Respiratory status: She has always remained in room air with oxygen saturation greater than 95 percent. Respirations are comfortable. She has had no apnea, bradycardia or desaturation. Cardiovascular status: Her blood pressure has been stable with systolic 168 to 81. Diastolic 38 to 50. Mean blood pressure 50 to 62. She has no murmur. Fluids, electrolytes and nutrition status: Her blood glucose was 90. She has a double lumen umbilical venous catheter with tip position confirmed at the diaphragm with xray Dextrose solution at 80 ml/kg/day. Hematology: At admission, her hematocrit is 48.6. She has received no blood product transfusion. Infectious disease status: Blood culture was sent. At the time of admission, her white blood cell count was 12.5 with a differential of 43 polys, 0 bands and 47 lymphocytes, platelet count 316,000. She is on Ampicillin and Gentamicin. Audiology: Hearing screening has not been done but is recommended prior to discharge. Psychosocial: Parents have been to the Neonatal Intensive Care Unit to visit and are updated on the infant's condition. CONDITION ON DISCHARGE: The infant is discharged in guarded condition. DISCHARGE STATUS: She is transferred to [Hospital3 1810] for repair of her myelocele. PRIMARY PEDIATRIC CARE: Her primary pediatric care will be provided by Dr. [First Name8 (NamePattern2) 1743] [Last Name (NamePattern1) 56983] of [Hospital 5344] Pediatrics, telephone number [Telephone/Fax (1) 56984]. RECOMMENDATIONS AFTER DISCHARGE: 1. The infant is NPO. 2. Medications: Ampicillin 150 mg/kg/dose every twelve hours, Gentamicin 4 mg/kg/dose every 24 hours. 3. State Newborn Screen was sent prior to transfer. 4. She has received no immunizations. DISCHARGE DIAGNOSES: Myelocele. Bilateral clubfeet. Rule out sepsis. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 48738], MD [MD Number(2) 55708] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2163-9-19] 18:21:45 T: [2163-9-19] 19:01:56 Job#: [Job Number 56985]	[ "V290" ]
Admission Date: [2135-5-31] Discharge Date: [2135-6-4] Date of Birth: [2058-11-16] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1854] Chief Complaint: S/P FALL Major Surgical or Invasive Procedure: S/P Craniotomy for subdural hematoma History of Present Illness: 76F found down on floor by son who stopped by to take his mother to dinner. Patient does not recall event very well. According to son, he believes that patient fell at least 36 hours ago since the newspapers for the last 2 days were not opened. Past Medical History: HTN, OA Social History: lives alone. No EtOH/smoking Family History: non-contributory Physical Exam: O: T: 97.1 BP: 151/61 HR: 94 R 20 O2Sats 99% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: Perrl B EOMs grossly intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person. Recall: 0/3 objects at 5 minutes. Language: Speech somewhat slurred with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2 to 1 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [4-16] Biceps B, [3-17] Triceps and Deltoid. [2-14] B IP,Q, [4-16] dorsiflexion/plantar flexion. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally Coordination: sluggish finger-nose-finger Pertinent Results: CT HEAD W/O CONTRAST [2135-5-31] 12:49 AM NON-CONTRAST HEAD CT: There is a 1.5 cm subdural hematoma of mixed density, likely hyperacute on acute, along the right hemisphere causing 1.3 cm leftward shift of normally midline structures and effacement of the subjacent sulci. The right lateral ventricle is compressed and the contralateral is slightly dilated, suggestive of early trapping. Small amount high density material is seen within sulci of right temporal lobe likely representing subarachnoid blood. There is probably subfalcine herniation. The visualized paranasal sinuses and mastoid air cells remain normally aerated. No fractures are identified within the osseous skeleton. IMPRESSION: Subdural hematoma along the right hemisphere with accompanied subfalcine herniation. Post-craniotomy CT HEAD W/O CONTRAST [2135-5-31] 1:30 PM FINDINGS: Since the prior examination of [2135-5-31] at 1:00 a.m., there has been reduction in the size of the right cerebral convexity subdural hematoma. Right frontal craniotomy is again present. There has been an improvement in the degree of leftward midline shift. Only minimal leftward midline shift remains. No significant herniation is identified. Small amounts of pneumocephalus are present. IMPRESSION: Status post evacuation of the right subdural hematoma with a mild residual remaining. There has been improvement in the degree of subfalcine herniation and mass effect. No new intracranial hemorrhage is noted. Brief Hospital Course: Patient was admitted to ICH for right-side subdural hematoma on [2135-5-31] and underwent right frontal craniotomy for evacuation of hematoma. She was successfully extubated post-op. No intra- or post-op complication. She was transfered to regular floor on [2135-6-2]. On [2135-6-1] she passed swallow test to be advanced to regular diet with thin liquid and pills can be taken in whole with thin liquid. Her foley catheter was d/ced on [6-3] and she is able to urinate on her own. Her mental status has improved to oriented to person/place/time. She is able to ambulate with assistance. PT/OT are consulted and recommended discharging to rehab. Medications on Admission: Aspirin 325mg, Welchol, synthroid, atenolol/chlorthalidone, atenolol, MVI, Aleve Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Right sided subdural hematoma Discharge Condition: Neurologically stable Discharge Instructions: ?????? Have your incision checked daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F PLEASE HAVE YOUR STAPLES REMOVED BETWEEN [2135-6-11] AND [2135-6-14], EITHER AT YOUR REHAB FACILITY OR IN DR[Doctor Last Name ] OFFICE (PLEASE CALL [Telephone/Fax (1) 1669] FOR AN APPOINTMENT IF YOU ARE COMING TO DR [Doctor Last Name ] OFFICE FOR STAPLE REMOVAL) Followup Instructions: YOUR STAPLES NEED TO BE REMOVED BETWEEN [2135-6-11] AND [2135-6-14]. PLEASE CALL [Telephone/Fax (1) 1669] FOR AN APPOINTMENT IF YOU ARE COMING TO DR[Doctor Last Name ] OFFICE FOR STAPLE REMOVAL. PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR.[Last Name (STitle) ] TO BE SEEN IN 4 WEEKS with head CT.	[ "4019" ]
Admission Date: [2105-7-2] Discharge Date: [2105-7-4] Service: MEDICINE Allergies: Ciprofloxacin Attending:[First Name3 (LF) 2901] Chief Complaint: Anemia/Hypotension Major Surgical or Invasive Procedure: Pericardiocentesis History of Present Illness: 86y/o F with h/o AFIB, Lacunar CVA, s/p nephrostomy tube for nephrolithiasis, and recent ICU admission for sepsis who presents with weakness for the past few days. She was brought to the ED from [Hospital3 ] because her nephrostomy tube had fallen out. . Per the patient she had been feeling well, until a few days prior to admission when she felt weak. She could describe no antecedent events, or etiology for her sense generalized fatigue. She did not report any lightheadedness, dizziness, palpiations or chest pain. At times her breath can be "smothering" but she has not had any recent SOB. Per the patient, her bowel and bladder habbits are unchanged, and she has not noticed any hematuria, dysuria, hematochezia, BRPR, melena, hematemesis, nausea, or emesis. She denies any recent fevers, chills, weakness, parasthesias, or numbness. Her coumadin dose was held today, and decreased yesterday. . In the ED initial vital signs were T96.9 P116 88%RA with tachypnea. At the time she was comfortable, aware, and talking with headphones and a mircophone. Her stool was guiac negative, her abdomen exam was benign, and a CXR demonstrated atelectasis. Her HCT dropped from a baseline of 29 to 21, and her K was elevated at 5.8 in the setting of a elevated Cr of 2.8 Further imaging of the abdomen demonstrated diverticulosis, a non-obstructive stone, a pericardial effusion, and no retroperitoneal bleed. On transfer, she was ordered two units of blood and her vitals were: T 98.5, BP 120/65, HR 90s, RR25 Sa: 95%3LNC. On arrival to the floor she was comfortable, alert, and oriented. She had no pain, although she reported feeling weak. Vital signs: T35.9 P86, BP 61/46 (on Lower Leg), RR21 SA 91 3LNC. Her Access is PIV and PICC. Past Medical History: 1. Severe hearing loss, associated with tinnitus. 2. Osteopenia. 3. Depression/anxiety, followed by Dr. [Last Name (STitle) 3532]. 4. History of breast cancer. 5. Meningioma. 6. Hypertension. 7. Obesity. 8. Osteoarthritis. 9. Lumbar spinal stenosis. 10. Nepthrolithasis with nephrostomy tube 11. Sepsis 12. Afib w RVR PAST SURGICAL HISTORY: 1. Cholecystectomy [2089]. 2. Cataract surgery [2095]. 3. Left radical breast mastectomy [2064]. Social History: Lives in [Location (un) ] in [Location 1268]. Husband lives in [Location ] x 17 years, deceased last year. No children. Previously used to work in Pathology. No EtOH, tobacco, or illicits. Family History: NC Physical Exam: GEN: NAD, alert and interactive. Requested microphone use for communication VS: 96.6, 82, 88/63, 19, 94% HEENT: mucous membranes [Last Name (un) ], no OP lesions, No discernable JVP at 50 degrees, neck is supple, CV: No carotid bruits. Decreased upstroke and volume. Irregularly irregular with faint S1 and S2. No S3 or S4. No hyperdynamic PMI PULM: Short shallow breaths. Dullness to percussion on the left, with left basilar crackles. ABD: BS+, soft, NTND, no masses or HSM, no flankdullness. LIMBS: Cool extremities with 3+ LE, no tremors or clubbing SKIN: No rashes. Two stage II decubs on posterior side. Nephrostomy site c/d/i. NEURO: CNII-XII nonfocal, strength 5/5 R and [3-2] Left arm and leg. No facial droop or smile asymmetry. Pertinent Results: [2105-7-2] 07:00PM URINE COLOR-Brown APPEAR-Cloudy SP [Last Name (un) 155]-1.025 [2105-7-2] 07:00PM URINE BLOOD-LG NITRITE-POS PROTEIN->300 GLUCOSE-NEG KETONE-15 BILIRUBIN-MOD UROBILNGN-1 PH-5.0 LEUK-NEG [2105-7-2] 07:00PM URINE RBC->50 WBC-21-50* BACTERIA-FEW YEAST-NONE EPI-0-2 [2105-7-2] 07:00PM URINE AMORPH-MANY [2105-7-2] 07:00PM URINE EOS-NEGATIVE [2105-7-2] 06:35PM GLUCOSE-135* UREA N-34* CREAT-2.8# SODIUM-131 POTASSIUM-5.8* CHLORIDE-96 TOTAL CO2-21* ANION GAP-20 [2105-7-2] 06:35PM estGFR-Using this [2105-7-2] 06:35PM ALT(SGPT)-43* AST(SGOT)-47* ALK PHOS-89 [2105-7-2] 06:35PM CALCIUM-8.8 PHOSPHATE-4.9# MAGNESIUM-2.4 [2105-7-2] 06:35PM PT-44.1 PTT-34.5 INR(PT)-4.7* [2105-7-2] 06:09PM COMMENTS-GREEN TOP [2105-7-2] 06:09PM GLUCOSE-115* LACTATE-2.3* NA+-136 K+-4.8 CL--106 TCO2-19* [2105-7-2] 06:05PM WBC-12.2* RBC-2.36# HGB-6.8# HCT-21.4# MCV-91 MCH-28.7 MCHC-31.6 RDW-14.8 [2105-7-2] 06:05PM NEUTS-85.5 LYMPHS-8.5* MONOS-5.7 EOS-0.2 BASOS-0.2 [2105-7-2] 06:05PM PLT COUNT-427 . Imaging: . TTE [2105-7-3]: There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a moderate to large sized circumferential pericardial effusion (2.5cm inferior and 2.0 cm lateral to the left ventricle, 1.5cm anterior to the right atrium and right ventricle) with eccentuated respiratory variation in transmitral Doppler E wave suggestive of impaired ventricular filling. but no right atrial or right ventricular diastolic collapse (may be absent in settings of pulmonary artery hypertension). Compared with the prior study (images reviewed) of [2105-6-16], the pericardial effusion findings are new and c/w impaired filling/early tamponade physiology . TTE [7-4] 11:08am There is a large pericardial effusion. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology . TTE [7-4] 11am Post pericardiocentesis. There is a small to moderate sized pericardial effusion. There are no echocardiographic signs of tamponade. Compred to the pre-tap study from today, the pericardial effusion is smaller and tamponade has resolved. Brief Hospital Course: 86y/o F with h/o AFIB, Lacunar CVA, s/p nephrostomy tube for nephrolithiasis, and recent ICU admission for sepsis who presents with weakness for the past few days. She was admitted through the ED from [Hospital3 ] because her nephrostomy tube had fallen out. Pericardial effusion was incidentally found on a CT abd/pelvis. Pt was transferred to CCU for findings suggestive of cardiac tamponade physiology on ECHO [7-3]. Her clinical status worsened overnight. In the morning of [7-4] pt underwent emergent bedside pericardiocentesis. She went into resp failure and was placed on ventilatory support. The decision to make her [Date Range 3225] was made by her HCP and she was kept on morphine drip titrated for comfort. She went into asystolic arrest on [7-4] 6:30pm. She was DNR per her HCP. . # Pericardial effusion - Echocardiography shows moderate to large pericardial effusion with impaired ventricular filling c/w early tamponade physiology. Diff dx of pericardial effusion includes viral, neoplastic (hx of breast CA), uremic, CHF, fluid overload from renal failure. Uremic unlikely as BUN of 38, and in ARF, baseline Cr of 0.7-1.0. AM of [7-4] echo showed increased severity of tamponade and pt appeared cold and nonperfusing. Bedside pericardiocentesis performed with resolution of tamponade on post-pericardiocentesis ECHO. She continued to decompensate and was placed on respiratory support per HCP wishes. . #. Hypotension: Initially presented to the floor with labile blood pressures, but pressures were fluid responsive and thereafter remained stable; there was no clinical evidence suggestive of sepsis. She was transferred to CCU for management of cardiac tamponade. She was noted to be hypotensive with low urine output which did not resolve after pericardiocentesis. She was started on pressors, intubated and continued to be hypotensive sbp 60-100. Decision was made by her hcp to make her [Date Range 3225] and she was taken off all support except morphine drip titrated for comfort. . # Dyspnea - Unsure etiology. Bilateral pleural effusions on CT scan and X-ray likely [12-30] tamponade physiology and elevated L sided pressures. No history of asthma, COPD or CHF. Denies anxiety. Pt too unstable to undergo pleurocentesis. She was intubated per HCP wishes and maintained at FiO2 100% and PEEP 8. She continued to desat 80s. The decision was made by her HCP to change her status to [Name (NI) 3225] and she was taken off ventilatory and pressor support. . #. ARF: Presented with Cr 3.1 from BL 0.7. Had a previous CT stone protocol showing a non-obstructive pattern; no recent CT contrast. Received Vancomycin prior to admission at [Hospital 4382] facility. Urine lytes, culture, were sent; CK and Vanc levels were drawn. Urology is aware of the patient's disposition and was following for possible replacement of nephrostomy tube. Pt was admitted to CCU for management of pericardial effusion. Pt had decreasing urine output via foley cath and on AM of [7-4] it was noted that she had no output overnight. Oliguria likely [12-30] hypotension and lack of perfusion from cardiac tamponade. . #. Bilateral Pleural Effusions. Likely due to tamponade physiology. . # Anemia: likely [12-30] large bleed a/w pericardial tamponade . #. UTI: UA nitrate positive. Started on Zosyn with empirically dosed Vancomycin. Urine and blood cultures sent. . #. AFIB with h/o RVR: Coumadin and ASA were held in the setting of a bleed and the patient was rate controlled with Metoprolol 5 mg IV prn. All antihypertensives and antiarrhythmic meds were held in the setting of shock and respiratory failure. . #. Elevated INR: Vitamin K IV and FFP given pre-pericardiocentesis to reverse her anticoagulation. Medications on Admission: Venlafaxine 150 mg daily Ascorbic Acid 500 mg daily Aspirin 81 mg daily Senna 2 tabs [Hospital1 ] Albuterol Sulfate neb q4PRN wheezing Magnesium Hydroxide 400 mg/5 ml PO qam Simvastatin 40 mg PO daily Olanzapine 2.5 mg [Hospital1 ] Docusate 100 mg [Hospital1 ] Lisinopril 10 mg daily Vitamin D 1000 units daily MV daily Nexium 20 mg daily Lasix 40 mg daily Bisacodyl 10 mg Sup. Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Pericardial tamponade Respiratory failure Renal failure Shock Discharge Condition: Expired [2105-7-4] [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909]	[ "51881", "5849", "5119", "2851", "5990", "2762", "42731", "4280", "4019", "2767", "311" ]
Unit No: [Numeric Identifier 70003] Admission Date: [2130-12-15] Discharge Date: [2131-2-2] Date of Birth: [2130-12-15] Sex: F Service: NB HISTORY: Baby is a 34-1/7 week gestational age twin girl [Year (4 digits) ] to a 35 year-old G1P0-1 mother with prenatal labs: blood type O+, antibody negative, hepatitis B surface antigen negative, rubella immune, RPR nonreactive and GBS unknown whose prenatal course was significant for conception by IVF of di-di twins. Mom had preterm labor at 28 weeks with a shortened cervix and received betamethasone and was placed on bed rest until the date of delivery. Mom also had an elevated blood pressure diagnosed several weeks before delivery which was followed at home. On the date of admission mom went to her [Name (NI) ] office for an appointment and was found to have a blood pressure of 152/96 and was brought to [Hospital1 69] for further evaluation. In the hospital her blood pressures were 140s/90s and she had proteinuria with no symptomatology including no headache, no visual changes, no epigastric pain and at that time there were no signs of preterm labor. Secondary to her preeclampsia her OB elected to deliver the infants. This twin was [Hospital1 ] at 2220 at C-section with Apgars of 8 and 8. Infant emerged pale which quickly improved with facial CPAP. Heart rate was always over 100, no respiratory distress and she was brought to the Neonatal Intensive Care Unit for further evaluation. PHYSICAL EXAMINATION: On admission weight was 1670 grams, 10th to 25th percentile. Head circumference was 29.25 cm, 10th to 25th percentile, and length was 43.5 cm, 25th to 50th percentile. Temperature 98.4. Heart rate 170. Respiratory rate 72, blood pressure 62/33 with a mean of 45 and FpO2 95% on room air. Baby was active with anterior fontanelle open and flat. She was nondysmorphic and intact palate. She was slightly pale. Breath sounds were clear with mild intercostal, subcostal retraction. No active grunting or distress. Baby had normal S1, S2, no murmur. Abdomen was soft, nontender, nondistended. Extremities were well perfused. Tone was appropriate for gestational age and patient had a patent anus with normal female genitalia. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: Baby was [Name2 (NI) ] in room air and remained on room air throughout her admission. She never had respiratory distress or needed any oxygen or ventilatory support. She has had a history of desaturation and bradycardia with feeds which has resolved with maturation. Cardiovascular: Baby's blood pressure has been normal throughout her stay. Heart rates have been normal and she more recently has been found to have an intermittent murmur, most likely secondary to anemia. Fluids, electrolytes and nutrition: The baby was started NPO on IV fluids, started on breast milk on DOL #2 which was advanced as tolerated. She currently is on full ad lib feeds of [Name2 (NI) 68900] 20 gaining weight well. Her weight at discharge is 3145 grams. GI: Baby had a peak bilirubin on day of life 3 of 7.3 and was on phototherapy for 2 days and it was discontinued and she has had no further bilirubin issues. More recently on day of life 45 ([1-29]) she had 1 grossly blood streaked stool and was worked up for sepsis and allergy. Work up for sepsis was negative. It is believed to be a milk protein allergy, of which there is a maternal family history, and she was changed from Similac to [Month (only) 68900] which she continues. She continues to have heme positive stool but has not had any grossly blood stools since [1-29]. Hematology: Baby's initial hematocrit was 44.1 and her most recent hematocrit was 26 on [1-30] with a retic count of 4.7. She had been started on iron on day of life 12 and she continues on iron to date. Infectious disease: Baby had a CBC at birth but was never started on antibiotics and she has never had any infectious issues except a fungal diaper rash for which she was treated with nystatin and is resolved. On DOL 45 on [1-29] with the bloody stool she was worked up for sepsis and had a blood culture and CBC which was negative. Neurology: Because baby was [Name2 (NI) ] at 34 weeks, a head ultrasound was never done initially secondary to gestational age and baby has been acting neurologically appropriate. However, her head circumference has increased significantly and she is currently at the 90th percentile. On day of life 47 ([1-31]) we did a head ultrasound which showed a resolving grade 1 IVH along with some extra-axial fluid that was there for unknown reasons. The radiologist recommended a repeat head ultrasound in [1-16] months or at your discretion. The baby has a normal neurological examination and has been referred for EI. Sensory: Audiology: Hearing screening was performed with automated auditory brain stem responses and she passed that on [1-18]. Ophthalmology: Because baby was 34 weeks at birth she has not received an eye examination to date. CONDITION ON DISCHARGE: Excellent. DISCHARGE DISPOSITION: Home. NAME OF PRIMARY PEDIATRICIAN: Dr. [First Name (STitle) ] at [Hospital 3307] Pediatrics. Phone # ([Telephone/Fax (1) 68584]. CARE RECOMMENDATIONS: Feeds at discharge: As stated before baby is on [Name (NI) 68900] 20 gaining weight well. It was questionable whether she would continue to gain weight well on 20 kilo-calorie formula because previously she had been on 24 kilocalorie formula, so we recommend following her weights closely and considering increasing her calorie density. Otherwise she is tolerating the formula and doing well with the hemoccult positive stools but without grossly bloody stools. Medications: She is on iron sulfate 0.3 cc p.o. q day which we recommend continuing. Care seat position screening test was done on [2-1] which she passed. Immunizations received: Baby has received her hepatitis-B immunization on [2130-2-7]. Immunizations recommended: 1. Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following 3 criteria: 1) [Month (only) ] at less than 32 weeks, 2) [Month (only) ] between 32 and 35 weeks with 2 of the following: Day care during the RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings; or 3) with chronic lung disease. 2. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life immunization against influenza is recommended for household contact and out of home care- givers. State Newborn Screening status: The baby received a state newborn screen on [12-18] which was normal. FOLLOW UP APPOINTMENTS: Baby will be following up with Dr. [First Name (STitle) ] at [Hospital 3307] Pediatrics on [Last Name (LF) 766], [2131-2-4]. DISCHARGE DIAGNOSES: 1. Prematurity. 2. Milk protein allergy. 3. Status post hyperbilirubinemia. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 48738], MD [MD Number(2) 55708] Dictated By:[Last Name (NamePattern1) 69933] MEDQUIST36 D: [2131-2-2] 08:22:32 T: [2131-2-2] 09:06:17 Job#: [Job Number 70004]	[ "7742", "V290", "V053" ]
Admission Date: [2161-8-30] Discharge Date: [2161-9-7] Date of Birth: [2093-4-15] Sex: F Service: MEDICINE Allergies: Codeine / Sulfa (Sulfonamide Antibiotics) / Penicillins / Tylenol 8 Hour Attending:[First Name3 (LF) 594] Chief Complaint: Several days of melena, associated with weakness and fatigue Major Surgical or Invasive Procedure: None History of Present Illness: Ms [Known lastname ] is a 68 yo F w/PMH significant for EtOH and GERD here following recent discharge from [Hospital1 18] on [2161-8-28]. Both patient and daughter report worsening black, tarry diarrhea since discharge. Patient states that she feels weak, lethargic, fatigued, and unable to care for herself. Has had decreased PO intake today and over weekend. Of note, diarrhea stopped today after d/c'ing tube feeds. Both patient and daughter wish to go to acute rehab facility, however, patient believes that she needs to cared for in hospital prior to rehab. Reports mild abdominal pain and non-productive cough improving since last discharge. Denies N/V, fever, chills, inability to tolerate oral intake, HA, syncope, chest pain, SOB, wheeze, On the floor: Pt went into bouts of SVT to 170's w/PVC's and eventual short runs of V. tach. K WNL, but Mg not checked in ED so given 2mg Mg and other electrolytes sent. Pt entirely asymptomatic. Left pt in sinus rhythm w/single PVC's. Past Medical History: Hypertension PVD Social History: She smoked a pack a day of cigarettes for over 20 years and has hyperglycemia, although she says she does not have diabetes. She has never had a stroke or heart attack. She has had eye surgery. Family History: N/C Physical Exam: Admission Exam: VS: 98 ??????F (36.7 ??????C), Pulse: 85, RR: 18, BP: 118/67, O2Sat: 98, O2Flow: 3L NC GENERAL: Jaundiced and in no acute distress, with NC and feeding tube in place. Conversive and in good spirits HEENT: Sclera icteric. Mucous membranes dry CARDIAC: Irregularly irregular. Tachycardic. NS1&S2. NMRG LUNGS: CTA b/l with no wheezing, rales, or rhonchi. ABDOMEN: Mild distension and firm, with mild diffuse tenderness to palpation No HSM appreciated. EXTREMITIES: 3+ pitting edema. Warm and well perfused, no clubbing or cyanosis. NEUROLOGY: no asterixis, A+Ox3. CN 2-12 intact, sensation grossly intact. moving all extremities freely. Discharge Exam: GENERAL: Jaundiced and breathing with accessory muscles, with NC and feeding tube in place. HEENT: Sclera icteric. Mucous membranes dry CARDIAC: Irregularly irregular. Tachycardia. NS1&S2. NMRG appreciated LUNGS: rales at base bilaterally. ABDOMEN: Mild distension and firm, with mild diffuse tenderness to palpation No HSM appreciated. EXTREMITIES: 4+ pitting edema to lower back. Warm and well perfused, no clubbing or cyanosis. NEUROLOGY: no asterixis, A+Ox3. CN 2-12 intact, sensation grossly intact. moving all extremities freely. Pertinent Results: Admission Labs: [2161-8-30] 12:00PM BLOOD WBC-22.0* RBC-2.63* Hgb-9.0* Hct-28.1* MCV-107* MCH-34.1* MCHC-31.9 RDW-19.2* Plt Ct-234 [2161-8-30] 12:00PM BLOOD Neuts-93.4* Lymphs-3.5* Monos-2.6 Eos-0.4 Baso-0.2 [2161-8-30] 12:00PM BLOOD PT-14.6* PTT-33.5 INR(PT)-1.4* [2161-8-30] 12:00PM BLOOD Glucose-105* UreaN-35* Creat-1.5* Na-132* K-4.7 Cl-95* HCO3-26 AnGap-16 [2161-8-30] 12:00PM BLOOD ALT-57* AST-186* AlkPhos-421* TotBili-23.1* [2161-8-30] 12:00PM BLOOD Albumin-2.9* Calcium-9.1 Phos-2.8 Mg-2.0 . Discharge Labs; [2161-9-7] 03:14AM BLOOD WBC-24.5* RBC-2.42* Hgb-8.4* Hct-26.5* MCV-110* MCH-34.9* MCHC-31.8 RDW-20.3* Plt Ct-199 [2161-9-7] 03:14AM BLOOD Neuts-92.5* Lymphs-3.5* Monos-3.4 Eos-0.4 Baso-0.1 [2161-9-7] 03:14AM BLOOD PT-17.3* PTT-39.6* INR(PT)-1.6* [2161-9-7] 03:14AM BLOOD Glucose-88 UreaN-72* Creat-1.8* Na-137 K-4.5 Cl-103 HCO3-22 AnGap-17 [2161-9-7] 03:14AM BLOOD ALT-49* AST-148* LD(LDH)-259* CK(CPK)-16* AlkPhos-261* TotBili-20.9* [2161-9-7] 03:14AM BLOOD Albumin-2.6* Calcium-8.7 Phos-4.9* Mg-2.3 . Pertinent Labs: [2161-9-4] 08:15AM BLOOD CK-MB-2 cTropnT-<0.01 [2161-9-6] 11:20AM BLOOD CK-MB-2 cTropnT-<0.01 [2161-9-7] 03:14AM BLOOD CK-MB-2 cTropnT-<0.01 [2161-8-30] 07:00PM BLOOD calTIBC-177* Ferritn-439* TRF-136* [2161-9-4] 02:11PM BLOOD Type-ART pO2-96 pCO2-33* pH-7.45 calTCO2-24 Base XS-0 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] . Micro: [2161-9-5] BLOOD CULTURE-pend [2161-9-5] BLOOD CULTURE-pend [2161-9-4] BLOOD CULTURE-pend [2161-9-4] BLOOD CULTURE-pend [2161-9-3] STOOL OVA + PARASITES-neg [2161-9-3] STOOL OVA + PARASITES-neg [2161-9-3] STOOL OVA + PARASITES- MICROSPORIDIA STAIN-PRELIMINARY; CYCLOSPORA STAIN-FINAL; Cryptosporidium/Giardia (DFA)-neg [2161-8-31] STOOL C. difficile; FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-[2161-8-30] URINE URINE CULTURE-neg [2161-8-30] BLOOD CULTURE-neg [2161-8-30] BLOOD CULTURE-neg Imaging; [2161-8-30] EKG:Sinus tachycardia with ventricular premature beats. Low QRS voltages throughout. Diffuse ST-T wave abnormalities grossly unchanged from previous tracing. . [2161-8-30] CHest AP: As compared to the previous radiograph, there is minimal increase in transparency of the lung parenchyma, potentially reflecting improved ventilation. At the right lung base, however, a combination of pleural effusion and parenchymal opacity persists. These changes might be consistent with pneumonia. The changes have neither increased nor decreased in severity and extent as compared to the previous examination. A prexeisting retrocardiac atelectasis is less severe than on the previous image. Unchanged moderate cardiomegaly, unchanged course and position of a nasogastric tube. . [2161-8-31] TTE: Small to moderate circumferential pericardial effusion without evidence for tamponade physiology. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Compared with the prior study (images reviewed) of [2161-8-18], the pericardial effusion is larger. If clinically indicated, serial evaluation is suggested. . [2161-8-31] RUQ U/S: Echogenic liver consistent with fatty infiltration. Other forms of liver disease, including more significant hepatic fibrosis, cirrhosis, or steatohepatitis, cannot be excluded on the basis of this examination. No evidence of biliary obstruction. Stones and gallbladder sludge, but no evidence of acute cholecystitis. Increasing splenomegaly, 15.5 cm (13.1 cm on [8-12]). Trace left-sided pleural effusion. . [2161-9-1] CT Torso: Worsening right lower lobe consolidation, superimposed on post-radiation changes, with trace right and small left simple pleural effusions. Differential considerations include increasing atelectasis or scarring, versus possibly superimposed infection. Moderate pericardial effusion, increased somewhat. Heterogeneous hepatic perfusion consistent with the history of hepatitis. Cholelithiasis without evidence of cholecystitis. . [2161-9-2] CT Head:No evidence of intracranial hemorrhage; given the patient's history of malignancy, if metastases are of a concern, MR is more sensitive in detecting small metastatic lesions . [2161-9-4] LENI Scan: No bilateral lower extremity deep venous thrombosis. Extensive superficial soft tissue edema. . [2161-9-7] CXR Portable: enlargement of the cardiac silhouette with pulmonary vascular congestion and bilateral pleural effusions with compressive atelectasis at the bases. Intestinal tube remains in position Brief Hospital Course: 68 year old woman with past medical history of lung cancer s/p chemotherpay and radiation 3 years prior, and alcohol abuse with acute alcoholic hepatitis recently admitted with it, who returned with worsening diarrhea and found to have worsening liver function and renal function and respiratory status despite treatment who changed her goals of care to comfort measures only given her poor prognosis and is discharged home with hospice. Active Issues: #Alcoholic hepatitis: Pt returned to [Hospital1 18] for worsening fatigue, lethargy, and diarrhea after being discharged 5 days prior. There was no significant change in bilirubin or leukocytosis on this admission from the last (T. bili:23, WBC:22). Increased bili and WBC originally thought to be [2-26] occult infection, so pt placed on broad spectrum abx. CT positive for ?RLL PNA and she was treated for HCAP with broad spectrum antibiotics. Her hepatitis continued to worsen with worsening bilirubin and she was started on pentoxyfilline without improvement in her liver function. #Tachypnea/dyspnea: Although pt had baseline need for 3L O2, she developed progressive tachypnea and SOB during her hospital stay. She was worked up for PE, pneumonia and pericardial effusion. It was felt that ultimately this worsening dyspnea was due to her anasarca and she was attempted to be diuresed. However with her worsening renal function she was not responding to IV diuretics and discussion with the renal team suggested that ultrafiltration would be the next step to diuresis. However, given that this was a form of dialysis and not in line with the patient's goals of care this was not pursued. She was discharged to home hospice with morphine sulfate for air hunger. #Acute renal failure- patient was originally pre-renal on admission, her renal function improved temporarily. In the setting of worsening liver function and IV contrast for a CT scan she developed worsening renal function with associated oliguria. Renal was consulted with her oliguria and she was no longer diuresing to higher doses of lasix. It is possible that this represented a pre-renal azotemia vs. hepatorenal syndrome. #Pneumonia- patient was found to have a possible new infiltrate on her right lower lobe in the area of previous scaring from her radiation so it was unclear if this was truely a pneumonia. Given her clinical status and worsening respiratory complaints she was treated for hospital associated pneumonia. Antibiotics were discontinued at the time of discharge given her goals of care. #Diarrhea: Multiple stool studies performed, and all negative. Diarrhea was dark, but not true melena. Thought to be [2-26] malabsorption from alcoholic GI insult and liver disease. #Paroxysmal A.fib: Pt had multiple episodes of atrial fibrillation with rapid ventricular rate and was started on metoprolol 25mg po TID. -She will be sent home on metoprolol 25mg po TID to control her rate Chronic Issues: #Pericardial Effusion: H/o stable effusion. Pulsus <10, and no signs/symptoms of tamponade #H/o lung cancer: H/o stage III lung cancer s/p XRT and chemo. CT findings suggest ?recurrence. Transitional Issues: Patient to be discharged to home with hospice. Medications on Admission: . Information was obtained from . 1. Isosource 1.5 Cal NF (lactose-free food with fiber) 40 ml/hr enteral daily Cycle 24 hours. No residual check. Flush with 30mL water q6h 2. Albuterol 0.083% Neb Soln 1 NEB IH TID 3. Fluticasone Propionate NASAL 1 SPRY NU [Hospital1 ] 4. FoLIC Acid 1 mg PO DAILY 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO BID 7. Thiamine 100 mg PO DAILY 8. Tiotropium Bromide 1 CAP IH DAILY 9. Bengay 1 Appl TP [Hospital1 ]:PRN muscle pain 10. Aspirin (Buffered) 81 mg PO DAILY 11. Furosemide 40 mg PO DAILY Hold for SBP<90 12. Spironolactone 100 mg PO DAILY Hold for SBP< 90 Discharge Medications: 1. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB RX ipratropium bromide 0.2 mg/mL (0.02 %) 1 neb inhalation every 6 hours Disp #60 Cartridge Refills:0 2. Lidocaine 5% Patch 1 PTCH TD DAILY Apply to back RX lidocaine 5 % (700 mg/patch) apply one patch to affected area once a day Disp #30 Transdermal Patch Refills:0 3. Metoprolol Tartrate 25 mg PO Q8H hold for MAP<55 or hr<60 RX metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a day Disp #30 Tablet Refills:0 4. Morphine Sulfate (Oral Soln.) 5-20 mg PO Q1-2H air hunger hold for sedation or rr<10 RX morphine 20 mg/5 mL [1-29] ml by mouth q1-2h Disp #1 Bottle Refills:0 RX morphine 10 mg/5 mL [3-6] ml by mouth q1-2h Disp #1 Bottle Refills:0 5. OLANZapine (Disintegrating Tablet) 2.5-5 mg PO TID:PRN anxiety RX olanzapine 5 mg 0.5-1 tablet(s) by mouth up to three times a day Disp #60 Tablet Refills:0 6. Tiotropium Bromide 1 CAP IH DAILY 7. Bengay 1 Appl TP [Hospital1 ]:PRN muscle pain 8. Albuterol 0.083% Neb Soln 1 NEB IH TID Discharge Disposition: Home With Service Facility: Hospice of the [Location (un) 1121] Discharge Diagnosis: Acute Renal Failure Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [Known lastname ], It was a pleasure taking care of you while you were here at [Hospital1 18]. You were readmitted to the hospital with diarrhea and developed worsening breathing and continued worsening function of your liver. Your kidneys were then injured with your worsening liver function and you decided to refocus your care to being comfort. You are being sent home to be on hospice who will continue to help treat your symptoms to make you feel more comfortable. Followup Instructions: with hospice	[ "5849", "486", "42789", "42731", "53081", "4019", "3051" ]
Admission Date: [2168-9-6] Discharge Date: [2168-9-13] Date of Birth: [2117-4-25] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1145] Chief Complaint: Chest tightness Major Surgical or Invasive Procedure: None History of Present Illness: 51yo M w/ HTN, diastolic CHF, hyperlipidemia, sleep apnea, asthma who had initially presented to an OSH on [2168-9-5] with chest tightness ([4-5]), SOB, hypoxia (02 sat to 88%). His initial EKG showed 2mm ST-T elevations in II, III, aVF and bigeminy which resolved with SL NTG. He also had elevated cardiac enzymes (tropT of 1.04). He was given [Month/Year (2) ], plavix, heparin, integrilin and transferred to [Hospital1 18] for cath. Here his CE were: CK 1009, CKMB 55, trop T 4.23. At cath, he was found to have CAD of a non-dominant RCA, probable prox. LPDA stenosis as well as mild stenoses of the OM and mid LAD. There was also iatrogenic dissection of the RCA w/o compromise of the lumen or flow and possible distal embolization/additional dissection of the AM1. No interventions were made (lesion not amenable to PCI). . Post-cath, the patient had 500cc of guaiac positive coffee ground emesis, he was orthostatic at the time. An NGT placement was attempted, however the pt. desated and vomited and the NGT was not placed. At this time, integrillin and heparin were stopped and IV PPI was started. A few hours later, the pt. became hypotensive to the 70's and hypoxic (74% on RA), he again vomited approx 100cc of coffee ground emesis. His hypotension responded well to a 500cc fluid bolus and his 02 sats improved to 95% on a face mask(10L). The patient was then tranferred to the CCU. Past Medical History: allergies: NKDA . HTN diastolic CHF asthma chronic back pain BPH obstructive sleep apnea (on home CPAP) congenital mild mental retardation? (per PCP) COPD per PCP, [Name10 (NameIs) ] [Name11 (NameIs) 11149] available, also has elements of restrictive disease secondary to obesity cerebral palsy depression s/p MVA in [2161]--c/b heart failure and mechanical ventilation unclear if pt has h/o murmur--PCP describes [Name9 (PRE) 1105]/VI systolic murmur at base on some visit notes back to [2165], but no murmur noted on PCP's exam [2168-6-26] Social History: Denies tobacco or alcohol use currently. Heavy user in the past however quit both > 20yrs ago. He lives in [Location 620] with brother and brother's partner. Minimal exercise. The patient works at [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Workshop in [Location (un) 620] (adult care worker). Contact: Brother, [Name (NI) ] [Name (NI) 55764] cell # [Telephone/Fax (1) 55765] Family History: Mother had an aneurysm, father had [Name (NI) 19917] disease. Physical Exam: VS-BP 116/49 HR 65 02 sat 96% Gen: obese male, awake and alert, 02 face mask in place, comfortable heent: face mask in place neck: elevated JVD to his ear with +hepato-jugular reflex CV: holosystolic III/VI SEM heard best at the LLSB with radiation to the axilla. chest: bibasilar rales bilaterally abd: obese, NT, ND. BS normoactive ext: non-edematous pulses: 2+ DP b/l Pertinent Results: [2168-9-10*] 07:10AM BLOOD WBC-8.5 RBC-3.92 Hgb-12.4* Hct-37.5* MCV-96 MCH-31.7 MCHC-33.2 RDW-14.0 Plt Ct-219 [2168-9-7] 02:28PM BLOOD PT-17.0* PTT-28.6 INR(PT)-1.6* [2168-9-9] 02:07PM BLOOD Glucose-94 UreaN-12 Creat-0.5 Na-140 K-4.2 Cl-98 HCO3-36* AnGap-10 [2168-9-6] 01:15AM BLOOD CK(CPK)-1009* [2168-9-6] 05:15AM BLOOD CK(CPK)-654* [2168-9-6] 04:49PM BLOOD CK(CPK)-376* [2168-9-6] 05:17PM BLOOD CK(CPK)-367* [2168-9-7] 04:43AM BLOOD CK(CPK)-241* [2168-9-7] 12:18PM BLOOD CK(CPK)-223* [2168-9-7] 12:18PM BLOOD CK-MB-12* MB Indx-5.4 cTropnT-1.07* proBNP-2251* [2168-9-7] 04:43AM BLOOD CK-MB-14* MB Indx-5.8 cTropnT-0.90* [2168-9-6] 05:17PM BLOOD CK-MB-17* MB Indx-4.6 cTropnT-1.05* [2168-9-6] 04:49PM BLOOD CK-MB-17* MB Indx-4.5 [2168-9-6] 05:15AM BLOOD CK-MB-41* MB Indx-6.3* cTropnT-3.04* [2168-9-6] 01:15AM BLOOD CK-MB-55* MB Indx-5.5 cTropnT-4.23* [2168-9-7] 12:18PM BLOOD TSH-0.23* . [2168-9-7] bedside ECHO: initial read per fellow- suboptimal quality due to body habitus-moderate to severe eccentric MR, preserved LV fxn with inferior hypokinesis, RV normal, PA pressures normal, trace TR, no significant pericardial effusion, no observed VSD. Mild LVH. LVEF of 55-60%. . [2168-9-7] TTE: Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). There is at least moderate resting left ventricular outflow tract obstruction. The findings are consistent with hypertrophic obstructive cardiomyopathy (HOCM). Trace aortic regurgitation is seen. There is systolic anterior motion of the mitral valve leaflets. At least moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is no pericardial effusion. Compared with the prior study (images reviewed) of [2168-9-7], the findings are similar (the resting LVOT gradient is slightly lower and the overall LVE is slightly greater). Peak Resting LVOT gradient: 60 mm Hg (nl <= 10 mm Hg) . [2168-9-6] Cardiac cath: LAD with mild calcification, ? of mild-mod mid LAD plaque after D1, LCX with mild-mod stenosis at origin of OM, prabable prox. moderate stenosis of LPDA, RCA with dissection possibly on top of pre-existing proximal RCA plaque. diffuse disease (80%) of AM2, AM3. . EKG on admission to CCU: NSR, normal axis, TWI in III, avF, V6. ?qwave in III, normal intervals. right sided EKG: no ST elevations or depression in the pre-cordial leads. . CTA Chest [9-12]: There is no intimal flap within the thoracic aorta to suggest aortic dissection. No filling defects are identified within the central pulmonary arteries to suggest acute or chronic pulmonary embolism. The main pulmonary artery measures 3.9 cm in greatest dimension suggestive of pulmonary arterial hypertension. There is a small pericardial effusion. Coronary artery calcification is notable within the left anterior descending coronary artery and left circumflex artery. There is cardiomegaly. No axillary, mediastinal or hilar adenopathy is detected. There is near-complete atelectasis/collapse of the left lower lobe. There is atelectasis within the right lower lobe. There is abnormal elevation of the right hemidiaphragm. This study was not performed to evaluate structures below the diaphragm. However, there is a simple-appearing cyst within the left lobe of the liver measuring 1.9 x 1.3 cm. Partially visualized spleen and stomach is unremarkable. . Echo [2168-9-13]: Focused study for patent foramen ovale: No ASD/PFO present via color Doppler, or saline administration. Moderate pericarial effusion located posterior to the inferolateral wall. Mild resting LVOT gradient that increases with Valsalva manuever. Brief Hospital Course: 51 yo M w/ HTN, hyperlipidemia, [Hospital ] transferred to [Hospital1 18] for cath for inferior-STEMI. No intervention at cath. Noted to have coffee-ground emesis post-cath with hypoxia and hypotension, transferred to CCU. . #CAD: Presented with inferior STEMI, no [Hospital1 ] at cath, medically managed. Patient discharged on plavix 75mg [Last Name (LF) ], [First Name3 (LF) ] daily, atorvastatin, and metoprolol. He has follow-up with his primary care doctor in 2 weeks and with cardiology in mid-[Month (only) 359]. He had no further episodes of chest pain during his hospitalization. . #Hypotension: Pt had transient episode of hypotension in the setting of a recent inferior MI and 2 episodes of bloody emesis. His blood pressure responded to IV fluids and home lasix was held, and his BP remained stable throughout the rest of his hospitalization. It was felt that his hypotension was due to preload dependence due to inferior MI, volume depletion after large volume emesis. In addition, it was noted that the patient had a possible new systolic murmur at the time of his hypotensive episode. Echo demonstrated a pressure gradient of 60 across his LVOT, suggestive of hypertrophic cardiomyopathy, which would make him further preload dependent. His murmur did indeed appear and disappear during his hospitalization, and cardiac MR was arranged for him as an outpatient. . #Hypoxia/Obstructive Sleep Apnea: Patient was noted to have oxygen desaturation to the low 80s without symptoms during his hospitalization, and it was felt that he was most likely chronically hypoxic and hypoventilating at home. He required 3L of oxygen by nasal cannula during the day and 12L oxygen with 12cm H20 CPAP at night to maintain his oxygen sats. Pulmonary was consulted, and it was felt that his poor oxygenation status was due to a combination of factors, including severe OSA, possible restrictive disease secondary to his obesity and possibly his cerebral palsy, asthma, and h/o diastolic congestive heart failure. Repeat Echocardiogram was negative for intracardiac shunt. CTA was obtained and was negative for pulmonary embolism, but did demonstrate near total collapse of his left lung. The patient received chest PT and was discharged with incentive spirometry. He was also continued on his home regimen of singulair, advair, [Doctor First Name 130], and albuterol. He will have follow-up with Sleep clinic, and a sleep study was scheduled for him. In addition, he has follow-up with his pulmonologist, Dr. [Last Name (STitle) 22882], in [Month (only) 359]. . #CHF-acute on chronic diastolic heart failure: Pt has known diastolic dysfunction and is on lasix 60mg qdaily at home. Echocardiogram after his MI revealed preserved EF (55%) with basal and mid inferior LV hypokinesis. His clinical exam was c/w heart failure, demonstrating JVD and pretibial edema. Patient was restarted on his home lasix at 60mg po daily at time of discharge. . # Episode of 30-40 beats of non-sustained Ventricular Tachycardia: This occurred about 48 hours after his MI, and pt was hemodynamically stable throughout. Electrophysiology was consulted, and advised that the patient have a Lifewatch monitor upon discharge. The patient had no further episodes of VTach during admission. He will have follow-up with Dr. [Last Name (STitle) ] in 3 months. . #GI bleed: Pt had two episodes of coffee ground, guaiac positive emesis on [9-6]. His stools were guaiac negative. He has no hx of GI bleeding, gastritis, GERD, though he does have remote h/o ETOH abuse. Although his Hct initially dropped from 42 to 37, his Hct remained stable thereafter and he had no further episodes of GI bleeding. GI was consulted and felt that he was not a candidate for EGD. Per their recommendations, he was continue on a PPI given twice daily for 1 month, after which time he should be switched to a once a day dose. His primary doctor can follow his hematocrit; he should not need an EGD unless he has further episodes of GI bleeding. . #HTN: Patient has been maintained on nadolol for years for his hypertension. In discussion with his PCP, [Name10 (NameIs) ] choice of this medication appeared to be historical. Given the patient's poor respiratory status and h/o reactive airway disease, he was switched to metoprolol with good blood pressure control. It was noted that the patient had been taking pseudoephedrine twice a day chronically. He was advised to stop this medication as it can increase the blood pressure. . #Hyperlipidemia: Patient was put on high dose statin and discharged on 80mg atorvastatin. . # Incidental ?liver cyst on CT chest: - Described as "simple-appearing cyst within the left lobe of the liver measuring 1.9 x 1.3 cm." Radiology did not make specific recommendations about follow-up, but the pt's PCP should pursue this as deemed appropriate. Medications on Admission: . Advair 1 puff [Hospital1 ] Advair 1 puff [Hospital1 ] Nadolol 20mg po daily Singulair 10mg po daily qpm Lasix 60mg po daily Potassium 30meq po daily Citalopram 40mg po daily Aspirin 81mg daily Tylenol PRN back pain Decongestants, [Hospital1 ] pseudoephedrin Fexofenadine 60mg po BID Discharge Medications: 1. oxygen Patient needs home oxygen by nasal cannula at 3L during the day and to be given with his CPAP at 12L overnight. 2. CPAP machine CPAP machine with nasal mask to be set at 12cm pressure support overnight; provide 12L oxygen during night with CPAP. 3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s)* Refills:2 8. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 9. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 10. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 11. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 12. Albuterol 90 mcg/Actuation Aerosol Sig: [12-29] Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:3 13. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2) Inhalation four times a day as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:3 14. Outpatient Physical Therapy Chest PT for atelectasis 15. incentive spirometer Please provide patient with an incentive spirometer, to be used during the day to be used 4 times/hour or per physical therapy and pulmonary clinic 16. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO once a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary Diagnosis: STEMI Secondary Diagnoses: Obstructive sleep apnea, hypoxia, GI bleed Discharge Condition: Improved. Patient was free of chest pain and he was breathing comfortably with stable oxygen saturation on 3L nasal cannula during the day and CPAP with 12cm H20 and 12L O2 at night. Discharge Instructions: You were admitted with a heart attack, and you received a cardiac catheterization. The blockage in your artery was not accessible for repair with a [Last Name (LF) ], [First Name3 (LF) ] your heart attack was managed with medicines. Your blood pressure dropped low and you started needing a lot of oxygen. You had a CT scan of your chest that showed no evidence of a blood clot in the lungs. 1. Please take all medications as prescribed. In particular please do not stop taking aspirin or plavix without talking to your cardiologist. Because of your heart attack you should not take pseudoephedrine. 2. Please attend all follow-up appointments as listed below. You have a sleep study scheduled for [9-25]; please make sure you go to this. 3. You will have a heart monitor delivered to your house. You can expect a call to help you know how to use this. 4. You should get a call letting you know when to come for a "cardiac MR", a radiology study that will help get a better picture of your heart. If you have not heard from the doctor about this in 2 weeks, please call Dr.[Name (NI) 1565] office at [Telephone/Fax (1) 285] for assistance. 5. You will get a new CPAP machine and oxygen delivered on the day you get home. 6. Please call your doctor or return to the hospital if you develop: chest pain, shortness of breath, lightheadedness/dizziness, palpitations, bloody vomit, blood in your stools, or other symptoms that worry you Followup Instructions: 1. Please see your primary doctor, Dr. [Last Name (STitle) 5292] in 2 weeks. [Telephone/Fax (1) 5294] 2. Sleep clinic. Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) 20111] & DR. [Last Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2168-9-20] 10:45 3. Sleep study scheduled for [2168-9-25], Sunday at 9:30pm. You will receive a packet in the mail with directions. Please call [Telephone/Fax (1) 38237] if you have questions or you need to reschedule. 4. You will need to follow up in cardiology clinic with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [10-10] at 9:20 at [Hospital1 18] [Hospital Ward Name 23] 7 5. Please follow up with your lung doctor Dr. [Last Name (STitle) 22882] at [Hospital 61] [Location (un) 620] Monday [9-26] at 1:15. 6. Electrophysiology: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. Phone:[Telephone/Fax (1) 285] Date/Time:[2168-12-13] 1:00. Completed by:[2168-9-15**]	[ "4280", "41401", "4019", "32723", "2724" ]
Admission Date: [2131-12-29] Discharge Date: [2132-1-7] Service: GENERAL SURGERY CHIEF COMPLAINT: Pneumoperitoneum. HISTORY OF PRESENT ILLNESS: Ms. [Known lastname 92834] is an 84 year-old female transferred to [Hospital1 69] from [Hospital 1281] Hospital. Ms. [Known lastname 92834] has a past medical history significant for coronary artery disease status post stent, congestive heart failure, hypertension. She was evaluated at [Hospital 1281] Hospital for fatigue, heme positive stool. Her hematocrit was found to be 17 and an esophagogastroduodenoscopy was negative. She then underwent a bowel prep and then colonoscopy at [Hospital 1281] Hospital. They found a right arterial venous malformation. That malformation was fulgurated on [12-27], which was two days prior to presentation to [Hospital1 188]. The patient then developed increased temperatures, abdominal distention. This prompted the physicians taking care of her to order a KUB. This KUB showed free air. She then received a CT, which showed free air, pelvic fluid and stranding. This CT accompanied her to [Hospital1 190] and was seen by us. The patient had been started on antibiotics and transferred to [Hospital1 346] for further evaluation and treatment. PAST MEDICAL HISTORY: 1. Coronary artery disease status post stenting. 2. Congestive heart failure. 3. Aortic stenosis. 4. Hypertension. 5. Colon cancer. 6. Left colectomy. 7. Left lumpectomy secondary to breast cancer. 8. Bilateral carotid end arteriectomies. MEDICATIONS: 1. Lipitor. 2. Zestril. 3. Lasix. 4. Aspirin. 5. Tamoxifen. 6. Aricept. 7. K-ciel. 8. Protonix. 9. Meclozine. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: In general, she is awake, alert and in no acute distress. Vital signs temperature 101.8. Heart rate 124. Blood pressure 158/70. Respirations 28. Her lungs are clear to auscultation bilaterally. Her heart is regular rate and rhythm. She has a 3 out of 6 systolic ejection murmur. Her abdomen is dissented, tympanic. It is diffusely tender. She has right lower quadrant rebound tenderness. She also has guarding. Extremities they are warm and well perfuse. PERTINENT IMAGING: CT of abdomen and pelvis from [Hospital 1281] Hospital shows positive free air, pelvic stranding and fluid. HOSPITAL COURSE: Ms. [Known lastname 92834] was admitted to the hospital the night of [12-29] with an apparent cecal perforation from her colonoscopy. She was made NPO, given intravenous fluids and antibiotics and laboratories were checked. It was soon apparent after she was admitted that she would need a repair of her cecal perforation. Therefore she went to the Operating Room. In the Operating Room she underwent an exploratory laparotomy, a colorrhaphy, and an abdominal irrigation. In the Operating Room there was seen gross fecal soilage of her abdominal cavity. The patient tolerated the procedure well. Please refer to the official operative note for all the details. Immediately postoperatively the patient was admitted to the PACU and was followed by the Intensive Care Unit team mostly due to the patient's critical aortic stenosis. The patient received a Swan-Ganz catheter for monitoring and adequate fluid resuscitation. Her postoperative antibiotics included Ampicillin, Levofloxacin and Flagyl. There were some difficulties in correctly placing her Swan secondary to her anatomy, but after multiple manipulations the Swan was placed correctly. Of note the patient also had some postoperative psychosis, which from past medical records the patient was found to have a history of. Therefore she was put on scheduled Haldol intravenous. This was soon discontinued after a couple of days when the patient slowly returned to baseline in mental status. Also immediately postoperatively, the patient was started on total parenteral nutrition secondary to the patient's deconditioned state. The patient did well in the Intensive Care Unit. The only issue being her high blood pressure and heart rate and the patient was switched to intravenous hypertension medications as the patient was not tolerating po. By postoperative day four the patient was able to be transferred to the floor. At this point she was also having return of her bowel function and was started on clears, however, the total parenteral nutrition was continued. By postoperative day five the patient was continued to have high blood pressures and heart rate. The patient was able to be switched to po hypertension medications to which she had much better blood pressure control. She was also being diuresed with intravenous Lasix with good response and over the next few days the patient was slowly weaned off of her total parenteral nutrition, restarted on a po diet and restarted on all of her home medications. The patient was discharged of all of her antibiotics, which were Ampicillin, Levofloxacin and Flagyl on postoperative day seven after a seven day course. She had been afebrile and her white count had returned to [Location 213]. Physical therapy and occupational therapy consults had been obtained during the [Hospital 228] hospital stay. They felt due to her deconditioned status that the patient would need an acute rehab stay immediately upon discharge from the hospital. This was also reinforced as the patient did have a fall the day before discharge in the bathroom while nursing was waiting outside. CONDITION ON DISCHARGE: The patient is stable tolerating a po diet and po medications, ambulating well with assistance, however, unstable without assistance. The patient was somewhat incontinent of urine. DISCHARGE STATUS: To rehab facility [Hospital1 ], staples still in place to be discontinued in one week. DISCHARGE DIAGNOSIS: Status post exploratory laparotomy, colorrhaphy for cecal perforation secondary to colonoscopy. DISCHARGE MEDICATIONS: 1. Lasix 40 mg po q day. 2. Protonix 40 po q day. 3. Tamoxifen 10 mg po b.i.d. 4. Atenolol 75 mg po q.d. 5. Donepazil 5 mg po q.h.s. 6. Isosorbide dinitrate 10 mg po q day. 7. Lisinopril 40 mg po q day prn. 8. Heparin subQ 5000 units b.i.d. until fully functional. 9. Albuterol inhalers prn. 10. Percocet one to two tabs po q 4 to 6 hours prn pain. FOLLOW UP: 1. The patient is to follow up with Dr. [First Name8 (NamePattern2) 333] [Last Name (NamePattern1) ] in one to two weeks. 2. The patient is to follow up with her primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 48579] in one to two weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 6066] Dictated By:[Doctor Last Name 46822] MEDQUIST36 D: [2132-1-7] 09:18 T: [2132-1-7] 09:26 JOB#: [Job Number 38781]	[ "4280", "4241", "4019", "V4582" ]
Admission Date: [2163-3-29] Discharge Date: [2163-4-4] Date of Birth: [2142-4-11] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 10293] Chief Complaint: 20 year old male s/p unintentional APAP overdose. Major Surgical or Invasive Procedure: None History of Present Illness: 20 year old male transferred from [Hospital1 112] for liver transplant evaluation after percocet overdose. On Sunday [3-27] had a stressful day and pt took approximately 20 percocet (5/325) throughout the day after a series of family arguments. Denies trying to hurt himself. Parents confirm to suicidal attempts in the past. Pt felt that he had a hangover on Monday secondary to "percocet withdrawal" and took an additional 5 percocet. Pt was admitted to the SICU and followed by Liver, Transplant, Toxicology, and [Month/Year (2) ]. He was started on NAC q4hr with gradual decline in LFT's and INR. His recovery was c/b hypertension, for which he was started on clonidine. Pt was transferred to the floor on [4-1]. Past Medical History: Bipolar D/o (s/p suicide attempts in the past) ADHD S/p head injury [2160]: s/p MVA with large L3 transverse process fx, small right frontal epidural hemorrhage-- with post-traumatic seizures (was previously on dilantin, now dc'd) Social History: Father is HCP, student in [Name (NI) 108], Biology major, parents and brother live in [Name (NI) 86], single without children, lived in a group home for 3 years as a teenager, drinks alcohol 1 night a week, denies illict drug use, pt in [Location (un) 86] for neuro eval Family History: no liver disease Physical Exam: VS. 96, 154/90, 67, 20, 97%RA Gen. comfortable, appears combative at times, using swears words, then appreciative at other times Heent. MMM Chest. CTA ant Cor. RR, nl s1 s2 Abd. +BS, soft, slight tenderness to palpation, improved overall, no rebound or guarding. Ext. no edema Pertinent Results: [2163-3-29] 11:53PM BLOOD WBC-6.4 RBC-4.71 Hgb-14.0 Hct-41.6 MCV-88 MCH-29.8 MCHC-33.7 RDW-14.2 Plt Ct-50# [2163-3-29] 11:53PM BLOOD Plt Smr-VERY LOW Plt Ct-50# [2163-3-29] 11:53PM BLOOD PT-23.7* PTT-28.9 INR(PT)-3.6 [2163-3-29] 11:53PM BLOOD Glucose-125* UreaN-13 Creat-1.1 Na-137 K-4.7 Cl-98 HCO3-30* AnGap-14 [2163-3-30] 03:36AM BLOOD ALT-[Numeric Identifier 37727]* AST-9060* LD(LDH)-5544* AlkPhos-75 Amylase-49 TotBili-5.0* [2163-3-29] 11:53PM BLOOD Lipase-32 [2163-3-29] 11:53PM BLOOD Albumin-3.4 Calcium-8.0* Phos-1.0# Mg-1.5 [2163-3-30] 03:36AM BLOOD Hapto-275* [2163-3-30] 04:49PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV Ab-NEGATIVE [2163-3-30] 12:11PM BLOOD [Doctor First Name ]-NEGATIVE [2163-3-30] 04:49PM BLOOD HIV Ab-NEGATIVE [2163-3-30] 03:36AM BLOOD Phenyto-<0.6* Valproa-<3.0* [2163-3-29] 11:53PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2163-3-29] 11:53PM BLOOD HCV Ab-NEGATIVE [2163-3-30] 10:53AM BLOOD Type-[Last Name (un) ] pO2-45* pCO2-44 pH-7.44 calHCO3-31* Base XS-4 CT Abd: LLL PNA There is a confluent air space opacity within the left lower lobe consistent with pneumonia. The right lung is grossly clear. There are no pleural effusions. The liver, gallbladder, spleen, pancreas, adrenal glands, and right kidney appear grossly normal. There are at least two (2) tiny low attenuation foci arising from the left kidney which are too small to characterize further. Stomach and visualized loops of small and large bowel are unremarkable. No pathologically enlarged retroperitoneal or mesenteric lymph nodes are present. There is no free fluid. Head CT: There is no intracranial hemorrhage. C-spine CT: There is no evidence of fracture or dislocation. There are numerous cervical lymh nodes seen and thickening of the adenoidal/nasopharyngeal soft tissues. Clinical correlation recommended. Brief Hospital Course: [Known firstname 20069] [Known lastname 37728] ia a 20 yo male with h/o bipolar disease, ADHD, h/o seizures p/w acute hepatitis due to unintentional percocet overdose. Acute Hepatitis due to APAP overdose: He was initially admitted to the SICU where he was evaluated by the liver transplant team. Luckily, his ALT/AST trended down with 17 doses of N-Acetylcysteine from a peak of 22,000/14,00 respectively, and an INR peak of 6.6. With his improvement, he was transferred to the floor on [4-1], with continued improvement of his LFT's. An abd CT was not surprising, showing expected signs of inflammation around the liver. Pt's abdominal pain was improving on discharge. Hypertension: in setting of acute hepatitis. Pt was treated with clonidine in house with. Anticipate resolution with resolution of acute process. ?Bipolar Disease/ADHD: Followed by psychiatry in house. They recommend not medically treating his reported diagnoses given pt could not provide names of any psychiatrists, and the psychiatry team questioned the pt's diagnoses. Pt will follow up with outpatient psychiatry, and was given the number of a psychiatry practice near his home. LLL PNA: Likely due to aspiration while pt was acutely sick. Pt spiked to 101.9, with evidence of LLL PNA on abd CT. He was started on Levo/Flagyl [4-2] for 1 week. He remained comfortable on room air and afebrile. ? H/O Seizures d/t subdural hemorrhage in setting of CVA in [2160]: Pt reported being on dilantin and depakote for seizures/mood stabalization. However, I spoke with both his PCP and primary neurologist who have no record of him being on either medication, and no record of him ever having a seizure. Further, he had an EEG for headaches on [2163-4-22] that was normal. Pt's dilantin and depakote levels on admission were below assay. Pt was not place on either dilantin or depakote. He remained seizure free in house and head CT showed no evidence of subdural hematoma as present three years ago after his car accident. He will follow up with outpatient neurology. Drug seeking behavior: Pt was clearly pain med seeking, being verbally abusive to staff. His episode of falling off the toilet [4-2] was likely due to opioid overuse, with no subsequent evidence of trauma on exam or CT. With some struggle, we have negotiated switching him from IV to PO dilaudid. He will be d/c'd off dilaudid, with a few oxycodones for breaktrough pain. Comm: PCP [Name9 (PRE) ] [Name (NI) ] [Telephone/Fax (1) 8539], Neuro [Doctor Last Name 10653] [Telephone/Fax (1) 37729] in [Location (un) ]. Dispo: Pt was discharge home with PCP, [Name10 (NameIs) ], GI, and neuro followup plans. Medications on Admission: Per patient: Dilantin (for seizure prophylaxis) Depakote Dexedrine Percocet prn Wellbutrin Xanax Neurontin --doses unknown Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:5 Tablet(s) Refills:0 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 5 days. Disp:15 Tablet(s) Refills:0 3. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO every [5-4] hours for 3 days. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1. Acute Hepatitis d/t Tylenol Overdose 2. Hypertension 3. Drug seeking behavior 4. ?Bipolar Disease 5. LLL Pneumonia Discharge Condition: Pt was in good condition, afebrile, on room air, with stable vital signs. Discharge Instructions: Follow up with Dr. [Last Name (STitle) ] on Friday. Please call your other doctors at the [Name5 (PTitle) 37730] provided so that you may follow up with them. Do not take any medications with Tylenol, including Percocet, until directed otherwise by your doctor. Followup Instructions: See you primary care doctor, Dr. [First Name (STitle) ] [Name (STitle) ] [Telephone/Fax (1) 8539] (phone), on Friday at 1pm (appointment made). Call Dr.[Name (NI) 37731] office at [Telephone/Fax (1) 37732] for a follow up GI visit in 2 weeks. Call your neurologist, Dr. [Last Name (STitle) 10653] [Telephone/Fax (1) 37729], for an appointment next week. Call [Hospital 86] Health Care at [Telephone/Fax (1) 37733] for a follow up psychiatric appointment in 2 weeks.	[ "486", "4019" ]
Admission Date: [2156-6-16] Discharge Date: [2156-6-22] Date of Birth: [2092-9-8] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 10593] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 63 year old male with h/o severe COPD who is being transferred from [Hospital1 2177] after a prolonged admission for hypercapneic respiratory failure from COPD complicated by pneumothorax and bleb rupture. He is being transferred for consideration of intrabronchial valve. He was admitted to [Hospital1 2177] [2156-5-19] with hypercapneic respiratory failure felt to be due to COPD. He has known COPD and was reportedly not compliant with his medications and still smoking. At baseline he reportedly has DOE and cannot climb a flight of stairs and is dyspneic with shaving. He presented with productive cough and dyspnea. His DNR/DNI status was reversed in the ED at [Hospital1 2177] and he was intubated (initial ABG 7.13/96/234). CXR showed left basilar PTX and urgent chest tube was placed by CT surgery. CT chest showed large bulla in [1-12] of RLL of lung. He was extubated on HD2. Course complicated by extensive SC emphysema felt to be related to bleb rupture. A SC incision into the left chest wall ("blow hole") was done by CT surgery which resulted in slow improvement in his SC emphysema. He had persistent air leak and small left sided PTX was seen on daily films. Pleurodesis was performed [2156-6-2]. He continued to have persistent air leaks and 2nd chest tube was placed on [6-10]. He is on -40 wall suction on 1st chest tube, and -20 on 2nd chest tube. He is now being transferred for placement of intrabronchial valve by IP service. During his course at [Hospital1 2177], he completed a course of steroids and azithromycin for COPD exacerbation. On [6-15], he desatted to the 80's requiring non-rebreather with resolution of his symptoms. CXR showed RLL infiltrate and he was started on vanco/cefepime for HCAP, although f/u xray showed chronic changes and antibiotics were stopped. He also developed diffuse abdominal pain on [5-10] with emesis. CT showed SBO but he refused NG tube per the discharge summary (per the patient, he agreed and the team couldn't get it in and he refused to let them try again). He was made NPO and started on IV fluids. He passed flatus x 1 on [6-14] but has not yet had a bowel movement (last BM [6-9]). Cause of SBO was felt unclear. Vitals on transfer 97.7 80 (100s-110s when moves) 106/57 [12-24] 95%4L. Currently, he reports pain at the site of his chest tubes and pain in his epigastrium. Denies any SOB, but has productive, wet cough. States his breathing is okay as long as he has his "best friend," referring to his nasal cannula. Denies CP. States he is still passing flatus, but has not had BM. Cannot recall any of the events leading up to the hospitalization and is not sure why he was transferred here. He does know that he does not want anyone to attempt to place another NG tube. Denies recent fevers. Denies current nausea or vomiting. Past Medical History: Severe COPD, not on home O2 as still smoking Malnutrition/FTT Chronic hyponatremia H/o PTX in setting of PNA many years ago EtOH abuse, remote Possible h/o cirrhosis per patient Gastric ulcer H/o cleft palate surgery in youth with subsequent difficulty speaking Social History: Lived in [Location 686] in senior housing by himself prior to hospitalization. Smokes 1ppd, history of alcohol abuse but quit [2137], no IVDU. Worked in movie theaters and unloading trucks in past. Family History: Brother had CABG, father died of MI, mother died of old age. Physical Exam: Admission Physical Exam Vitals: 96.0 104/58 79 24 100%6L GENERAL: Pleasant, but very cachectic male in NAD. Has dysarthria that he reports is his baseline. HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. MMM. OP clear. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or gallops. LUNGS: Diminished breath sounds throughout L>R with coarse expiratory wheezing. Right base also with rhonchi. Two chest tubes in place. ABDOMEN: Diminished bowel sounds but present, soft and only mildly tender to palpation over epigastrium, not distended or tympanic. No HSM palpable. Has diffuse subcutaneous emphysema across abdomen EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. NEURO: A&Ox3. Appropriate. PSYCH: Listens and responds to questions appropriately, pleasant Discharge exam: Deceased Pertinent Results: Admission labs: [2156-6-17] 02:12AM BLOOD WBC-5.1 RBC-3.13* Hgb-10.2* Hct-31.6* MCV-101* MCH-32.6* MCHC-32.4 RDW-12.2 Plt Ct-212 [2156-6-17] 02:12AM BLOOD PT-12.6* PTT-27.4 INR(PT)-1.2* [2156-6-17] 02:12AM BLOOD Glucose-86 UreaN-5* Creat-0.4* Na-139 K-3.8 Cl-99 HCO3-36* AnGap-8 [2156-6-17] 02:12AM BLOOD Calcium-8.5 Phos-2.0* Mg-1.9 [2156-6-17] 02:12AM BLOOD ALT-9 AST-19 AlkPhos-55 TotBili-0.4 [2156-6-17] 08:03AM BLOOD Type-ART pO2-168* pCO2-72* pH-7.31* calTCO2-38* Base XS-7 Intubat-NOT INTUBA [2156-6-17] 08:03AM BLOOD Lactate-0.9 Discharge labs: Deceased Imaging: -CXR ([2156-6-17]): The lung volumes are increased. At the right apex, there are severe emphysematous and bullous parenchymal alterations. Identical lesions are seen in the lateral aspects of the left lung and at the bases of the right lung. At the bases of the right lung, a small pleural effusion is visible. On the left, two chest tubes are seen. According to the lateral radiograph, they appear to be correctly positioned. One of the tubes, however, has its sidehole very close to the chest wall and, as a consequence, could be advanced. The presence of a small basal pneumothorax cannot be excluded with certainty. There are extensive bilateral parenchymal opacities in the middle and lower lung zones. The multiple air bronchograms with irregular border suggest that these changes have a chronic component. The size of the cardiac silhouette is normal. Also normal are the hilar and mediastinal contours. Given that this is the admission radiograph and that the morphologic feature is complex, CT is recommended to obtain a better assessment of the complex morphology and a valid baseline for further followups. -CT head ([2156-6-19]): 1. Thin 2.5 mm subdural hematoma at the right frontal lobe without evidence of fracture or mass effect. 2. Left sphenoid bone lytic lesion. DDx includes hemangioma, fibrous dysplasia, but also metastasis or chondrosarcoma. Further workup with MRI might be considered. 3. Small amount of fluid in the left mastoid air cells. -Right shoulder plain film ([2156-6-19]): There are no signs for acute fractures or dislocations. There is normal osseous mineralization. There are mild degenerative changes of the glenohumeral joint. The visualized right lung apex is clear. -Pelvis ([2156-6-19]): Single view of the pelvis demonstrates no displaced fractures or dislocations. There are degenerative changes of the right hip with spurring in the superolateral acetabula. There are mild degenerative changes of the lower lumbar spine. The sacroiliac joints are within normal limits. There are vascular calcifications. Brief Hospital Course: MR. [Known lastname 106556] is a 63 yo M with endstage COPD who was admitted to [Hospital1 18] from [Hospital1 2177] for evaluation for a bronchial valve to help treat his bullous emphysema which had resulted in pneumothoraces whose goals of care were shifted to comfort measures only during this hospitalization, and he expired on [2156-6-22]. #Bullous Emphysema- The patient has long standing COPD, not on home o2, as he continued to smoke and it has been complicated by bleb rupture with pneumothoraces. On admission to the outside hospital he was in hypercarbic respiratory distress and required intubation (temporarily reversed his DNI status at that time). He was ultimately extubated and required bipap while there. He completed a course of antibiotics for COPD exacerbation at the OSH. Patient was transferred to [Hospital1 18] for further evaluation by interventional pulmonary. On admission here he was originally on 6L of NC and was stable. He acutely became tachypneic, dyspneic and complaining of not being able to breath and was transferred to the ICU. In the ICU he was placed on a shovel mask, received morphine and had an NG tube placed. His CXR showed bullae in the left and right lung. IP evaluated the patient and switched his Chest tubes to water seal on admission to the ICU and then pulled them on HD#3. Ultimately, IP felt there was no intervention that would be of benefit to the patient. He complained of multiple episodes of air hunger and was treated with escalating doses of morphine. He was transferred to the floor where his respiratory status continued to deteriorate. After discussion with the patient and his family/HCP, he was transitioned to [Name (NI) 3225] with inpatient hospice, as discussed below. He expired on [2156-6-22] with his family at the bedside. #Goals of care- the patient was originally DNR/DNI on admission to the outside hospital however on admission to their ED he changed this to DNR but okay to intubate. On admission to the ICU here, he expressed his wishes to be DNR/DNI and that he did not wish to have any further interventions and was looking for hospice. Palliative care was consulted and helped to arrange inpatient hospice. As his respiratory status continued to decline, he was made full [Date Range 3225] and was transitioned to inpatient hospice care. #Small bowel obstruction- The patient had a known SBO at the OSH and had refused NG tube placement there as well as on admission here. When he was transferred to the ICU he agreed to a NG tube placement and reported feeling better. There was audible air that came out of the NG tube on placement. The plan was to get a CT abd/pelvis to further evaluate however given that he was unable to lie flat this was not performed and was not pursued given his change in GOC. The patient pulled the NGT on HD3 while he was delirious and it was not replaced. #Fall abd subdural hemorrhage- Early on HD4, the patient tried to leave his room while he was delirious and had a fall with head strike. Her reported right shoulder and arm pain after the fall, no fracture on right shoulder plain film and no fracture on pelvic fx. Head CT showed a 2.5mm frontal subdural hematoma. He did not have any major apparent neurological sequelae of this subdural (pupils remained reactive and equal, moving all extremities) and no repeat imaging was obtained after his GOC were changed to [Date Range 3225]. Medications on Admission: 1000 mL NS Continuous at 75 ml/hr Albuterol 0.083% Neb Soln 1 NEB IH Q6H Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB/wheeze Acetaminophen 650 mg PO/NG Q6H:PRN pain, fever Famotidine 20 mg IV Q12H Heparin 5000 UNIT SC TID Ipratropium Bromide Neb 1 NEB IH Q6H Lidocaine 5% Patch 1 PTCH TD DAILY MethylPREDNISolone Sodium Succ 125 mg IV Q8H Morphine Sulfate 2-4 mg IV Q4H:PRN air hunger Hold for sedation Morphine Sulfate 4 mg IV ONCE Duration: 1 Doses Ondansetron 4-8 mg IV Q8H:PRN nausea Discharge Medications: Expired Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired	[ "2761", "3051" ]
Admission Date: [2184-1-29] Discharge Date: [2184-2-10] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1148] Chief Complaint: Found down Major Surgical or Invasive Procedure: intubation History of Present Illness: History was obtained from a friend who talks with her a few times a week, but the last time he saw her was 4 years ago (history was not obtained from her neighbor who found her), and also from ED records. . 84 F with unknown medical history, was found down tonight on her kitchen floor by her neighbor. [Name (NI) ] neighbor noticed that she had been SOB and panting over the past few days, and he kept telling her she had to go to a physician, [Name10 (NameIs) 6643] she refused. He was walking by her [Last Name (un) ] this afternoon and heard moaning. He unlocked the door to her [Last Name (un) ] and found her lying on the kitchen floor, no blood or apparent trauma. She states that she fell off the couch due to sudden weakness, no CP, no abd pain. +back pain due to position in bed. Neighbor called 911 and patient was brought to [Hospital1 18] ED. . In the ED, SBP was 60s, received 2L with BP still in 70s, received 2 more L with little SBP improvement. Sats started dropping to 85, so she was intubated for airway protection and had LIJ central line placed. Norepinephrine was started and SBP improved to 110s. T102 rectally. NGT put out 250 ml coffee ground fluid, received 1 U RBC. UO 230 ml after 4 L IVF. . UA was positive, CXR shows LLL infiltrate. WBC 21, Bands 5. Hct 35.5. Lactate 4.1. INR 1.9. CK 1677, MB 21, Trop 0.03. CT chest shows LLL infiltrate, aorta is mildly dilated but nonaneurysmal with no dissection, large goiter, RML centrilobular nodules suggestive of atypical Mycobacterial infection, large hiatal hernia with intrathoracic stomach. . At baseline, the patient is independent, lives alone, walks with a cane, pays a woman who does her shopping for her. Past Medical History: Goiter on R side of neck L hip replacement Hypertension Social History: Has no close relatives, is a private person. Never been married, has no children. Used to work at [Location 17448] in unknown job. Likes brandy before bed but unknown if has ETOH problem, doesn't smoke, no illicit drugs. Lives alone in [Last Name (un) ] [Location (un) ]. Has a siamese cat, Frank, for the last 10 years. Family History: Unknown Physical Exam: VS: 100.8 / 116/65 / 103 99% on AC 550 pulling in 600 / 15 breathing 7 over vent at RR 22 / 5 / 0.5 . GEN: Sedated, arousable to voice and holding hand, looks comfortable HEENT: JVD 7 cm, no LAD, intubated, PERRL. 6x6 cm goiter, soft and mobile in R central neck. LUNGS: Coarse breath sounds, clear anteriorly CHEST: Petechiae on upper chest, upper arms, in axillary areas bl HEART: 2/6 systolic flow murmur, no r/g ABD: Soft, +BS, surgical scar RUQ, ND, NT EXTR: No c/c/e, 2+ DP bl NEURO: Withdraws from painful stimuli SKIN: Petechiae as noted on chest/back Pertinent Results: CT chest: IMPRESSION: 1. Within the limitations of a non-IV contrast examination, the aorta is mildly dilated but non-aneurysmal with no secondary evidence of dissection. 2. There is a large goiter. Correlate with physical exam and thyroid biochemical profile. If indicated, consider thyroid ultrasound for further evaluation. 3. Likely small focus of evolving pneumonia or aspiration in the lateral basal segment of the left lower lobe. 4. Centrilobular nodules in the right middle lobe suggestive of atypical Mycobacterium infection (indolent and chronic). 5. Large hiatal hernia with resultant intrathoracic stomach. . CT C spine: FINDINGS: There is no fracture. There is exaggeration of the lordotic curvature otherwise no malalignment noted. There is disc space narrowing at C5-C6 and C6-C7 with small marginal osteophytes. The _____ osteophytes favor the right lateral recess resulting in bony neural foraminal encroachment. Endotracheal and nasogastric tubes are evident. There is a large heterogeneous thyroid, likely goiter. Otherwise, the prevertebral and other soft tissues of the neck are unremarkable. IMPRESSION: Degenerative disc disease as detailed above. No acute traumatic findings. . CXR: FINDINGS: There has been interval withdrawal of a left internal jugular central venous catheter with tip now in the left brachiocephalic vein. The remainder of the lines and tubes are in unchanged position. Again seen is a large hiatal hernia with an intrathoracic stomach. There is mild airspace opacity adjacent to the left heart border. The remainder of the examination remains unchanged. IMPRESSION: 1. Interval withdrawal of left internal jugular central venous catheter with 2. Mild airspace opacity adjacent to the left heart border. . [2184-1-30] Abdominal U/S: . [2184-1-30] CT abdomen/pelvia: [2184-1-29] 03:10PM PLT SMR-LOW PLT COUNT-92* [2184-1-29] 03:10PM NEUTS-94* BANDS-5 LYMPHS-1* MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2184-1-29] 03:10PM WBC-21.3* RBC-4.07* HGB-12.3 HCT-35.5* MCV-87 MCH-30.3 MCHC-34.8 RDW-15.6* [2184-1-29] 03:10PM ETHANOL-NEG [2184-1-29] 03:10PM CK-MB-21* MB INDX-1.3 [2184-1-29] 03:10PM cTropnT-0.03* [2184-1-29] 03:10PM CK(CPK)-1677* [2184-1-30] 12:25AM BLOOD CK-MB-32* MB Indx-0.9 cTropnT-0.05* [2184-1-30] 11:33AM BLOOD CK-MB-16* MB Indx-0.8 cTropnT-0.03* [2184-1-30] 12:25AM BLOOD ALT-65* AST-165* LD(LDH)-542* CK(CPK)-3747* AlkPhos-221* Amylase-33 TotBili-0.9 [2184-1-30] 06:09AM BLOOD CK(CPK)-2938* TotBili-0.6 [2184-1-30] 11:33AM BLOOD ALT-63* AST-139* CK(CPK)-1894* AlkPhos-132* TotBili-0.5 [2184-1-29] 03:10PM BLOOD Glucose-78 UreaN-47* Creat-2.3* Na-137 K-3.8 Cl-99 HCO3-19* AnGap-23* [2184-1-30] 06:09AM BLOOD FDP-[Telephone/Fax (1) 14007]* [2184-1-30] 11:33AM BLOOD Fibrino-353 D-Dimer-[Numeric Identifier 961]* [2184-1-30] 12:25AM BLOOD Fibrino-261 [2184-1-29] 05:10PM BLOOD PT-19.5* PTT-40.3* INR(PT)-1.9* [2184-1-30] 12:25AM BLOOD PT-16.9* PTT-35.7* INR(PT)-1.6* [2184-1-30] 11:33AM BLOOD PT-15.6* PTT-35.2* INR(PT)-1.4* . CT abdomen/pelvis IMPRESSION: 1. Left lower lobe consolidation, probably representing pneumonia. Small bilateral pleural effusions. 2. Very large hiatal hernia containing contrast. NG tube in place. 3. Stranding in the mesentery and perirenal spaces, consistent with history of recent percussive resuscitation. 4. Bilateral staghorn calculi. 5. Enlargement of left adrenal gland, which is not specific for adenoma as there is no definite mass. Dedicated imaging with adrenal CT or MRI is recommended for further evaluation. . ABDOMINAL ULTRASOUND: The gallbladder is unremarkable without evidence of stones or wall edema. The common bile duct is not dilated. The liver is coarsened in echotexture. There are multiple echogenic portal triads. There are no focal lesions. The portal vein is patent with appropriate directional flow. The right kidney measures 13.5 cm. The left kidney measures 12.6 cm. There are no stones or hydronephrosis bilaterally. The spleen and visualized portions of the pancreas are unremarkable Brief Hospital Course: 84 F found down, temperature of 102 and significant leukocytosis admitted with severe sepsis from GU source. . # Severe sepsis: Initially required levophed in order to maintain MAPs. There was question.- On Ceftriaxone and Azithro for CAP and UTI, Flagyl for possible aspiration pna, start [1-29]. No growth from cultures (urine or blood). Eventually found to have staghorn calculus in kidneys and believed most likely to be urinary source of infection. Later also question of aspiration pneumonia. Received 10 day course of flagyl and finishing 14 day course CAP/urinary antibiotic (one more day of levofloxacin). Initially had element of DIC as well, resolved. Patient transferred to floor with stable blood pressure. . # Respiratory insufficiency: Was intubated for airway protection after sats dropped to 85% after receiving 2 L NS. Hypoxemia may have been from element pulmonary fluid overload, although also treated for aspiration pneumonia. . # UTI: Urine cultures remained no growth but received broad spectrum coverage. Has staghorn calculi which puts her at increased risk of recurrence. Has follow up appointment with urology to address. . # Leukocytosis: Patient had wbc count peak at [Numeric Identifier 7670], down to [Numeric Identifier 20476] on day of discharge. Given flagyl empirically for c diff, although stools negative here. [Month (only) 116] have been all reactive to infection but will follow up with hematology as an outpatient. . # UGIB: Coffee ground fluid from NGT. Received 1 U RBC in ED. Has a large hiatal hernia with resultant intrathoracic stomach. [Month (only) 116] predispose to UGIB and gastritis. Cont PPI. H. pylori serology was negative. . # Goiter on R side of neck: TSH and rest of TFTs wnl in 12/[2183]. Mild airway involvement. Should get ultrasound as outpatient and endocrine follow up arranged. Repeat TFTs in 6 weeks. . # Adrenal gland: Enlargement of left adrenal gland, which is not specific for adenoma as there is no definite mass. Dedicated imaging with adrenal CT or MRI is recommended for further evaluation as an outpatient. . # Anxiety: Patient reports longstanding anxiety. Started on SSRI and given lorazepam prn, as well as trazodone to help with sleep. Reports some increased symptom control with combination. Should be reviewed in outpatient setting. . # Dispo: Patient deconditioned after MICU admission. Will be discharged to [Hospital 100] Rehab today for STR with plan for eventual discharge home. Medications on Admission: Given lorazepam previously by PCP. Discharge Medications: 1. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - [Location (un) 550] Discharge Diagnosis: Severe sepsis from urinary tract infection Staghorn calculi Leukocytosis, most likely from infection Acute renal failure (pre renal and infection) Goiter Gastritis Anxiety/Depression Discharge Condition: Good Discharge Instructions: Please take your medications as prescribed. You will need to follow up with multiple physicians after discharge. Please see the appointments below. You have been found to have a large stone in your kidneys that needs to be reevaluated by the urologists after discharge. You also have been found to have a goiter that needs to be followed up as an outpatient. Your primary care doctor (Dr. [First Name (STitle) ] will arrange this. Your white blood cell count got very high here. Most likely this was from infection and has now resolved, but you will need to follow up with hematology as an outpatient as well. Followup Instructions: Provider: [First Name11 (Name Pattern1) 2295] [Last Name (NamePattern4) 11222], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2184-2-18] 1:30 Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] HEMATOLOGY/ONCOLOGY-CC9 Date/Time:[2184-2-18] 1:30 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1239], [Name Initial (NameIs) ].O. Phone:[Telephone/Fax (1) 719] Date/Time:[2184-2-24] 11:30 (general medicine/geriatrics) Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 986] (urology) [2184-2-25] @ 10:15am phone:([Telephone/Fax (1) 93948]	[ "0389", "5990", "5849", "5070", "78552", "51881", "99592" ]
Admission Date: [2113-3-12] Discharge Date: [2113-3-19] Date of Birth: [2036-4-12] Sex: F Service: CARDIOTHORACIC Allergies: Amoxicillin / Tape / Lipitor Attending:[First Name3 (LF) 1505] Chief Complaint: Fatigue/Dyspnea on exertion Major Surgical or Invasive Procedure: [2113-3-14] Coronary artery bypass graft x 1, aortic valve replacement with [Street Address(2) 6158]. [Male First Name (un) 923] porcine valve [2113-3-14] Right axillary 8 mm Dacron conduit. History of Present Illness: 76 year old female with history of paroxysmal SVT including paroxysmal atrial fibrillation and flutter, high degree AVB s/p dual chamber pacemaker and coronary artery disease with prior LAD stenting who has been followed by serial echaocardiograms for worsening aortic insufficiency. Over the past year, she has noticed a significant decline in her exercise tolerance. She has gone from being able to walk 30minutes on a treadmill to now experiencing significant dyspnea climbing stairs or walking up a [Doctor Last Name ]. She underewent a cardiac catheterization in [2112-10-2] which revealed recurrent left anterior descending artery disease and mild right coronary artery disease. Given the progression of her symptoms and her worsening aortic insufficiency, she has been referred for surgical evaluation. Past Medical History: -history of paroxysmal SVT including paroxysmal atrial fibrillation/flutter (27% of the time, up from 14% on recent Holter) -Coronary Artery Disease s/p prior LAD stenting [6-2] -Hypertension -Hyperlipidemia -Hypothyroidism -glaucoma s/p laser therapy -Hx of Meniere's (not currently a problem) -Breast CA [2070] s/p left radical mastectomy and chest radiation with persistent left arm lymphedema and recurrent cellulitis in left arm -Tracheobronchomalacia (Mild) and Pulmonary nodules on right (mild) -moderate aortic stenosis and mitral regurgitation, moderate pulmonary hypertension -Anemia -Hiatal hernia -Glaucoma s/p laser therapy -Susceptible to pneumonia Past Surgical History: -s/p dual chamber pacemaker for high degree AVB [2104], generator change [10-10] -s/p left radical mastectomy [2070] with radiation -s/p thyroidectomy for benign thyroid nodule -s/p bilateral cataract surgery -s/p left eye [Last Name (un) ] surgery -s/p cataract surgery Social History: Lives in [Location ] alone, goes to [State 108] in the winter. -Tobacco history: Denies -ETOH: Denies -Illicit drugs: Denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Mother had heart surgery in her 80's. Physical Exam: Pulse: 70 Resp: 16 O2 sat: 100% B/P Right: 123/59 Left: - mastectomy side Height: 5'5" Weight: 161 lbs General: Well-devloped, well-nourished elderly female in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR, High picthed III/VI SEM radiating to left carotid Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema: Left arm lymph edema noted. No peripheral edema of LE's. Varicosities: some bilateral, GSV appeared suitable on previous exam in [Month (only) 956]. Neuro: Grossly intact [X] Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 PT [Name (NI) 167]:2 Left:2 Radial Right:2 Left:2 Carotid Bruit Transmitted vs bruit bilaterally Pertinent Results: [3-14] Echo: PRE-BYPASS: The left atrium is moderately dilated. Moderate to severe spontaneous echo contrast is seen in the body of the left atrium. No spontaneous echo contrast is seen in the body of the right atrium. A left-to-right shunt across the interatrial septum is seen at rest. A small secundum atrial septal defect is present. Left ventricular wall thicknesses and cavity size are normal. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Moderate to severe (3+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is moderate thickening of the mitral valve chordae. There is severe thickening of the mitral valve chordae. There is mild valvular mitral stenosis (area 1.5-2.0cm2). Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. POST CPB: 1. Preserved [Hospital1 ]-ventricular systolic function. 2. Bioprosthetic valve in aortc position. Well seated, stable and has good leaflet excursion. 3. No AI, Peak gradient = 18 mm Hg. 4. MR is now trace to mild. 5. Intact aorta and no other change. [2113-3-19] 05:25AM BLOOD WBC-6.7 RBC-3.13* Hgb-9.1* Hct-27.3* MCV-87 MCH-29.1 MCHC-33.4 RDW-15.4 Plt Ct-243 [2113-3-19] 05:25AM BLOOD PT-19.2* PTT-28.7 INR(PT)-1.8* [2113-3-18] 04:40AM BLOOD Plt Ct-187# [2113-3-19] 05:25AM BLOOD Plt Ct-243 [2113-3-18] 04:40AM BLOOD PT-17.2* INR(PT)-1.5* [2113-3-18] 04:40AM BLOOD Glucose-112* UreaN-15 Creat-0.7 Na-138 K-3.9 Cl-104 HCO3-27 AnGap-11 [2113-3-18] 04:40AM BLOOD WBC-7.7 RBC-3.16* Hgb-9.2* Hct-27.3* MCV-87 MCH-29.1 MCHC-33.6 RDW-15.5 Plt Ct-187# Brief Hospital Course: Ms. [Known lastname 50183] was admitted to the [Hospital1 18] on [2113-3-12] for surgical management of her cardiac disease. She was placed on heparin as she had been off Coumadin in preparation for surgery. She was worked-up in the usual preoperative manner. On [2113-3-14], she was taken to the operating room where she underwent right axillary artery cannulation with and aortic valve replacement and coronary artery bypass grafting to one vessel. Please see operative note for details. Postoperatively she was taken to the intensive care unit for monitoring. Over the next 24 hours, she awoke neurologically intact and was extubated. She was weaned from all vasoactive medications. The EP service interrogated her pacemaker without changing any settings. She was later transferred to the step down unit for further recovery. She was gently diuresed towards her preoperative weight. Chest tubes and pacing wires were removed per cardiac surgery protocol. Coumadin was resumed for her chronic atrial fibrillation and she is to have an INR drawn on [3-20] with results called to the [Hospital 197] Clinic. She was receiving her home dose of 3 mg po daily. The physical therapy service worked with her daily to increase strength and endurance. On post operative day 5 she was tolerating a full oral diet, ambulating without difficulty and her incisions were healing well. It was felt that she was safe for discharge home with visiting nurse services at this time. Medications on Admission: Coumadin 4mg Fridays and 3mg all other days ([Hospital 197] clinic with Dr. [Last Name (STitle) ]- LAST DOSE [2113-3-9] Proair HFA 90mcg 1-2puffs every 4 hours prn Cephalexin 2grams 1 hour prior to dental work and 1gram 6 hours after. Lasix 40mg daily Synthroid 112mcg daily Mastectomy bra Metoprolol succinate 100mg daily Ramipril 10mg daily Zocor 40mg daily Aspirin 81mg daily Calcium 500 + D 500mg (1250mg)-200U twice daily Systane eye drops Fibercon 625mg daily Discharge Medications: 1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 4. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:100 Tablet, Delayed Release (E.C.)(s) Refills:2 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. Disp:10 Tab Sust.Rel. Particle/Crystal(s) Refills:0 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever. 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 11. Ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:0 12. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:1 1 Refills:0 13. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:10 Tablet(s) Refills:0 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 15. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: Take as directed daily for INR goal 2.0-2.5. Disp:30 Tablet(s) Refills:0 16. Multivitamin with Iron-Mineral Tablet Sig: One (1) Tablet PO once a day: Take at a separtate time from Synthroid. Disp:30 Tablet(s) Refills:1 17. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed for constipation. Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass graft x 1 Aortic insufficiency s/p aortic valve replacement Past medical history: -history of paroxysmal SVT including paroxysmal atrial fibrillation/flutter (27% of the time, up from 14% on recent Holter) -Coronary Artery Disease s/p prior LAD stenting [6-2] -Hypertension -Hyperlipidemia -Hypothyroidism -glaucoma s/p laser therapy -Hx of Meniere's (not currently a problem) -Breast CA [2070] s/p left radical mastectomy and chest radiation with persistent left arm lymphedema and recurrent cellulitis in left arm -Tracheobronchomalacia (Mild) and Pulmonary nodules on right (mild) -moderate aortic stenosis and mitral regurgitation, moderate pulmonary hypertension -Anemia -Hiatal hernia -Glaucoma s/p laser therapy -Susceptible to pneumonia Past Surgical History: -s/p dual chamber pacemaker for high degree AVB [2104], generator change [10-10] -s/p left radical mastectomy [2070] with radiation -s/p thyroidectomy for benign thyroid nodule -s/p bilateral cataract surgery -s/p left eye [Last Name (un) ] surgery -s/p cataract surgery Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call to schedule appointments Surgeon Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Primary Care Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in [12-3] weeks ([Telephone/Fax (1) 1300] Cardiologist Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] in [12-3] weeks Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will schedule Coumadin management postop with Dr. [Last Name (STitle) ]. Goal INR 2.0-2.5. Please have blood drawn (INR) on [2113-3-20] with results called to [Hospital 197] Clinic. Completed by:[2113-3-19]	[ "4241", "41401", "V5861", "4168", "4019", "2724", "4240", "4280", "V4582" ]
Admission Date: [2143-5-28] Discharge Date: [2143-6-5] Date of Birth: [2071-2-1] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Doctor First Name 1402] Chief Complaint: "Cardiogenic Shock, CHF, Critical AS" Major Surgical or Invasive Procedure: Pulmonary Vein Isolation Thrombin injection of the left femoral pseudoaneurysm History of Present Illness: Mr. [Known lastname 37217] [Last Name (Titles) 1834] pulmonary vein isolation on [2143-4-11] due to increasing burden of atrial fibrillation. Afib and left sided atrial tachycardia were noted at the time of the study. During the ablation, the patient went into heart block. External pacing was without effect and he received CPR for several minutes without any drop in BP or saturation during the episode. He also reverted to atrial flutter with a SBP in the 80's during the procedure and was externally cardioverted with 100 J with reversion of sinus rhythm briefly. The procedure was terminated prior to completion of the procedure for the above reasons. He was transferred to the CCU over night for monitoring and eventually was discharged to home with a KOH monitor after uptitration of Amiodarone. After his discharge, he was evaluated in the holding area on [2143-4-15] for mild CHF that was felt to be due to his ablation and conversion to sinus rhythm. He was treated with increasing doses of Lasix. His Amiodarone dosing was also cut back. He was re-evaluated on [2143-4-25] for complaints of left groin pain with bruising. Ultrasound revealed a small hematoma but no vascular injury. Mr. [Known lastname 37217] reports that for the past several weeks he has been week his heart rate was noted to be in the 130's. He reports that there has been quite a bit of manipulation of his beta blocker dosing in the recent weeks, as he was bradycardic when in sinus and tachycardic when in fib. He is now being referred back for repeat PVI. Of note, the patient apparently slipped on the stairs on Saturday and hit both his face and his left leg. He reports that his head was minimally injured and that he did not have any type of hematoma. His leg on the other hand is bothering him quite a bit with significant discomfort in the left lateral thigh. His friend who is a doctor thinks that he most likely sprained the quadricep. He has discomfort with walking but other wise is doing all right. . He was taken to the OR to map fluter and re-isolate PV. He receive 100 of Fentanyl, 100 of Rocuronium, 5 of Neostigmine, 150 mcg of Propofol, 3.4 mg of Phenylephrine and 79.16 mL of Desflurane. He received 1200 cc of LR and put out 1600 cc urine. He had a successful a-tach ablation. post-proc he was hypotensive to 70's (dry and got a lot of lasix for high LAP). In PACU, briefly on dopa/neo, then on 5 of Dopa with sBP 150 at the time of sign out. A Stat echo: no effusion. Patient is bradycardic at baseline. . In the CCU, he is still on Dopa and c/o back pain. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension (Patient denies this as per pre-procedure interview dated [2143-4-9] but in old notes) 2. CARDIAC HISTORY: - Paroxysmal atrial fibrillation, on Amiodarone, Coumadin and Toprol s/p cardioversion x2 ([2141-3-31]) - Coronary Artery Disease - PERCUTANEOUS CORONARY INTERVENTIONS: Initial stenting done in [2131], clean cath in [2139], repeat cardiac catheterization in [Month (only) ] [2141] for chest discomfort in the setting of AFib, which demonstrated mild in-stent restenosis to 30% in the LAD stent. - PACING/ICD: None - CABG: None 3. OTHER PAST MEDICAL HISTORY: - GERD - Left hernia repair, excision of inclusion cyst from chest wall ([8-/2142]) - Ptosis surgery - Bilateral cataract surgery Social History: Married with 3 children and stays with wife. ADL independent. Works as a lawyer. - Tobacco history: Remote. - ETOH: One drink 5x/week. - Illicit drugs: None. Family History: Father (51), uncle (51) and grandfather (51) all had MIs at ages provided. Sister with DM, valve disease and heart failure at age 50. Otherwise, no family history of arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: CCU ADMISSION PHYSICAL EXAMINATION: GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NEURO: PERRL, EOMI. Facial asymmetry on inspection with decreased nasolabial fold and facial drooping on left. NECK: Supple with JVP of 3 cm. CARDIAC: PMI located in 6th intercostal space, 1cm lateral to the midclavicular line, thrusting in nature. Regular rhythm, normal S1, S2. No mrg. No thrills, lifts. No S3 or S4. No midline sternotomy scar. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp was unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ DISCHARGE PHYSICAL EXAM vitals: 97.8, HR 69-90, RR 16-18, BP 97-115/58-71 GEN: alert, oriented, NAD HEENT: supple, no JVD CV: irreg irreg rhythm. No M/R/G RESP: CTAB post ABD: soft, NT, ND, pos BS, pt is constipated EXT: Left groin area and thigh diffusely swollen with mild ecchymosis (resolving) and tenderness at the puncture site. Right groin with puncture site but no swelling or hematoma. Feet warm. pulses palp. Skin: diffuse macular rash on back, thought [1-2] hospital sheets, mildly itchy. Pertinent Results: Labs on admission: [2143-5-28] GLUCOSE-184* UREA N-22* CREAT-0.9 SODIUM-134 POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-25 ANION GAP-14 [2143-5-28] WBC-5.7 RBC-3.26* HGB-11.0* HCT-32.0* MCV-98 MCH-33.7* MCHC-34.4 RDW-13.9 [2143-5-28] PLT COUNT-265# [2143-5-28] PT-32.1* INR(PT)-3.2* Labs on discharge: [2143-6-5] WBC-7.3 RBC-2.65* Hgb-8.5* Hct-25.5* MCV-96 MCH-32.2* MCHC-33.5 RDW-15.0 Plt Ct-445* [2143-6-5] Glucose-183* UreaN-18 Creat-0.7 Na-133 K-4.5 Cl-98 HCO3-26 AnGap-14 [2143-6-4] Calcium-8.3* Phos-3.0 Mg-2.2 ECHO ([5-28]): The left atrium is moderately dilated. The left ventricular cavity size is normal. Overall left ventricular systolic function appears grossly preserved. Cannot exclude inferolateral hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. At least mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a trivial/physiologic pericardial effusion. ECHO ([5-30]): Compared with the findings of the prior study (images reviewed) of [2143-5-28], atrial fibrillation now present; left ventricular ejection fraction somewhat reduced. Renal ultrasound ([5-29]) - to evaluate cyst seen on prior MRI ([5-24]) Rim calcified benign-appearing right upper pole cyst. This should be followed for expected stability by repeat US in one year. CT chest/abdomen/pelvis with contrast ([5-30]) 1. Bilateral groin hematomas involving the obturator internus muscles, larger on the left. Closely associated with the right groin hematoma, is a 9-mm round focus of enhancement which may represent a pseudoaneurysm, possibly involving a branch of the superficial femoral artery. No definite active extravasation is seen. 2. Asymmetric enlargement of the left lower extremity with loss of normal fat planes could be due to fluid tracking into the thigh musculature. 3. Hyperdense right renal lesion with amorphous calcifications should be further evaluated with ultrasound. R. femoral ultrasound:([5-30]) 1.3 x 0.7 cm pseudoaneurysm arising from the right deep femoral artery. Results were discussed in person with the patient's nurse [First Name (Titles) 1023] [Last Name (Titles) ]d him to the ultrasound suite on [2143-5-30] at the time of the examination. (Please refer also to separately reported left groin ultrasound performed on the same date as regards a concurrent left sided pseudoaneurysm). L. femoral ultrasound ([5-30]) 1.4 x 2.3 cm pseudoaneurysm off a left common femoral artery branch. L. and R. femoral ultrasound ([6-2]) 1. Persistent left-sided pseudoaneurysm arising from a branch of the left common femoral artery. 2. Right groin pseudoaneurysm could not be demonstrated, though this could be partially technical. pseudoaneurysm injection([6-4]) 1. Successful treatment of a left inguinal pseudoaneurysm with 300 units of topical thrombin. Pseudoaneurysm appear to arise from a small branch of the profunda femoral artery. 2. No evidence of a pseudoaneurysm or AV fistula involving the right inguinal region. Brief Hospital Course: 72 yo M with hx of Afib and complaints of fatigue s/p pulmonary vein isolation ([4-10]) that was c/b transient CHB who re-presented for left aflutter mapping and PVI that was c/b hypotension requiring pressor support and bilateral hematomas with L. femoral pseudoaneurysm requring thrombin injection. . ACTIVE ISSUES: # Paroxysmal Atrial Fibrillation s/p Pulmonary vein isolation- Paroxsymal atrial fibrillation throughout hospital stay. Amiodarone was increased to 400 mg daily and Metoprolol increased to 150 mg daily. Warfarin was held in the setting of groin hematoma and drop in HCT. When HCT stabilized, pt was continued on home coumadin 5 mg for anticoagulation. INR should be checked on [6-7]. . # Bilateral groin hematomas: The evening of procedure, bilateral hematomas were present over groin site. Anticoagulation was stopped. HCT was 22 and pt was transfused with PRBC. CT chest/abd/pelvis showed evidence of bilateral hematomas with no evidence of retroperitoneal bleed. Bilateral groin ultrasounds were done which showed pseudoanerysm of L common femoral artery branch and a small pseudoaneurysm off R. deep femoral artery. Given that HCTs remained stable, he was restarted on his home dose of Warfarin. On [5-31] patient complained of increased pain in L. groin requiring morphine for pain control. Repeat ultrasound and HCT showed no change. Vascular was consulted and recommended pressure dressings and thrombin injection of L. pseudoaneurysm which was completed on [6-4] without complication. Given anterior thigh pain and difficulty with ambulation, PT determined that acute rehab would be beneficial upon discharge. . # Hypotension: Patient was initially admitted with hypotension which was likely multifactorial and related to hypovolemia and anesthesia given in pulmonary vein thrombosis. Has baseline SBP of 90's. Pt was given IV fluid boluses and dopamine for fluid support. He was blood and urine cultures were sent to rule out sepsis as cause of hypotenion in the setting of fever. Blood cx negative, urine cx with 3000 gram positive cocci (likely contaminant) and negative CXRs. The pt was successfully weaned off the dopamine drip within 24 hours. His blood pressures remained stable throughout admission. . # Coronary Artery Disease - Pt had one episode of chest pain on [5-30]. No EKG changes were seen. Enzymes showed troponin 0.62, MB 3. Elevated troponin is related to recent pulmonary vein isolation proceedure and not acute myocardial infarction. Enzymes trended down. Patient was continued on ASA 81 daily, Plavix 75 rousouvastatin, and nitro as needed for chest pain. . CHRONIC ISSUES: . # HTN: Pt was hypotensive upon admission to the CCU and home antihypertensives were held. As pressures stabilized, he was started on metoprolol and titrated up to dose of 150 mg daily. . # DM: Held pioglitazone, metformin and glucophage while inpatient and blood sugars covered with humalog sliding scale. PO medications were restarted at discharge. . # DYSLIPIDEMIA: - Continued Rosuvastatin . # GERD: - Continued Omeprazole . TRANSITIONAL ISSUES: Pt has significant deconditioning that necessitates acute rehab. His L groin pseudoaneurym is s/p thrombin injection. Will need to follow serial exams. No restriction on activity. Pt will f/u with vascular as an outpatient. For his A fib, his INR should be checked on [6-7], along with CBC and Chem 7. His metoprolol will need to be titrated to HR 70-80s. Medications on Admission: AMIODARONE - 200 mg Tablet qd FUROSEMIDE - 40 mg Tablet qd LISINOPRIL - 10 mg Tablet qHS LORAZEPAM - 2 mg Tablet - Tablet(s) by mouth q hs METFORMIN - 1,000 mg Tablet [Hospital1 ] METOPROLOL SUCCINATE - 25 mg qd OMEPRAZOLE - 20 mg Capsule [Hospital1 ] PIOGLITAZONE [ACTOS] 30 mg Tablet ROSUVASTATIN [CRESTOR] - 10 mg qam SILDENAFIL [VIAGRA] - 50 mg prn WARFARIN - 5 mg Tablet - 1-1.5 Tablet ASPIRIN - 162 mg qpm Discharge Medications: 1. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. lorazepam 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for anxiety/insomnia. 4. metformin 1,000 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 6. pioglitazone 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: on six days a week, then 7.5 mg on Wednesdays. 9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. Outpatient Lab Work Please check INR, chem 7 and CBC on Friday [2143-6-7] 11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily). 12. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): hold for diarrhea. 13. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. 14. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three times a day. 15. oxycodone 5 mg Capsule Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 16. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO once a day. 17. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] [Hospital 1108] Rehab Unit at [Hospital6 1109] - [Location (un) 1110] Discharge Diagnosis: primary diagnoses: Atrial fibrillation status post pulmonary vein isolation hypotension groin hematoma femoral artery pseudoaneurysm secondary diagnoses: hypertension type 2 diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 37217], It was a pleasure caring for you while you were in the hospital. You were admitted after your pulmonary vein isolation procedure because your blood pressures were low requiring medication support. Your blood pressures improved. You also developed bilateral hematomas (blood collections) in your groin. You had ultrasounds showing pseudoaneurysms on the left and a thrombin injection was done to fix this issue. Right now you are in atrial fibrillation but we hope that you will convert to a normal rhythm soon. We have made the following changes to your medication regimen: 1. Increase the amiodarone to 400 mg daily 2. Increase the metoprolol to 150 mg daily 3. Increase aspirin to 325 mg daily 4. Start tylenol three times a day to treat your left leg pain 5. Start oxycodone as needed to treat left leg pain 6. Start Miralax, senna and dulcolax as needed to treat constipation Followup Instructions: Departent: Cardiology When: Wednesday [6-12] at 10:30am with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] NP[MD Number(3) ]: [Hospital Ward Name 23] 7, Clnical Center, [Hospital Ward Name 516] . Department: VASCULAR SURGERY When: TUESDAY [2143-6-18] at 1:30 PM With: VASCULAR LAB [Telephone/Fax (1) 1237] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: VASCULAR SURGERY When: TUESDAY [2143-6-18] at 2:30 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1244], MD [Telephone/Fax (1) 1237] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2143-6-6]	[ "42731", "25000", "V4582", "4019", "2724", "2859", "V5861" ]
Admission Date: [2156-9-15] Discharge Date: [2156-9-25] Date of Birth: [2091-11-24] Sex: M Service: CARDTHOR SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 64 year old white male with a history of hypertension, hyperlipidemia, chronic obstructive pulmonary disease and diabetes mellitus who presented to an outside hospital on the day prior to admission with chest pain and EKG changes. He reportedly had chest pain on and off for the previous two weeks. He recently underwent a stress echocardiogram without ischemic changes, but which showed aortic stenosis. His pain increased one to two days prior to admission with associated gastrointestinal symptoms. In the Emergency Room at the outside hospital, his EKG showed 1 to [Street Address(2) 2915] depressions in leads I and V2 through V6, AVL and ST elevations in leads III and AVF. His troponin on admission to that hospital was 0.3 with a CK of 98. PAST MEDICAL HISTORY: 1. Hypertension. 2. Asthma. 3. Chronic obstructive pulmonary disease. 4. Diabetes mellitus type 2. 5. Elevated cholesterol. 6. Rosacea. 7. Status post a left carotid endarterectomy in [2155-11-19]. 8. Colitis. 9. Diverticulitis. 10. Positive for transient ischemic attack with no residual. 11. Question of nonsustaining ventricular tachycardia on Holter Monitor. SOCIAL HISTORY: He is a retired fire fighter. He lives with his wife. [Name (NI) ] is a remote smoker, having smoked with a 40 pack year history. ALLERGIES: He has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Serevent two puffs twice a day. 2. Pulmicort three puffs twice a day. 3. Norvasc 5 mg q. day. 4. Enteric-coated aspirin 325 mg q. day. 5. Asacol 800 mg three times a day. 6. Zantac 150 mg twice a day. 7. Lipitor 10 mg twice a day. 8. Folate 1 mg q. day. 9. Minocycline 50 mg twice a day. REVIEW OF SYSTEMS: His review of systems shows he has positive weight loss which was intended; he had been dieting. He has no palpitations, no syncope. He states that he has easy bleeding. He currently has an upper respiratory infection which is resolving. His dental situation is that he had seen his dentist over the summer; he has broken teeth on the right but no treatment was undertaken. He has basal cell carcinoma of his legs, arm and head that have been resected. Positive osteoarthritis; positive dyspnea on exertion from his chronic obstructive pulmonary disease. He does have a history of rectal bleeding, of hemorrhoids. PHYSICAL EXAMINATION: His physical examination shows his heart rate to be 58 and in sinus rhythm; blood pressure 154/77; respiratory rate is 14 with an O2 saturation of 99% on three liters of nasal cannula. He is in general a pleasant male who is awake and alert and lying on the stretcher in no apparent distress. His lungs have an increased A/P diameter. His breath sounds are clear but diminished bilaterally; there is no wheezing or rhonchi. His heart is regular rate and rhythm without rub. There is a positive III/VI harsh systolic murmur. His abdomen is positive bowel sounds, soft, nontender, nondistended. Liver is palpable to 2 centimeters below the costal margin. There are no masses and no splenomegaly, no bruit. Extremities: Show bilateral lower extremity edema with stasis changes, left anterior shin dark. He has no edema and no evidence of varicosities. He has no clubbing or cyanosis. The skin examination shows multiple well healed surgical scars. His neurological examination shows strength to be equal on bilateral upper and lower extremities. His pulse examination shows his carotids to be without bruit on the right and with a bruit on the left. His radial artery pulses are two plus bilaterally; femoral arteries are two plus bilaterally; popliteal pulses are one plus bilaterally and dorsalis pedis and posterior tibialis are two plus bilaterally. LABORATORY: White blood cell count of 8.4, hematocrit of 36.6, platelet count 228,000. Sodium 137, potassium 3.8, chloride 104, carbon dioxide 27, BUN 17, creatinine 0.8 and a blood glucose of 113. His liver enzymes were all within normal limits. HOSPITAL COURSE: On [2156-9-16], the patient underwent a cardiac catheterization which showed an ejection fraction of 60%; no mitral regurgitation. His left main coronary artery was short with moderate calcifications; left anterior descending artery has proximal moderate calcifications with a 70% tubular lesion at the ostium. The first diagonal has a 90% lesion at the origin; left circumflex has a 70% lesion at the origin and 90% lesion at the bifurcation of the obtuse marginal 1. The distal left patent ductus arteriosus with competitive flow. His right coronary artery is co-dominant with an 80% lesion at the origin. A consultation was then put in to Cardiac Surgery for a possible coronary artery bypass graft and a question of an aortic valve replacement. On [2156-9-17], the patient underwent coronary artery bypass graft times four with left internal mammary artery to left anterior descending artery; saphenous vein graft to left patent ductus arteriosus; saphenous vein graft to the right patent ductus arteriosus and a saphenous vein graft to the obtuse marginal. He also had an aortic valve replacement with a #23 millimeter pericardial DE valve. This surgery was performed under general endotracheal anesthesia with cardiopulmonary bypass time of 174 minutes and a cross clamp time of 140 minutes. The surgery was performed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 70] with [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 54443] and [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], PA-C and [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], N.P. as assistants. The patient tolerated the procedure well and was transferred to the Surgical Cardiac Recovery Unit with atrial pacing wires, two ventricular pacing wires, two mediastinal and one left pleural chest tube. He was on a Neo-Synephrine drip and a Propofol drip and paced at 74 beats per minute. Intraoperatively, the patient had been coagulopathic and had received 4 units of packed red blood cells and 6 units of fresh frozen plasma, two units of platelets and protamine. When he arrived in the Intensive Care Unit, he did receive more fresh frozen plasma to help control bleeding. By the morning of postoperative day number one, he was awake, but agitated. His ventilator was weaned to extubate. He was extubated on postoperative day number one, but throughout the day continued to have increasing secretions and was re-intubated. He subsequently underwent bronchoscopy at the bedside on postoperative day number two, where it was noted that he had thick secretions in both the right and left main stem bronchi. He was then kept intubated for the following couple of days, again bronched for copious secretions. On postoperative day number four, he was extubated without incident. During this time that he was intubated, his chest tubes were discontinued without incident. On postoperative day number five, he remained in the unit and had intermittent periods of confusion and delirium. He did remain this way until the following day, but he was thought to be ready for discharge to the floor. He was transferred to the Surgical Floor on postoperative day number six, and continued to be pleasantly confused. He did have a Code Purple called on postoperative day number six in the evening as the patient attempted to leave the floor. He was then started on Haldol and was more cooperative by the morning. Throughout this time, he continued to work with Physical Therapy and by postoperative day number seven, they felt that he could be cleared for discharge to home. By postoperative day number seven, his confusion was present at times and he still does have hallucinations but he has been stable and it is felt that he will be ready to be discharged to home on postoperative day number eight. PHYSICAL EXAMINATION: His discharge examination shows his vital signs to be stable with a heart rate of 71, blood pressure of 138/71; respiratory rate 20; O2 saturation of 99% on room air. His lungs were clear to auscultation bilaterally. His heart was regular rate and rhythm. He has positive bowel sounds, soft, nontender, nondistended. His extremities show one plus pitting edema bilaterally. His incision was clean, dry and intact; sternum is stable. LABORATORY: On discharge is white blood cell count of 7.3, hematocrit of 26.7, platelet count of 346,000. Sodium of 139, potassium 3.8, chloride 103, carbon dioxide 26, BUN 29, creatinine 1.1 and blood glucose of 81. DISCHARGE MEDICATIONS: 1. Lipitor 10 mg p.o. q. day. 2. Protonix 40 mg p.o. q. day. 3. Lopressor 25 mg p.o. twice a day. 4. Lasix 40 mg p.o. twice a day. 5. [First Name5 (NamePattern1) 233] [Last Name (NamePattern1) 1002] 20 mEq p.o. twice a day. 6. Enteric-coated aspirin 325 mg p.o. q. day. 7. Albuterol MDI two puffs q. four hours p.r.n. 8. Advair two puffs twice a day. 9. Asacol 800 mg p.o. three times a day. 10. Minocycline 50 mg p.o. twice a day. DISCHARGE INSTRUCTIONS: 1. He is to follow-up with Dr. [First Name (STitle) ] in one to two weeks. 2. He is to follow-up with Dr. [First Name (STitle) ] in two to four weeks. 3. He is to follow-up with Dr. [Last Name (STitle) 70] in six weeks. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], P.A.-C. MEDQUIST36 D: [2156-9-24] 16:37 T: [2156-9-24] 17:44 JOB#: [Job Number 54444]	[ "41401", "4241", "496", "25000", "4019", "2724" ]
Admission Date: [2166-11-8] Discharge Date: [2166-11-12] Date of Birth: [2091-11-12] Sex: F Service: MEDICINE Allergies: Keflex / Augmentin / Amoxicillin Attending:[First Name3 (LF) 348] Chief Complaint: Respiratory Distress Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 74 yo F with PMH of DM, COPD, and hx of foot osteo s/p multiple debridements and surgeries admitted with respiratory distress. The pt was found at home today in bed in respiratory distress by her family. EMS was called and she was found to have a O2 sat 60% and appeared to be cyanotic. She was given sl NTG and nebulizer and started on Bipap in the field. On arrival to [Hospital1 18] ED Vitals T 102.2 HR 114 BP 156/60 RR 24 100% 40 FIO2. ECG with sinus tachycardia. CXR negative for evidence of PNA. She was started on Vancomycin and Levofloxacin for fever and was given solu-medrol 125 X1. . On arrival to the MICU, the patient was in no acute distress. Answering questions appropriately. She denies shortness of breath or chest pain. She was alert and oriented to place and time. Her family reports that she has increased her tobacco usage over the past week secondary to R hip pain. She was found by her husband and daughter to be gagging, with minimal respiratory effort and appeared to have a blue-tinged color. Past Medical History: COPD/Asthma Hypertension Diabetes Type II Peripheral neuropathy History of MRSA osteomyelitis right foot MRSA bacteremia [6-18] . [Doctor First Name ]: Bilateral cataracts, debridement of right foot osteomyelitis x3 Social History: Lives with husband, smokes 2 ppd x 50 years, has recently been under stress and admits to increasing her smoking to 3 ppd. Occ ETOH, lives in [Location 686]. Family History: Noncontributory. Physical Exam: ADMISSION EXAM: VS: T:98.7 R:18 Sat:95% on Bipap 10/8 BP:162/59 HR:89 GEN: NAD, well nourished HEENT: PERRLA, NCAT Neck: no LAD CV: s1/s2 no murmur, pulses present PULM: wheezes and rhonchi throughout ABD: soft NTND BS + EXT: no edema, TTP of R hip bursal sac, no pain on ROM Pertinent Results: ADMISSION LABS: . BLOOD: [2166-11-8] 04:07PM GLUCOSE-284* UREA N-30* CREAT-1.3* SODIUM-136 POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-29 ANION GAP-15 [2166-11-8] 04:07PM CALCIUM-9.0 PHOSPHATE-4.2 MAGNESIUM-1.7 [2166-11-8] 04:07PM WBC-12.9* RBC-4.91 HGB-15.1 HCT-44.7 MCV-91 MCH-30.7 MCHC-33.8 RDW-13.5 [2166-11-8] 04:07PM PLT COUNT-219 [2166-11-8] 01:11PM cTropnT-0.03* [2166-11-8] 01:11PM CK-MB-9 [2166-11-8] 01:11PM CK(CPK)-120 . URINE: [2166-11-8] 01:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500 GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2166-11-8] 01:30PM URINE RBC-[4-16]* WBC-[7-22]* BACTERIA-MANY YEAST-NONE EPI-0 . . DISCHARGE LABS: CBC:13.3/15.5/45.1/287 Chem 7: 142/3.7/102/30/54/1.2/123 IMAGING: PROCEDURE: CTA chest with and without contrast on [2166-11-10]. . COMPARISON: [2165-6-3]. . TECHNIQUE: Pre- and post-contrast examination of the thorax with contiguous axial images from the thoracic inlet to the subdiaphragmatic area, coupled with sagittal/oblique and coronal reformatted images. . HISTORY: 74-year-old woman with hypoxemia and tachycardia, please evaluate for PE. . FINDINGS: . The pulmonary arteries are well visualized up to the first segmental level showing no PE. Beyond that the opacification is faint and so no peripheral PE can be excluded. The aorta is unremarkable in size, showing no evidence of dissection or aneurysmal dilatation. . Stable coronary calcifications are again seen. The heart size is within normal limits. Mitral annular valve calcification is stable. There is no pleural or pericardial effusion. . The lungs have relatively cleared as previously there was diffuse tree-in-[Male First Name (un) 239] nodularity, indicative of an infectious process. However, there are persistent prominent lymph nodes in the mediastinum and hilar areas stable to slightly increased in size on today's examination. For example, the subcarinal lymph node which is 9.3 mm is stable in size while the 5.4-mm left prevascular lymph node was previously 4.6 mm in size. . Mitral annular valve calcification is stable. . New minimal bibasilar atelectasis is seen in both lung fields. . The bony structures do not show any lesion suspicious for malignancy, however, there are significant disc osteophyte complexes seen at multiple thoracic vertebral body levels better appreciated in the sagittal reformatted images. . In the abdomen, stable subcentimeter right adrenal adenoma is noted. No other abnormalities are seen. . IMPRESSION: 1. Negative examination for PE in the major and first segmental branches. 2. Almost complete resolution of the infectious process seen in both lungs. 3. Persistent but slightly increased bilateral lymphadenopathy. 4. Stable pulmonary artery calcifications. 5. Stable right adrenal adenoma. . . CHEST XRAY [2166-11-9]: HISTORY: 74-year-old female with shortness of breath. . COMPARISON: None available. . PORTABLE UPRIGHT CHEST RADIOGRAPH: The heart size is normal and the aortic contour mildly unfolded. The lungs are well expanded, and note is made of patchy infiltrate in the left lung base. No evidence of pneumothorax or large pleural effusion is seen. Degenerative changes are noted along the visualized thoracic spine. . IMPRESSION: Patchy infiltrate in the left lung base could be consistent with pneumonia. Brief Hospital Course: Pt is a 74 yo F with PMH of DM, COPD, and hx of foot osteo admitted with respiratory distress, found to have UTI and question of lingular PNA. Initially managed in MICU with non-invasive ventilation support, steroids, and antitbiotics and transferred to the floor once no longer requiring ventilation support. On floor patient was continued on po steroids and antibiotics for UTI and concern for lingular PNA. Patient continued to require oxygen therapy and was discharged to rehab in stable condition with O2, steroid taper and antibiotics. Patient was also counseled for smoking cessation. . RESPIRATORY FAILURE: Pt found by EMS with 02 sat 60% at home, improved with initiation of CPAP. Patient initially managed in MICU and then on floor with po steroids and antibiotics. She continued to require oxygen, which was a change from her home status so there was a concern for PE. CTA was done and showed no central PE. Her lung exam improved as did her symptoms however she continued to need oxygen and it was determiend she needed home O2 and was discharge on it. . FEVER: Febrile on initial presentation with a negative workup. No clear infiltrate on CXR though concern for lingular PNA and was treated with 7 day course of po levofloxacin. . UTI: Found on screening UA, pan-sensitive E. coli, treated with 7 day course of levofloxacin. . DIABETES: Continue home regimen of 70/30 28U QAM and 32 U QPM. Fingersticks elevated with start of steroids, managed with SSI. . RIGHT HIP PAIN: On admission, pt with point tenderness over R hip bursa on exam, no pain on ROM of hip. Managed with home dose of Ultram. . PERIPHERAL NEUROPATHY: Continued home gabapentin. . CODE STATUS: FULL per patient. Medications on Admission: ALBUTEROL - 90 mcg Aerosol PRN CITALOPRAM - 10 mg Tablet - daily FEXOFENADINE - 60mg daily FLUTICASONE-SALMETEROL 250 mcg-50 mcg/Dose daily GABAPENTIN - 300 mg Capsule QHS HYDROCHLOROTHIAZIDE - 12.5 mg daily METOPROLOL SUCCINATE [TOPROL XL] - 100 mg Tablet daily SIMVASTATIN - 40 mg Tablet QHS ASPIRIN - 81 mg Tablet daily Ultram INSULIN NPH & REGULAR HUMAN [HUMULIN 70/30] - 100 unit/mL (70-30) Suspension - 28 units QAM, 32 units QPM twice a day Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: Two (2) puffs Inhalation Q6H (every 6 hours). 2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every four (4) hours: can do nebs instead if needed. 3. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day: hold for sbp < 100. 9. Calcium 500 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day: hold for sbp < 95 or HR < 55. 11. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every other day for 1 doses: last dose due [2166-11-14]. 12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day: hold for sbp < 100. 13. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 14. Ultram 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): stop when patient is ambulatory. 16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 18. Prednisone 10 mg Tablet Sig: variable Tablet PO once a day: see instructions and calendar. 19. insulin insulin 70/30, 28 units every morning and 32 units every evening with dinner plus attached sliding scale 20. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) patch Transdermal every twenty-four(24) hours. 21. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for constipation. 22. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital3 2732] & Retirement Home - [Location (un) 55] Discharge Diagnosis: Primary: Chronic Obstructive Pulmonary Disease, acute exacerbation Secondary: Asthma Hypertension Diabetes, type 2 Discharge Condition: Stable. Discharge Instructions: You were admitted to the hospital for respiratory distress and low oxygen. Upon admission, you first went to the Medical Intensive Care Unit where antibiotics and steroids were started. Once stabilzed, you were transferred to the medical floor. A CT Angiogram was performed and showed no evidence of pulmonary embolism. A urinalysis showed a urinary tract infection which will be covered with your current antibiotic. Physical therapy was consulted for support and logistics regarding outpatient disposition. . Please continue taking the antibiotic as prescribed. . Follow-up with Dr. [Last Name (STitle) 6680] as outpatient for COPD/Asthma. . Resume your home medication regimen, but please note the following important changes: * METOPROLOL (TOPROL XL) increased to 150 mg daily. * AMLODIPINE started due to high blood pressure. * HCTZ increased due to high blood pressure. * Started PREDNISONE taper per attached calendar for COPD flare. Briefly, Prednisone 50 mg daily for 2 days, 40 mg daily for 2 days, 30 mg daily for 2 days, 20 mg daily for 2 days, 10 mg daily for 2 days, then stop. * Start CALCIUM and VITAMIN D for protection of the bones. * You will need one more dose of LEVOFLOXACIN (which you will get on Friday) for treatment of pneumonia and urinary tract infection. . Please contact your doctor or return to the Emergency Department if you develop fevers (>101.5), shaking chills, difficulty breathing, shortness of breath, or pain on urination. . PLEASE STOP SMOKING, as we have discussed. This is the most important thing you can do for your overall health! Followup Instructions: Please follow-up with your primary care physican, Dr. [Last Name (STitle) 6680], on Friday, [11-28] at 11:10am. Provider: [First Name11 (Name Pattern1) 354] [Last Name (NamePattern4) 3013], M.D. Phone:[Telephone/Fax (1) 253] Date/Time:[2167-2-17] 1:00 Provider: [Name10 (NameIs) 6800] CLINIC Phone:[Telephone/Fax (1) 253] Date/Time:[2167-2-17] 1:00	[ "5990", "25000", "4019" ]
Admission Date: [2133-1-19] Discharge Date: [2133-1-25] Date of Birth: [2057-8-2] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) / Bactrim Attending:[First Name3 (LF) 1505] Chief Complaint: chest/back heaviness- Major Surgical or Invasive Procedure: [2133-1-20] 1.Coronary artery bypass graft x 3 Left internal mammary artery grafted to left anterior descending artery, Saphenous vein grafted to Obtuse Marginal, Saphenous vein grafted to posterior descending artery. 2.Primary sternal repair using Synthes plating system times 5. History of Present Illness: 75F who has c/o chest/back heaviness times several months. Persantine Stress Test was abnormal and she was referred for cardiac catheterization. This revealed two vessel coronary artery disease. Admitted pre-operatively for heparin drip before high risk CABG. Past Medical History: coronary artery disease s/p coronary bypass grafting Secondary: Chronic atrial fibrillation on Coumadin, diagnosed [2123] stable primary biliary cirrhosis Type II diabetes Hypothyroidism Polymyalgia rheumatica diagnosed [3-31], On Prednisone Hypercholesterolemia Osteoarthritis Vulvar cancer [2129] s/p vulvectomy at [Hospital1 2025] (no chemo or radiation) Urinary incontinence s/p vulvectomy nephrolithiasis chronic lower extremity edema r/t lymphedema urosepsis arthritis left knee- needs replacement Past Surgical History: right hip replacement [2130] right knee replacement [2130] Back surgery x 4 Appendectomy Tonsillectomy Social History: Race: Caucasian Last Dental Exam: edentulous Lives with: husband Occupation: retired director of nursing at [Hospital1 18] Tobacco: quit 35yrs ago ETOH: 1 drink/day Family History: sister died last year at age 71. S/P CABG at age 39, repeat age 49, peripheral bypass. Father had an MI at age 50, died at age 76 from ruptured AAA Physical Exam: Pulse: 69 a-fib Resp: 16 O2 sat: B/P Right: 130/54 Left: Height: 5'[31]" Weight: 310lb General: NAD, obese female Skin: Dry [x] intact [x] HEENT: PERRLA [] EOMI [x] pupils fixed (bilat. cataracts) Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x- chronic afib] Murmur Abdomen: Obese, Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: 2+ pitting edema Varicosities: moderate varicosities and spider veins Neuro: Grossly intact x Pulses: Femoral Right: 2+ Left: 2+ DP Right: doppler Left: doppler PT [Name (NI) 167]: doppler Left: doppler Radial Right: 2+ Left: 2+ Carotid Bruit NO bruits Pertinent Results: Pre-op labs [2133-1-19] 07:16PM PT-14.3* PTT-23.1 INR(PT)-1.2* [2133-1-19] 07:16PM PLT COUNT-184 [2133-1-19] 07:16PM WBC-7.7 RBC-3.82* HGB-11.2* HCT-34.1* MCV-89 MCH-29.5 MCHC-33.0 RDW-14.3 [2133-1-19] 07:16PM %HbA1c-6.9* eAG-151* [2133-1-19] 07:16PM ALBUMIN-3.8 MAGNESIUM-2.0 [2133-1-19] 07:16PM LIPASE-25 [2133-1-19] 07:16PM ALT(SGPT)-11 AST(SGOT)-17 LD(LDH)-199 ALK PHOS-103 AMYLASE-50 TOT BILI-0.3 [2133-1-19] 07:16PM GLUCOSE-253* UREA N-26* CREAT-1.1 SODIUM-139 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-27 ANION GAP-13 [2133-1-19] 09:54PM URINE RBC-1 WBC-63* BACTERIA-FEW YEAST-NONE EPI-5 [2133-1-19] 09:54PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-150 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD [2133-1-19] 09:54PM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.014 Discharge labs: [2133-1-23] 04:22AM BLOOD WBC-7.3 RBC-3.03* Hgb-9.2* Hct-27.3* MCV-90 MCH-30.5 MCHC-33.8 RDW-15.5 Plt Ct-107* [2133-1-23] 04:22AM BLOOD Plt Ct-107* [2133-1-23] 04:22AM BLOOD PT-14.3* INR(PT)-1.2* [2133-1-23] 04:22AM BLOOD Glucose-167* UreaN-31* Creat-1.7* Na-139 K-4.8 Cl-104 HCO3-28 AnGap-12 [2133-1-23] 04:22AM BLOOD Mg-2.3 [2133-1-22] 01:59AM BLOOD WBC-11.9* RBC-2.82* Hgb-8.6* Hct-24.9* MCV-88 MCH-30.7 MCHC-34.7 RDW-15.3 Plt Ct-105* [2133-1-23] 04:22AM BLOOD WBC-7.3 RBC-3.03* Hgb-9.2* Hct-27.3* MCV-90 MCH-30.5 MCHC-33.8 RDW-15.5 Plt Ct-107* [2133-1-24] 05:45AM BLOOD WBC-6.3 RBC-2.91* Hgb-8.8* Hct-26.4* MCV-91 MCH-30.3 MCHC-33.4 RDW-15.2 Plt Ct-129* [2133-1-25] 06:07AM BLOOD Hct-26.5* [2133-1-24] 05:45AM BLOOD PT-15.6* INR(PT)-1.4* [2133-1-24] 05:45AM BLOOD Plt Ct-129* [2133-1-25] 06:07AM BLOOD PT-15.3* INR(PT)-1.3* [2133-1-23] 04:22AM BLOOD Glucose-167* UreaN-31* Creat-1.7* Na-139 K-4.8 Cl-104 HCO3-28 AnGap-12 [2133-1-24] 05:45AM BLOOD Glucose-156* UreaN-32* Creat-1.4* Na-140 K-3.6 Cl-102 HCO3-32 AnGap-10 [2133-1-25] 06:07AM BLOOD Glucose-140* UreaN-30* Creat-1.3* Na-137 K-4.1 Cl-97 HCO3-34* AnGap-10 Radiology Report CHEST (PORTABLE AP) Study Date of [2133-1-22] 8:46 AM Final Report: In comparison with study of [1-21], the left chest tube has been removed and there is no pneumothorax. Right central catheter has been exchanged for a sheath in the internal jugular vein. Remainder of the examination is unchanged. [2133-1-20] Carotid US On the right systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 52/22, 68/22, 91/28, , cm/sec. CCA peak systolic velocity is cm/sec. ECA peak systolic velocity is 67 cm/sec. The ICA/CCA ratio is 1.9. These findings are consistent with <40% stenosis. -On the left systolic/end diastolic velocities of the ICA proximal, mid and distal respectively are 65/20, 71/30, 64/26, cm/sec. CCA peak systolic velocity is 53 cm/sec. ECA peak systolic velocity is 73 cm/sec. The ICA/CCA ratio is 1.3. These findings are consistent with <40% stenosis. -There is antegrade right vertebral artery flow. There is antegrade left vertebral artery flow. -Impression: Right ICA stenosis <40%. Left ICA stenosis <40%. Blunted RCCA waveform may indicate more proximal CCA or innominate stenosis. [2133-1-20] Vein Mapping RIGHT: The right greater saphenous is patent throughout its length with diameters in the lower leg ranging from 3.6-4.2 mm. The thigh diameters range from 3.6-6.3 mm. LEFT: The left greater saphenous is patent throughout with lower leg diameters ranging from 3.7-5.2 mm and thigh diameters ranging from 3.9-6.1 mm. All veins are thin-walled and compressible. IMPRESSION: Patent bilateral greater saphenous vein with good quality and appropriate diameters for conduit. [Hospital1 18] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.9 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 60% >= 55% Aorta - Sinus Level: 3.8 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.6 cm <= 3.0 cm Aorta - Ascending: 3.9 cm <= 3.4 cm Aorta - Arch: 2.9 cm <= 3.0 cm Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec Aortic Valve - LVOT diam: 1.8 cm Findings Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: Mild spontaneous echo contrast in the body of the LA. Mild spontaneous echo contrast in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in the body of the RA. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Mildy dilated aortic root. Mildly dilated ascending aorta. Normal aortic arch diameter. Normal descending aorta diameter. Focal calcifications in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Filamentous strands on the aortic leaflets c/with Lambl's excresences (normal variant). No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The rhythm appears to be atrial fibrillation. Results were personally reviewed with the MD caring for the patient. Conclusions Prebypass Mild spontaneous echo contrast is seen in the body of the left atrium. Mild spontaneous echo contrast is present in the left atrial appendage. No spontaneous echo contrast is seen in the body of the right atrium. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There are filamentous strands on the aortic leaflets consistent with Lambl's excresences (normal variant). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Postbypass The patient is A-paced on a phenylephrine infusion. Left ventricular function continues to be normal (LVEF >60%), although it is underfilled. Mitral regurgitation is now trace and there is still no aortic regurgitation. The thoracic aorta is intact post decannulation. Brief Hospital Course: Ms [Known firstname ] was admitted for surgical management of coronary artery disease. Pre operatively she had a routine workup that included Heparinization as a bridge for anticoagulation. She also had carotid ultrasound and vein mapping. On [2133-1-20] she was brought to the operating for for coronary bypass grafting, please see the operative report for details. In summary she had: 1.Coronary artery bypass graft x 3 Left internal mammary artery grafted to left anterior descending artery, Saphenous vein grafted to Obtuse Marginal, Saphenous vein grafted to posterior descending artery. 2.Primary sternal repair using Synthes plating system times 5. Her bypass time was 53 minutes with a crossclamp of 42 minutes. she tolerated the procedure well and was transferred to the cardiac surgery ICU in stable condition. She woke from anesthesia neurologically intact and was extubated. she remained in the ICU on Neosynephrine to support her hemodynamically, this was weaned to off over the first 24 hours. On POD2 she was transferred from the CVICU to the stepdown floor for continued post-operative recovery. The remainder of her post-operative course was generally uneventful. All tubes lines and drains were removed per cardiac surgery protocol. Once on the floor she continued to make slow progress in advancing her activities of daily living, she remained hemodynamically stable throughout this period. She had atrial fibrillation and therefore her Coumadin was resumed. On POD5 she was transferred to rehabilitation at [Hospital1 ]-[Location (un) 86] in stable condition. Medications on Admission: Medications at home: Medications - Prescription ESTRADIOL [ESTRING] - (Prescribed by Other Provider) - Dosage uncertain FUROSEMIDE [LASIX] - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth daily GABAPENTIN - (Prescribed by Other Provider) - 300 mg Capsule - 1 Capsule(s) by mouth twice a day INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100 unit/mL Cartridge - 24 units HS LEVOTHYROXINE - (Prescribed by Other Provider) - 137 mcg Tablet - 1 Tablet(s) by mouth daily METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth twice daily OXYBUTYNIN CHLORIDE - (Prescribed by Other Provider) - 5 mg Tablet Extended Rel 24 hr - 2 Tablet(s) by mouth twice a day PRAVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth at hs PREDNISONE - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 1 mg Tablet - 6 Tablet(s) by mouth once a day TRAMADOL - (Prescribed by Other Provider) - 50 mg Tablet - [11-23] Tablet(s) by mouth prn TRIMETHOPRIM - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth daily URSODIOL [ACTIGALL] - (Dose adjustment - no new Rx) - 300 mg Capsule - 3 Capsule(s) by mouth twice a day WARFARIN [COUMADIN] - (Prescribed by Other Provider) - 4 mg Tablet - 1 Tablet(s) by mouth daily Resume on Friday [2132-12-26] and INR on Tuesday [2132-12-30] per usual Medications - OTC CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever or pain. 6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 9. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 10. cyanocobalamin (vitamin B-12) 50 mcg Tablet Sig: One (1) Tablet PO once a day. 11. trimethoprim 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 12. vitamin A 10,000 unit Capsule Sig: Two (2) Capsule PO DAILY (Daily). 13. oxybutynin chloride 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 14. prednisone 1 mg Tablet Sig: Six (6) mg PO DAILY (Daily). 15. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 16. ursodiol 300 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 17. levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO once a day. 18. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 19. warfarin 1 mg Tablet Sig: as directed to keep INR 2-2.5 Tablets PO Once Daily at 4 PM: Target INR 2-2.5 was taking 4mg daily(pre-op). 20. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. 21. insulin glargine 100 unit/mL Solution Sig: Twenty Five (25) units Subcutaneous once a day. 22. insulin regular human 100 unit/mL Solution Sig: sliding scale Injection Q AC&HS. 23. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: coronary artery disease Secondary: Chronic atrial fibrillation on Coumadin, diagnosed [2123] stable primary biliary cirrhosis Type II diabetes Hypothyroidism Polymyalgia rheumatica diagnosed [3-31], On Prednisone Hypercholesterolemia Osteoarthritis Vulvar cancer [2129] s/p vulvectomy at [Hospital1 2025] (no chemo or radiation) Urinary incontinence s/p vulvectomy nephrolithiasis chronic lower extremity edema r/t lymphedema urosepsis arthritis left knee- needs replacement Past Surgical History: right hip replacement [2130] right knee replacement [2130] Back surgery x 4 Appendectomy Tonsillectomy Discharge Condition: Alert and oriented x3 nonfocal Activity-OOB to chair with assist Incisional pain managed with Percocet Incisions: Sternal - Keep tegaderm intact until appt with Dr. [First Name (STitle) ]. healing well, no erythema or drainage. JP drain to bulb suction- to be removed by Dr. [First Name (STitle) ] in 1 week. Bilat LE: [1-23]+ bilat pedal edema; with staples no erythema, serosang drainage d/t edema. leg staples may be removed by Rehab NP/MD in 2weeks Discharge Instructions: Keep sternal tegaderm dressing on until postop appointment with Plastic Surgery-Dr. [First Name (STitle) ]. He will remove dressing and JP drain in one week- please call to make this appointment. Please do sponge bath every day. Wash legs daily, but keep sternum dry. You can wash with with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra AT ALL TIMES to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [Last Name (STitle) ]: on [2-19] at 1pm [Telephone/Fax (1) 100534] Cardiologist: Dr [Last Name (STitle) ] on [3-10] at 3:40pm Please call to schedule the following: Primary Care Dr.[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 11198] in [2-24] weeks ([Telephone/Fax (1) 100531] Plastic Surgeon: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in one week - will remove JP drain and sternal dressing at this appointment. [Street Address(2) ]., [Apartment Address(1) ], [Location (un) ], [Numeric Identifier 1415] Office Phone: ([Telephone/Fax (1) 1429] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Please call to schedule appointments with your Primary Care Dr [First Name (STitle) ],[First Name8 (NamePattern2) ] [Doctor First Name ] [Telephone/Fax (1) 1408] in [11-23] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Labs: PT/INR for Coumadin ?????? indication: Atrial Fibrillation Goal INR:2-2.5 First draw : day after discharge Completed by:[2133-1-25]	[ "41401", "42731", "25000", "2449", "V5861", "2720", "V5867" ]
Admission Date: [2126-5-23] Discharge Date: [2126-5-28] Date of Birth: [2056-8-18] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2126-5-24] - CABGx4 (Mammary to left anterior descending artery, vein to diagonal artery, vein to obtuse marginal artery, vein to right coronary artery) [2126-5-23] - Cardiac Catheterization History of Present Illness: This 69 year old woman has a history of diabetes, hyperlipidemia and clinical depression. The patient reports that over the past month she has noticed episodes of mild mid chest pressure, occurring when under emotional stress or when climbing a flight of stairs. She has difficulty offering specifics but states that these episodes typically resolve with rest. She is unclear on how often they have been occurring. She recently saw her primary care provider for her yearly physical. Upon being questioned on whether or not she has been having any chest discomfort, she described her recent symptoms. He has since referred her for stress testing has noted below. Given these finding she was referred for a cardiac catheterization which was significant for severe three vessel disease. She is now referred for surgical revacularization. [2126-5-17] ETT: Preliminary reports mention that the patient exercised 3.5 minutes on [Initials (NamePattern4) ] [Last Name (NamePattern4) ] protocol, 77% max PHR, stopping due to fatigue. She had no chest pain. Imaging revealed evidence of septal, anterior and apical defects, mostly fixed. There was septal hypokinesis confirmed by echo. LVEF 50%. Past Medical History: Hyperlipidemia Diabetes Depression s/p left breast cancer treated by lumpectomy, radiation and chemotherapy Glaucoma Frequent diarrhea of unknown etiology Social History: She is married with 2 adult children. Lives in [Location 95107]. Family History: Moter with MI in her 70's. Father with CABG in his 80's. Physical Exam: 153/63 62" 57.2 KG GEN: Well appearing SKIN: Unremarkable NECK: Supple, full range of motion LUNGS: Clear HEART: RRR, Nl S1-S2 ABD: Nontender, nondistended, soft, normoactive bowel sounds EXT: Warm, well perfused, no edema, vein small but no varicosies, pulses 2+ throughout. NEURO: Left sided facial droop which has been there for a long time. Pertinent Results: [2126-5-23] 02:00PM PT-12.1 PTT-30.7 INR(PT)-1.0 [2126-5-23] 02:00PM PLT COUNT-223 [2126-5-23] 02:00PM WBC-5.3 RBC-4.02* HGB-11.8* HCT-33.9* MCV-84 MCH-29.2 MCHC-34.7 RDW-13.4 [2126-5-23] 02:00PM ALT(SGPT)-9 AST(SGOT)-12 ALK PHOS-64 TOT BILI-0.3 [2126-5-23] 02:00PM GLUCOSE-82 UREA N-12 CREAT-0.6 SODIUM-138 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12 [2126-5-23] 08:06PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2126-5-28] 07:35AM BLOOD WBC-6.5 RBC-3.24* Hgb-9.3* Hct-26.7* MCV-83 MCH-28.7 MCHC-34.7 RDW-16.2* Plt Ct-242 [2126-5-28] 07:35AM BLOOD Plt Ct-242 [2126-5-28] 07:35AM BLOOD Glucose-145* UreaN-10 Creat-0.6 Na-140 K-3.8 Cl-103 HCO3-29 AnGap-12 [2126-5-23] Carotid series No evidence of hemodynamically significant stenosis bilaterally with less than 40% stenosis in the proximal left internal carotid artery. [2126-5-23] Cardiac Catheterization 1. Selective coronary angiography revealed a right dominant system with patent non-obstructive LMCA. The LAD was proximally subtotally occluded and gave off a large, patent D1. The left circumflex was not obstructived. The OM1 has a hazy, eccentric 80% lesion. The RCA was diffusely disease with a 80% proximal lesion that caused catheter damping. 2. Left ventriculography showed an ejection fraction of 55% and normal wall motions. No significant mitral regurgitation was noted. 3. Limited hemodynamic assessment showed mildly elevated left sided filling pressures and mildly elevated systemic pressure. [2126-5-25] X-ray Following line and tube removal, a small left apical pneumothorax is visualized. Dr. [Last Name (STitle) 67549] was left an Alpha message via the page system and telephone contact was made at 8:37 p.m. on [2126-5-25]. [2126-5-24] ECHO Pre-cpb: No spontaneous echo contrast is seen in the left atrial appendage. Left ventricular wall thicknesses are normal. EF 50 - 55%. The left ventricular cavity size is normal. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Moderate (2+) mitral regurgitation is seen. There is no pericardial effusion. Post- CPB: Preserved biventricular systolic fxn. 1- 2+ MR. 1+ AI. Aorta intact. Other parameters as pre-bypass Brief Hospital Course: Mrs. [Known lastname 3075] was admitted to the [Hospital1 18] on [2126-5-23] for a cardiac catheterization. This revealed severe three vessel coronary artery disease. Given the severity of her disease, the cardiac surgical service was consulted for surgical management. Mrs. [Known lastname 3075] was worked-up in the usual preoperative manner including a carotid duplex ultrasound which revealed no evidence of hemodynamically significant stenosis bilaterally with less than 40% stenosis in the proximal left internal carotid artery. On [2126-5-24], Mrs. [Known lastname 3075] was taken to the operating room where she underwent coronary artery bypass grafting to four vessels. Please see operative note for details. Postoperatively she was taken to the cardiac surgical intensive care unit for monitoring. By postoperative day one, Mrs. [Known lastname 3075] was awake, neurologically intact and extubated. Beta blockade, a statin and aspirin were started. She was then transferred to the step down unit for further recovery. Mrs. [Known lastname 3075] was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with her postoperative strength and mobility. Mrs. [Known lastname 3075] made steady progress and was discharged home on postoperative day four. She will follow-up with Dr. [Last Name (STitle) ], her cardiologist and her primary care physician as an outpatient. Medications on Admission: Admission Medications: Nortriptyline 75mg daily at bedtime Haldol 1mg daily at bedtime Lipitor 20mg daily every evening Klonopin 0.5mg daily at bedtime Aspirin 81mg daily at bedtime Plavix 75mg daily every evening (recently prescribed) Atenolol 25mg daily every evening (recent prescribed) Prandin 0.5mg, two tablets daily at dinner Metformin 1000mg twice a day Nitroglycerin SL prn Lumagen eye drops, one drop OU qhs Refresh tears prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:90 Tablet, Delayed Release (E.C.)(s) Refills:4 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days: Take twice daily with potassium then stop. Disp:10 Tablet(s) Refills:0 4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 5 days: Take twice daily with lasix then stop. Disp:10 Tab Sust.Rel. Particle/Crystal(s) Refills:0 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 7. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 8. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 9. Nortriptyline 75 mg Capsule Sig: One (1) Capsule PO at bedtime. Disp:30 Capsule(s) Refills:1 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 11. Repaglinide 0.5 mg Tablet Sig: Two (2) Tablet PO BIDWM (2 times a day (with meals)). Disp:60 Tablet(s) Refills:1 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Coronary artery disease Hyperlipidemia Diabetes Depression s/p left breast cancer with lupectomy/chemotherapy/radiation Glaucoma Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of greater then 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lifting greater then 10 pounds for 10 weeks. 5) No driving for 1 month. 6) You may wash incision and gently pat dry. No swimming or bathing until wounds have healed. No lotions, creams or powders to incision. 7) Take lasix 20mg twice daily and potassium 20mEq twice daily for five days then stop. 8) Please have liver function studies checked upon follow-up with either cardiologist or primary care physician. [Name10 (NameIs) ] is to check your tolerance to lipitor. 9) You may resume your other sleep medications as needed. 10) Please call with any questions or concerns. Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] (Surgeon) in 1 month. ([Telephone/Fax (1) 1504] Follow-up with cardiologist Dr. [Last Name (STitle) ] in [11-19] weeks. ([Telephone/Fax (1) 29561] Follow-up with primary care physician [Last Name (NamePattern4) ] 2 weeks. ([Telephone/Fax (1) 16005] Call all providers for appointments. Completed by:[2126-5-28]	[ "41401", "25000", "2720", "311" ]
Admission Date: [2118-4-18] Discharge Date: [2118-7-5] Date of Birth: [2054-9-13] Sex: F Service: MEDICINE Allergies: Penicillins / meropenem / cefepime / vancomycin Attending:[First Name3 (LF) 38616] Chief Complaint: Admission for allogenic stem cell transplant Major Surgical or Invasive Procedure: allogenic stem cell transplant Right subclavian central venous line placement and removal Right internal jugular cental venous line placement bronchoscopy Bone marrow biopsy History of Present Illness: 63 year old woman with AML progressing out of MDS. She was induced with 7+3 (daunorubicin and cytarabine) and achieved remission. She has received 1 cycle of MiDAC for consolidation on [2118-2-28]. She is admitted in CR1 for allogenic transplant on protocol 07-384. She reports feeling well, except for mild persistent fatigue. She was examined today by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3236], NP and Dr. [Last Name (STitle) ], who determined that she was OK to be admitted for transplant today. Past Medical History: ONCOLOGY HISTORY: - Panyctopenia noted on preop for excisional biopsy, CBC revealed a white blood count of 2.2, hematocrit of 34.2, platelet count of 116,000, and MCV of 101 at OSH. - BM Bx at OSH on [2117-12-7] showed dyspoietic granulocytes and 13% myeloblasts. There was no immunophenotypic evidence for lymphoproliferative disorder and the findings were most suggestive of a clonal myeloid neoplasm thought to be MDS with excess blasts. - Referred to [Hospital1 18], repeat BM bx on [1-13] showed 15% blasts on aspirate and translocation between chromosome 6 at band 6p23 and chromosome 9 at band 9q34 - s/p Idarubicin 7+3 induction Day 1: [2118-1-21] Cycle end: [2118-2-17]. During her neutropenic period, she developed acute fevers with focal erythroderm on her L forearm and distal L>R leg. Prior to the hospitalization, she had a L parotidectomy for what turned out to be parotiditis and sialadenitis with a large retained duct stone. Ultimately, it became clear she had no persistent infectious process in the parotid bed, but had evolving carbapenem and cephalosporin erythroderm. Her rashes improved dramatically with transition to from meropenem to cefepime to aztreonam. Her course was further complicated by a fever curve that had regular Tmax in the 101 range, resolving while on vancomycin, aztreonam, clindamycin and micafungin, but then recurred first low grade then becoming very hectic and high grade to 104 without any focal findings. The vancomycin was stopped and she defervesced after 72 hours. She soon thereafter recovered her counts and all antibiotics were discontinued when her ANC approached 500. - [2118-2-28] - MiDAC Consolidation OTHER PAST MEDICAL HISTORY: -Osteoarthritis -Left total knee replacement -Remote cholecystectomy and appendectomy. -Epilepsy with a history of grand mal seizures. Her last seizure was four to five years ago. She is followed by a neurologist in [Hospital1 392]. -Hypertension -Anxiety. Social History: She has been married for 41 years. She is a retired post-office worker. She has three daughters who all live locally. She is a smoker who quit 26 years ago. She smoked one pack per week for about 30 years. She does not drink any alcohol due to her antiepileptic medications. Family History: Her mother died of heart complications. Her father died of emphysema. She has a healthy brother. She has a daughter who was diagnosed with colon cancer at age 29, currently in remission. She has another daughter age 31 with a pituitary tumor and she has a third daughter who is healthy. Physical Exam: Admission Physical Exam: VS: 98.6 133/86 89 18 99%RA Weight: 276 Height 62 BMI: 50.5 Gen: WD/overnourished in NAD HEENT: alopecia, anicteric, [Last Name (LF) 3899], [First Name3 (LF) 13775], clear OP, supple neck, no masses Lungs: CTAB CV: RRR NL S1,S2; no murmurs, rubs or gallops Abd: Soft, obese, non-tender no HSM or masses Skin: Reddish reticular flat pruritic rash on left side of back Ext: without C/C/E; petechial and confluent rash on bilteral LE resolved Neuro: Non-focal and symmetric . Discharge Physical Exam VS: tc 98.0, 142-158/72-78, 70, 18-20, 99% RA. Gen: obese woman in NAD HEENT: alopecia, anicteric, [Last Name (LF) 3899], [First Name3 (LF) 13775], clear OP, supple neck, no masses Lungs: CTAB CV: RRR NL S1,S2; no murmurs, rubs or gallops Abd: Soft, obese, non-tender no HSM or masses Skin: Reddish reticular flat pruritic rash on left side of back Ext: without C/C/E; petechial and confluent rash on bilteral LE resolved Neuro: Non-focal and symmetric Pertinent Results: ADMISSION LABS: [2118-4-18] 08:00AM BLOOD WBC-4.6 RBC-3.72* Hgb-12.6 Hct-37.8 MCV-102* MCH-33.9* MCHC-33.4 RDW-17.2* Plt Ct-211 [2118-4-19] 12:00AM BLOOD WBC-6.9 RBC-3.34* Hgb-11.4* Hct-33.3* MCV-100* MCH-34.1* MCHC-34.1 RDW-17.1* Plt Ct-109* [2118-4-20] 12:00AM BLOOD WBC-5.5 RBC-3.12* Hgb-10.8* Hct-31.3* MCV-100* MCH-34.6* MCHC-34.5 RDW-16.8* Plt Ct-100* [2118-4-18] 08:00AM BLOOD Neuts-53.6 Lymphs-24.1 Monos-10.2 Eos-10.4* Baso-1.7 [2118-4-19] 12:00AM BLOOD Neuts-94* Bands-2 Lymphs-2* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [2118-4-20] 12:00AM BLOOD Neuts-95.9* Lymphs-0.7* Monos-3.1 Eos-0 Baso-0.2 [2118-4-19] 12:00AM BLOOD Fibrino-211 [2118-4-20] 12:00AM BLOOD Fibrino-250 [2118-4-21] 12:20AM BLOOD Fibrino-234 [2118-5-30] 03:20PM BLOOD CD3%-89.1 CD3Abs-307 16/56%-9.9 16/56Ab-34 [2118-4-23] 12:00AM BLOOD Ret Aut-1.6 [2118-5-30] 03:20PM BLOOD WBC-4.3 Lymph-8* Abs [Last Name (un) ]-344 CD3%-80 Abs CD3-275* CD4%-39 Abs CD4-135* CD8%-38 Abs CD8-130* CD4/CD8-1.0 [2118-4-18] 09:15AM BLOOD UreaN-18 Creat-0.9 Na-140 K-4.8 Cl-103 HCO3-29 AnGap-13 [2118-4-19] 12:00AM BLOOD Glucose-174* UreaN-16 Creat-0.8 Na-137 K-4.3 Cl-101 HCO3-24 AnGap-16 [2118-4-20] 12:00AM BLOOD Glucose-178* UreaN-16 Creat-0.8 Na-133 K-4.3 Cl-99 HCO3-26 AnGap-12 [2118-4-18] 09:15AM BLOOD ALT-12 AST-18 LD(LDH)-189 AlkPhos-61 TotBili-0.2 DirBili-0.1 IndBili-0.1 [2118-4-21] 12:20AM BLOOD LD(LDH)-175 [2118-4-22] 12:00AM BLOOD ALT-12 AST-11 LD(LDH)-163 AlkPhos-46 TotBili-0.2 [2118-5-20] 07:37AM BLOOD CK-MB-4 cTropnT-0.06* [2118-5-20] 02:37PM BLOOD cTropnT-0.15* [2118-5-20] 08:32PM BLOOD CK-MB-4 cTropnT-0.08* [2118-4-18] 09:15AM BLOOD TotProt-6.6 Albumin-4.2 Globuln-2.4 Calcium-10.1 Phos-3.4 Mg-1.9 UricAcd-5.9* [2118-4-19] 12:00AM BLOOD Calcium-9.6 Phos-2.7 Mg-1.5* [2118-4-20] 12:00AM BLOOD Calcium-9.0 Phos-2.7 Mg-2.1 Test ---- Fungitell (tm) Assay for (1,3)-B-D-Glucans Results Reference Ranges ------- ---------------- <31 pg/mL Negative Less than 60 pg/mL Indeterminate 60 - 79 pg/mL Positive Greater than or equal to 80 pg/mL Test Result Reference Range/Units ASPERGILLUS ANTIGEN 0.1 <0.5 URINE: CSF: [2118-5-23] 05:12PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-285* Polys-33 Lymphs-10 Monos-0 Eos-2 Macroph-55 [2118-5-23] 05:12PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-81* Polys-3 Lymphs-17 Monos-0 Macroph-80 [2118-5-23] 05:12PM CEREBROSPINAL FLUID (CSF) TotProt-31 Glucose-74 LD(LDH)-18 Test Result Reference Range/Units CMV DNA, QL PCR NOT DETECTED Not Detected Test Name In Range Out of Range Reference Range --------- -------- ------------ --------------- Herpes Virus 6 DNA, Qualitative Real-Time PCR HHV-6 DNA Not Detected Not Detected Test Name In Range Out of Range Reference Range --------- -------- ------------ --------------- [Doctor Last Name 3271] [Doctor Last Name ] Virus DNA, Qualitative Real-Time PCR EBV DNA, QL PCR Not Detected Not Detected Test Name Flag Results Unit Reference Value --------- ---- ------- ---- --------------- Herpes Simplex Virus PCR Specimen Source CSF Result Negative Not Applicable MICRO: WOUND CULTURE (Final [2118-4-29]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. C. difficile DNA amplification assay (Final [2118-5-1]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. Blood Culture, Routine (Final [2118-5-9]): STAPHYLOCOCCUS EPIDERMIDIS. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS EPIDERMIDIS \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ =>16 R LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 4 S VANCOMYCIN------------ 1 S Anaerobic Bottle Gram Stain (Final [2118-5-7]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. Reported to and read back by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], RN @ 0231 ON [2118-5-7]. Aerobic Bottle Gram Stain (Final [2118-5-7]): GRAM POSITIVE COCCI IN CLUSTERS. WOUND CULTURE (LINE TIP) (Final [2118-5-10]): STAPHYLOCOCCUS EPIDERMIDIS. <15 colonies. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS EPIDERMIDIS \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ =>16 R LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S VANCOMYCIN------------ 1 S Blood cultures ([5-7], [5-14], [5-15], [5-17], [5-19], [5-20], [5-21], [5-22], [5-24], [5-25], [5-26]): no growth Urine cultures ([5-15], [5-17], [5-20], [5-22], [5-24]): no growth CMV Viral Load (Final [2118-5-18]): 1,040 copies/ml. Respiratory Viral Culture (Final [2118-5-19]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [Telephone/Fax (1) 6182] within 1 week if additional testing is needed. [2118-5-17] 2:23 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. PLS R/O KLEBSIELLA. R/O CMV. GRAM STAIN (Final [2118-5-17]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2118-5-19]): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. LEGIONELLA CULTURE (Final [2118-5-24]): NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [2118-5-17]): Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (7-2306). Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [2118-5-17]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [2118-5-18]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. VIRAL CULTURE (Final [2118-5-20]): TEST CANCELLED, PATIENT CREDITED. FURTHER [Location (un) ] OF THE CULTURE WILL BE PERFORMED ON REQUEST ONLY. Refer to CMV early antigen test result for further information. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): CULTURE REQUESTED BY DR [First Name (STitle) ]. No Cytomegalovirus (CMV) isolated. CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final [2118-5-20]): POSITIVE FOR CYTOMEGALOVIRUS. Early antigen detected by immunofluorescence. Reported to and read back by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [2118-5-20] 11:10AM. [2118-5-17] 2:23 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE. PLS R/O KLEBSIELLA. R/O CMV. GRAM STAIN (Final [2118-5-17]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2118-5-19]): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. LEGIONELLA CULTURE (Final [2118-5-24]): NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [2118-5-17]): Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our in-house studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (7-2306). Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [2118-5-17]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [2118-5-18]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. VIRAL CULTURE (Final [2118-5-20]): TEST CANCELLED, PATIENT CREDITED. FURTHER [Location (un) ] OF THE CULTURE WILL BE PERFORMED ON REQUEST ONLY. Refer to CMV early antigen test result for further information. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary): CULTURE REQUESTED BY DR [First Name (STitle) ]. No Cytomegalovirus (CMV) isolated. CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final [2118-5-20]): POSITIVE FOR CYTOMEGALOVIRUS. Early antigen detected by immunofluorescence. Reported to and read back by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [2118-5-20] 11:10AM. Respiratory Viral Culture (Final [2118-5-20]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [Telephone/Fax (1) 6182] within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final [2118-5-18]): Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture for further information. CMV Viral Load (Final [2118-5-20]): 9,380 copies/ml. Performed by PCR CMV Viral Load (Final [2118-5-24]): 1,470 copies/ml. Performed by PCR. CSF: CRYPTOCOCCAL ANTIGEN (Final [2118-5-23]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. STUDIES: ECG ([4-18]): rate 86. Sinus rhythm. Within normal limits. EEG ([4-20]): IMPRESSION: This is an abnormal EEG due to the presence of moderate diffuse background slowing and frequent generalized bursts of high amplitude slow waves. These findings are indicative of a moderate diffuse encephalopathy which suggests widespread cerebral dysfunction but is etiologically non-specific. There were no epileptiform features. ECG ([4-23]): Sinus rhythm. Non-specific inferior ST-T wave flattening. INVESTIGATION OF TRANSFUSION RXN ([2118-4-29]): DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mrs. [Known lastname ] experienced chills and urticaria after receiving an infusion of hematopoietic stem cells. The laboratory work-up revealed no evidence of hemolysis. Noncryopreserved allogeneic stem cell products are generally well tolerated. Approximately 2% of infusions will be complicated by chills likely resulting from recipient anti-HLA antibodies reacting with donor white blood cells. Additionally, recipient antibodies against plasma proteins present in the component may cause allergic type reactions characterized by urticaria. We recommend no changes in infusion practice in the patient at this time. INVESTIGATION OF TRANSFUSION RXN ([2118-5-4]): DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mrs. [Known lastname ] experienced a urticarial reaction after transfusion of an apheresis platelet transfusion. Urticarial transfusion reactions are thought to be triggered by exposure to soluble substances/antigens within the donor product that cause IgE mediated histamine release. Urticarial reactions complicate 1-3% of transfusions. The presence of one urticarial transfusion reaction does not predict future reactions. We recommend no changes in standard transfusion practices in this patient at this time. CT Head noncon ([2118-5-4]): 1. No acute intracranial hemorrhage, edema or mass effect. 2. Highly symmetric confluent hypoattenuation in bihemispheric white matter, unusual for typical sequelae of chronic small vessel ischemic disease, and more characteristic of intrathecal methotrexate or other treatment-effect, which should be correlated with more detailed clinical information. INVESTIGATION OF TRANSFUSION RXN ([2118-5-13]): DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Ms. [Known lastname ] developed an urticarial reaction after receiving a bag of apheresis platelets on [2118-5-13]. Urticarial transfusion reactions are thought to be triggered by exposure to soluble substances/antigens within the donor product that cause IgE mediated histamine release. Urticarial reactions complicate 1-3% of transfusions. The presence of occasional urticarial transfusion reactions does not typically predict future severe reactions. We recommend no changes in transfusion practices in this patient at this time. ct head noncontrast ([5-13]): 1. No acute intracranial process. 2. Stable periventricular and subcortical white matter hypodensities may be related to intrathecal methotrexate or other treatment effect and less likely the sequela of chronic microvascular ischemic disease. 3. Mild global atrophy. ct chest non-con([5-16]): 1. Diffuse ground-glass opacities within the entire right lung. These findings are not typical of any one particular etiology. Given that the patient is status post bone marrow transplant prior to engrafting, bacterial, viral, and fungal etiologies should all be considered including infections such as toxoplasmosis or CMV. 2. Bilateral trace pleural effusions, right greater than left. Echo ([5-17]): The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. No aortic regurgitation is seen. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2118-3-29], no change. renal u/s ([5-17]): IMPRESSION: No hydronephrosis bilaterally. cxr ([5-18]); FINDINGS: As compared to the previous radiograph, there is no relevant change. The severity and extent of the pre-existing extensive bilateral parenchymal opacities is constant. Also constant is the absence of pleural effusions, the moderate cardiomegaly and the position of the right internal jugular vein catheter. LENI ([5-19]): 1. No DVT to the popliteal veins bilaterally. Bilateral calf veins not well visualized. 2. Right popliteal [Hospital Ward Name 4675] cyst. CXR ([2118-5-21]): 1. Right internal jugular central line has its tip in the distal SVC, unchanged. When compared to the most recent prior study, there has been slight interval improvement in the bilateral airspace process suggestive of moderate-to-severe pulmonary edema. However, there is still a substantial residual pulmonary edema present on the current examination. Overall, cardiac and contours are likely unchanged. No evidence of pneumothorax. CT head noncon ([5-21]): 1. No acute intracranial process. 2. Stable periventricular and subcortical white matter low-attenuating regions may be related to treatment effect or the sequelae of chronic small vessel ischemic disease. 3. Mild age-related involutional changes. EEG ([5-22]): IMPRESSION: This is an abnormal continuous ICU monitoring study because of a diffuse encephalopathy manifest by a mild to moderate background slowing. Superimposed upon this is focal slowing in the left central temporal region with superimposed admixed paroxysmal epileptiform transients in the same region. No seizures were identified. CXR ([5-22]); There is a right central venous catheter with distal lead tip in distal SVC. Heart size is upper limits of normal. There are again seen diffuse airspace densities and more confluent areas of opacity within the left lobe. These may represent pulmonary edema; however, superimposed infection is not entirely excluded. A small left-sided pleural effusion is also seen. UENI ([5-22]): IMPRESSION: No evidence of DVT in the right upper extremity. EEG ([5-23]): IMPRESSION: This is an abnormal continuous ICU monitoring study because of disorganized theta and delta background indicative of mild to moderate diffuse encephalopathy. In addition, there is focal slowing in the left frontocentral region with superimposed epileptiform discharges. There were no electrographic seizures. Compared to the prior day's recording, there were no significant changes. CSF ([5-23]): Cerebrospinal fluid: NEGATIVE FOR MALIGNANT CELLS. Rare lymphocytes. EEG ([5-24]): MPRESSION: This is an abnormal continuous ICU monitoring study because of disorganized theta and delta background indicative of mild to moderate diffuse encephalopathy. In addition, there is focal slowing in the left frontocentral region with superimposed epileptiform discharges. There were no electrographic seizures. Compared to the prior day's recording, there were no significant changes. KUB ([5-25]): IMPRESSION: Limited study. No evidence of obstruction. CT Chest non-con ([5-27]): IMPRESSION: Increased pulmonary ground-glass opacities and interstitial abnormality. New pleural and increased pericardial effusions. Appearance is most compatible with viral infection, such as CMV, or Pneumocystis. Graft versus host disease could also have this appearance, but should also produce extrathoracic manifestations. BMB [2118-5-31]: Peripheral Blood Smear: The smear is adequate for evaluation. Red blood cells are normochromic and normocytic with slight anisopoikilocytosis including rare teardrop microcytes and schistocytes seen. The white blood cell count appears decreased. Platelet count appears decreased; large forms are seen. Differential shows 72% neutrophils, 4% monocytes, 10% lymphocytes, 4% eosinophils, 2% basophils, 3% metamyelocytes. Aspirate Smear: The aspirate material is suboptimal for evaluation due to paucity of spicules and hemodilution. M:E ratio is 5:1 (hemodilution). Erythroid precursors are relatively, proportionately decreased in number and exhibit dyspoietic maturation; forms with irregular nuclear contours are seen. Myeloid precursors appear relatively increased in number. Abnormal nuclear lobation and hypogranular forms are seen. Megakaryocytes are not seen. A 200 cell differential shows 4% Promyelocytes, 7% Myelocytes, 22% Metamyelocytes, 45% Bands/Neutrophils, 7% Lymphocytes, 15% Erythroid. Clot Section and Biopsy Slides: The core biopsy material is suboptimal for evaluation, severely limited by aspiration and crush artifact. It consists of a 0.8 cm core, trabecular marrow with a cellularity of 5%. Minimal hematopoietic tissue is seen in one space. No excess of blasts. Erythroid precursors are decreased in number and exhibit mildly dyspoietic maturation. Myeloid precursors are decreased in number with complete maturation to neutrophilic stage with left shifted maturation with dyspoietic maturation. Blood clot is non-contributory. SKIN BIOPSY [2118-6-2]: Skin, left inferior abdomen, biopsy (A-B): Mild superficial perivascular lymphocytic infiltrate, with occasional eosinophils, see note. Note: Rare dyskeratotic keratinocyte are seen. The interface changes are minimal, and although early graft versus host disease cannot be entirely excluded, the findings are more in favor of a drug hypersensitivity reaction. Clinical correlation is recommended. Multiple levels examined. MR HEAD [2118-6-1]: 1. No acute intracranial abnormality. 2. No pathologic focus of enhancement. 3. Extensive FLAIR-signal abnormality in bihemispheric subcortical and periventricular, as well as central pontine white matter. Though this likely represents sequelae of chronic small vessel ischemic disease, a contribution of treatment effect is a consideration, and should be closely correlated with detailed history (e.g. Is there any history of intrathecal methotrexate or other chemotherapeutic [Doctor Last Name 360]?). NCHCT [2118-6-9]: There is no evidence of hemorrhage, edema, mass, mass effect, or infarction. Periventricular and subcortical white matter hypodensities are suggestive of chronic small vessel ischemic disease. The ventricles and sulci are normal in size and configuration. There is no fracture. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Chest CT [2118-6-17]: There is been marked improvement in the interstitial opacities in the lungs with mild residual or recurrent disease seen in the right lower lobe. Bilateral pleural effusions have resolved. A small unchanged cyst is seen in the left upper lobe. Right internal jugular catheter terminates in the distal SVC. The thyroid is normal and symmetric in appearance. Normal three vessel branching aortic arch is seen with mild atherosclerotic calcification. The heart appears normal with mitral and aortic valvular calcifications and perhaps mild calcification of the left main coronary artery. Small pericardial effusion is unchanged or minimally more prominent than the previous examination. No pathologically enlarged axillary, supraclavicular, mediastinal or hilar nodes are seen. The esophagus is normal in appearance. The trachea and central airways are patent to the segmental level. Although this study is not tailored for subdiaphragmatic evaluation imaged upper abdomen reveals unchanged left adrenal lipoma. Rounded low-attenuation structure in the pancreatic tail is likely invaginated fat. Calcification is seen at the celiac and SMA origins [2118-6-20] Radiology MR HEAD W/O CONTRAST IMPRESSION: 1. No evidence of acute infarct or hemorrhage. 2. Stable bilateral subcortical and periventricular T2/FLAIR hyperintensities likely representing microangiopathic ischemic changes versus post-treatment changes. [2118-6-20] Radiology CT ABD & PELVIS W/O CON . IMPRESSION: 1. No evidence of PTLD on this non-contrast CT of the abdomen. 2. Diverticulosis, without evidence of diverticulitis. 3. Pericardial thickening, unchanged from [2118-1-23]. 4. Nonspecific peribronchovascular ground-glass opacity in the right lower lobe. 5. Hypodense blood pool, consistent with anemia. [2118-6-21] Neurophysiology EEG . IMPRESSION: This is an abnormal continuous ICU monitoring study because of one electrographic seizure in the left temporal region with spread to the left parasagittal area lasting 48 seconds. On video, patient's view is limited but there is no obvious ictal clinical correlation; however, immediately in the postictal phase, she has an arousal with purposeful movements. In addition, there are frequent left temporal epileptiform discharges and intermittent prominent slowing in this region. These findings are indicative of an epileptogenic focus with underlying subcortical dysfunction in the left temporal lobe. Furthermore, the posterior dominant rhythm was poorly sustained with further bursts of bifrontal intermittent rhythmic delta (FIRDA) slowing indicative of mild to moderate diffuse cerebral dysfunction. Potential causes include, but are not limited to, medication effect, or metabolic, toxic, and infectious disturbances. [2118-6-22] Neurophysiology EEG IMPRESSION: This is an abnormal continuous ICU monitoring study because of occasional left temporal epileptiform discharges as well as intermittent significant slowing in this region. These findings are suggestive of a potentially epileptogenic focus in the left temporal region with underlying subcortical dysfunction. In addition, the posterior dominant rhythm was not well-sustained and there were frequent bursts of bifrontal intermittent rhythmic delta (FIRDA) slowing indicative of mild to moderate diffuse cerebral dysfunction. Potential causes include, but are not limited to, medication effect or metabolic, toxic, and infectious disturbances. There are no electrographic seizures. Compared to prior day's recording, this study shows improvement due to less frequent left temporal epileptiform discharges and the absence of electrographic seizures. [2118-6-23] Neurophysiology EEG IMPRESSION: This is an abnormal continuous ICU monitoring study because of intermittent focal slowing and rare epileptiform discharges in the left temporal region. These findings are indicative of a potentially epileptogenic focus in the left temporal region with underlying subcortical dysfunction. There is also a poorly sustained alpha rhythm, excess diffuse admixed theta and delta activity and rare bursts of frontal intermittent rhythmic delta activity. These findings are indicative of mild to moderate diffuse cerebral dysfunction which is etiologically non-specific. There are no electrographic seizures. Compared to the prior day's recording, there is less frequent and less prominent left temporal slowing and epileptiform discharges have also decreased in frequency. Discharge labs: [2118-7-5] 12:00AM BLOOD WBC-2.1* RBC-2.58* Hgb-7.9* Hct-24.0* MCV-93 MCH-30.7 MCHC-33.0 RDW-19.1* Plt Ct-83* [2118-7-5] 12:00AM BLOOD WBC-2.1* RBC-2.58* Hgb-7.9* Hct-24.0* MCV-93 MCH-30.7 MCHC-33.0 RDW-19.1* Plt Ct-83* [2118-7-5] 12:00AM BLOOD Neuts-67 Bands-1 Lymphs-21 Monos-4 Eos-6* Baso-0 Atyps-0 Metas-1* Myelos-0 [2118-7-5] 12:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+ Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Tear Dr[Last Name (STitle) 833] [Name (STitle) 4486] Ellipto-OCCASIONAL [2118-7-5] 12:00AM BLOOD Plt Ct-83* [2118-7-3] 11:39PM BLOOD Gran Ct-2450 [2118-6-30] 01:43PM BLOOD WBC-1.4* Lymph-19 Abs [Last Name (un) ]-266 CD3%-71 Abs CD3-188* CD4%-31 Abs CD4-84* CD8%-35 Abs CD8-93* CD4/CD8-0.9 [2118-6-30] 01:43PM BLOOD CD3%-79.2 CD3Abs-211 16/56%-19.0 16/56Ab-51 [2118-7-5] 12:00AM BLOOD Glucose-107* UreaN-24* Creat-1.7* Na-134 K-4.1 Cl-106 HCO3-20* AnGap-12 [2118-7-5] 12:00AM BLOOD ALT-7 AST-16 LD(LDH)-311* AlkPhos-65 TotBili-0.3 [2118-7-5] 12:00AM BLOOD Albumin-3.4* Calcium-9.2 Phos-3.6 Mg-2.0 [2118-6-30] 01:43PM BLOOD IgG-1471 IgA-222 IgM-122 [2118-7-5] 09:45AM BLOOD Cyclspr-PND [2118-7-3] 09:43AM BLOOD Cyclspr-112 Brief Hospital Course: BRIEF CLINICAL SUMMARY: 63 year old woman with AML progressing out of MDS who was admitted in CR1 on [2118-4-18] for allogenic transplantation. Admission complicated by bacteremia, hyponatremia/SIADH, mild mucositis, CMV pneumonitis and altered mental status. ISSUES: # AML: s/p 7+3 (daunorubicin and cytarabine) and achieved remission. She has received 1 cycle of MiDAC for consolidation on [2118-2-28]. The patient was admitted for allogenic stem cell transplant with conditioning regimen of TLI, ATG, and clofarabine. Transplant on [2118-4-29]. She tolerated the transplant well. She was provided zofran for nausea. The patient was on acyclovir for prophylaxis. Fluconazole prophylaxis was not initiated during admission secondary to medication interaction with anti-epileptic medications, micafunfin was used instead. Her counts started to recover near the beginning of [Month (only) 116], but then decreased again. She needed support with intermittent blood transfusions and injections of filgrastim. She had a repeat bone marrow biopsy on [2118-6-29], which preliminarily showed hypoplastic marrow consistent w/ suppression from medication (suspected to be due to valgancyclovir, see below). Pt will need to have continued follow-up for her continued neutropenia. For now, Pt will need continued filgrastim 480 mcg sc on Mon and Thursday, with 2x weekly CBC with differential. Pt was started on cyclosporine and mycophenolate for graft-versus host prophylaxis, which has been tapered to current dosage of cyclosporine 50mg po q12h and mycophenolate mofetil 250mg po bid. Pt will need continued cyclosporine levels weekly with results faxed to primary oncologist Dr [Last Name (STitle) ] at [Telephone/Fax (1) 21962]. # Bacteremia: Patient found to have staph epidermitis bacteremia [2-24] line infection, complicated by fevers to 103 and severe rigors. Fevers resolved and blood cultures cleared with addition of Daptomycin and Aztreonam and replacement of her central line. Other infectious sources, including UA and CXR remained normal. # Hypoxia: Patient desaturated on night of [5-20] and was in respiratory distress. Was in ICU for 5 days for respiratory distress (likely caused by CMV pneumonitis and pulmonary edema). CMV VL positive. Never required intubation. Now stable on 3-5L NC, on meropenem, micafungin and gancyclovir. Received IVIG as well. Of note, pt has many allergies, most notably antibiotic allergies that have caused severe and painful body rashes. Patient was desensitized of meropenem in ICU, and if pt comes off of meropenem, would need to be desensitized again if want to put it back on. Per ID, will continue meropenem through Monday, [5-30], as low likelihood infection in lung is a bacterial cause. Follow-up CT scan done [5-27] shows worsening of pulm interstitial and ground glass, but patient clinically much better. Patient has had no fevers since [5-25]. qMON CMV VL were drawn. Patient also had pulmonary edema. Has already been diuresed about 11L in ICU and a couple more slowly on floor. Patient responded to PRN 40mg IV lasix doses. . # CMV PNEUMONITIS: patient was admitted to the ICU on [5-20] in the setting of acute respiratory distress as above. At this time a CMV viral load returned elevated at 9000. She was initially treated with gancyclovir and anti-CMV IVIG starting on [5-18]. Her over all clinical status improved and she was gradually weaned from oxygen. On [5-30] her CMV VL again was elevated to 22,000 raising concern for gancylcovir resistance and she was switched to foscarnate on [5-31]. She continued to do well clinically, but developed acute renal insufficency with a gradual rise in her creatinine from 1.0 to 2.2 over the 2 weeks she recieved foscarnate. Pt was switched to gancyclovir on [6-11] and placed on maintenace dosing of 1.4 mg/kg on [6-17]. Interval Chest CT on [6-17] showed dramatic improvement in her pulmonary infiltrates. A CMV resistance genotype was sent and was negative for any resistant mutations. Pt was switched to valgancyclovir and on a dose of 450mg po daily after discussion with ID attending and CMV viral load was not detectable x 4 after [2118-6-6], to be continued until 12 months after her transplant ([2119-4-29]). Pt will need to have weekly CMV viral loads. Given her continued need for valgancyclovir, Pt will need filgrastim and 2x weekly CBC (see below). # Hyponatremia. While undergoing conditioning for transplant, the patient became hyponatremic to 129. Serum/Urine OSM consistent with SIADH. The patient is chronically on oxcarbamazepine, but no other new offending medications were identified as the source of her hyponatremia. The patient was started on a 1L fluid restriction, but continue to have persistent hyponatremia. The patient was evaluated by the renal team and was started on 1 salt tab TID. Sodium stabilized around 130. The patient was also on hypertonic saline for a brief amount of time. While anti-epileptics changed in ICU, pt was able to keep Na of low 130s w/ no need for hypertonic saline or salt tabs, only fluid restriction. However, later during her admission, Pt's sodium was still low but her hyponatremia was in the setting of [Doctor First Name 48] and appropriately dilute urine (low osms). Pt's hyponatremia was resolved and sodium was stable by discharge at ~135, although pt continued to have mild diuresis. Pt will need 2x weekly Chem 7 (Na, K, Cl, HCO3, BUN, Cr, Gluc). # Back pain: Patient with low midline back pain that began when getting onto a CT scanner table. Back pain-free at rest, but present with movement. Back pain likely mechanical secondary to strain. Pain improved with lidocaine patch. . # Esophagitis: While neutropenic, the patient experienced mild symptoms of mucositis. However, she was able to tolerate food by first eating something cold, such as a popsicle. Breakthrough symptoms were controlled on oxycodone 5 mg PO and resolved prior to discharge. # Seizures : The patient's home regimen was: LeVETiracetam 500 mg [Hospital1 ], Clonazepam 0.5 mg TID:PRN, Oxcarbazepine 900 mg PO BID. Patient had 48hrs EEG w/out definitive seizures, but seizure-like activity while in the ICU. neuro changed anti-epileptics, and they are following. currently on keppra and lacosamide. CT head on [5-21] had no acute intracranial changes. Patient also had altered mental status in the ICU, unclear whether etiology was seizures vs. ICU delirium. Patient's mental status at baseline prior to discharge from the ICU. Begining the week of [6-16] the patient was again noted to be slightly lethargic and confused. Neurology was contact[Name (NI) ] and agreed with decreasing her dose of keppra in the setting of her renal insufficency this change was made on [6-18]. Pt had more seizures, as evidenced on EEG. Her keppra was increased back to 750mg po bid as her renal function improved, and her seizure activity lessened as viewed on EEG. Pt was discharged on levetiracetam 750mg po bid and Lacosamide 150 mg po bid for seizure prophylaxis. She should see neurology for possible uptitration of her medications as an outpatient since her latest EEG showed some minor epileptiform activity, although she is currently asymptomatic. # acute renal insufficiency: Patient initially developed acute renal insufficency on [5-5] in the setting of gancyclovir administration and her acute clinical deterioration related to CMV infection. She was maintained supportively and her creatinine reached a max of 2.0 before returning to baseline of 1.0 on [5-27]. On [6-1] her creatinine was again noted to be elevated in the setting of foscarnate administration for refractory CMV infection as described above. This trend continued before hitting a max of 2.4 on [6-16], nephrology was again consulted and felt that her [Doctor First Name 48] was multifactoral from several nephrotoxic medications. Micafungin and foscarnate were discontinued and her renal function improved slightly but then regressed. Renal service was reconsulted on [2118-6-27]. Urine only had a few muddy brown casts, not really consistent with ATN or AIN. Renal service is also unclear on etiology of [Name (NI) 1094] continued diuresis or hyponatremia (see above). Renal feels that it may be related to medications, including cyclosporin and suggested lower dosing. Also felt that hypovolemia may be contributing and mild response with fluids. Cyclosporin was decreased, with level 112 on [2118-7-3]. Pt's creatinine on discharge is 1.7. Pt will need 2x weekly chemistry panels (see above). . # HYPERCALCEMIA: on [6-14] the patient's calcium was noted to be elevated to 11.0 despite her hypoalbuminemia. A venous free calcium was sent and returned elevated at 1.5 confirming hypercalcemia. Initially her fluids were increased to promote diuresis without effect. PTH was inappropriately elevated at 29, but not felt to be the primary driving mechanism of her hypercalcemia. Endocrinology was consulted and felt that her elevated calcium and phosphate was the result of primary hyperparathyroidism combined with secondary causes including imobility. Various efforts to control her hypercalceima were trialed including diuresis with lasix, calcitonin, phosphate binders and promindronate none of which substantially reversed her hypercalcemia which was felt to be driving her symptoms of constipation, abdominal pain and lethargy. Her calcium was finally controlled after receiving IV palmindronate. Her PTH then increased further to 141, suggestive of primary hyperparathyroidism. Endocrine service recommended outpatient MIBI parathyroid scan for adenoma. Pt will need 2x weekly calcium and albumin levels (to calculate corrected calcium). Pt was started on vitamin d [2106] u daily per endocrine service. # hypertension: previously on lisinopril, held due to [Doctor First Name 48]. Was on labetalol, switched to nifedipine but back to labetalol 200mg po bid on [2118-6-25]. [Month (only) 116] need to increase dose as BP has been 130s-140s/60s-80s. # deconditioning: Pt has been hospitalized for over two months. She is extremely weak and deconditioned from her stay and needs intensive physical therapy. She occasionally suffers from "buckling" of her knees and is currently a high fall risk. # increased urinary frequency: Pt had increased urinary frequency for the last 2 days of her admission, no fevers. UA on [2118-7-5] showed WBC 85, RBC 33, no bacteria. Urine culture pending at the time of discharge. TRANSITIONAL ISSUES: -needs 2x weekly complete blood count with differential -needs weekly CMV viral load -needs 2x weekly cyclosporine levels -monitor 2x weekly chemistry panel, calcium and albumin for sodium, Cr, Ca -outpatient MIBI parathyroid scan -outpatient neurology follow-up to further uptitrate anti-epileptics / consider further seizure treatment as needed -needs continued filgrastim 480mcg sc on Mondays and Thursdays -urine culture from [2118-7-5] results still pending Medications on Admission: acyclovir 400 mg PO q8hrs clonazpam 0.5 mg PO BID levetiracetam 500 mg PO BID lisinopril 20 mg PO daily oxcarbazepine 900 mg PO BID paroxetine 5 mg PO daily docusate sodium 100 mg PO BID Discharge Medications: 1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO twice a day. 3. lacosamide 150 mg Tablet Sig: One (1) Tablet PO twice a day. 4. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO once a day for 10 months. 5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection three times a day: Pt may refuse if ambulating. 6. filgrastim 480 mcg/0.8 mL Syringe Sig: Four [Age over 90 11578]y (480) mcg Injection q Mon and q Thurs. 7. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 8. atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO DAILY (Daily). 9. mycophenolate mofetil 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. cyclosporine modified 50 mg Capsule Sig: One (1) Capsule PO twice a day. 12. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for sbp < 100 or hr < 60. 13. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for loose stool. 15. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Primary: -Myelodysplastic syndrome, with allogenic matched unrelated donor stem cell transplant -epilepsy -acute renal insufficiency -CMV pneumonitis / pneumonia -hypercalcemia (likely primary hyperparathyroidism) -hyponatremia (resolved) Secondary: -hypertension -anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [Known lastname ], You were admitted to the hospital for an allogenic stem cell transplant. You also were treated with antibiotics for an infection with your bloodstream and a severe viral infection of your lungs. You were also treated for low blood sodium, reduction of your kidney function, and seizures. We have made the following changes to your medications: -STOP acyclovir -STOP lisinopril -STOP oxcarbazapine -INCREASE your levetiracetam (Keppra) to 750mg tablets, 1 tab by mouth twice daily -START fluconazole 200mg tabs, 2 tabs by mouth daily -START senna 8.6mg tabs, 1 tab by mouth twice daily -START polyethylene glycol (miralax) 17g packet, 1 packet as needed for constipation -START mycophenolate 250mg tabs, 1 tab by mouth twice daily -START cyclosporine 50mg tabs, 1 tab by mouth twice daily -START labetalol 200mg tabs, 1 tab by mouth twice daily -START lacosamide 150mg tabs, 1 tab by mouth twice daily -START atovaquone liquid, 1500mg by mouth once daily -START filgrastim 480 mcg subcutaneous injections every Monday and Thursday -START vitamin D 1,000 unit tabs, 2 tabs by mouth daily -START valganciclovir 450mg tabs, 1 tab by mouth daily Please continue to take your other medications as previously prescribed. We have made an appointment for you to be seen by your oncologist. Please have your rehab facility make arrangements for your transportation to your appointment. Followup Instructions: Department: HEMATOLOGY/BMT When: THURSDAY [2118-7-7] at 9:00 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3920], RN [Telephone/Fax (1) 3241] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/BMT When: THURSDAY [2118-7-7] at 9:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 9574], NP [Telephone/Fax (1) 3237] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [Name6 (MD) 11021] [Name8 (MD) 11022] MD [MD Number(2) 38620] Completed by:[2118-7-5]	[ "5849", "4280", "4019", "2875" ]
Admission Date: [2188-6-2] Discharge Date: [2188-6-5] Date of Birth: [2110-5-6] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6578] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname ] is a 78 year old female with a remote history of lung cancer s/p lobectomy, COPD on 2L at baseline, type II diabetes and hypertension who presents from [Hospital 100] Rehab with shortness of breath. Per notes over the past weekend she developed upper respiratory tract symptoms with nasal congestion, and cough productive of thick sputum. She was not experiencing any fevers. She was given increased nebulizer treatments with some relief. She was not experiencing chest pain or pleuritic type pain. She was not experiencing nausea, vomiting, abdominal pain, constipation, dysuria, hematuria, leg pain or swelling. She does endorse some mild diarrhea. She says that her breathing has been getting progressively worse over the past three days despite increasing nebulizer and oxygen therapy (titrated to 4L). She appeared progressively worse and EMS was called for transport to [Hospital1 18]. When EMS arrived she was complaining of shortness of breath. Initial oxygen saturations were in the low 80s and these improved to 94% on a non-rebreather. She was noted to have scant wheezes in her upper lung fields. EKG showed sinus tachycardia, right bundle branch block, q waves in III, avF, TWF V1-V3. She was taken to the emergency room. . In the ED, initial vs were: T: 98.8 P: 113 BP: 130/84 R: 25 O2 sat: 85% on RA. Initial CXR showed possible infiltrate in the L upper lobe. EKG showed sinus tachycardia, left axis, right bundle branch block, TWI V1-V3, q waves III, avF, no change compared to prior earlier in the day. She received vancomycin 1 gram IV x 1, zosyn 4.5 grams x 1, combivent nebulizers x 3, solumedrol 125 mg IV x 1. She was placed on BIPAP with mild improvement. She also received nitroglycerine for potential volume overload as well as lasix 20 mg IV x 1. Her BNP was elevated at 1122. Her WBC was 15.1 with 91% neutrophils. She had one set of negative cardiac enzymes. She was admitted to the intensive care unit for further management. . On arrival to the ICU she reported that her shortness of breath has improved somewhat from this morning. She denied fevers, chills, chest pain, nausea, vomiting, abdominal pain, constipation, dysuria, hematuria, leg pain or swelling. Comes from rehab. Has had recent rhinorrhea and productive cough without fevers. Mild diarrhea at rehab. All other review of systems negative in detail. Past Medical History: Lung Cancer s/p chemotherapy and lobectomy (date unknown) Type II Diabetes on insulin Macular Degeneration (legally blind) Hypertension COPD Breast Cancer s/p lumpectomy Hypercholesterolemia Diverticulosis Obesity Depression/Anxiety Anemia B12 deficiency Colon Polyps s/p polypectomy [2186] Social History: Positive smoking history, quit at the time of her diagnosis of lung cancer. No current smoking, alcohol or illicit drug use. She has been living at [Hospital 100] rehab for one year. Family History: No history of lung disease Physical Exam: Vitals: T: 99.6 BP: 151/76 P: 111 R: 27 O2: 99% on NRB General: Aggitated, oriented, mild respiratory distress using abdominal musculature HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP 12 cm, no LAD Lungs: Decreased breath sounds throughout, scarce expiratory wheezes, no crackles or ronchi appreciated, right sided thoracotomy scar well healed CV: Tachycardic, normal s1 + s2, no murmurs, rubs or gallops appreciated Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley draining clear yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neurologic: Grossly intact Pertinent Results: Labs on Admission [2188-6-2] 06:35PM BLOOD WBC-15.1* RBC-4.00* Hgb-10.5* Hct-31.8* MCV-80* MCH-26.2* MCHC-32.9 RDW-15.2 Plt Ct-269 [2188-6-2] 06:35PM BLOOD Neuts-91.0* Lymphs-5.2* Monos-3.1 Eos-0.5 Baso-0.2 [2188-6-2] 06:35PM BLOOD PT-12.1 PTT-24.8 INR(PT)-1.0 [2188-6-2] 06:35PM BLOOD Glucose-201* UreaN-25* Creat-1.2* Na-139 K-4.3 Cl-97 HCO3-31 AnGap-15 [2188-6-2] 06:35PM BLOOD Calcium-11.1* Phos-3.0 Mg-1.9 [2188-6-2] 06:44PM BLOOD Lactate-1.2 [2188-6-2] 06:35PM BLOOD proBNP-1122* [2188-6-2] 06:35PM BLOOD CK(CPK)-126 CK-MB-5 proBNP-1122* [2188-6-3] 02:54AM BLOOD CK(CPK)-204* CK-MB-7 cTropnT-0.02* [2188-6-2] 10:17PM BLOOD Type-ART pO2-51* pCO2-47* pH-7.44 calTCO2-33* Base XS-6 . [2188-6-3] Influenza DFA: negative [2188-6-3] Urine legionella Ag: negative [2188-6-2] Blood cultures x 2: no growth [2188-6-3] Urine culture: no growth . [2188-6-2] CXR: Opacities at the left lung base, left upper lung, and right mid lung as above, these are nonspecific. Multifocal pneumonia is primarily considered. In addition, note is made of cardiomegaly and sequelae of thoracic surgery. Labs on discharge: [2188-6-5] 08:50AM BLOOD WBC-16.0* RBC-4.01* Hgb-10.2* Hct-32.4* MCV-81* MCH-25.5* MCHC-31.5 RDW-15.6* Plt Ct-422 [2188-6-5] 08:50AM BLOOD Plt Ct-422 [2188-6-5] 08:50AM BLOOD Glucose-177* UreaN-55* Creat-1.6* Na-146* K-3.6 Cl-104 HCO3-29 AnGap-17 [2188-6-5] 08:50AM BLOOD Calcium-10.0 Phos-3.4 Mg-2.3 [2188-6-4] 09:58AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.013 [2188-6-5] 08:50AM BLOOD WBC-16.0* RBC-4.01* Hgb-10.2* Hct-32.4* MCV-81* MCH-25.5* MCHC-31.5 RDW-15.6* Plt Ct-422 [2188-6-5] 08:50AM BLOOD Glucose-177* UreaN-55* Creat-1.6* Na-146* K-3.6 Cl-104 HCO3-29 AnGap-17 VBG [2188-6-4] 12:15PM BLOOD Type-[Last Name (un) ] pO2-41* pCO2-42 pH-7.49* calTCO2-33* Base XS-7 Comment-GREEN TOP Brief Hospital Course: This is a 78 year old female with a history of lung cancer s/p lobectomy, COPD on two liters at baseline, insulin dependent diabetes, hypertension who presents with rhinorrhea, cough and shortness of breath likely due to COPD exacerbation and multifocal pneumonia. Cough/Shortness of Breath: Questionable small infiltrate in left upper lung field in setting of low grade fevers, leukocytosis, and upper respiratory tract symptoms. Likely represents exacerbation of patients known COPD in the setting of possible viral versus bacterial lung infection. There may be a component of volume overload although no clear cardiac history. Started on vancomycin, zosyn and levofloxacin for HCAP as coming from rehab facility and titrated from BIPAP to 4 liters nasal cannula in ICU. Urine legionella negative. Influenza DFA was negative. Solumedrol weaned to prednisone for possible COPD exacerbation with plan for quick taper, which was completed while patient was in house. Ruled out for MI. Patient was started on vancomycin, zosyn and levofloxacin x 7 day course (D1 = [2188-6-2] for Vancomycin and Zosyn and D1 = [2188-6-6] for Levofloxacin.) Blood cultures were negative for growth at discharge. On the floor, patient had an episode of persistent hypoxia to 85% on oxygen likely in the setting of delerium that was relieved with ativan and anti-psychotics. She was satting >90% on discharge, but still had evidence of multifocal pneumonia on CXR and expiratory wheezes on exam. COPD: On 2L nasal cannula at baseline. Started on solumedrol and standing ipratropium and albuterol nebs for likely exacerbation. Finished a quick prednisone taper given emotional lability. O2 sats were titrated sats 88-92% . Acute Renal Failure: Baseline of 0.9-1.0 as of 10/[2186]. Creatinine up to 1.9 this morning from 1.2 on presentation. Likely prerenal in the setting of infection and decreased PO intake. Differential diagnosis includes ATN v. AIN with zosyn. Urine eosinophils negative. Patient was hydrated with normal saline. Creatinine improved from 1.9 to 1.6. Hydration was changed to 1/2 normal saline in the setting of mild hypernatremia. Her lisinopril and hydrochlorothiazide were held. All medications were renally dosed. . Delirium: Patient was noted to be delirious on the floor. This is likely caused by a combination of being in a hospital setting with underlying infectious process and uremia. It should resolve with the patient returning to the familiar setting and treating the underlying infectious process and prerenal causes of ARF. Hypertension: Blood pressures were stable throughout hospitalization. Home amlodipine continued but lisinopril and HCTZ held in setting of ARF. . Positive UA: Urine culture negative during this hospitalization. . Hypercalcemia: Calcium levels elevated at 11.1. Calcium supplement was held with improvement in Ca from 11.1 to 9.9 with IV fluids. . Anion gap: The patient has an anion gap, likely secondary to dehydration in setting of decreased PO intake. Lactate was normal. Gap closed with administration of IV fluids and resumtion of diet on repeat labs. . Depression/Anxiety: The patient was very tearful, anxious throughout hospitalization and reported ongoing difficulties with depression. Continued home venlafaxine, trazodone prn and ativan with holding parameters. The patient was given Ativan IV q12h:PRN for anxiety. Pt. stated that she has suicidal ideations if she stays in the hospital. Should resolve with return to her home environment. . Anemia: Hematocrit remained stable at baseline 26-28. We continued iron supplements Type and screen was active. . Type II Diabetes: The patient was continued on Lantus [Hospital1 ] and Humalog sliding scale. Home lantus dose initially halved given NPO status but increased when diet was restarted. The patient had elevated FSG, likely secondary to steroid treatment, Humalog Insulin Sliding Scale tightened and pt restarted on home dose lantus. . Hypercholesterolemia: Continued statin. . Lung Cancer: Details are unclear but patient is s/p chemotherapy and lobectomy at unknown date. This is not currently considered an active issue. . FEN: Low Sodium / Heart Healthy / Diabetic Diet. Prophylaxis: Patient was on PPI for GI prophylaxis and Subutaneous Heparin for DVT Prophylaxis. . Access: peripheral IV . Code: DNR/DNI (discussed with patient) . Communication: [Name (NI) ] [Name (NI) 22090] (friend) [Telephone/Fax (1) 22091] Dispo: Pt. with improved oxygenation. Discharge to [Hospital 100] Rehab MACU. Medications on Admission: Bactrim DS [Hospital1 ] (started [6-2]) Lorazepam 1 mg QHS Trazodone 25 mg QHS Albuterol nebulizers Q4H (started [6-2]) Ipratropium nebulizers Q4H (started [6-2]) Fluticasone inhaler 1 Puff [Hospital1 ] Iron 1250 mg [Hospital1 ] Lorazepam 0.5 mg daily:RPN Tylenol 650 mg Q4H:PRN and QHS Amlodipine 10 mg daily Cholecalciferol 1000 U daily Hydrochlorothiazide 25 mg daily Lisinopril 40 mg daily Insulin glargine 54 U QAM, 30 U QPM Calcium Carbonate 650 mg [Hospital1 ] Venlafaxine XR 75 mg daily Simvastatin 40 mg daily Albuterol Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 1 injection Injection TID (3 times a day). 2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 2 doses: Needs 1 dose on [2188-6-7] and a final dose on [2188-6-9]. 9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation Inhalation Q6H (every 6 hours). 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) inhalation Inhalation Q6H (every 6 hours). 12. Fluticasone 100 mcg/Actuation Disk with Device Sig: One (1) puff Inhalation twice a day. 13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for anxiety. 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 15. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 4 days: Start date: [2188-6-5] End date: [2188-6-8] Pt. received antibiotics at [Hospital1 18] from [2188-6-2] to [2188-6-5]. Total course of antibiotics should be 7 days. 16. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q48H (every 48 hours) for 4 days: Start date: [2188-6-5] End date: [2188-6-8] Pt. received antibiotics at [Hospital1 18] from [2188-6-2] to [2188-6-5]. Total course of antibiotics should be 7 days. 17. Insulin Glargine 100 unit/mL Cartridge Sig: Fifty Four (54) units Subcutaneous qAM. 18. Insulin Glargine 100 unit/mL Cartridge Sig: Thirty (30) units Subcutaneous qPM. 19. Insulin Lispro 100 unit/mL Cartridge Sig: as directed units Subcutaneous four times a day: Per attached sliding scale. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: COPD Exacerbation, Pneumonia and Delirium Secondary: DM2, HTN, Lung Ca (s/p lung resection), depression Discharge Condition: Vitals stable, O2 saturation >90% on 2 liters nasal canula. Discharge Instructions: You were admitted to [Hospital1 18] with shortness of breath, which likely resulted from a combination of exacerbation of your COPD and a respiratory infection, likely pneumonia. You were treated for pneumonia with antibiotics (Vancomycin, Zosyn, Levaquin). You were given nebulizer treatments and steriods (Solumedrol, followed by Prednisone) for COPD exacerbation. You initially were put on noninvasive positive pressure respiration (BiPAP) to help with you breathing and later were switched to oxygen. Your kidney function has worsened over the past several days likely secondary to dehydration. You should continue to receive IV fluids and drink plenty of fluids over the next several days to help your kidneys. Your breathing and oxygenation have improved over several days. You should continue taking IV antibiotics (Zosyn, Vancomycin and Levaquin) for a period of 7 days total (you received 4 days in the hospital). We treated you with a fast steroid taper which has completed while in the hospital. You should also continue with nebulizer treatments (Albuterol, Atrovent) for now. We have made the following medication changes. We have held your Lisinopril and hydrochlorothiazide because of your acute renal failure. We have also stopped your Advair Discus and switched you to Fluticasone inhaler, because you were tachycardic and because your are already getting Albuterol and Atrovent nebs. We have made the changes to your sliding scale to control your blood sugars while you were on steroids. We do not recommend that you receive any further antipsychotics or Lasix. You should return to the hospital should your breathing worsen or you develop new chest pain, fever, severe cough. You should follow up with your PCP at [Hospital 100] Rehab upon discharge from the hospital. Followup Instructions: You should follow up with your PCP at [Hospital 100] Rehab upon discharge. You should follow up with your psychiatrist upon discharge. Completed by:[2188-6-5]	[ "486", "5849", "25000", "4019", "311" ]
Admission Date: [2100-11-5] Discharge Date: [2100-11-9] Date of Birth: [2027-9-18] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 371] Chief Complaint: rigors Major Surgical or Invasive Procedure: [2100-11-6] CT-guided aspiration of right hepatic abscess History of Present Illness: 73 year-old Cantonese-speaking-only man s/p cholecystectomy on [2100-10-17] presents after syncopal episode. He was noted on post-op day #1 to be unsteady on his feet and complaining of dizziness but was not orthostatic, and physical therapy consult cleared him on post-op day #2 to go home without any assistance, despite oxygen desaturation to mid 80s without dyspnea. He now has 2-3 days of subjective fever, chills, night sweats, shaking, malaise, poor PO intake, and diffuse abdominal ache. At the time of consultation he had a prodrome of lightheadedness and syncope in the morning. There was brief loss of consciousness, and he was incontinent of stool. He has no history of previous syncope or seizures. He had stopped taking tramadol on [2100-11-2] because his PCP said it might be affecting his appetite. CT scan performed in the ED showed a fluid collection in the gallbladder fossa and an additional fluid collection (likely abscess) in the liver parenchyma. Past Medical History: Past Medical History: hypertension, GERD, H. Pylori, symptomatic cholelithiasis Past Surgical History: laparoscopic cholecystectomy Social History: Denies alcohol/drug use Denies tobacco use Cantonese-speaking Lives alone Family History: notable for a family history of TB. otherwise non-contributory Physical Exam: On admission: Vitals: T 97.1, HR 88, BP 118/63, RR 16, 98% 2L NC GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, normoactive bowel sounds, no palpable masses Ext: No LE edema, LE warm and well perfused On discharge: Vitals: 99.2 70 140/70 18 94% RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, nontender, no rebound or guarding, no palpable masses Ext: No LE edema, LE warm and well perfused, + pedal pulses Pertinent Results: 17.7>12.9/39.6<344 N 95.0, L 3.4, M 1.3, E 0.1, B 0.2 . 136/98/20 ---------<134 4.1/26/1.5 . Lactate 2.7 PT 13.5, PTT 26.8, INR 1.3 ALT 47, AST 45, AP 61, Lip 19, Tbili 0.7 [11-4] CXR: Stable moderate right pleural effusion and resolution of previously noted left pleural effusion. Bibasilar airspace opacities likely reflect atelectasis, though infection cannot be completely excluded. [2100-11-4] CT abdomen/pelvis 1. Post-surgical changes related to recent cholecystectomy. There is fluid collection within the resection bed, which may represent a biloma, hemorrhage, or alternatively an abscess formation. Just superior to the resection bed within segment [Doctor First Name 690]/b, there is a multicystic lesion involving the liver parenchyma, most compatible with an abscess formation. This lesion appears new from [2100-10-17] ultrasound exam. There is apparent hyperemia surrounding the lesion. Dilated tubular structures within the resection bed likely represent residual cystic ducts. 2. Multiple liver cysts or hamartomas. 3. Right lung base consolidation may represent aspiration, infection in the appropriate setting, or atelectasis with adjacent small pleural effusion. [2100-11-4] Blood culuture results: KLEBSIELLA PNEUMONIAE Brief Hospital Course: Mr. [Known lastname ] was admitted on [2100-11-5] with fevers, rigors s/p syncope on [2100-11-4]. Labs and imaging were concerning for peri-hepatic abscess. He was admitted to the floor and started on zosyn and IV fluids for hydration. While on the floor he had persistent fevers and rigors, with oxygen desaturation and tachycardia, so was transferred to the ICU. In the ICU he remained stable and underwent CT guided drainage of intra-abdominal abscess: drained 18cc of purulent fluid, no drain left in place. The intrahepatic collection not amenable to perc drainage. He was subsequently transferred back to the floor, where he remained hemodynamically stable with a heart rate in the 70s-80's. His oxygen was weaned at his O2 sats remained in the mid 90's on room air. He had minimal low grade temps, not above 100.0. ON [11-8] his blood cultures (which grew kleibsiella pneumoniae) came back as sensitive to ciprofloxacin, and his antibiotic regimen was changed to PO cipro. On [2100-11-9], he remained afebrile and hemodynamically stable on oral antibiotics. His respiratory status remained uncompromised. He denied further syncopal episodes or abdominal pain. He was tolerating a regular diet and out of bed ambulating indepdendently with a steady gait. He felt well and was discharged to home with VNA services and scheduled follow up in [Hospital 2536] clinic. Medications on Admission: MEDS at previous discharge: - sertraline 50 mg qd - omeprazole 20 mg qd - acetaminophen 1000 mg tid - oxycodone 5 mg Q4H PRN - docusate sodium 100 mg [Hospital1 ] - bisacodyl 10 mg qd PRN - magnesium hydroxide PRN - senna 8.6 mg [Hospital1 ] PRN - atenolol 50 mg - vitamin D3 [2088] IU qd - alendronate 70mg 1x/wk - vitamin D [Numeric Identifier 1871] IU 1x/wk Discharge Medications: 1. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:9 Tablet(s) Refills:0 2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:20 Tablet(s) Refills:0 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: 1. Bacteremia 2. Intraabdominal abscess Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You came to the hospital with fevers, chills and a report of a syncopal episode. On CT scan, you were found to have a fluid collection near the area where your gallbladder was removed on your previous hospital admission. You were also found to have bacteria in your blood. You were given IV antiotics, and are not being discharged home with a prescription for oral antibiotics. It is important that you take the entire course of antibiotics as prescribed, even if you are feeling better. You may resume a regular diet. You should resume all of your regular home medications that you were taking prior to coming to the hospital. You are being given a prescription for narcotic pain medication. Take the medication as need, but do not take it more frequently than prescribed. You may also take tylenol as needed for pain, but do not take more than 4 grams (4,000 mg) of tylenol in 24 hours. Narcotic medications can cause constipation so be sure to drink plenty of fluids to avoid this. You may take an over the counter stool softener such as colace or milk of magnesia if needed to prevent constipation. Do not drink alcohol or drive/operate heavy machinery while taking narcotics. Please call your doctor or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Completed by:[2100-11-9]	[ "4019", "53081" ]
Admission Date: [2163-12-6] Discharge Date: [2163-12-30] Date of Birth: [2078-5-30] Sex: F Service: MEDICINE Allergies: Penicillins / Latex / lisinopril / levothyroxine sodium Attending:[First Name3 (LF) 13685] Chief Complaint: Leg swelling Major Surgical or Invasive Procedure: None History of Present Illness: 85F history of aortic aneurysm s/p repair, diastolic CHF, Afib, severe aortic regurgitation, and multiple recent admissions for CHF exacerbation and pneumonia, presenting with bilateral lower extremity swelling. Says her leg swelling has been persistent for the past month despite hospital admission and diuresis with IV lasix. She is on home torsemide increased on [2163-12-5] to 30 mg daily from 20 mg. No shortness of breath, chest pain, palpitation, fevers, chills, cough, URI symptoms, changes in diet or salt intake, medication noncompliance, nausea, vomiting. Of note, patient had multiple readmissions, 3 at [Hospital1 5109] and 2 at [Hospital6 ] over the past 3 months per patient's report. At [Last Name (un) 1724] admission on [2163-9-27], she was treated with doxycycline and uptitrated her home Lasix to 120 mg daily. Patient reports hospital admissions for 7 days at [Hospital3 ] in early [11/2163] for CHF exacerbation, pneumonia, and LLE cellulitis for which she is on a course of Clindamycin (exact timecourse is unclear, will obtain OSH records). At baseline, patient is on home O2 2L which she wears all the time. Denies CP, SOB, lightheadedness at home. Sleeps on 2 pillows, denies PND. Mobility limited by leg swelling and pain. In the ED, initial VS: 96.3 77 98/65 20 95% 4L Nasal Cannula. Labs notable for Cr of 1.7 ([12-2]: cr 1.28). EKG showed A. fib at 67, QTC 478, and nonspecific ST changes. CXR concerning for RLL inflitrate c/f CAP. Per ED report, assessed to be volume overloaded on exam. Patient was given ASA 325 and Levofloxacin 750 mg IV. VS prior to transfer: 97 76 107/58 16 98% room 4LNC (wears 02 4lnc at home). ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: ?????? Aortic Aneurysm, Thoracic s/p open heart surgery and repair ?????? Aortic valve insufficiency ?????? COPD (chronic obstructive pulmonary disease) ANEMIA ?????? HYPERCHOLESTEROLEMIA ?????? HYPERTENSION - ESSENTIAL, BENIGN ?????? HYPOTHYROIDISM ?????? LOW BACK PAIN ?????? ATRIAL FIBRILLATION ?????? HEART FAILURE - DIASTOLIC, CHRONIC ?????? MYOCARDIAL INFARCT - INFERIOR, UNSPEC CARE ?????? LOW BACK PAIN ?????? GASTRITIS - ACUTE ?????? DIVERTICULITIS ?????? THORACIC BACK PAIN Social History: Lives in same house as son in [Name (NI) 4444], MA. Worked as elderly caretaker until last year. Able to perform ADLs well, feels like memory has declined over past few years. Smoking - Quit 40 yrs ago, previously [1-9] ppd Alcohol - None currently, used to have occasional wine. Illicits - None. Family History: Family history positive for "heart disease." Physical Exam: ADMISSION PHYSICAL EXAM: VS - 97.0 96.2 108/68 72 18 99%2L GENERAL - Elderly-appearing woman in NAD, comfortable, pleasant HEENT - MMM, OP clear NECK - Supple, JVD at 15cm, no carotid bruits LUNGS - Mild crackles at the bases bilaterally, no r/rh/wh, decreased air movement, resp unlabored, no accessory muscle use HEART - Irregular rhythm, loud S2, RV heave, no MRG ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - 2+ to 3+ pitting edema bilaterally to mid-thigh, chronic venous stasis changes on left ankle, warm and well perfused, tender to palpation throughout, DP and PT pulses intact, no cellulitis noted on LEs. SKIN - no rashes or lesions LYMPH - no cervical LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact. DISCHARGE PHYSICAL EXAM: VS: Afebrile, BP 80/50-110/60 50-72 94%2L GENERAL: Elderly-appearing woman in NAD, comfortable, pleasant NECK: Supple, JVD at 15cm with markedly dilated peripheral neck veins LUNGS: Crackles at the bases bilaterally, with decreased air movement throughout, respirations unlabored HEART: Irregular rhythm, at times bradycardic, loud S2, RV heave ABDOMEN: NABS, slightly protuberant with mild diffuse tenderness throughout, without rebound or guarding EXTREMITIES - 2+ to 3+ pitting edema bilaterally to mid-thigh, chronic venous stasis changes on left ankle, warm and well perfused, mildly tender to palpation throughout Pertinent Results: ADMISSION LABS: [2163-12-6] 03:00PM GLUCOSE-91 UREA N-50* CREAT-1.7* SODIUM-134 POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-31 ANION GAP-11 [2163-12-6] 03:00PM WBC-5.2 RBC-3.35* HGB-9.9* HCT-30.9* MCV-92 MCH-29.5 MCHC-32.0 RDW-18.2* [2163-12-6] 03:00PM NEUTS-64.7 LYMPHS-23.0 MONOS-9.2 EOS-2.2 BASOS-0.9 [2163-12-6] 03:00PM PLT COUNT-154 [2163-12-6] 03:00PM PT-15.8* PTT-43.1* INR(PT)-1.5* [2163-12-6] 03:00PM proBNP-6945* [2163-12-6] 03:00PM cTropnT-<0.01 DISCHARGE LABS: [2163-12-28] 04:16AM BLOOD WBC-6.7 RBC-2.93* Hgb-8.6* Hct-27.3* MCV-93 MCH-29.4 MCHC-31.5 RDW-18.0* Plt Ct-173 [2163-12-27] 02:58AM BLOOD PT-14.1* PTT-36.9* INR(PT)-1.3* [2163-12-28] 04:16AM BLOOD Glucose-97 UreaN-71* Creat-3.0* Na-128* K-4.7 Cl-84* HCO3-33* AnGap-16 [2163-12-24] 08:25AM BLOOD ALT-14 AST-29 LD(LDH)-303* AlkPhos-120* TotBili-0.8 [2163-12-23] 03:50PM BLOOD proBNP-7498* [2163-12-28] 04:16AM BLOOD Calcium-8.9 Phos-9.2* Mg-3.0* STUDIES: CXR [2163-12-6] IMPRESSION: 1. Opacity in the right lower lobe consistent with pneumonia or aspiration. 2. Emphysema 2. Severe cardiomegaly with mild interstitial edema. EKG [2163-12-6] Afib at 67, diffuse TWI, no ST changes, normal axis CXR [2163-12-8] 1. Minimally increased right lower lobe opacity, either representing aspiration or pneumonia. 2. Cardiomegaly with unchanged mild interstitial edema. KUB [2163-12-18] AP supine and left decubitus views of the abdomen show that the gut is fluid filled and not demonstrably distended. There is no free intraperitoneal gas. ECHO [2163-12-27]: The left atrium is moderately dilated. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thickness and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is markedly dilated with moderate global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Trace aortic regurgitation is seen. Moderate (2+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Dilated and hypokinetic right ventricle. Severe functional tricuspid regurgitation. Small left ventricle with normal global and regional systolic function. Normally-functioning aortic valve bioprosthesis. Moderate mitral regurgitation. ECG [2163-12-28]: Sinus bradycardia, rate 54. Sinus bradycardia persists. There is low voltage throughout raising question of hypothyroidism. Otherwise, tracing is unchanged. Brief Hospital Course: 85F with history of aortic aneurysm s/p repair, diastolic CHF, Afib, severe aortic regurgitation, and multiple recent admissions for CHF exacerbations and pneumonia, presenting with bilateral lower extremity swelling and dyspnea. #. Acute on chronic diastolic congestion heart failure: She presented with substantial peripheral edema, JVD, and hepatomegaly felt to be severe right-sided heart failure from severe tricuspid regurgitation. Also has some moderate to severe MR felt to be contributing to her dyspnea. She has had multiple recent admissions for her difficult to control CHF. Denies any chest pain or palpitations during this admission, but did have waxing and [Doctor Last Name 688] shortness of breath. She was aggressively diuresed on a lasix drip (sometimes with metolazone augmentation) with some improvement in her symptoms. She was transitioned once to oral torsemide but began to gain weight again and was placed back on a lasix drip. However, eventually her urine output downtrended despite a lack of improvement in her dyspnea and she became oliguric with rising creatinine. She still had evidence of profound volume overload at that time. she was evaluated by cardiac surgery regarding her severe TR but was not deemed to be a surgical candidate. She was transferred to the CCU in the setting of hypotension and oliguria, where she was continued on a lasix drip without improvement in her symptoms or urine output. A meeting with the family and patient was held, and she decided to transition to comfort measures only and decided to be DNR/DNI. She is being discharged to home on hospice. #. Acute Kidney Injury: She had admission Cr of 1.7 which fluctuated during her hospital course. This is above her baseline of around 1.3 and was felt to be prerenal in the setting of CHF with poor forward flow. Her creatinine initially improved with diuresis but her diuresis limit was reached and she became oliguric. Her creatinine remained elevated around 3.0 at the time of discharge. #. Clostridium difficile colitis: She had been treated with clindamycin at an OSH for possible cellulitis of the legs. She became delirious on [12-17] with fevers and increased stool output, and was found to be C.diff positive. She was started on PO vancomycin on [12-18] for a fourteen day course. She remained afebrile, without leukocytosis and with KUB showing no signs of colonic dilatation, just stool. Her diarrhea and abdominal cramping were improving at the time of discharge. She will continue PO vancomyin q6h until [2163-12-31]. #. History of deep vein thrombosis: She has a history of recent DVT that was complicated by GI bleed so was discharged from OSH without anticoagulation. Repeat LENIs normal on [2163-12-7]. Despite her history of DVT and CHADS2 score of 3, anticoagulation was held due to her history of multiple GI bleeds in the past. She will not be anticoagulated at discharge. #. GI Bleed: She was guaiac positive, with occasional dark stools but stable Hct. OSH endoscopies this year/late last year have shown duodenal AVMs and moderate gastritis. She was started on IV PPI but as patient's Hct remained stable, she was switched back to her home dose PPI. Heparin SC was decreased in dose initially, and discontinued after she was made CMO. #. Thrombocytopenia: She was noted to have downtrending platelets during this admission with nadir of 103. Patient with intermittent dried blood in nose from nasal cannula and with one episode of hemoptysis. Platelet count rebounded and was back to the normal range at the time of discharge. It was not felt to be associated with heparin use. #. COPD: She was maintained on her home oxygen at 2L NC. Patient continued on her home regimen, which will be continued for comfort after discharge. #. Back pain: She had continued chronic right-sided back spasms that were controlled with her home regimen of Vicodin and Fentanyl patch. #. Atrial fibrillation: She has been previously on coumadin which was held permanently due to recurrent GI bleeds. Despite CHADS2 score of 3, we continued no anticoagulation and she will not be anticoagulated at discharge. She was rate controlled on metoprolol for much of her admission, which was stopped in the ICU for bradycardia to the 40's. HR at the time of discharge was about 60. #. HTN: Systolic blood pressures ran in 90's-100's for most of her admission which is at her baseline. We monitored pressures closely in setting of diuresis and held metoprolol for SBP <100's. She did have episodes of hypotension in the setting of worsening renal function necessitating CCU transfer for 2 days. At discharge, metoprolol has been discontinued due to low blood pressures and heart rates. #. HLD: Continued Simvastatin during admission, this was stopped at discharge because she is CMO. #. Hypothyroidism: Continued Levothyroxine. #. Code status and goals of care: She was admitted as full code, which was transitioned to DNR/DNI while she was in the CCU. After she failed medical therapy with IV diuretics and was determined not to be a surgical candidate, a family meeting was held. She was transitioned to CMO and was discharged to home with hospice. TRANSITIONAL ISSUES: - Sent home with hospice, goals of care are to focus on comfort Medications on Admission: Budesonide-Formoterol (SYMBICORT) 80-4.5 mcg/Actuation Inhalation HFA Aerosol Inhaler take 1 puff twice per day Torsemide 30 mg Oral Tablet Take 1 tablet daily or as directed Clindamycin HCl 150 mg Oral Capsule Take 2 capsules 3 times a day 10 days Fentanyl 25 mcg/hr Transdermal Patch 72 hr apply 1 patch every 72hrs Hydrocodone-Acetaminophen (VICODIN) 5-500 mg Oral Tablet 1 tab qid prn Simvastatin 40 mg Oral Tablet Take 1 tablet every evening for cholesterol Levothyroxine 200 mcg Oral Tablet 1 tab daily Omeprazole (PRILOSEC) 20 mg Oral Capsule, Delayed Release(E.C.) 1po qd Nitroglycerin 0.4 mg Sublingual Tablet, Sublingual 1 tablet sublingually every 5 minutes as needed for chest pain Metoprolol Succinate 25 mg Oral Tablet Extended Release 24 hr 1 tab daily Polyethylene Glycol 3350 17 gram/dose Oral Powder 17gm in liquid daily Senna 187 mg Oral Tablet take 1-2 tablets daily as needed Ferrous Sulfate 325 mg (65 mg Iron) Oral Tablet take two times daily Docusate Sodium 100 mg Oral Capsule Take [1-9] capsules daily as needed; available over the counter CALCIUM CARBONATE-VITAMIN D3 600 MG, 1,500 MG,-400 UNIT CAP 600 mg(1,500mg) -400 unit Oral Cap Take 1 tablet twice daily; available over the counter Discharge Medications: 1. levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 2. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Back pain. Disp:120 Tablet(s) Refills:0 3. Symbicort 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation twice a day. Disp:1 inhaler Refills:2 4. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours. Disp:30 patches Refills:2 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN PAIN Q5MIN as needed for chest pain: Please take only up to 3 times. Disp:15 Tablet, Sublingual(s) Refills:0 7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) unit PO DAILY (Daily) as needed for constipation. Disp:30 units Refills:2 8. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. Disp:60 Tablet(s) Refills:2 9. docusate sodium 100 mg Capsule Sig: [1-9] Capsules PO BID (2 times a day) as needed for Constipation. Disp:60 Capsule(s) Refills:2 10. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 2 days: Last dose on [12-31]. Disp:8 Capsule(s) Refills:0 11. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath. Disp:120 nebs Refills:2 12. torsemide 20 mg Tablet Sig: Four (4) Tablet PO once a day. Disp:120 Tablet(s) Refills:2 13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. Disp:3600 ML(s) Refills:3 14. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for indigestion. Disp:120 Tablet, Chewable(s) Refills:2 15. nystatin 100,000 unit/mL Suspension Sig: 5-10 MLs PO QID (4 times a day) as needed for thrush for 3 days. Disp:1200 ML(s) Refills:2 16. sodium chloride 0.65 % Aerosol, Spray Sig: [1-9] Sprays Nasal QID (4 times a day) as needed for nasal congestion. Disp:240 sprays Refills:2 17. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. Disp:90 Tablet(s) Refills:2 18. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:360 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: Hospice of the [Location (un) 1121] Discharge Diagnosis: Primary Diagnosis: Acute on chronic diastolic congestive heart failure C.diff colitis Secondary Diagnosis: COPD HYPERCHOLESTEROLEMIA HYPERTENSION HYPOTHYROIDISM LOW BACK PAIN ATRIAL FIBRILLATION HISTORY OF GASTRITIS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [Known lastname 92530], You were admitted to [Hospital1 18] for an exacerbation of congestive heart failure. You were given a medicine to help remove excess fluid from your body and your shortness of breath improved. You also acquired an infection called Clostridium difficile (also called C.diff), which is a bacteria that leads to inflammation of the gut and causes diarrhea. We will send you home with antibiotics to treat this infection. After discussion with you and your family, we have decided to focus on comfort measures after you return home. You will be seen by a home hospice service after discharge. The following changes were made to your medications: START vancomycin 125mg by mouth every six hours until [12-31] STOP clindamycin STOP simvastatin STOP metoprolol STOP ferrous sulfate (iron pills) INCREASE torsemide to 80mg daily Followup Instructions: Please follow-up with your hospice nurses for any questions or concerning symptoms.	[ "5849", "2875", "2761", "4280", "42731", "4240", "40390", "2859", "2720", "2449" ]
Admission Date: [2168-3-27] Discharge Date: [2168-4-1] Date of Birth: [2116-5-12] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 14820] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Coronary catheterization History of Present Illness: 51 yo M smoker w/ hx HTN, dyslipidemia, pafib, CAD s/p STEMI x2 s/p DESX2 to proximal and middle RCA and BMS to distal RCA, p/w CP [2-22] dull L chest w/ N, SOB, diaphoresis, simlar to MI in [10-21] relieved w/ NTG, took ASA 325 en route. The patient had been drinking and smoking while watching a ball game this afternoon. He reports that he had sudden onset of substernal chest pain occuring at rest, radiating to this neck and associated with diaphoreis. No SOB, diaphoresis, nausea, or vomiting. He reports this is similar to angina he had prior to MI in [Month (only) ]. He called EMS 1 hour later and came to the ED. CP relieved somewhat by SL nitro but not completely. When seen on the floor CP about [1-24], left-sided, not radiating. Diaphoresis resolved. No N/V/LH. When seen on the floor pt states he has not takn any cocaine since his last MI. He also states he has been nauseous lately which he attributed to labetalol which he stopped taking one week ago with resolution of nausea. . In the ED, initial vitals were BP112/69, HR83, RR26, O2 96%RA. CXR was unremarkable. EKG showed NSR with ventricular bigemy (no ST changes). Upon arrival to the ED he received SL Nitro x 1 and 1" nitro paste. Also received morphine 4mg IV x 1. Cardiology was consulted and he was started on a heparin drip. Past Medical History: # CAD - s/p STEMI on [2165-7-10] s/p DESx2 to proximal and mid RCA - s/p STEMI on [2167-11-27] s/p BMS to distal RCA # paroxysmal atrial fibrillation # depression # possible personality disorder # external hemorrhoids by history # ACL tear of the right knee # osteoarthritis of the left knee # Hypertension # Dyslipidemia # Substance abuse - cocaine and MJ # Current Smoker . Cardiac Risk Factors: positive family history (father with 2 MI's at age 55); past and present smoking (2 packs per day X 35 years); and cocaine use. + Dyslipidemia, + Hypertension Social History: Social history is significant for smoking 1ppd. There is no history of alcohol abuse. Occasional marijuana use. no cocaine since last STEMI Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: (on admission) VS - 99.2 159/93 65 18 100RA Gen: NAD. Oriented x3. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP of 6 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: 2D-ECHOCARDIOGRAM performed on [2168-3-24] demonstrated: The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. LV systolic function appears moderately-to-severely depressed (ejection fraction 30 percent) secondary to akinesis of the inferior free wall and severe hypokinesis of the posterior (inferolateral) wall; the inferior septum is also hypokinetic. There is no ventricular septal defect. The right ventricular cavity is dilated with depressed free wall contractility. The aortic root is mildly dilated at the sinus level. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild to moderate ([12-16]+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. . Prelim cath ([2168-3-28]): 1. Coronary angiography in this right dominant system demonstrated an LMCA without angiographically apparent disease. The LAD had a 50% mid-vessel lesion. The LCX system had a 70-80% OM1 lesion and a 50%OM2 lesion. The RCA was totally occluded in the distal aspect of the previously placed stents. 2. Limited resting hemodynamics showed normal systolic arterial pressure. 3. Successful stenting of the OM1 with a 3.0 X 18 mm Vision bare metal stent postdilated proximally to 3.5 mm with no residual stenosis (see PTCA comments for detail). Residual 50% ostial disease in OM2 with normal flow. 4. Aborted attempt at recanalization of the chronically totally occluded RCA stents. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Successful stenting of OM1 with bare metal stents. 3. Aborted chronic total occlusion RCA intervention. 4. Successful closure of the right femoral arteriotomy with Mynx device. . [2168-3-31] Cardiac MRI: Impression: 1. Moderately increased left ventricular cavity size and moderately decreased left ventricular systolic function with mild global hypokinesis and akinesis of the entire inferior wall and the mid and basal inferoseptum. The LVEF was moderately decreased at 33%. Delayed contrast-enhanced MR [First Name (Titles) 38373] [Last Name (Titles) 4579]d areas of delayed enhancement as described above. These findings are consistent with poor likelihood of functional recovery of the entire inferior wall and the mid and basal inferoseptum after mechanical revascularization. 2. Mildly increased right ventricular cavity size and moderately decreased systolic function with mild global hypokinesis and akinesis of the mid and basal inferior segments. The RVEF was moderately depressed at 29%. Delayed contrast-enhanced MR [First Name (Titles) 38373] [Last Name (Titles) 4579]d areas of delayed enhancement in the mid and basal inferior segments, suggestive of prior right ventricular infarction. 3. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was normal. 4. Biatrial enlargement. Brief Hospital Course: 51 yo M smoker w/ hx HTN, dyslipidemia, pafib, CAD s/p STEMI x2 s/p DESX2 to proximal and middle RCA and BMS to distal RCA, p/w SSCP, diaphoresis, simlar to MI in [10-21] found to have NSTEMI entered two 30s runs of vtach prior to cath, now s/p BMS to OM1 . # CAD s/p STEMI x2 now s/p NSTEMI and BMS to OM1 - taken to cath with BMS to OM1 (70-80% OM1 lesion on cath) - CK peaked at 242 and MBI 21 - continued ASA, atorvatatin, plavix - integrillin for 18hrs - changed BB to carvedilol given nausea wih labetalol and wanted to maintain for alpha blockade givenhx of cocaine use - restarted lisinopril . # Pump - no evidence of failure on exam but with known EF 30% (from last week prior to NSTEMI) - cardiac MRI confirmed low EF with EF 33% - continued on BB, ACEi - EP consult for possible AICD given known previous EF 30% but EP did no think beneficial . # Rhythm - pt had 2 runs of symptomatic VT on the night of admission, each lasting 30 seconds and associated with LH with spont resolution - was given lidocaine bolus with drip with no further arrhythmias after the night of admission - was taken off lido gtt after cath per EP recommendation (EP was consulted) - had cardiac MRI with mild global hypokinesis and akinesis of the entire inferior wall and mid/basal inferoseptum with delayed contrast-enhanced MR images in these areas as well as mild global hypokinesis and akinesis of the mid and basal inferior segments of the RV with areas of delayed enhancement in the mid and basal inferior segments, suggestive of prior right ventricular infarction. - pt was taken to lab for EP study and ablation in the posterior/inferior wall and cleared by EP to be safely discharged the following day since no further arrhythmias . # Hypertension - BB and ACEi as above . # Dyslipidemia - cont lipitor Medications on Admission: ASA 325 mg labetalol 100mg [Hospital1 ] --> stopped taking a week ago Plavix 75 mg Simvastatin 80 mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 4. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual prn as needed for chest pain: - may repeat x3 q minutes - if use call 911. Disp:15 tabs Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: # CAD - s/p STEMI on [2165-7-10] s/p DESx2 to proximal and mid RCA - s/p STEMI on [2167-11-27] s/p BMS to distal RCA - s/p NSTMEI on [2168-3-27] s/p BMS to OM1 # Symptomatic ventricular tachycardia, peri-MI # Hypertension # Dyslipidemia # Current Smoker Secondary Diagnoses: # paroxysmal atrial fibrillation # depression # possible personality disorder # external hemorrhoids by history # ACL tear of the right knee # osteoarthritis of the left knee # Hypertension # Dyslipidemia # Substance abuse - cocaine and MJ # Current Smoker Discharge Condition: Stable, chest pain free Discharge Instructions: You were admitted to [Hospital1 18] with a myocardial infarction. We placed a cardiac stent into one of your coronary arteries. You also had symptomatic ventricular tachycardia due to a scar in you heart for which an ablation in order to prevent another episode was attempted, but it was unsuccessful. You may need a defibrillator in the future, but this decision will be made with you and your doctor at a later date. Please take your previous medications as prescribed. The following changes has been made to your medications: - Please start taking lisinopril 5 mg daily for your heart and blood pressure (prevents remodelling of the heart) - Please start taking carvedilol 3.125 mg [Hospital1 ] for your heart and blood pressure (prevents remodelling of the heart) If you develop chest pain, jaw pain, or chest pressure with pain radiating into arm, or if you for any reason become concerned about your medical condition please call 911 or present to nearest ED. We also gave you Nitroglycerin tablets to take if you experience chest pain, please call 911 or your doctor if chest pain recurs even if it dissapears with nitroglycerine. DO NOT STOP TAKING THE ASPIRIN OR PLAVIX UNLESS INSTRUCTED TO DO SO BY YOUR CARDIOLOGIST EVEN IF ANOTHER DOCTOR TELLS YOU TO We strongly recommend you stop smoking as discussed. Please go to your scheduled appointments listed below. Followup Instructions: Please call you PCP, [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 2393], to confirm the appointment we have set up for you on [4-20] Please call Dr. [Last Name (STitle) 22478] at [Telephone/Fax (1) ] for an appointment to be seen within 1-2 weeks Please call Dr. [Last Name (STitle) 38374] at [Telephone/Fax (1) ] for an appointment to be seen within 1-2 weeks	[ "4019", "4280", "2724", "42731", "412" ]
Admission Date: [2193-11-28] Discharge Date: [2193-12-10] Service: MEDICINE Allergies: Calcium Channel Blocking Agents-Benzothiazepines / Beta-Adrenergic Blocking Agents / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 30] Chief Complaint: Left main stem stent obstruction Major Surgical or Invasive Procedure: Bronchoscopy and left main stem stent removal History of Present Illness: 80 yo female with COPD, tracheobonchomalacia, CAD s/p MI (12yrs ago), seizure d/o, HTN, Type II DM s/p left mainstem stent [10-11] who presented to [Hospital 1562] hosp [11-24] with SOB and respiratory failure [1-14] LLL mucus plugging and L mainstem 90% occlusion. Also had seizure with sub-therapeutic dilantin level. Transferred to [Hospital1 18] for w/u of L mainstem stent obstruction. Dr.[Last Name (STitle) 57475] took patient to bronch, which revealed granulation tissue obstruction, then entire stent removed [11-29]. Since the patient did not feel better when the stent was placed, she was not considered to be a good candidate for tracheoplasty. Ms.[Known lastname 17562] could not be extubated after stent removal because of laryngeal edema/spasm, finally extubated [12-4] with no plans for further intubation if necessary (i.e. DNI). Vanc (started at OSH on [11-24])/levo (started [11-30]) to complete 10 day course for LLL opacities suspicious for PNA. Initially started on Nipride for tight BP control, weanded off on [11-30]. Started on captopril on [12-2] with good response to borderline hypotension. Past Medical History: Tracheobronchomalacia Respiratory distress COPD Depression Hypothyroid Hypertension Diabetes Hyperlipidemia Seizure disorder s/p MI (~12 years ago) Social History: Smoker since [2132], 1pack/week, quit ~12 years agoDenies alcohol and IDU useLives in nursing home, [Location (un) 6598] Manor, [Hospital3 ] Family History: Father with COPD Brother with stomach cancer Brief Hospital Course: 1. Stent Obstruction: Pt presented with shortness of breath and fever to [Hospital 1562] hospital [11-24] with SOB and LL mucus plugging. Bronch revealed left mainstem occlusion and pt transferred to [Hospital1 18] for care. Bronchoscopy at [Hospital1 18] also revealed nearly totally occluded L main stem stent, which was removed. No tracheostomy was placed since pt had no subjective improvement when stent initially went in, late [9-16]. Ms.[Known lastname 17562] was unable to be extubated second to lack of air-leak, and presumed laryngeal edema/spasm. Finally, she was extubated [12-4] and tolerated the extubation well. Currently, denies shortness of breath, cough, sputum production or chest pain. Interventional pulmonary no longer feels Ms.[Known lastname 17562] to be an interventional candidate for her tracheobronchiomalacia. 2. Seizure D/O: Pt experienced a seizure at OSH, by report. She was placed on dilantin and dosed by level. No further seizure activity. 3. DMII: Kept on insulin sliding scale and diabetic diet. No episodes of hyperglycemic coma or hypoglycemia. 4. ID: Vanc (started at OSH [11-24]) and levoquin (started [11-30]) to complete a 10 day course of possible post-obstructive PNA (will finish [12-10]). Now without features of pneuomonia by physical. No septic hemodynamics. Lactate normal. 5. HTN: Transiently required nipride gtt for BP control, easily transitioned to PO ACE-inhibitor, with good control. 6. Mental Status Change: Pt noted to have a decreased sensorium and behaving inappropriately. This was attributed to sedatives (while intubated), possible hypoxia, ICU psychosis and sundowning. She was at baseline by time of discharge. Medications on Admission: [Last Name (un) ] prn phenobarbital 120 po qhs dilantin 200 IV q8h levothyroxine 75 mic/d hep 5000 sq tid protonix 40 IV qD solumedrol 125 mg IV q8h levaquin 500 IV qd vanc 1g q12h propofol gtt atrovent nebs q6h albuterol nebs prn Discharge Medications: 1. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. Disp:qs Refills:0 3. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:30 Tablet(s) Refills:0 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours). Disp:180 neb Refills:2 6. Phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet, Chewable PO TID (3 times a day). Disp:270 Tablet, Chewable(s) Refills:2 7. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Location (un) ] mannor Discharge Diagnosis: Primary: 1. Tracheo-bronchomalacia. 2. Post-Obstructive Left Lower Lobe Pneumonia. 3. Delirium. 4. Larnygeal Edema. Secondary: 1. Hypertension. 2. Seizure D/O NOS. 3. Diabetes Mellitis. Discharge Condition: Good Discharge Instructions: If you have these symptoms, call your doctor or go to the ER: - fever/chills - shortness of breath (slowly worsening or sudden) - cough with blood/sputum - weakness - Headache - visual changes Followup Instructions: Pulmonary. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 7631], MD [Hospital1 57476], [Numeric Identifier 19665] ([Telephone/Fax (1) 57477] Completed by:[2193-12-10]	[ "486", "496", "4019", "25000" ]
Admission Date: [2124-5-9] Discharge Date: [2124-5-22] Date of Birth: [2069-5-31] Sex: M Service: MEDICINE Allergies: Penicillins / Enalapril Attending:[First Name3 (LF) 800] Chief Complaint: found down Major Surgical or Invasive Procedure: Intubation, Sedation Femoral line placement and removal History of Present Illness: The patient is a 54 yoM w/ a h/o ETOH and hep C related cirrhosis, ETOH cardiomyopathy (although last EF was normal in [1-24]), atrial fibrillation and ETOh abuse who presents after being found by [Location (un) ] police in an ally way. He was unable to get up and so EMS was called and he was brought to the ER. . In the emergency department, initial vitals: T 97.0 HR 120 BP 116/82 RR 28 O2 100%. Last drink 10 a.m. this a.m., found by [Location (un) ] police who asked he get up and leave and he could not. FSBH 35 by EMS, improved w/ amp of D50. He felt like he was withdrawing in the ER and got valium 40mg IV valium (in 10mg increments). Given levo / flagyl in ER for aspiration PNA. Got rectal ASA given that he had CP in ER upon initial presentation. Given 7L IVF in ER. Thiamine given by EMS. In addition the patient had 3 runs of NSVT up to 20 seconds and spontaneously. He was given an amiodarone bolus and started on 1mg / hr of amiodarone- in addition he was given 1 amp of bicarbonate. . VS prior to transport to ICU: HR 130 121/68 RR 39 O2 97% on 4L . In the ICU the patient complains of only nausea x 1 day, diarrhea x 2 days, chronic low back and knee pain as well as some chills. No abdominal pain, no current chest pain although did have chest pressure associated w/ SOB in the ER, he is unsure how long this lasted, no radiation. This has happened to him 2 x in the past month, independent of any exertion. Has happened occasionally for the past "many years." Baseline functional capacity is "walking around," not up stairs and no longer than a city block- without symptoms. No unexplained syncope or LH, no palpitations. No orthopnea, or PND. No bleeding. No pedal edema. Rest of ROS is negative. No h/o w/d seizures, no h/o DTs. Has had w/d characterized by tremor and agitation in the past. Past Medical History: Atrial fibrillation Cardiomyopathy (although EF [1-24] was normal) Alcohol abuse Hypertension Pancreatic cyst Status post knee replacement Hepatitis C cirrhosis Back arthritis Social History: Active drinker, drinks at least [11-19] pint vodka daily, + tobacco 2ppd for 40 years, denies other drug use. Lives alone in [Location (un) ] housing. Not married. Family History: Positive for coronary artery disease (details unknown) and hypertension. His father had an aortic aneurysm. There is a history of cancer of the brain and the breast. Physical Exam: VITAL SIGNS: T 96.5 (PO) HR 130 BP 151/92 RR 28 O2 sat 94% 3L NC GEN: NAD, AOx3 HEENT: EOMI, MMM, OP clear CHEST: bibasilar rales, diffuse wheezes bilaterally, tachypneic CV: tachycardic, RR, no m/r/g ABD: soft, moderate distension, NT, no masses, liver felt 3cm below R costal margin, no splenomegaly EXT: WWP, no c/c/e NEURO: 5/5 strength all 4 extremities, CN2-12 normal, AOx3 Pertinent Results: Osmolar gap: calculated osms: 144x2 + 75/18 + 30/2.8 + 90/4.6 = 322.5 serum osm 342 osmolar gap 19.5 . MICROBIOLOGY: Blood cultures [2124-5-9] P . STUDIES: [2124-5-9] CT head w/o contrast: No acute intracranial abnl. [2124-5-9] CXR: R basilar atelectasis, lungs otherwise clear [2124-5-9] EKG: sinus tachycardia with a rate of 128, normal axis and intervals. no ST T WAve changes, no Q waves. normal R wave progression . Old studies: [1-24] ECHO: mild symmetric LVH, normal EF, no valvular dysfunction, indeterminate PASP. . [2124-5-10] ECHOCARDIOGRAM: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Dilated thoracic aorta. No structural heart disease or pathologic flow identified. Compared with the prior study (images reviewed) of [2124-1-17], the findings are similar. . [2124-5-18] VIDEO SWALLOW STUDY: RECOMMENDATIONS: 1. PO diet: regular solids, thin liquids 2. PO meds whole with thin liquids 3. TID oral care 4. Distant supervision with meals to maintain aspiration precautions and assist with self-feed as willing. 5. Please page/reconsult if we can be of further assistance. . LABS: [2124-5-9] 01:40PM WBC-5.0 RBC-3.52* HGB-12.3* HCT-39.9* MCV-113# MCH-35.0# MCHC-30.8* RDW-17.5* [2124-5-9] 01:40PM NEUTS-34* BANDS-32* LYMPHS-21 MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-6* MYELOS-1* NUC RBCS-1* [2124-5-9] 01:40PM PLT SMR-LOW PLT COUNT-132* . [2124-5-9] 01:40PM ASA-NEG ETHANOL-90* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG . [2124-5-9] 01:40PM OSMOLAL-342* [2124-5-9] 01:40PM GLUCOSE-75 UREA N-30* CREAT-3.2# SODIUM-144 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-6 ANION GAP-39* . [2124-5-9] 01:50PM LACTATE-9.6* . [2124-5-9] 04:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-8* PH-5.0 LEUK-TR [2124-5-9] 04:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-8* PH-5.0 LEUK-TR . [2124-5-9] 04:20PM BLOOD Lipase-481* [2124-5-10] 05:42AM BLOOD Lipase-68* . [2124-5-9] 01:40PM BLOOD CK-MB-11* MB Indx-2.9 cTropnT-<0.01 [2124-5-9] 01:40PM BLOOD CK(CPK)-378* [2124-5-9] 08:56PM BLOOD CK-MB-31* MB Indx-2.4 cTropnT-<0.01 [2124-5-9] 08:56PM BLOOD CK(CPK)-1308* [2124-5-10] 05:42AM BLOOD CK-MB-34* MB Indx-2.1 cTropnT-<0.01 . [2124-5-10] 05:42AM BLOOD ALT-70* AST-175* CK(CPK)-1636* AlkPhos-61 TotBili-1.0 [2124-5-11] 04:05AM BLOOD ALT-56* AST-112* LD(LDH)-346* CK(CPK)-654* AlkPhos-61 TotBili-0.7 Brief Hospital Course: #. Anion gap metabolic acidosis: combination of lactic acidosis and alcoholic ketoacidosis with bicarbonate of 6 at admission. Lactic acidosis from unclear reason, possibly from hypoperfusion from relative hypotension and the pneumonia seen on imaging. Lactate normalized after 7 liters of fluid. Acidosis improved with bicarbonate gtt as patient was unable to bring pH above 7.19 on his own, initially. pH then corrected and bicarb was stopped. He was intubated due to escalating alcohol withdrawal (see below). #. Alcohol withdrawal/Agitation: At admission, had positive alcohol level. He had been drinking the night of admission. He drinks [11-19] pints of vodka per day. At the end of HD1, he demonstrated signs/sypmtoms of withdrawal with tachycardia, hypertension, agitation, diaphoresis, tremors and anxiety. He was treated with escalating doses of benzodiazepines and ultimately required intubation. He was maintained on a propofol gtt and then was transitioned to standing valium. On [5-10] he had received nearly 300 mg of valium. He was extubated after 4 days of intubation. Psychiatry was consulted for continued agitation post-extubation requiring high doses of haldol. He eventually stablized out off of benzos and on haldol scheduled. - Psyche following #. Aspiration risk: Patient presented with aspiration pna vs. community acquired Pneumonia. Initial S&S evaluation showed patient aspirating ->Placed NG tube but patient pulled it out shortly after placement. Repeat Video S&S on [2124-5-18] showed no aspiration and he tolerated a regular diet. - Completed levofloxacin x 5 days on [2124-5-13] for aspiration pna #. Black stool: reports liquid black stool as baseline. Hematocrit decreased after aggressive hydration but stabilized. Did not require transfusion and was continued on PPI [Hospital1 ]. # C Diff positive: presented with Diarrhea. Treated with flagyl for 14 day course to end on [2124-5-24]. #. Acute renal failure: in the setting of extreme dehydration at admission. Improved with hydration and supportive care to Cr of 0.6 - 0.8. #. Chest pain: vague description at presentation. Ruled out for MI, but elevated CK indicative of some rhabdomyolysis. This improved with hydration. No further long runs of NSVT. Echo with mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Dilated thoracic aorta. No structural heart disease or pathologic flow identified. #. COPD: extensive wheezing at admission and smoking history. Treated with frequent nebs and steroids initially. Steroids discontinued following intubation as wheezing improved with nebs. He was extubated on [5-14] and did not require any further O2 or nebs. #. HCV cirrhosis/EtOH pancreatitis/EtOH hepatitis: LFTs trended down and remained stable. # Smoking history: nicotine patch # NSVT: 20 sec in ED in setting of multiple electrolyte abnormalities. Started on beta blocker, and had only 1 repeat episode since ED. Lytes were repleted aggressively. # Disposition: Patient was discharged to the street per his request. Patient was repeatedly offered our help in brokering housing at a shelter, as despite his insistence to contrary he seemed to be a homeless man. He repeatedly declined offers of help in arranging housing / shelter. At discharge, as he was leaving, he declared however that we were "throwing him out" and that he would spend the night sleeping in front of the hospital. Medications on Admission: Aspirin 325 mg po daily Multivitamin po daily Hydrochlorothiazide 12.5 mg po daily Omeprazole 20 mg Capsule po bid Atenolol 100mg po daily Diltiazem HCl 300 mg SR po daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Cyanocobalamin 100 mcg Tablet Sig: 0.5 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 Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 7 days: Until [5-27]. Disp:21 Tablet(s) Refills:0 7. Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Disp:30 Capsule, Sustained Release(s) Refills:2 8. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO once a day. Disp:30 Capsule(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. Alcohol withdrawal 2. Aspiration Pneumonia 3. C. diff colitis Secondary Diagnoses: Alcohol dependence Atrial fibrillation Cardiomyopathy Alcohol abuse Hypertension Hepatitis C cirrhosis Discharge Condition: Afebrile, vital signs stable and wnl, tolerating PO, ambulating, AOx3, pleasant Discharge Instructions: You have been admitted to the hospital for alcohol withdrawal. While you were here you were sent to the ICU, intubated and put on medicine for withdrawal. You developed a pneumonia (lung infection) and an infectious diarrhea for which you are currently undergoing treatment. We urge you to accept treatment for alcoholism and have provided you with resources to do so. There have been several changes to your medicines, please take as directed. Please call your doctor or 911 for any concern of alcohol withdrawal, chest pain, difficulty breating or any other medical concern. Followup Instructions: Please call [Last Name (LF) ],[First Name3 (LF) 2946] S. [Telephone/Fax (1) 2205] for an appointment after discharge. Please also call the gastroeneterology (stomach doctors') clinic ([Telephone/Fax (1) 2233] for an appointment to have a colonoscopy, because you had some stomach track bleeding while you were in the hospital. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 810] MD, [MD Number(3) 811] Completed by:[2124-5-26]	[ "5070", "51881", "2762", "5849", "42731", "4019", "42789" ]
Admission Date: [2181-6-26] Discharge Date: [2181-6-29] Date of Birth: [2099-8-14] Sex: M Service: CARDIOTHORACIC Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 165] Chief Complaint: Back Pain Major Surgical or Invasive Procedure: none History of Present Illness: 81 y/o spanish speaking only, from [Country 26231], on family visit in US. Reports falling yesterday afternoon in restroom. Pt is poor historian but he denied CP, SOB, seizure or LOC before or after fall. c/o CP and back pain today that prompted ER visit to OSH where CXR was done, then a CT SCAN showing type B dissection, extending from L sblcv artery all the way down to both iliacs. Was given labetalol during transport and in ER. Denies any prior medical problems, but no PCP visit for "a while". pt reports no extremity weakness in ER. Past Medical History: Denies Social History: Tobacco: remote, 20 y ago ETOH remote, 5-6 beers/WE Family History: Denies Physical Exam: Pulse: 67 Resp: O2 sat: 98 B/P Right: 115/78 Left: 112/80 Height: Weight: General: relatively comfortable Skin: Dry [x] intact [] HEENT: PERRLA [] EOMI [x] Neck: Supple [x] Full ROM [] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [] Neuro: Grossly intact, moves 4 ext, R handed. follows commands Pulses: Femoral Right: Left: DP Right: + Left: + PT [Name (NI) 167]: Left: Radial Right: + Left: + Carotid Bruit Right: - Left: - Pertinent Results: [2181-6-26] CT Scan Chest 1. Aortic dissection as described above originating just at the level of the origin of the left subclavian and extending through the entire descending thoracic aorta, the abdominal aorta, and both common iliac arteries. The SMA, celiac axis, both renal arteries, and [Female First Name (un) 899] all originate from the true lumen with no flap visualized. Good opacification of both true and false lumens. Aneurysmal dilation of the descending abdominal aorta most prominent just at the bifurcation with associated thrombus formation up to 5.8 x 5.5 cm. 2. Cirrhosis of the liver with sequelae of portal hypertension such as recanalization of the umbilical vein and gastroepiploic varices. [2181-6-29] 05:45AM BLOOD WBC-5.6 RBC-3.88* Hgb-13.4* Hct-37.5* MCV-97 MCH-34.5* MCHC-35.7* RDW-13.9 Plt Ct-157 [2181-6-29] 05:45AM BLOOD Glucose-89 UreaN-21* Creat-0.9 Na-139 K-4.1 Cl-103 HCO3-24 AnGap-16 Brief Hospital Course: Mr. [Known lastname ] was admitted to the [Hospital1 18] on [2181-6-26] for further medical management of his Type B aortic dissection. His blood pressure was tightly controlled with labetalol for a target systolic blood pressure of less then 120mmHg. He was transitioned to oral blood pressure medications. The vascular surgery service was consulted. Medical management was optimized and Mr. [Known lastname ] was discharged to home with VNA services. He was advised to obtain a chest CT every 3 months for one year. Medications on Admission: None Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Type B Aortic Dissection Discharge Condition: Good Discharge Instructions: 1) Monitor blood pressure and keep systolic blood pressure less then 130mmHg. 2)Call 911 for chest pain, or burning pain radiating to your back. Followup Instructions: Please follow-up with your primary care physician [Last Name (NamePattern4) ] [1-12] weeks. Please obtain a CT scan of the chest every 3 months for the next year. Mandarse a hacer una tomografia computarizada de [First Name9 (NamePattern2) 83540] [Last Name (un) 33424] tres meses por un ano. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2181-6-29]	[ "4168" ]
Admission Date: [2132-7-31] Discharge Date: [2132-8-1] Date of Birth: [2048-7-1] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 594] Chief Complaint: urosepsis Major Surgical or Invasive Procedure: CMO History of Present Illness: 84M with advanced dementia, atrial fibrillation, CHF (EF 25%), BPH presenting from rehab with acute renal failure and urinary tract infection/hematuria. He was noted to have an increase of creatinine from 1.2 to 2.6. He was started on a cefepime for a proteus urinary tract infection diagnosed on [2132-7-29]. He had an ultrasound on [2132-7-28] that showed hydronephrosis. Of note, he is confused at baseline but seems more agitated recently. He has no documented fevers. He denies chest pain, shortness of breath, vomiting. In addition, patient was admitted from [2132-6-13] to [2132-6-19] for confusion x 1 days and noted to have a congestive heart failure exacerbation. Cardiology evaluation and consultation advised medical management and ECHO showed wall motion abnormalities consistent with multivessel coronary artery disease. He was also noted that have a 3 month cognitive decline, which was corroborated with his wife and [Hospital 228] health care proxy [Name (NI) ]. In the ED, initial VS were: Triage 12:51 0 99.5 74 92/66 16 92% He was noted to have a foley with purulent red urine. His was AAOx1 and very lethargic (said "yes" to some questions) - he has been like this for past 4 weeks per wife. [Name (NI) ] does have history of attacking people at rehab. Current access includes left PICC and 18G on right arm. He was given cefepime at 11:30 AM today and vancomycin 1gm IV in [Hospital1 18] ER. His initial SBP was in the 90s, which then dropped to the 80s. He was given 250 mL normal saline with SBP 100-110s. Labs were performed - Lactate 2.4 - cTropnT 0.05 - Na 141, Cl 105, K 3.6, HCO3 20, BUN 55, Cr 3, Glc 95 - ALT 31, AST 97, ALP 97, Lipase 12, tbili 0.8, Alb 3.4 - WBC 25.2, Hgb 13.4, Plt 171 Diff N 93.8 L 3.3 INR 1.5 - UA Cloudy, pH 9, Tbili Lg, LE Lg, Nit Pos, Prot > 300, Glu > 1000, Ket 150, RBC > 182, WBC > 182, Bacteria None A prelim CT Abd showed no renal stones, discrepancy in renal size (11cm right, 7.4cm left) likely reflects chronic kidney disease. Moderate perinephric stranding is consistent with pyelonephritis in the appropriate clinical setting, which appears worse on the right. A foley is present within the bladder, which is decompressed. A recently passed stone could also account for these findings although none is seen. In addition, there was moderate cardiomegaly. Overall, this scan is limited by lack of contrast and respiratory motion, but no other significant abnormalities are detected. Blood and urine cultures were obtained; however, patient did receive antibiotics before arrival at rehab. He is being admitted to the ICU for sepsis with hemodynamic changes including tachycardia in 110-120s and relative SBP 90s. On arrival to the MICU pt had an episode of pulseless VTACH, spontaneously converted. he was dyspneic and received IV metop 5mg x 1 for RVR, lasix 20 IV, IV morphine. Review of systems: Past Medical History: Congestive heart failure (EF 25 %) - advanced dementia - Atrial fibrillation not on coumadin - Hypertension - Osteoporosis - Mild aphasia - s/p hip fracture - benign prostatic hypertrophy Social History: Lives at [Location 19582] Point at [Location (un) 1887] ([Hospital3 ]). Lives with wife in apartment. Former hospital overseer of [Hospital ] Hospital. Family History: Non-contributory Physical Exam: ADMISSION EXAM: Vitals: T 98.8 HR 1354 in a fib BP 143/106 RR 31 SpO2 81% General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact DEATH EXAM: General: motionless CV: no heart sounds Pulses: no radial, carotid, or femoral pulses Neuro: no corneal blink reflex, eyes do not track Pertinent Results: [2132-7-31] 01:15PM BLOOD WBC-25.2# RBC-4.29 Hgb-13.4* Hct-40.2 MCV-94 MCH-31.3 MCHC-33.3 RDW-15.0 Plt Ct-171 [2132-7-31] 01:15PM BLOOD Neuts-93.8* Lymphs-3.3* Monos-2.8 Eos-0 Baso-0.2 [2132-7-31] 01:15PM BLOOD PT-16.1* PTT-29.3 INR(PT)-1.5* [2132-7-31] 01:15PM BLOOD Glucose-95 UreaN-55* Creat-3.0# Na-141 K-3.6 Cl-105 HCO3-20 AnGap-20 [2132-7-31] 01:15PM BLOOD ALT-31 AST-47* AlkPhos-97 TotBili-0.8 [2132-7-31] 01:15PM BLOOD Lipase-12 [2132-7-31] 01:15PM BLOOD cTropnT-0.05* [2132-7-31] 06:00PM BLOOD Calcium-8.7 Phos-3.7 Mg-2.1 [2132-7-31] 08:29PM BLOOD Type-[Last Name (un) ] pO2-66* pCO2-29* pH-7.37 calTCO2-17* Base XS--6 [2132-7-31] 01:51PM BLOOD Lactate-2.4* [2132-7-31] 08:29PM BLOOD Lactate-2.1* [2132-7-31] 01:15PM URINE Color-Red Appear-Cloudy Sp [Last Name (un) ]-1.005 [2132-7-31] 01:15PM URINE Blood-LG Nitrite-POS Protein->300 Glucose->1000 Ketone-150 Bilirub-LG Urobiln->8 pH-9.0* Leuks-LG [2132-7-31] 01:15PM URINE RBC->182* WBC->182* Bacteri-NONE Yeast-NONE Epi-0 Micro: Blood culture [7-31]- PENDING urine culture [7-31]- PENDING Cdiff assay [7-31]- PENDING Brief Hospital Course: Mr. [Known lastname ] is an 84 yo gentleman with PMH of ischemic congestive heart failure with depressed ejection fracture, atrial fibrillation not on anti-coagulation, moderate dementia, mild expressive aphasia who was admitted to the MICU with urosepsis and made CMO. # Sepsis from a urinary source (pyelonephritis): On presentation to the ED, the patient met [1-12] SIRS criteria and he had a urinary tract infection per UA. He had an elevated lactate at 24. He was hypotensive and unable to be fluid resuscitated due to worsening respiratory status. He was started on pressors with improvement in his BP. He was started on Vanc/Cefepime and Ciprofloxacin for antibiotics and he was admitted to the ICU. In the ICU he continued to be hypotensive and was volume resuscitated which transiently improved his hemodynamics, but was complicated by acute pulmonary edema (attributed to his depressed EF and 3+ MR). In addition, he developed A fib with RVR in the acute setting and was treated with beta blockade, but subsequently developed frequeny runs of non-sustained V tach. Despite these interventions, the patient continued to clinically deteriorate hemodynamically and respiratorially. He was DNR/I on admission and given the accuity and severity of his acute presentation and his progressive deterioration despite aggressive medical management with broad spectrum antibiotics, goal-directed volume resuscitation, supplemental oxygen, and beta-blockade, the decision was made, in concert with his wife, health care proxy (attorney [Name (NI) ] [Name (NI) ]), and his primary care provided (Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1007]), to transition to CMO care. The patient passed away within several hours of transitioning his goals of care. He appeared to be comfortable, without pain or dyspnea. The time of death was 3:14PM, [2132-8-1]. His wife, health care proxy, and primary care provider were informed. The medical examiner was contact[Name (NI) ] as the patient had died within 24 hours of admission and Dr. [Last Name (STitle) 9037] declined the case. Medications on Admission: Metoprolol Succinate XL 12.5 mg PO DAILY hold for sbp<90 hr <60 2. Simvastatin 20 mg PO DAILY 3. Valsartan 20 mg PO DAILY hold for sbp <90 4. Aspirin 325 mg PO DAILY 5. Furosemide 20 mg PO DAILY hold for sbp<90 6. Quetiapine Fumarate 12.5 mg PO DAILY:PRN agitation 7. Quetiapine Fumarate 12.5 mg PO Q4PM 8. Tamsulosin 0.4 mg PO HS Discharge Medications: N/A - expired Discharge Disposition: Expired Discharge Diagnosis: Sepsis Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A Completed by:[2132-8-2]	[ "5849", "42731", "4280", "4019" ]
Admission Date: [2172-2-26] Discharge Date: [2172-3-1] Date of Birth: [2103-7-3] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: chest pain Major Surgical or Invasive Procedure: CABG x 3 History of Present Illness: The patient is a 68-year-old gentleman who presented with acute coronary syndrome last week. Cardiac cath on Friday evening showed severe two-vessel coronary disease. The patient did rule-in for a minor non-ST elevation myocardial infarction which was treated medically. Due to Plavix load, it was felt that he was stable enough to return home for Plavix washout and return 1 week from his diagnostic cath for elective coronary artery bypass grafting. The patient did well for several days as an outpatient but presented last night with prolonged chest pain with low level of enzyme leak with a troponin bump. The patient was hemodynamically stable without chest pain prior to bringing the patient to the operating room on heparin and nitroglycerin. It was felt that the patient needed to proceed with urgent coronary bypass grafting at this time. The patient understood the risks, benefits and possible alternatives including, but not limited to, bleeding, infection, myocardial infarction, stroke, death, renal and pulmonary insufficiency, as well as the possibility of a blood transfusion and future revascularization procedures and agreed to proceed. Past Medical History: Dyslipidemia Hypertension blood in semen BPH [Last Name (un) 865] esophagus Social History: Lives at home. Quit smoking 25 years ago, prior to that 2 packs per day for 20 years. One to two drinks per day. Exercises regularly. He plays paddle tennis and golf. . Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: There is a family history of premature coronary artery disease in his uncle. Uncle died of MI in 40s. Physical Exam: a/o nad grossly intact supple farom neg lymphandopathy cta rrr abd - benign palp pulses all surgical sites C/D/I Pertinent Results: [2172-2-29] 06:50AM BLOOD WBC-8.5 RBC-3.35* Hgb-10.1* Hct-29.3* MCV-87 MCH-30.1 MCHC-34.4 RDW-12.9 Plt Ct-185 [2172-2-29] 06:50AM BLOOD Glucose-110* UreaN-15 Creat-1.0 Na-137 K-4.1 Cl-101 HCO3-29 AnGap-11 [2172-2-26] 06:00AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.012 URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [2172-2-29] 9:07 AM CHEST (PA & LAT) Lung volumes are improved, though substantial atelectasis persists in the right lower lobe. Lungs are otherwise clear. There is no pulmonary edema. Bilateral pleural effusion is minimal and there is a very tiny right apical pneumothorax. Heart size normal. Brief Hospital Course: pt admitted pre-op'd PROCEDURE: 1. Urgent coronary artery bypass grafting x3 with left internal mammary artery to the left anterior descending coronary artery; reverse saphenous vein single graft from the aorta to the first obtuse marginal coronary artery; reverse saphenous vein single graft from the aorta to the first diagonal coronary artery. 2. Endoscopic left greater saphenous vein harvesting. no complications transfered to the cvicu in stable conditions weaned from pressure support / extubated ct removed - cxr small left pnuemo repeat stable pw and foley removed pt clears for home taking po / ambulating and urinating on dc Medications on Admission: [Last Name (un) 1724]:toprol xl 25', lipitor 80', asa 325', flomax 0.4', lisinopril 2.5', nexium 20', zetia 10 qod Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 2. Ezetimibe 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:15 Tablet(s) Refills:2 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:2 9. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 12. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. Disp:60 Tablet(s) Refills:0 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital ] Hospice and VNA Discharge Diagnosis: CAD ^chol, HTN, BPH Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [Name2 (NI) 5059] at ([Telephone/Fax (1) 1504]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Call with any questions or concerns. PLEASE TAKE NEW MEDICATIONS AS DIRECTED UNTILL YOU SEE YOUR PCP. [Name10 (NameIs) ] PCP [Month (only) ] WANT TO START YOU ON THE MEDICATIONS THAT YOU WERE ON BEFORE PROCEDURE Followup Instructions: PCP: [Name10 (NameIs) ],[First Name3 (LF) ] L. [Telephone/Fax (1) 2697], call and make an appointment for 2 weeks. [Last Name (LF) ],[First Name3 (LF) 177] C. [Telephone/Fax (1) 170] Call to schedule appointment in four weeks Completed by:[2172-3-1]	[ "41401", "5180", "2720", "4019" ]
Admission Date: [2168-1-5] Discharge Date: [2168-1-15] Date of Birth: [2097-2-20] Sex: F Service: [Location (un) 259] M CHIEF COMPLAINT: Nausea, vomiting, fevers. HISTORY OF PRESENT ILLNESS: The patient is a 70 year old female with a history of coronary artery disease and chronic obstructive pulmonary disease recently admitted status post fall with surgical resection of damaged lung parenchyma, multiple compound rib fractures. Her course was complicated by acute abdominal infections. She was found to have a gangrenous right colon status post colectomy with end ileostomy, second look on [10-23] small bowel resection and end ileostomy preceded by third look, found to have small bowel perforations times two. She had multiple bowel resections with end jejunostomy. She was placed on a tracheostomy on [11-9] and was noted to have positive Klebsiella sputum Methicillin resistant Staphylococcus aureus and Pseudomonas at that time; she was discharged on [11-21] to rehabilitation on TPN via PICC line. She presents this evening after two day history of fever, temperature around 103.0 F., mild abdominal pain, nausea, vomiting. No diarrhea and no bright red blood per ostomy. She was cultured on [2167-11-4], and found to have GPCs in blood and was sent to [Hospital1 69]. In the Emergency Room, the patient was noted to be hypotensive at 80/47, was given Solu-Medrol 125 intravenously times one, started on Linezolid, Ciprofloxacin and Ceftazidime with aggressive intravenous volume resuscitation. Temperature at that time was 103.0 F., heart rate 92; respiratory rate 23, 92% on three liters nasal cannula. The patient was admitted to the Medical Intensive Care Unit Service for septic shock physiology. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. 2. Coronary artery disease status post myocardial infarction and percutaneous transluminal coronary angioplasty with stent in [2162]. 3. Hypercholesterolemia. 4. Hypothyroidism. 5. Status post fall with multiple rib fractures, spontaneous pneumothorax and hemothorax requiring Intensive Care Unit level care. 6. Post care complications with gangrenous colon resection, small bowel perforation status post multiple bowel resections. 7. Diabetes mellitus type 2. 8. Nutritionally compromised secondary to short gut. ALLERGIES: Rash to penicillin; codeine with nausea and vomiting. MEDICATIONS ON ADMISSION: 1. Lopressor 12.5 p.o. twice a day. 2. Levothyroxine 100 micrograms p.o. q. day. 3. Regular insulin sliding scale. 4. Ceftazidime which was started in the Emergency Room, one gram q. eight. 5. Micronidasol cream. 6. Klobesterol. 7. Atrovent. 8. Octreotide 0.1 mg subcutaneously twice a day. 9. B12 shots. 10. Ativan 1 mg p.r.n. 11. Lasix 40 mg p.o. q. day. 12. Hydroxyzine 25 q. four p.r.n. 13. Tylenol p.r.n. 14. Albuterol. 15. Linezolid 600 mg intravenously q. 12. SOCIAL HISTORY: Positive for tobacco, smoking one pack per day, 100 pack years; occasional alcohol. LABORATORY: She was anemic with a hematocrit of 27.5, white blood cell count of 13.5 without left shift, hyponatremic at 122. Potassium 3.8, chloride 86, bicarbonate 27, BUN 15, creatinine 0.8, glucose 159, lactate 2.3, ALT 27, AST 35, alkaline phosphatase 110, amylase 52, lipase 19, total bilirubin 0.7. Sinus tachycardia on EKG at a rate of 130. Reciprocal S waves leads I, II, AVL, V5, V6, right bundle branch block. Echocardiogram on [2167-10-20] revealed an ejection fraction of greater than 55%, left atrial mild dilatation. HOSPITAL COURSE: This is a 70 year old female with coronary artery disease, chronic obstructive pulmonary disease status post lengthy surgical admission requiring multiple bowel resections, who presented from a rehabilitation facility on TPN via PICC. The patient was admitted for a sepsis protocol. 1. Started on Dopamine a.d., weaned off [First Name8 (NamePattern2) ] [Last Name (un) ] of greater than 70; started on Vancomycin to cover Methicillin resistant Staphylococcus aureus possible line infection. Outside hospital microdata revealed six out of six enterococcus species; later speciated to be pan sensitive as well as three cultures positive for fungal, later speciated to be C. albicans. Repeat blood cultures were drawn on [12-2] and [1-10], of which only [1-5] revealed C. albicans moderate growth. The PICC line was discontinued and culture of tip grown again positive for fungemia and bacteremia. In light of high grade sepsis, the patient was continued on Linezolid initially and transitioned to Vancomycin to cover enterococcus species. She was initially started on a dose of amphotericin transitioned to intravenous fluconazole. Transthoracic echocardiogram and transesophageal echocardiogram revealed no presence of endocarditis or vegetations. An ophthalmology consultation was obtained to rule out fungal retinopathy which was negative. The patient was weaned off pressors on hospital day one and stabilized. She was afebrile on hospital day one with a decreasing white count and no true evidence of leukocytosis or intra-abdominal process. A CT scan of the abdomen was obtained given patient's multiple anastomoses with concern for abdominal abscess and/or free fluid collection. CT scan of the abdomen revealed no abscess, no fluid collection and no intra-abdominal process. Empiric antibiotic coverage was discontinued at that time. The patient was weaned off pressors and successfully volume resuscitated and given one unit of packed red blood cells as well as normal saline boluses to maintain MAP. The patient remained afebrile throughout hospital days two through ten with no leukocytosis, no physical examination findings suggestive of intra-abdominal process. Culture data remained no growth to date after [1-6]. A PICC line was placed on [2168-1-12] via Interventional Radiology. The patient has per report a history of a penicillin allergy. On questioning, the patient's allergies were small facial rash. Given lack of anaphylactic reaction or hives, a trial of Ampicillin was performed with 250 mg intravenously times once. The patient did not have pruritus, rash, hives or any evidence of hemodynamic compromise. Transition from Vancomycin to Ampicillin 2 grams three times a day was made. The patient to continue on Intravenous Ampicillin times two weeks and transition to amoxicillin for an additional two more weeks at rehabilitation facility. Anti-fungal [Doctor Last Name 360], fluconazole was transitioned from intravenous to p.o. without sequelae. Will continue on fluconazole for remaining four week course as well to be terminated at same time as amoxicillin. Note: In rehabilitation facility, PICC line may be removed once completion of Ampicillin therapy. 2. Cardiac: The patient has a history of percutaneous transluminal coronary angioplasty with stent. At outside hospital EKG with deep S waves and tachycardia. Cycled enzymes revealed small troponin leak of 0.04. In light of sepsis, likely due to demand ischemia without significant EKG changes. Continued on a beta blocker titrated up, metoprolol and an addition, Lisinopril once blood pressure stabilized was made. Hemodynamics remained stable throughout remaining hospital course. One event on Telemetry in the Medical Intensive Care Unit pertinent for a 25 beat of nonsustained ventricular tachycardia. Electrolytes were repleted appropriately. No further events were recorded on Telemetry. The patient would benefit from outpatient stress test once intravenous antibiotics are complete. 3. Gastrointestinal: Status post multiple bowel surgeries. The surgical team is following. No significant findings on examination, although in light of extent of resection, the patient was unable to meet p.o. nutrition requirements on her own. The decision to place a G-tube was made on hospital day seven. G-tube was placed by General Surgery. The patient tolerated the procedure well and began continued tube feeds with goal of cycle tube feeds at night to meet 100% of nutritional requirements. The patient will be able to eat during the day for additional caloric needs. 4. Pulmonary: Initially with hypoxia on admission. Chest x-ray with no clear indication of pneumonia nor aspiration pneumonia. The patient remained on nebulizers and aggressive pulmonary toilet, appropriately diuresing once hypotension resolved and mobilization of extra vascular fluid was achieved. At time of discharge, the patient was saturating 97% on two liters nasal cannula with a goal of weaning per O2 saturations greater than 92%. The patient to continue on nebulizers and appropriate respiratory Physical Therapy, incentive spirometry, at outpatient rehabilitation. 5. Endocrine: The patient was noted to be hypothyroid. Continued on Synthroid. Diabetes per patient; the patient was non-diabetic in the [Month (only) ] admission after her fall. Blood sugar is consistently in the 100s, not requiring regular insulin sliding scale coverage. Insulin sliding scale was continued during hospital course in concern for insulin resistance secondary to hypercortisol state during sepsis, currently resolved. No requirements for insulin. DISCHARGE MEDICATIONS: 1. Ampicillin two grams intravenously q. eight hours times two weeks. 2. At completion of #1, amoxicillin 875 mg p.o. twice a day times an additional two weeks. 3. Fluconazole 400 mg p.o. q. day times four weeks. 4. Captopril 6.25 mg p.o. three times a day. 5. Albuterol nebulizers, one nebulizer inhaler q. two p.r.n. 6. Metoprolol 12.5 mg p.o. twice a day. 7. Fentanyl patch 50 micrograms an hour transdermal q. 72 hours. 8. Micronidasol powder, 2%, one application topical four times a day p.r.n. 9. Albuterol Ipratropium one to two puffs inhaler q. four hours. 10. Tylenol 650 mg q. four to six p.r.n. 11. Zofran 2 mg intravenously q. six p.r.n. nausea. 12. Pantoprazole 40 mg p.o. q. day. 13. Heparin 5000 units subcutaneously q. hour until ambulating. 14. Aspirin 325 mg p.o. q. day. 15. Octreotide acetate 100 micrograms subcutaneously twice a day. 16. Levothyroxine 100 micrograms p.o. q. day. DISCHARGE INSTRUCTIONS: 1. The patient is to continue with rehabilitation and Physical Therapy as well as Respiratory Therapy with goal to wean O2 to oximetry saturation of greater than 92%. 2. Will continue course of intravenous antibiotics times two weeks; at that point, PICC line will be discontinued and transitioned to oral for a total of one month of therapy. 3. Per recommendations of Rehabilitation facility, the patient will be returning to primary care physician in [Name9 (PRE) 108] for remainder of care and rehabilitation. 4. As caloric goals are met via G-tube, if patient is able to tolerate increased p.o., discontinuation of G-tube can be made at that time. 5. Recommend follow-up closely per General Surgery in [State 108] and/or sooner. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1207], M.D. [MD Number(1) 1208] Dictated By:[Last Name (NamePattern1) 972] MEDQUIST36 D: [2168-1-13] 14:02 T: [2168-1-13] 14:03 JOB#: [Job Number 50869] (cclist)	[ "2761", "496", "78552" ]
Admission Date: [2134-6-15] Discharge Date: [2134-6-25] Date of Birth: [2072-7-8] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Optiray 300 / Keflex / Ciprofloxacin Attending:[First Name3 (LF) 603] Chief Complaint: s/p MVC Major Surgical or Invasive Procedure: [2134-6-21]: Percutaneous pinning right SI joinig History of Present Illness: Ms. [Known lastname ] is a 62 y.o. female unrestrained driver presents [6-15] after high speed MVC (45-50mph), patient was ejected via driver's side window and landed 15-20 feet away. No LOC. Patient was flown from the scene via [Location (un) ] to [Hospital1 18] for further evaluation. Past Medical History: (1) IDDM type 2 (2) DVT, PE, and pulmonary infarct (greater than 20 years ago) (3) Lumbar disc herniations (4) osteoarthritis (5) COPD Social History: no tobacco, drugs; occ ETOH Family History: NC Physical Exam: VITAL SIGNS: tmax ([6-22]):100.0 tc:98.7 bp:117/77 hr:95 (92-106) rr:14, 98%NC PHYSICAL EXAM GENERAL: Obese female sitting in chair in NAD HEENT: MMM, no pharyngeal erythemia, no lymphadenopathy, No conjunctival pallor. Non icteric sclera. PERRLA CV: Tachycardic, Normal S1, S2. RRR No murmurs, rubs or [Last Name (un) 549]. Difficult to assess JVP. PULM: CTA BL, no wheezes, no ronchi ABD: Obese. Soft, NT, ND. No HSM EXTREMITIES: Multiple ecchymoses on extremities, including right anticubitis, and left forearm, and right calf which patient reports are from trauma. Right hand with healing laceration and stitches in place, no drainage, no erythemia. SKIN: ecchymosis over right hip NEURO: A&Ox3. Appropriate. CN II_XII grossly intact. Pertinent Results: [2134-6-15] 01:15PM BLOOD WBC-10.6 RBC-4.19* Hgb-12.7 Hct-38.5 MCV-92 MCH-30.4 MCHC-33.0 RDW-13.2 Plt Ct-278 [2134-6-15] 01:15PM BLOOD PT-13.1 PTT-23.1 INR(PT)-1.1 [2134-6-15] 11:10PM BLOOD Glucose-172* UreaN-18 Creat-0.7 Na-139 K-4.0 Cl-103 HCO3-25 AnGap-15 [2134-6-15] 11:10PM BLOOD Calcium-8.7 Phos-4.0 Mg-1.8 . [2134-6-16] 04:30AM BLOOD WBC-11.8* RBC-3.61* Hgb-11.2* Hct-32.5* MCV-90 MCH-31.1 MCHC-34.5 RDW-13.0 Plt Ct-227 [2134-6-17] 07:30AM BLOOD WBC-12.3* RBC-3.04* Hgb-9.4* Hct-27.9* MCV-92 MCH-30.9 MCHC-33.6 RDW-13.1 Plt Ct-155 [2134-6-20] 12:50PM BLOOD WBC-7.5 RBC-2.86* Hgb-9.0* Hct-26.6* MCV-93 MCH-31.4 MCHC-33.8 RDW-13.9 Plt Ct-189 [2134-6-22] 06:10AM BLOOD WBC-7.9 RBC-2.64* Hgb-8.1* Hct-24.8* MCV-94 MCH-30.6 MCHC-32.6 RDW-14.6 Plt Ct-108* [2134-6-22] 01:30PM BLOOD WBC-9.2 RBC-2.77* Hgb-8.5* Hct-26.8* MCV-97 MCH-30.7 MCHC-31.7 RDW-14.1 Plt Ct-193# [2134-6-22] 04:15PM BLOOD WBC-9.1 RBC-2.64* Hgb-8.2* Hct-25.1* MCV-95 MCH-31.2 MCHC-32.8 RDW-13.7 Plt Ct-181 [2134-6-23] 04:20PM BLOOD WBC-7.3 RBC-2.92* Hgb-9.0* Hct-27.4* MCV-94 MCH-30.9 MCHC-33.0 RDW-14.7 Plt Ct-265 [2134-6-24] 06:40AM BLOOD WBC-7.7 RBC-2.86* Hgb-8.7* Hct-26.8* MCV-94 MCH-30.3 MCHC-32.4 RDW-15.3 Plt Ct-279 [2134-6-25] 06:50AM BLOOD WBC-8.4 RBC-3.08* Hgb-9.0* Hct-29.0* MCV-94 MCH-29.2 MCHC-31.0 RDW-15.3 Plt Ct-359 [2134-6-16] 04:30AM BLOOD Glucose-158* UreaN-18 Creat-0.6 Na-136 K-3.9 Cl-105 HCO3-26 AnGap-9 [2134-6-17] 07:30AM BLOOD Glucose-153* UreaN-17 Creat-0.6 Na-137 K-4.2 Cl-101 HCO3-30 AnGap-10 [2134-6-22] 06:10AM BLOOD Glucose-191* UreaN-13 Creat-0.4 Na-132* K-4.0 Cl-99 HCO3-28 AnGap-9 [2134-6-25] 06:50AM BLOOD Glucose-166* UreaN-16 Creat-0.5 Na-133 K-4.0 Cl-96 HCO3-30 AnGap-11 [2134-6-15] 01:15PM BLOOD Lipase-19 IMAGING: CT HEAD EXAM: CT head exam dated [2134-6-15]. COMPARISON: None. CLINICAL INFORMATION: 62-year-old female in an MVC. TECHNIQUE: Contiguous 5-mm axial images were acquired of the head without the use of intravenous contrast, and these were reformatted in the coronal and sagittal planes. FINDINGS: There is no intracranial hemorrhage. There is no mass effect or midline shift. The ventricles and sulci are normal in size and configuration. [Doctor Last Name ]-white differentiation is preserved. The orbits are unremarkable. Visualized soft tissue structures are normal in appearance. The mastoid air cells are clear. The visualized paranasal sinuses are clear. Incidental note is made of hyperostosis frontalis. IMPRESSION: No acute intracranial injury. ....................................................... EXAM: CT of the torso. COMPARISON: None. CLINICAL INFORMATION: 63-year-old female involved in motor vehicle collision. TECHNIQUE: 5-mm axial images were acquired of the chest, abdomen and pelvis. Intravenous contrast was not administered due to history of anaphylactic reaction. Images were reformatted in the coronal and sagittal planes. FINDINGS: CHEST: The lungs are clear, with the exception of minimal bibasilar atelectasis. While limited by lack of intravenous contrast, there is no evidence of injury to the thoracic aorta. No pericardial effusion is seen. The heart is normal in size and configuration. Incidental note is made of coronary artery calcifications. There are fractures of the left fourth through eighth ribs laterally, additionally with anterior fractures of the sixth and seventh ribs anteriorly. No pneumothorax is seen. There is no pleural effusion. The central airways appear patent. ABDOMEN: While limited by lack of intravenous contrast, the liver, spleen, pancreas, gallbladder, adrenals, and kidneys are unremarkable. No intraperitoneal free fluid is seen. The small bowel and its mesenteries appear unremarkable. PELVIS: There is a comminuted fracture of the right hemisacrum, posterior iliac spine, and inferior and superior pubic rami. Hematoma is seen within the pelvis in the area of these fractures, which measures 4.5 x 7 cm at the right ischium. Additionally, there are distracted fractures of the right transverse processes of L4 and L5. The bladder is deviated to the left by hematoma but otherwise demonstrates no evidence of injury. The uterus is normal in appearance. The colon is significant for diverticulosis, with no evidence of diverticulitis. BONES: The thoracolumbar spine is significant for flowing osteophytes along the anterior thoracic spine, consistent with DISH. There is degenerative disease of the lumbar spine with vacuum phenomenon and disc space narrowing, most significant at the L5-S1 level. Alignment is preserved. A posterior disc osteophyte complex at the L2-3 level causes moderate central canal narrowing. IMPRESSION: 1. Comminuted fractures of the right hemisacrum, right posterior iliac spine, and right superior and inferior pubic rami. Pelvic hematoma surrounds these fractures. Additionally, there are right L4 and L5 transverse process fractures. 2. Left-sided fourth through eighth rib fractures, with no evidence of pneumothorax. 3. While limited by lack of intravenous contrast, there are no other injuries identified of the chest, abdomen or pelvis. ....................................................... EXAM: CT of the C-spine. COMPARISON: None. CLINICAL INFORMATION: 62-year-old female involved in a motor vehicle collision. TECHNIQUE: Contiguous 2.5-mm axial images were acquired of the cervical spine, and these were reformatted in the coronal and sagittal planes. FINDINGS: There is no fracture, and alignment is preserved. The prevertebral soft tissues are normal in appearance. There is multilevel disc space narrowing, most prominent at C5-6, where a posterior disc osteophyte complex mildly narrows the central canal. Facet joint, and uncovertebral joint hypertrophy narrow the neural foramina at multiple levels, most severely on the right at the C5-6 level. The visualized lung apices are clear. The thyroid and soft tissues of the neck are unremarkable. IMPRESSION: 1. No evidence of acute injury to the cervical spine. 2. Multilevel degenerative change, with mild narrowing of the central canal at the C5-6 level. If there is concern for cord injury, an MRI would be helpful for the evaluation of this. ....................................................... HISTORY: Right percutaneous SI joint pinning. Fluoroscopic assistance provided to the surgeon in the OR without the radiologist present. Seven spot views obtained. These demonstrate steps related to placement of screws across the right SI joint and right sacral ala. Correlation with real-time findings and when appropriate conventional radiographs are recommended for full assessment. Fluoro time not recorded on the electronic requisition. ....................................................... EXAM: Bilateral lower extremity ultrasound to rule out DVT. CLINICAL INFORMATION: 61-year-old female with history of peristent tachycardia, prior pelvic surgery, question lower extremity DVT. COMPARISON: None. FINDINGS: Real-time [Doctor Last Name 352]-scale and color Doppler son[Name (NI) 493] evaluation of bilateral common femoral, superficial femoral, and popliteal veins was performed. There is normal compressibility, color flow, and augmentation seen throughout. Color flow is also seen in the peroneal veins in the proximal calves bilaterally. There is limited evaluation of the posterior tibial veins. IMPRESSION: No evidence of deep venous thrombosis in bilateral lower extremities. ....................................................... V/Q scan RADIOPHARMACEUTICAL DATA: 8.2 mCi Tc-[Age over 90 ]m MAA ([2134-6-22]); 40.3 mCi Tc-99m DTPA Aerosol ([2134-6-22]); HISTORY: increased oxygen requirement and tachycardia after hip surgery INTERPRETATION: Perfusion images obtained with Tc-[Age over 90 ]m MAA in 8 views show a defect in the superior segment of the left lower lobe and a partial defect in the superior portion of the basal segments of the left lower lobe. There is also an overall decrease in perfusion in the left lobe when compared with the right lobe. Ventilation images obtained with Tc-[Age over 90 ]m aerosol in the same 8 views demonstrate a defect in the same region, partially matching the perfusion defects. Chest x-ray (portable film from [2134-6-21]) shows possible new retrocardiac opacity and blunting of left costophrenic sulcus. In view of her prior history of pulmonary embolism, these findings may represent chronic changes; however acute embolus cannot be excluded. The above results are consistent with an indeterminate likelihood for acute pulmonary embolism. IMPRESSION: Indeterminate likelihood for acute pulmonary embolism. The perfusion defects may be chronic and related to her prior pulmonary embolism. If clinical suspicion remains, a CT pulmonary angiogram using gadolinium may be warranted . . . . . . . . . . . ................................................................ HISTORY: 61-year-old female with multiple traumatic injuries after MVC, now with oxygen requirement and tachycardia after hip surgery, concerning for pulmonary embolism. COMPARISON: CT torso from [2134-6-15]. V/Q scan was also performed on [2134-6-22]. TECHNIQUE: MDCT axial imaging was performed through the chest initially using low-dose technique during full inspiration prior to administration of IV contrast, and then after administration of IV contrast. Axial images were displayed using 5- and 2.5-mm collimation. Coronal and sagittal reformations as well as bilateral oblique maximal-intensity projection images were then obtained on a separate workstation. Due to the patient's reported history of prior reaction to CT IV contrast, the study was performed after uneventful intravenous administration of 50 mL of IV gadolinium-DTPA. CTA CHEST WITH IV GADOLINIUM: Unfortunately, due to multiple technical factors including timing of the contrast bolus and timing of the CT table, post-contrast images show insufficient opacification of the pulmonary arteries for diagnosis of pulmonary embolism. The pulmonary artery and aorta are of normal caliber. Mitral annular calcifications are noted. There is no pericardial effusion. Multiple mediastinal nodes are subcentimeter, not meeting size criteria for adenopathy. Multiple both anterior and posterolateral left rib fractures are redemonstrated, with stranding noted in the overlying soft tissues, but no pneumothorax or subcutaneous gas. There is moderate left pleural effusion which measures fluid density, with secondary compressive atelectasis of the left lower lobe, sparing only the anterior basal segment. The central airways are patent to the subsegmental levels. On the right, there are dependent atelectatic changes. Additionally, there are multiple small peripheral ground-glass opacities in the right upper, right middle, and right lower lobes, which were not present on [2134-6-15]. No focal abnormality is demonstrated within the visualized upper abdomen on this exam not tailored for subdiaphragmatic diagnosis. Degenerative changes are redemonstrated in the thoracic spine. IMPRESSIONS: 1. Multiple anterior and posterolateral left rib fractures redemonstrated. Moderate left pleural effusion, with associated left lower lobe atelectasis. 2. Non- diagnostic study for pulmonary embolism. 3. New small peripheral ground-glass opacities in the right upper, right middle, and right lower lobes are nonspecific. While infection is possible, location and morphology raise the possibility of small areas of infarction in setting of clinical suspicion for PE. Findings and recommendations were discussed in detail with Dr. [First Name8 (NamePattern2) 2092] [Last Name (NamePattern1) ] over the phone at 3:30 p.m., who states that the patient reports her prior contrast reaction consisted of hives and lightheadedness. If this can be confirmed, then CTA after pre-medication may be considered. Otherwise, a non- contrast, flow-related MRA study would be recommended. ................................... Brief Hospital Course: Ms. [Known lastname ] presented to the [Hospital1 18] on [2134-6-15] via [Hospital ] transfer from the scene of her MVC where she was ejected. She was found to have a right hemi sacral and iliac fracture, pubic rami fractures and multiple left sided rib fractures, 4-8th rib fractures, with 6th and 7th ribs fractured in two places, and a right transverse process fractures, L4 and 5. She was admitted to the TICU for observation and serial hematocrits. On [2134-6-16] she was transferred to the floor. She was taken to the operating room on [2134-6-21] and underwent a percutaneous pinning of her right hemisacral fracture. She toleratd the procedure well, was extubated, and transferred to the floor. her pain was well controled with dilaudid 6mg. She will need follow up with [Hospital1 18] ortho clinic for revaluation 2 weeks after discharge and to remove the stitches on her right hand. . # Tachycardia: patient was observed to be persistently tachycardic to the 120's despite adequate fluid resussitation and a stable hematocrit. Medicine was consulted. The patient states that she has been 'known to have a higher heart rate' but is unsure how high her rates have been. Given immobility after surgery and history of DVT/PE (28 years ago) concern for pulmonary embolism was elevated. Lower ext dopplars were negative for DVT. She was sent for a V/Q scan which was equivical and followed up with a CTA with gadolinium (given hx anaphalaxis to contrast). The study was incomplete and unable to rule in or out PE. Discussed these findings with the patient and the need for repeat imaging, and she refused repeat scan. Discussed with her the importance of diagnosing and treating PE to prevent respiratory distress, cardiac compromise and death. She acknowledges these risks and declines repeat imaging. Given recent surgery and equivical studies she was not anticoagulated and is being discharged in lovanox 40mg [Hospital1 ] for 4 weeks for DVT prophylaxis post surgery. . # Pneumonia: patient developed productive cough while in the hospital. Initially, there was concern for hospital acquired pneumonia and she was started on vancomycin/zosyn. After a two day course of abx, she reported having had the cough prior to admission and she was switched to augmentin (given allergy to fluroquinolones and cephalosporins) and azithromycin. She will complete a 7 day course of antibiotics. Medications on Admission: Iinsulin sliding scale Metformin 500mg Daily Lantus 50 Units daily Flexaril 20mg daiy Albuterol prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Nebulizer Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Tablet, Chewable(s) 5. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 4 days. Tablet(s) 6. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours) for 4 days. 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 8. Cyclobenzaprine 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Insulin Glargine 100 unit/mL Solution Sig: Fifty (50) units Subcutaneous once a day. 10. Humalog 100 unit/mL Solution Sig: asdir Subcutaneous asdir: At Breakfast/lunch/dinner/bed time: Below 120: no coverage 120-159 4 Units 160-199 6 Units 200-239 8 Units 240-279 10 Units 280-319 12 Units . 11. Cholecalciferol (Vitamin D3) 400 unit Capsule Sig: One (1) Tablet PO three times a day. 12. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) as needed for itching. 13. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain: Hold for sedation, hold for rr<12. Disp:30 Tablet(s) Refills:0 14. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia. ML(s) 15. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 16. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous twice a day for 4 weeks. Discharge Disposition: Extended Care Facility: [Location (un) ] rehab [Hospital1 ] NH Discharge Diagnosis: s/p MVC Right acetabular fracture Left sided rib fractures, [3-4], with 6th and 7th ribs fx in 2 places Right transverse process fractures, L4 and 5 Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. [Known lastname ], As you know, you were admitted to the hospital with pelvic and rib fractures after your motor vehicle accident on [2134-6-15]. You were treated by our orthopedic surgeons who put a pin into your pelvis to hold the bone in place. As we discussed, the broken ribs will take six to ten weeks to heal, you will need to use pain as your guide regarding your activity level. Orthopedics recommends that you ontinue to touchdown weight bearing on your right leg. . You were found to have pneumonia and are being treated with antibiotics (Amoxicillin-Clavulanic and Azithromycin). You will need to continue to take the anti biotics for four days after you are discharged from [Hospital1 18]. Continue your lovenox injections as instructed for a total of 4 weeks after surgery Please take all medication as prescribed If you have any increased redness, drainage, or swelling, or if you have a temperature greater than 101.5, please call the office or come to the emergency department. Followup Instructions: Please follow up with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], NP in orthopaedics in 2 weeks, please call [Telephone/Fax (1) 1228] to schedule that appointment. . Please follow up with your PCP 2-4 weeks after discharge Name: [Last Name (LF) ],[Name8 (MD) ] MD Location: [Hospital ] MEDICAL CENTER Address: [Doctor Last Name 80300], [Apartment Address(1) ], [Location (un) ],[Numeric Identifier 66328] Phone: [Telephone/Fax (1) 63696]	[ "486", "2761", "496", "25000", "V5867" ]
Admission Date: [2171-8-13] Discharge Date: [2171-8-14] Date of Birth: [2114-11-11] Sex: F Service: NEUROSURGERY Allergies: Sulfonamides / Fioricet / Fiorinal / Phenytoin Attending:[First Name3 (LF) 2724] Chief Complaint: CC:[CC Contact Info 80161] Major Surgical or Invasive Procedure: Cerebral angiogram with partial coiling of cerebral aneurysm History of Present Illness: HPI: 56F p/w 4d h/o HA unrelieved by Imitrex. Presents to [Hospital1 18] ED for pain control. vomited 5x since Fri. Seized in ED. Past Medical History: PMHx: migraine HA endometriosis depression ^chol Social History: Social Hx: married, w children, no EtOH, no tob Family History: Family Hx: no aneurysms per husband Physical Exam: ON ARRIVAL PHYSICAL EXAM: 98.9 70 166/80 22 Gen: WD/WN, comfortable, NAD, originally conversant. HEENT: Pupils: 4->2mm bilaterally Neck: nuchal rigidity. Lungs: CTAB. Cardiac: RRR. nl S1/S2. Abd: +BS, S, NT/ND Extrem: Warm and well-perfused. no c/c/e. Neuro: Mental status: Eyes closed, not cooperative with exam. Orientation: Oriented to person, and place. Cranial Nerves: II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No observed abnormal movements or tremors. No pronator drift. Pt unable to cooperate with motor exam. Moves all 4 extremities, withdraws to noxious stimuli. Toes downgoing bilaterally. Exam this am as desribed in progress note Pertinent Results: RADIOLOGY Preliminary Report CT HEAD W/O CONTRAST [2171-8-14] 8:16 AM CT HEAD W/O CONTRAST Reason: EVD placement, eval for changes [Hospital 93] MEDICAL CONDITION: 56F presents with SAH intubated in ED, EVD placed REASON FOR THIS EXAMINATION: EVD placement, eval for changes CONTRAINDICATIONS for IV CONTRAST: None. NON-CONTRAST HEAD CT SCAN HISTORY: Subarachnoid hemorrhage, intubated in the Emergency Department. Ventricular drain placed. Evaluate for changes. TECHNIQUE: Non-contrast head CT scan. COMPARISON STUDY: Non-contrast head CT scan. FINDINGS: Once again, there is massive subarachnoid hemorrhage identified. There is also intraventricular hemorrhage layering within both atria and occipital horns. Blood is also noted within the fourth ventricle. In the interval between scans, a right-sided ventriculostomy catheter has been placed via the right frontal lobe, with its tip in the region of the foramen of [Last Name (un) 2044]. Despite catheter placement, there appears to be moderate interval enlargement of the supratentorial ventricular system. There are no other definite interval changes seen other than the burr hole which provides passage for the catheter as well as a tiny amount of gas within the adjacent scalp, presumably postoperative in nature. CONCLUSION: Findings of concern for mild interval enlargement of the supratentorial ventricular system, despite placement of the right-sided ventriculostomy catheter. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9987] RADIOLOGY Preliminary Report CTA HEAD W&W/O C & RECONS [2171-8-13] 5:22 PM CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Reason: r/o hemorrhage [Hospital 93] MEDICAL CONDITION: 56Y F w/ headache. Just seizure attack while in ED REASON FOR THIS EXAMINATION: r/o hemorrhage CONTRAINDICATIONS for IV CONTRAST: None. EMERGENCY HEAD CT SCAN AND CT ANGIOGRAPHY HISTORY: 56-year-old woman with headache. Seizures attack while in the emergency department. TECHNIQUE: Non-contrast head CT scan. COMPARISON STUDIES: None. FINDINGS: There is massive subarachnoid hemorrhage filling virtually all of the basal cisternal spaces. There is a small amount of hemorrhage within both occipital horns as well as the fourth ventricle. There is mild dilatation of the temporal horns. Remainder of the ventricular system is of normal size. There is no shift of normally midline structures. The brain parenchyma has normal density at this time. There is no sign for the presence of an overt mass lesion or infarction. The surrounding osseous and soft tissue structures do not display additional abnormalities. CONCLUSION: Massive subarachnoid hemorrhage. Clearly, a ruptured aneurysm needs to be excluded. CT ANGIOGRAPHY OF THE NECK AND HEAD: TECHNIQUE: Bolus intravenously enhanced imaging with multiplanar reconstructions. FINDINGS: There is a normal configuration and caliber of the origins of both vertebral arteries, the left common carotid and innominate arteries as well as the origin of the right common carotid artery from the innominate artery. Both common carotid bifurcations are within normal limits. Particularly as the right vertebral artery enters the skull, at the level of the foramen magnum, its caliber is rather attenuated, which could simply be a congenital variant. However, just beyond this point, the artery undergoes a relatively fusiform dilatation, which measures 13 mm in length x 4 mm in maximum width. The configuration appears more in keeping with a fusiform, rather than a saccular aneurysm. The remainder of the visualized tributaries of the circle of [Location (un) 431] are within normal limits. There is no definite sign of an aneurysm elsewhere nor a definable vasospasm at this time. CONCLUSION: Unusually configured fusiform aneurysm arising from the distal right vertebral artery. COMMENT: It appears that the right posterior inferior cerebellar artery arises likely to the distal aspect of this aneurysm. This vascular origin should be carefully assessed, during what is likely to be selective angiography. DR. [First Name (STitle) ] [Name (STitle) ] DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9987] CEREBRAL ANGIOGRAM FINAL REPORT NOT COMPLETE AT THIS TIME [2171-8-13] 05:20PM PT-12.3 PTT-20.7* INR(PT)-1.1 [2171-8-13] 05:20PM PLT COUNT-244 LPLT-1+ [2171-8-13] 05:20PM NEUTS-68.3 LYMPHS-23.1 MONOS-7.0 EOS-1.1 BASOS-0.4 [2171-8-13] 05:20PM WBC-14.7# RBC-5.09 HGB-15.6 HCT-44.4 MCV-87# MCH-30.6 MCHC-35.1 RDW-13.4 [2171-8-13] 05:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-7.4 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2171-8-13] 05:20PM CALCIUM-10.1 PHOSPHATE-3.7 MAGNESIUM-2.7* [2171-8-13] 05:20PM estGFR-Using this [2171-8-13] 05:20PM GLUCOSE-105 UREA N-18 CREAT-0.8 SODIUM-134 POTASSIUM-5.5* CHLORIDE-94* TOTAL CO2-28 ANION GAP-18 [2171-8-13] 08:21PM TYPE-ART RATES-18/0 TIDAL VOL-500 PEEP-5 O2-100 PO2-528* PCO2-30* PH-7.55* TOTAL CO2-27 BASE XS-5 AADO2-158 REQ O2-36 -ASSIST/CON INTUBATED-INTUBATED [2171-8-13] 11:30PM PT-13.2* INR(PT)-1.2* [2171-8-13] 11:30PM PLT COUNT-239 LPLT-1+ [2171-8-13] 11:30PM WBC-18.6* RBC-4.80 HGB-14.6 HCT-41.4 MCV-86 MCH-30.3 MCHC-35.2* RDW-13.6 [2171-8-13] 11:30PM CALCIUM-9.6 PHOSPHATE-3.7 MAGNESIUM-2.3 [2171-8-13] 11:30PM GLUCOSE-162* UREA N-15 CREAT-0.7 SODIUM-140 POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-27 ANION GAP-16 [2171-8-13] 11:54PM GLUCOSE-152* LACTATE-1.8 NA+-137 K+-3.4* CL--100 [2171-8-13] 11:54PM TYPE-ART PO2-416* PCO2-31* PH-7.56* TOTAL CO2-29 BASE XS-6 Brief Hospital Course: 56 yo woman with h/o migraines, presented with headache since friday. Witnessed seizure in ED and had SAH, intraventricular blood and fusifor aneurysm off the right vertebral artery. On examination initially she had inattention, somnolence, impaired right eye abduction, possibly right dorsiflexion weakness but exam difficult. SHe was intubated for airway protection and an external ventricular drain was placed after CT revealed hydrocephalus and SAH. CTA was performed. She was admitted to the ICU and anti-seizure medications were continued. The am of Hospital day 2 she had a formal cerebral angiogram after CT. She had partial obliteration of Right vertebral artery aneurysm. CT this am demonstrated slightly enlarged ventricles. Catheter in place. Pt care was discussed by Dr. [Last Name (STitle) 548] with attending Dr. [Last Name (STitle) 97607] at [Hospital1 112]. Her care is going to be transferred over to Dr. [Last Name (STitle) ]. Pt report and status discussed with Dr. [Last Name (STitle) 101269]. Transpor tis being arranged. Her EVD this 230pm was with dampened wave form. It flushes proximally without difficulty / 1 cc PFNS, the distal catheter was flushed as well. Her current ICP is 11 however the CSF flow is limited. Dr. [Last Name (STitle) 548] made aware - we will continue to assess until transport. Medications on Admission: simvastatin claritin effexor imitrex codeine klonipin wellbutrin Discharge Medications: see list Discharge Disposition: Home Discharge Diagnosis: SAH Resp failure Right vertebral artery aneurysm with partial coiling Discharge Condition: neurologically stable at present / condition remains guarded Discharge Instructions: per receiving neurosurgical team Followup Instructions: per receiving neurosurgical team Completed by:[2171-8-14]	[ "51881", "2720", "2449" ]
Admission Date: [2124-10-20] Discharge Date: [2124-11-16] Date of Birth: [2066-12-31] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 695] Chief Complaint: failure to thrive Major Surgical or Invasive Procedure: [2124-10-25]: Orthotopic liver [Month/Day/Year ] (retransplant) [2124-11-5]: Exploratory laparotomy, Roux-en-Y, hepaticojejunostomy History of Present Illness: Mr. [Known lastname 64239] is a 57 year-old man with a history of hepC cirrhosis s/p OLT [12-31]. He was recently admitted [Date range (1) 64240] and found to have hepatic artery thrombosis. He was anticoagulated and transitioned to coumadin. During that admission he was also found to have bile lakes, likely secondary to biliary ischemia secondary to hepatic artery thrombosis, as well as a common bile duct stricture, for which sphincterotomy with placement of two stents was peformed. . In light of the hepatic artery thrombosis, he also underwent evaluation for repeat [Date range (1) ]. He was recently re-listed for [Date range (1) ] on [10-12] with a MELD of 25. Rapamycin was stopped and prograf started during that admission. . Since the time of his [Month/Year (2) ], Mr. [Known lastname 64239] has had loss of appetite with failure to thrive. He initially required tube feeds that were stopped [3-30]. He reports no nausea, vomitting, or abdominal pain, but "lack of taste buds." His weight was 206 lbs prior to [Month/Year (2) ], fell peri-[Month/Year (2) ] to 136 lbs. He then gained weight and was 158 in [4-30], but since then has been gradually losing weight. Since the time of his recent discharge two weeks ago, he has not eaten more than a few bites daily. He continues to drink water. He has tried supplemental shakes but can not stand them. His current weight is 128. . He has also not been able to carry out his usual activities and has not been working. He attributes this to physical weakness, including shortness of breath with walking more than room-to-room. His sleeping pattern is unchanged (helped by Ambien), no trouble concentrating, reports mood is generally "fine." . He has also been having fevers as high as 101-102 intermittently since the time of [Date Range ]. No nausea or vomitting, no change in bowel movements or blood in bowel movements. No change in urine output or dysuria. No chest pain. Past Medical History: -History of UGIB ([2120]) -Hepatitis C cirrhosis - s/p OLT [12-31] in the setting of decompensated liver failure [12-25] infection. Hepatitis thought to be from blood transfusions vs tattoos, noticed on random LFTs. Genotype 1, treated with Peg-IFN and ribavirin several times with no response. He has three Grade II varices with portal gastropathy s/p banding. Last EGD in [5-29] showed Varices at the lower third of the esophagus w/ scarring from previous banding, portal hypertensive gastropathy. -hx L leg cellulitis, necrotizing fascitis, osteomyelitis and group A strep sepsis [11/2123], requiring skin graft -Chronic thrombocytopenia -Hypersplenism -Cellulitis [2119] -MVA [2101], surgery to R leg, multiple fractures to L leg -Failure to thrive after liver [Year (4 digits) ] -Multiple episodes of acute renal failure with unclear baseline creatinine (was as low as .8 in [12-31], range .8-4.5) Social History: Denies tobacco use. No alcohol x 18 years. Denies ever using IV drugs. Lives with wife, has 6 children, 5 grandchildren. Owns his own towing/auto body repair business. Family History: Son died of colon cancer, grand father died of colon cancer. No history of liver disease Physical Exam: PE: VS T 95.5 BP 84/58 Pulse 60 RR 20 O2 96% on RA Gen: NAD, cachectic, pale HEENT: oropharynx clear, dry mucous membranes CV: RRR, no murmurs Lungs: clear bilaterally Abd: well-healed y-scar. Normoactive bowel sounds. Nondistended, nontender. No appreciable ascites. Ext: warm, no cyanosis. Left leg extensively scarred below mid-shin with nonpitting edema below ankle, nontender, distal pulses strong. Skin: multiple tattos on trunk and arms Pertinent Results: Admission labs: [2124-10-20] WBC-11.4# RBC-2.89 Hgb-7.5* Hct-23.9* MCV-83 MCH-25.9* MCHC-31.2 RDW-15.8* Plt Ct-257# PT-36.3* PTT-49.4* INR(PT)-3.9* Glucose-121* UreaN-64* Creat-3.1# Na-131 K-4.9 Cl-98 HCO3-22 AnGap-16 ALT-59* AST-94* LD(LDH)-200 AlkPhos-789* TotBili-0.6 Albumin-2.8* Calcium-8.9 Phos-4.3 Mg-2.1 At Discharge [2124-11-15] WBC-3.5* RBC-3.27* Hgb-10.0* Hct-28.2* MCV-86 MCH-30.5 MCHC-35.4* RDW-17.3* Plt Ct-108* PT-32.5* INR(PT)-3.4* Glucose-76 UreaN-64* Creat-1.4* Na-134 K-5.7* Cl-110* HCO3-19* AnGap-11 ALT-50* AST-41* AlkPhos-201* TotBili-0.6 Calcium-8.8 Phos-2.7 Mg-2.0 Alb 2.3 TacroFK-9.2 Brief Hospital Course: A 57 year-old man 9 months s/p OLT and 2 weeks after hepatic artery thrombosis presents with failure to thrive, acute renal failure, hypotension, leukocytosis, and fevers. WBC on presentation was 11.7 with 14% bands. Wife and patient both stated that he had been having intermittent fevers as high as 102 measured at home since the time of [Month/Day/Year ], although this had not previously been documented. Blood cultures grew enterococcus and Neisseria, and urine cultures grew pseudomonas. He underwent CT guided drainage of a hepatic collection on [10-23]. The fluid grew out Enterococcus and [Female First Name (un) 564]. Vanc and Zosyn were initially started, then coverage was broadened to Vanco, Zosyn, Cipro and Caspofungin. US showed there is slow flow in the main hepatic artery with a tardus and parvus waveform (velocity up to 32 cm/s), but no flow in the right hepatic artery. There is no intrahepatic biliary dilation. The portal vein and its branches are patent. Patient was continued on coumadin. Regarding failure to thrive: This was likely multifactorial, with acute bacteremia and renal failure playing a role. However, he had a long history of weight loss and poor PO intake (had required feeding tube for several months after [Female First Name (un) ]) and was thought to also have some underlying depression. Given that he was on the [Female First Name (un) ] list, feeding tube was considered however patient had refused initially at admission and then was transplanted. He was maintained on TPN post [Female First Name (un) ] and was using PO supplements with good tolerance and was encouraged to use the supplements at home following discharge. On [2124-10-25] a liver became available and the patient underwent a second orthotopic liver [Year (4 digits) ] due to the hepatic artery thrombosis and subsequent biliary necrosis and hepatic abscess. He was taken to the OR with Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. An Orthotopic deceased donor liver [Last Name (NamePattern1) ] (piggyback), portal vein - portal vein anastomosis, common bile duct -common bile duct anastomosis (no T tube). Donor iliac artery conduit from the supraceliac aorta was performed. He received routine induction immunosuppression to include Cellcept, solumedrol with prednisone taper and Prograf restarted on the evening of the [Last Name (NamePattern1) ]. The broad coverage with antibiotics was continued with patient receiving 12 days of Vanco, 15 days of Cipro, 19 days of Zosyn and 14 days of Caspo which was then converted to PO fluconazole. He initially did well in the SICU, remained afebrile. On POD 6 his coumadin was restarted. The lateral drain was removed on POD 3. The medial drain was noted to be becoming more bilious in nature and he was having increased abdominal pain and an elevation in his WBC. An ERCP was attempted and extravasation of contrast was noted at the duct to duct anastamosis and a stent was placed. However, it was determined that he was going to require Roux-en-Y hepaticojejunostomy and was taken back to the OR with Dr [Last Name (STitle) ]. He did well following the surgery but was continued on the TPN until he was able to start tolerating liquids and started supplements. He was still refusing Dobhoff tube placement and instead wanted to eat and use supplements. Calorie counts showed him getting about [11-24] to [12-26] of caloric needs and he was instructed to take 4 of the Ensure bottles daily. On POD 13/3 he was switched to oral Fluconazole off the Caspofungin with appropriate adjustment in the Prograf dosing. ID recommended changing to Ceftrixone and getting him off the other antibiotics and keeping him on the antibiotic until the second JP drain was removed. That drain continued with about 1 Liter output daily, but remained serous, so it was decided to remove the drain and suture. The Ceftrixone was taken off at this time. His Coumadin was managed, INRs followed daily. The INR was 5.4 2 days prior to discharge and the dose was dropped with followup with outpatient labs. Cholangiogram on [11-10] showed no leak and tube was capped with no subsequent fever. LFTs dropped appropriately and were WNL at time of discharge. Medications on Admission: metoprolol 25 mg [Hospital1 ] Cellcept [Pager number ] mg [Hospital1 ] tacrolimus 2 mg [Hospital1 ] (previously 3 mg [Hospital1 ]) metoprolol 25 [Hospital1 ] Bactrim SS qd calcium carbonate 500 mg tid (takes [Hospital1 ]) coumadin 1 mg qd (previously 2 mg qd) Ambien 5 mg qhs Senna, Docusate PRN (not using) Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). Disp:60 Tablet(s) Refills:2 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:50 Tablet(s) Refills:0 7. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO once a day: Per [Hospital1 ] clinic taper. Disp:105 Tablet(s) Refills:2 10. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:120 Capsule(s) Refills:2 11. 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 12. Outpatient Lab Work CBC, Chem10, AST, ALT, alk phos, albumin, T.bili, and tacrolimus PT/INR biweekly - Monday and Thursday 13. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 14. Outpatient Lab Work INR/PT Discharge Disposition: Home With Service Facility: Diversified VNA Discharge Diagnosis: Hepatic artery thrombosis s/p re-[Hospital1 ]: orthotopic liver [Hospital1 ] s/p Exploratory laparotomy, Roux-en-Y, hepaticojejunostomy Discharge Condition: Stable/Fair Discharge Instructions: Please call the [Hospital1 ] clinic at [Telephone/Fax (1) 673] for fever > 101, chills, nausea, vomiting , diarrhea, increased abdominal pain or girth, inability to take or keep down food, fluids or medications. Monitor the incision for redness, drainage or bleeding No heavy lifting Drink enough fluids to keep urine light yellow in color. You may shower, allowing water to run over abdomen. Pat dry, do not rub. No tub baths No driving if you are taking narcotic pain medication Please call your PCP, [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2405] at [Telephone/Fax (1) 64241], to manage your coumadin levels with outpatient INR/PT labs. Followup Instructions: [Name6 (MD) 2105] [Name8 (MD) 2106], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2125-1-30] 1:00 Please call the [Year/Month/Day 1326] Surgery Clinic at [Telephone/Fax (1) 673] to set up a follow up appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2124-11-17]	[ "5849", "2761", "2875", "2859" ]
Admission Date: [2176-7-8] Discharge Date: [2176-7-10] Date of Birth: [2110-2-8] Sex: F Service: MEDICINE Allergies: Penicillins / Bactrim DS Attending:[Known firstname 23009] Chief Complaint: Angina (Transfer from [Hospital3 1280] for Interventional Cath) Major Surgical or Invasive Procedure: cardiac catheterization with drug eluting stent x1 and bare metal stents x2 to right coronary artery History of Present Illness: Mrs. [Known lastname ] is a 66 year old woman with COPD and PVD transfered from [Hospital3 1280] for interventional cath after worsening CP X 4 days. Over the past 3-4 months, she endorses recurrent non-exertional substernal chest pressure. These last 4 days the chest pressure worsened, increasing in intensity and frequency. She called 911 and was taken to [Hospital3 ] by ambulance. In the ED she reported same chest pain- ECG revealed no ischemic changes. Sx were relieved with SL nitroglycerine. Patient was admitted to [Hospital3 1280] where she received Nitro and heparin gtt, ASA, plavix, metoprolol, and lipitor. She had no CP since receving Nitro in [Location 44023]. Troponin T peaked at 0.2. Diagnostic cardiac catheterization at [Hospital3 1280] revealed: 1.Severe single vessel CAD, with a focal 90% stenosis of the distal RCA involving the origin of the PDA. Diffuse calcification and mild-to-moderate disease of all three coronary arteries 2.Normal LV systolic function. 3. Mild LV diastolic dysfunction 4.No evidence of valvular disease. She was transferred to [Hospital1 18] this AM for interventional catheterization. . At [Hospital1 18], she underwent cardiac catheterization with identification of significant RCA disease. She received a DES to the distal RCA and BMS x 2 to the mid RCA. The procedure was complicated by closure of the PDA. The patient also experienced significant oozing with a drop in hematocrit from 29.8 to 22.9. . Following the procedure, the patient was transfered from the cath lab to the CCU for close overnight monitoring. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: CAD 2. CARDIAC HISTORY: - PERCUTANEOUS CORONARY INTERVENTIONS: [2176-7-8] DES to distal RCA and BMS x 2 to mid RCA 3. OTHER PAST MEDICAL HISTORY: COPD, Glaucoma, Anemia Social History: - Tobacco history: 80 pack-years, now [12-24] pack per day - ETOH: History of EtOH abuse, quit 15 years ago - Illicit drugs: None Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Brother passed at age 58 from CAD Brother and Sister with HTN/HLD Brother and Sister with arrhythmias Sister with breast and colon cancer Father and brother with alcoholism Physical Exam: ADMISSION EXAM: GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, loud P2. left 2nd intercostal 2/6 systolic murmur. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Prolonged expiratory phase. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No edema. No femoral bruits. Cath site without bruit or oozing. SKIN: No stasis dermatitis, ulcers, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ PT 2+ Left: Carotid 2+ Femoral 2+ PT 2+ . DISCHARGE EXAM: T 97.8 HR 74-78 RR 18 BP 112-145/61-68 O2 Sat 100% RA Wt 57.5kg GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, loud P2. 1/6 systolic murmur best heart at the L upper sternal border. No thrills, lifts. LUNGS: CTAB, no chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Prolonged expiratory phase. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No edema. No femoral bruits, cath site with moderately sized hematoma, not pulsatile, not expanding. Pulses 2+ bilaterally. Pertinent Results: ADMISSION LABS: [2176-7-8] 08:00PM BLOOD Hct-25.1* [2176-7-9] 12:56AM BLOOD Glucose-110* UreaN-6 Creat-0.5 Na-137 K-3.6 Cl-106 HCO3-20* AnGap-15 [2176-7-9] 12:56AM BLOOD CK-MB-7 cTropnT-0.11* [2176-7-9] 05:26AM BLOOD CK-MB-15* [2176-7-9] 06:00PM BLOOD CK-MB-14* cTropnT-0.25* [2176-7-9] 12:56AM BLOOD Calcium-8.3* Phos-4.2 Mg-1.5* . DISCHARGE LABS: [2176-7-10] 06:35AM BLOOD WBC-7.6 RBC-3.72* Hgb-11.1* Hct-31.8* MCV-86 MCH-30.0 MCHC-35.0 RDW-15.9* Plt Ct-267 [2176-7-10] 06:35AM BLOOD Plt Ct-267 [2176-7-10] 06:35AM BLOOD Glucose-106* UreaN-8 Creat-0.7 Na-144 K-4.1 Cl-109* HCO3-27 AnGap-12 [2176-7-10] 06:35AM BLOOD CK-MB-8 [2176-7-10] 06:35AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.0 . Cardiac Cath ([2176-7-8]): 1. Limited coronary angiography in this right-dominant system demonstrated one-vessel disease. The RCA had a 30% proximal stenosis, diffuse stenosis in the mid-RCA to 60% with a question of thrombus and a distal RCA 95% stenosis and an ostial rPDA 99% stenosis. 2. Successful PTCA and stenting of the distal RCA into the PL system with a 2.75 x 15 mm Promus [Name Prefix (Prefixes) ] [Last Name (Prefixes) 7930] to 3.5 distally and 3.0 proximally complicated by loss of the rPDA (see PTCA comments). 3. Successful PTCA and stenting of the mid-RCA with overlapping 2.75 x 12 mm (distally) and 3.0 x 26 mm Integrity (proximally) stents postdilated to 3.0 (see PTCA comments). . TTE ([2176-7-9]): The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Brief Hospital Course: PRIMARY REASON FOR ADMISSION: 66 year-old woman with COPD and worsening CP/[Hospital ] transferred from OSH for interventional cath now status post PCI with stent x 3 to RCA. . ACTIVE DIAGNOSES: . # CAD: Cardiac cath showed significant RCA disease now s/p PCI with stent x3. She had BMS x2 placed to the mid RCA (2.75 x 12 mm (distally) and 3.0 x 26 mm Integrity (proximally) stents postdilated to 3.0) and DES x1 to the distal RCA (2.75 x 15 mm Promus [Name Prefix (Prefixes) ] [Last Name (Prefixes) 7930] to 3.5 distally and 3.0 proximally). PCI was c/b jailing of the rPDA which resulted in cessation of flow to the PDA that was confirmed by angiography. She had a slight bump in CKMB post procedure consistent with this finding, but CKMB was downtrending at the time of discharge. Post-cath echo showed normal RV size and wall motion. . # Post Procedure Hct Drop: Cardiac cath was c/b significant oozing at the femoral insertion site and the pt's Hct dropped to 23 immediately post cath. She was transfused 2U pRBCs with an appropriate response, and her Hct at the time of discharge was stable at 32. She was admitted to the CCU for monitoring overnight and remained hemodynamically stable throughout her course. There was no evidence of femoral bruit or expaning hematoma at the femoral sheath site, but there was moderate superficial ecchymoses. . CHRONIC DIAGNOSES: . # COPD: She has a ~80 year smoking history and was maintained on her home medications while hospatilized. A nicotine patch was provided. She was counseled on the importance of smoking cessation. Pt was never SOB after cardiac cath and never had any signs of symptoms of COPD exacerbation. . # Anxiety: Pt was continued on her home Citalopram and had no problems with anxiety during her course. . TRANSITIONAL ISSUES: Pt was discahrged home with ASA 325, Plavix 75, Metoprolol, Nitro, Lipitor 80mg and nicotine patches as well as her existing COPD meds. She was instructed on the importance of continuing ASA/Plavix and was counseled extensively on smoking cessation. She will follow up with Cardiology and her PCP. Medications on Admission: Ipratropium Bromide 17- 2INH by mouth QID PRN Fluticasone 110 mcg/Actuation- 2 INH [Hospital1 ] Budesonide-Formoterol (Symbicort)- 160-4.5- 2INH [Hospital1 ] Citalopram 10mg QAM 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:11 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:30 Tablet Extended Release 24 hr(s) Refills:2 5. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation QID (4 times a day) as needed for shortness of breath or wheezing. 6. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 7. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation twice a day. 8. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily) for 6 weeks. Disp:45 Patch 24 hr(s) Refills:0 10. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed as needed for chest pain. Disp:25 tablets Refills:0 11. Outpatient Lab Work Please check labs at [Location (un) 2274] [University/College ] on Friday [7-12] Discharge Disposition: Home Discharge Diagnosis: Non ST Elevation Myocardial Infarction Chronic Obstructive Pulmonary disease S/P Bunion Surgery Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a heart attack and blockages were found in your right coronary artery at [Hospital ] Hospital. You were transferred to [Hospital1 18] for a procedure to open the blocked artery and you had one drug eluting stent and two bare metal stents placed in your right coronary artery. It is crucially important that you take aspirin and plavix every day to prevent the stents from clotting off and causing another heart attack. Do not miss [First Name (Titles) 691] [Last Name (Titles) 4319] or stop taking aspirin and plavix for any reason unless Dr. [Last Name (STitle) ] tells you it is OK. You had some bleeding from the catheterization site and required two units of blood to replace the blood that was lost. You are recovering well and have had no further chest pain. During the catheterization, you received a lot of contrast (dye) and we will check your kidney blood tests on Friday to make sure that your kidneys are functioning well. It is very important that you quit smoking in order to prevent the arteries from developing blockages and causing another heart attack. You have been given a prescription for a nicotine patch to help with the cravings. Please get your blood checked on Friday [7-12] at [Location (un) 2274] in [University/College ]. . We made the following changes to your medicines: 1. Start taking aspirin 325 mg and Plavix 75 mg every day for at least one year to prevent the stents from clotting off. 2. Start taking metoprolol to lower your heart rate and help your heart recover from the heart attack. 3. Start taking a high dose of Lipitor (Atorvastatin) to lower your cholesterol and help your heart recover. 4. Use nitroglycerin under your tongue as needed for chest pain. Please take one pill, wait 5 minutes and you can take one more pill if the chest pain is still there. Please call Dr. [Last Name (STitle) ] if you have any chest pain and take nitroglycerin. 5. Start nicotine patches daily to help you quit smoking. Followup Instructions: Primary care: [Doctor Last Name ],MAHMOODA [Telephone/Fax (1) 17465]. Date/Time: [7-24] at 1:40pm. [Location (un) 2274] [Location (un) 38] . Cardiology: You will have an appt with Dr. [Last Name (STitle) ] in about a month, her office will call you at home with an appt.	[ "41071", "41401", "496", "2859" ]
Admission Date: [2136-5-17] Discharge Date: [2136-6-8] Date of Birth: [2064-5-24] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2160] Chief Complaint: Jaundice Major Surgical or Invasive Procedure: PTC - biliary drain Multiple cholangiographies ERCP Embolization of hepatic artery PICC placement History of Present Illness: Ms. [Known lastname 11622] is a 71 y/o F w/ DM2, pancreatic CA (dx'd [3-31]), who was admitted on [5-17] after she had presented with biliary obstruction. ERCP attempted [5-17] but unable to cannulate CBD. On [5-18] the patient underwent placement of a percutaneous biliary drain. She tolerated the procedure well and bili was trending down. On [5-18] she began complaining of RUQ pain and Hct trended down from 33 -> 28 -> 26.9 from [Date range (1) ]. On the morning of [5-22] Hct was seen to drop from 28.9 to 19.1 and pt became hypotensive with sBP's in the 80's and HR in the 110's. She was complaining of diffuse tenderness in her abdomen and had guaiac positive brown stool. Transferred to ICU. . [Hospital Unit Name 153] brief course: A R subclavian line was attempted but not successful, and R IJ was similarly unsuccessful. A cordis was placed in the R groin and she received a total of 5 units pRBC's over the next few hours (17->29). She was taken to IR but pullback cholangiogram was normal. She was then taken for a pRBC scan which revealed bleeding in the liver parenchyma. Arteriogram performed w/ positive bleeding from pseudoaneurysm at a posterior branch of the right hepatic artery. Successful embolization of the lesion w/ 2 straight coils. She was given another two units of packed red blood cells on morning of [5-23] when hct dropped from 29 -> 22. Her hct remained stable (31->32->27->29->29). Her CT abdomen [5-23] noon showed no retroperitoneal bleed but did show hemoperitoneum and two sources within the liver. Past Medical History: Type 2 DM with Retinopathy h/o Gastric Ulcer as per [3-/2136] EGD, H. pylori (-) HTN Pancreatic CA underwent EUS at [Hospital1 18] with bx which demonstrated mass in the head of the pancreas) Hypercholesterolemia . Social History: Retired cook, lives with dtr. 40pk-year tob history. No EtOH or IV drug use. Family History: Father with HTN and Cancer; many Aunts with [Name2 (NI) ]. Physical Exam: : laying in bed, NAD HEENT: NCAT, +Jaundiced Neck: supple, JVD flat, no carotid bruits Chest: crackles at bases CVS: rrr, no m/r/g Abd: soft, hypoactive bs's, RUQ drain in place Extrem: no c/c/e Neuro: CN II-XII intact MSK: no joint effusions, normal ROM Pertinent Results: [2136-6-8] 06:30AM BLOOD WBC-26.9* RBC-3.24* Hgb-10.0* Hct-29.2* MCV-90 MCH-30.8 MCHC-34.2 RDW-16.4* Plt Ct-397 [2136-6-7] 07:18PM BLOOD Hct-29.8* [2136-6-4] 05:00AM BLOOD WBC-26.2* RBC-3.37* Hgb-10.2* Hct-30.3* MCV-90 MCH-30.2 MCHC-33.6 RDW-16.1* Plt Ct-532* [2136-5-17] 08:30AM BLOOD WBC-11.8* RBC-4.11* Hgb-11.7* Hct-34.5* MCV-84 MCH-28.5 MCHC-34.0 RDW-16.0* Plt Ct-435 [2136-5-22] 04:39AM BLOOD WBC-17.3* RBC-2.26# Hgb-6.7# Hct-19.1# MCV-84 MCH-29.6 MCHC-35.1 RDW-17.1* Plt Ct-394 [2136-6-2] 06:22AM BLOOD PT-18.9* PTT-31.9 INR(PT)-1.8* [2136-6-8] 06:30AM BLOOD Glucose-84 UreaN-33* Creat-1.2* Na-124* K-5.0 Cl-86* HCO3-25 AnGap-18 [2136-6-1] 05:00AM BLOOD Glucose-82 UreaN-16 Creat-1.0 Na-129* K-4.8 Cl-91* HCO3-26 AnGap-17 [2136-5-17] 05:20PM BLOOD Glucose-79 UreaN-18 Creat-0.8 Na-131* K-3.8 Cl-94* HCO3-28 AnGap-13 [2136-6-8] 06:30AM BLOOD ALT-53* AST-127* AlkPhos-514* TotBili-20.9* [2136-5-28] 05:52AM BLOOD ALT-196* AST-94* AlkPhos-436* Amylase-30 TotBili-10.9* [2136-5-22] 08:14AM BLOOD ALT-374* AST-875* AlkPhos-527* TotBili-3.9* [2136-5-17] 05:20PM BLOOD ALT-374* AST-260* AlkPhos-1177* Amylase-78 TotBili-10.1* [2136-6-4] 05:00AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.2 [2136-5-31] 06:06AM BLOOD Osmolal-261* [2136-5-21] 07:30AM BLOOD Cortsol-28.0* [2136-5-21] 07:30AM BLOOD TSH-0.72 [2136-5-22] 03:33PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE [2136-5-22] 03:37PM BLOOD HIV Ab-NEGATIVE [2136-5-17] 05:54PM BLOOD CA [47]-9 -Test [2136-5-29] 12:13PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.005 [2136-5-29] 12:13PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-250 Ketone-NEG Bilirub-MOD Urobiln-NEG pH-7.0 Leuks-NEG [2136-6-2] 04:18PM URINE Hours-RANDOM Creat-78 Na-17 [2136-6-7] 4:46 pm BILE FINAL REPORT [2136-6-10] GRAM STAIN (Final [2136-6-7]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): BUDDING YEAST. FLUID CULTURE (Final [2136-6-10]): YEAST, PRESUMPTIVELY NOT C. ALBICANS. MODERATE GROWTH. [2136-5-28] 12:19 pm BILE FINAL REPORT [2136-6-3] GRAM STAIN (Final [2136-5-28]): REPORTED BY PHONE TO [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 109900] 5PM [2136-5-28]. 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. FLUID CULTURE (Final [2136-6-3]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). ENTEROCOCCUS SP.. HEAVY GROWTH. STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. ENTEROCOCCUS SP.. MODERATE GROWTH. 2ND STRAIN. ENTEROCOCCUS SP.. Isolated from broth media only, INDICATING VERY LOW NUMBERS OF ORGANISMS. 3RD STRAIN. GRAM POSITIVE RODS. GROWING IN BROTH ONLY. UNABLE TO GROW FOR FURTHER IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| ENTEROCOCCUS SP. \| \| ENTEROCOCCUS SP. \| \| \| AMPICILLIN------------ =>32 R <=2 S =>32 R LINEZOLID------------- 2 S 2 S PENICILLIN------------ =>64 R 8 S =>64 R VANCOMYCIN------------ =>32 R <=1 S =>32 R [2136-5-22] 8:14 am BILE FINAL REPORT [2136-5-25] GRAM STAIN (Final [2136-5-22]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). FLUID CULTURE (Final [2136-5-25]): RESEMBLING MICROCOCCUS/STOMATOCOCCUS SPECIES. MODERATE GROWTH. LACTOBACILLUS SPECIES. SPARSE GROWTH. Cholangiogram - IMPRESSION: 1. Pullback cholangiogram demonstrates biliary leak at the posterior and inferior aspect of the right hepatic lobe with extravasation of contrast into the abdominal cavity. There is no communication with vascular structures. 2. Successful placement of a 10 French biliary catheter with side holes draining the left biliary system and the common bile duct. The pigtail was coiled within the duodenum. An ultrasound of the abdomen is recommended in order to determine if there is any abdominal collections in the right upper quadrant. DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] PreliminaryApproved: [Doctor First Name ] [2136-6-7] 2:28 PM CT abdomen: IMPRESSION: 1. Contrast administered during recent cholangiogram collects at the base of the liver extending subhepatically and represents a biloma. Previously described heterogeneous hepatic intraparenchymal lesions demonstrate hyperdense material within and it is difficult to tell whether this represents bleeding or recent contrast administration. Previously noted evolving hemoperitoneum has decreased in size. 2. Poor evaluation of pancreatic head mass extending into portahepatus and portal vein thrombosis without IV contrast. 3. Increased size of small right pleural effusion. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3904] DR. [First Name (STitle) 3934] [Name (STitle) 3935] Approved: FRI [2136-6-8] 5:28 PM Cholangiogram: IMPRESSION: 1. Cholangiogram via existing catheter demonstrates decompressed intrahepatic ducts and good drainage of contrast through the catheter into the duodenum. 2. 10 cc of bile were sent for culture analysis. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] DR. [First Name11 (Name Pattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 6888] Approved: [Doctor First Name ] [2136-5-31] 11:25 AM IMPRESSION: Active extravasation originating from the region around the right liver edge. The findings were discussed with Dr. [Last Name (STitle) 15785] by Dr. [Last Name (STitle) ]. Brief Hospital Course: 72 F with Metastatic pancreatic cancer - with a complicated hospital ourse - 1. Blood loss anemia - due to hemoperitoneum as a complication of the procedur (PTC) - after transfusion, hepatic artery branches were embolised with stoppage of bleeding. The hematocrit remained stable thereafter. 2. Obstructive jaundice, s/p biliary drain placed by IR. After initial decrease in bilirubin, the bili started rising and peaked >20. Cholangigram showed a bile leak. The patient did not want further interventions as her goal was home with hospice. the cath was left in and hospice/VNA arranged for cath checks/dressings. 3. Bile infection with micrococcus, VRE, yeast - to complete 2 weeks on linezolid, metronidazole and fluconazole as per our ID service. Blood culures remained negative at the time of discharge. 4. Leucocytosis - likely due to 3. above. No other source of infection found. 5. SIADH - Na maintained in the mid-120's with 1 lit water restriction/day. 6. Hypertension - po meds as below. 7. Metastatic pancreatic cancer - deemed inoperable by surgery. Med oncology did not think chemo would be indicated unless the current bleeding, infection clear up. The patient did not wish any further treatment for cancer and her goal was to go home with her family. She was disharged to her daghter, [Doctor First Name 109901] home with hospice. Case management, SW, palliative care all involved in a safe and appropriate discahrge plan. Pain control was fairly well achieved. There was a concern that one of the patient's son has psychiatric issues ([Name (NI) 5656]) and would occasionally verbally abuse patient. SW involved and elder svcs were contact[Name (NI) ] who refused to take report as the patient was in hospital. The patient was not dicharged to her home (where [Doctor Last Name ] lives) but to [Doctor First Name ] (daughter's) home. Patient did not want to file a restraining order against this son. Our palliative care SW, [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 10794] will relay this to the hospice palliative care SW. The above was communicated to Dr [First Name8 (NamePattern2) 333] [Last Name (NamePattern1) 42604] (PCP) on the [Last Name (un) ] of discharge. Medications on Admission: Metformin Lisinopril Avandia Glipizide ASA Plavix (recently held) Prilosec Insulin (15-20U) qam Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 2. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO every [6-1] hours as needed for constipation. Disp:3 ML(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:0 6. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). Disp:60 Tablet Sustained Release 12 hr(s) Refills:0 7. Simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable PO QID (4 times a day) as needed. Disp:60 Tablet, Chewable(s) Refills:0 8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-27] Drops Ophthalmic Q4H (every 4 hours) as needed. Disp:2 Refills:0 9. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day for 14 days. Disp:14 Tablet(s) Refills:0 10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 days. Disp:18 Tablet(s) Refills:0 12. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days. Disp:8 Tablet(s) Refills:0 13. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) units Subcutaneous before breakfast every morning. Disp:3 Refills:0 14. [Hospital 12106] Hospital bed, Bedside commode, Shower chair Discharge Disposition: Home With Service Facility: [Hospital 109902] HealthCare of [Location (un) 86] Discharge Diagnosis: Metastatic pancreatic cancer Blood loss anemia Obstructive jaundice, s/p biliary drain Bile infection with micrococcus, VRE, yeast Leucocytosis SIADH Acute renal failure Hypertension Discharge Condition: Fair Discharge Instructions: Please contact the hospice services or your primary doctor if you have worsening pain or any other symptoms of concern to you. Take medicines as prescribed. Followup Instructions: Provider: [Name10 (NameIs) 1948] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2136-6-22] 12:30 Provider: [Name10 (NameIs) ] WEST,ROOM THREE GI ROOMS Date/Time:[2136-6-22] 12:30 If you decide on further treatment for cancer - call Dr [Last Name (STitle) ] and make a follow up appointment -- [Telephone/Fax (1) 13006]. Dr [First Name4 (NamePattern1) 333] [Last Name (NamePattern1) 109903] - your primary doctor will care for your further medical needs.	[ "2851", "5849", "4019", "2724" ]
Admission Date: [2111-3-24] Discharge Date: [2111-4-6] Date of Birth: [2048-2-19] Sex: F Service: VSU CONTINUED... Patient was discharged to rehabilitation in stable condition. She should follow up with Dr. [Last Name (STitle) ] in one to two weeks. She should follow up with her orthopedic surgeon upon discharge from rehabilitation. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3186] Dictated By:[Last Name (NamePattern1) 2382] MEDQUIST36 D: [2111-4-6] 16:56:26 T: [2111-4-6] 18:29:59 Job#: [Job Number 61142]	[ "2851", "4019", "2724", "25000" ]
Admission Date: [2150-8-29] Discharge Date: [2150-9-2] Date of Birth: [2077-9-5] Sex: M Service: MEDICINE Allergies: Enalapril Attending:[First Name3 (LF) 15519] Chief Complaint: Seizure Major Surgical or Invasive Procedure: None History of Present Illness: 72 year old male with h/o type 2 diabetes mellitus who presented with hyperglycemia, hypertension and seizure. Up until one day prior to admission, he had been feeling well, then on the day of admission he noted that his right hand was shaking. That night he had lethargy, no focal symptoms, just not feeling well and ate dinner with his wife. [Name (NI) ] then went to bed. His wife checked on him at about 21:30 and found him in tonic-clonic seizure. He was brought to the ED by EMS his VS on arrival were 98.9, 130, 192/122, 17 96%NRB. Got head CT and had another seizure on the way back from CT. Glucose was critically high. He was given 2mg ativan, 10 units IV insulin, decadron, ceftriaxone, and vancomycin. LP was done. He was also given 2.5 liters of normal saline. Neuro saw him and felt his seizures were most likely secondary to hyperglycemia, but checked LP and there was no evidence of infection. LFTs normal. Pt. was noted to be "post-ictal" in the ED, not responding to commands. On the floor, he is following commands, but still lethargic and delerious. Past Medical History: - Diabetes mellitus type II, dx'ed 15-20 years ago, followed at [Last Name (un) ] - Chronic renal insufficiency, Cr baseline 1.8-2.2 - Hypertension, patient states BPs in 130s/70s - Colon cancer, s/p resection - Gout (proven with joint fluid analysis) - Cataracts - Secondary hyperparathyroidism - Cholelithiasis - Mild Diastolic Dysfunction Social History: Originally from [Country 2045], the patient has lived in [Location 86] for 40+ years. He retired as a CPA, and lives at home with his wife. His children are grown. He manages his ADLS. He used tobacco for 5 years many years ago, occasional social alcohol, no IVDU. Family History: Family hx of hypertension. Pt denies family hx of CAD, stroke, cancer. Physical Exam: Vitals- BP: 198/108 P: 108 R: 16 100% RA Gen- AOx 2 says that year is [2076], well appearing, well nourished, NAD HEENT- NC/AT, EOMI, PERRL, fleks of blood on lower lip. No tongue lesions noted. Neck: supple, JVP not elevated Cor-Tachycardic, normal S1 + S2, no m/r/g, 2+ carotid, radial, DP/PT pulses Pulm- lungs CTA b/l; no wheezes, rales, or rhonchi, no supraclavicular or subcostal retractions Abd- s/nt/nd, +BS, no hernia, no scars, no rebound or guarding, no organomegaly, negative [Doctor Last Name 515] sign Skin- no rashes, lesions Extremities/Spine: extremities warm and well perfused, no clubbing, cyanosis, trace lower extremity edema Neurologic: no focal deficits, CN II-XII intact, moving all 4 extremities independently, but only intermittently following commands. Pertinent Results: LABORATORY DATA: [2150-8-28] 11:10PM WBC-6.7 RBC-4.20* HGB-11.4* HCT-36.4* MCV-87 MCH-27.2 MCHC-31.4 RDW-16.7* [2150-8-28] 11:10PM PLT COUNT-137* [2150-8-28] 11:10PM GLUCOSE-663* UREA N-37* CREAT-2.8* [2150-8-28] 11:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2150-8-28] 11:10PM ALT(SGPT)-18 AST(SGOT)-19 ALK PHOS-133* TOT BILI-0.2 [2150-8-28] 11:10PM LIPASE-37 [2150-8-28] 11:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2150-8-29] 03:00AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-1* POLYS-17 LYMPHS-33 MONOS-50 [2150-8-29] 03:00AM CEREBROSPINAL FLUID (CSF) PROTEIN-32 GLUCOSE-276 CSF: GRAM STAIN (Final [2150-8-29]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2150-9-1]): NO GROWTH. IMAGING: [2150-8-28] CT head: No acute hemmorhage. MRI is more senitive for acute ishemia. [2150-8-29] CXR: Mild volume overload EEG: This is a mildly abnormal extended routine EEG due to low voltage of the background rhythm with diffuse beta activity. There were no focal, lateralized, or epileptiform features noted. EKG: Sinus tachycardia, rate 127. There are slight non-specific ST-T wave changes in leads I, II, aVF and leads V4-V6. Consider left atrial abnormality. Compared to the previous tracing of [2149-3-22], except for the change in rate, no other diagnostic interval change. MRI/MRA Brain: 1. Motion-limited head MRI and MRA. 2. No acute infarction. New chronic microvascular infarcts since [2142]. 3. Unremarkable head MRA. Brief Hospital Course: 72 year old male with history of type 2 diabetes mellitus who presented with hyperglycemia, hypernatremia, hypertension and seizures. He was originally admitted to the MICU and once stabilized, was transferred to the floor. # Seizures: He presented with two seizures in the setting of severe hyperglycemia. He had a lumbar puncture and his CSF did not suggest meningitis or encephalitis. His tox screen was negative. His seizures could also have been secondary to hyperosmolality due to both hyperglycemia and hypernatremia. He had altered mental status after his seizures which cleared prior to discharge. He had an MRI with no acute changes (although it did show chronic microvascular infarcts). He also had an EEG that showed no epileptiform activity. Neurology followed the patient while he was in the hospital, and recommended to start dilantin if he were to have another seizure in the future. The patient was advised not to drive for 6 months. He is scheduled for outpatient follow-up in epilepsy clinic. # Hyperglycemia: On admission, his blood sugars were so high they could not be measured. He was initially on an insulin drip and then rapidly switched to NPH and sliding scale insulin. His blood sugars remained slightly labile during the rest of his admission, and he was transitioned back to his home regimen. It is not clear what incited this hyperglycemic episode, as he reports no history of medication or diet changes, recent insomnia, or recent illness. On discharge, he was instructed to keep a blood sugar diary and check his blood sugars at least three times daily. # Hypertension: Upon arrival to the ICU, he had hypertension with systolic blood pressures in the 190-200's. Quickly after admission, his hypertension resolved and he was restarted on his home medications. He had one episode of relative hypotension with BP of 100/60 after receiving his morning medications. Therefore, his clonidine was switched to an evening medication. He was continued on minoxidil, valsartan, and metoprolol at his home dosing regimens. #. Hypernatremia: He was hypernatremic on admission and for a 2-3 days after admission with a serum Na of 145-147. This was likely caused by osmotic diuresis from his hyperglycemia. Also there was likely some contribution by impaired access to free water with change in mental status. Seizures can also cause intracelluluar osmole generation and transient hypernatremia. Free water intake was encouraged and his sodium level returned to normal range by the time of discharge. #. Diastolic CHF: He has a history of diastolic heart failure but was thought to be volume depleted on admission. His torsemide was held throughout the hospitalization and at discharge. #. Chronic renal insufficiency: He has a baseline creatinine of about 2.1 (although fluctuates substantially) and his creatinine was elevated on admission to 2.8. His urine electrolytes were consistent with a prerenal etiology and his creatinine came back to baseline with rehydration. #. Gout: His allopurinol was initially held due to concern for worsening renal failure, but he was started back on his home dose at discharge. #. Prophylaxis: He was given subcutaneous heparin for DVT prophylaxis #. Code Status: He was full code during this hospitalization Medications on Admission: -Allopurinol 300 mg once a day on Mon, Wed, Fri and 200mg qd on other days -Clonidine 0.3 mg Tablet 1 Tablet(s) by mouth once a day -Insulin Glargine 9 units at bedtime -Insulin Lispro -Metoprolol Tartrate 50 mg Tablet 1 Tablet(s) by mouth twice a day -Minoxidil 10 mg Tablet 1 Tablet(s) by mouth twice a day -Paricalcitol 4 mcg Capsule 1 Capsule(s) once a day -Simvastatin 20 mg Tablet once a day \ -Torsemide [Demadex] 20 mg Tablet once a day -Valsartan 160 mg Tablet q day -Ascorbic Acid 500 mg Tablet once a day -Aspirin 81 mg Tablet, once a day (OTC) -Multivitamin with Iron-Mineral once a day Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: Three (3) Tablet PO once a day: Take 300mg daily on Monday, Wednesday, and Friday. 2. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day: Take 200mg daily on Tuesday, Thursday, Saturday, and Sunday. 3. Clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO at bedtime. 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Insulin Glargine 100 unit/mL Solution Sig: 9 (nine) units Subcutaneous at bedtime. 6. Insulin Lispro 100 unit/mL Solution Sig: Per sliding scale Subcutaneous three times a day: Please take insulin per sliding scale as you were doing prior to hospitalization. 7. Minoxidil 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Zemplar 4 mcg Capsule Sig: One (1) Capsule PO once a day. 9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. Multivitamin with Iron-Mineral Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Seizures Hypertension Diabetes Mellitus Secondary Diagnosis: Chronic diastolic heart failure Discharge Condition: Good, vital signs stable, ambulating independently Discharge Instructions: You were admitted to the hospital with seizures. Your sugar was found to be very high, which may have contributed to your seizure. You were evaluated by neurology, and you underwent an MRI/MRA to evaluate for any acute pathology. You were found to have very tiny strokes which can be a complication of renal disease and diabetes. You will follow up with the neurologists in their clinic. Weigh yourself every morning, call Dr. [First Name (STitle) ] if your weight is increased by 3 lbs or more. Changes to your medications: STOPPED torsemide temporarily. If you experience swelling in your legs, you should restart this medication at your home dose (20 mg Tablet once a day by mouth) CHANGE clonidine from 0.3mg by mouth every morning to 0.3mg by mouth every evening. Start taking this dose on [2150-9-3]. You should also check your blood sugars three times per day and use insulin as you were at home before you were admitted to the hospital. You should write your blood sugars in a diary and bring it with you to your follow-up appointment with Dr. [First Name (STitle) ]. If you find that your blood sugars are higher than normal, you should call Dr. [First Name (STitle) ]. If you experience any shaking, increasing thirst, or increased urination, you should check your blood sugar. You should also call your primary care doctor. If you experience any chest pain, shortness of breath, or seizures, you should call 911 and go to the nearest hospital You should NOT DRIVE for at least 6 months since you've had a seizure. Followup Instructions: You have the following appointments scheduled: Primary care: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Phone: [Telephone/Fax (1) 250] Date/Time: [2150-9-9] 9:50 Neurology: Provider: [First Name11 (Name Pattern1) 3292] [Last Name (NamePattern1) 3293], MD Phone:[Telephone/Fax (1) 44] KS [Hospital Ward Name ] BUILDING ([Hospital Ward Name ]/[Hospital Ward Name ] COMPLEX), 4TH FLOORDate/Time:[2150-9-16] 1:00	[ "5849", "2760", "5859", "4280", "40390" ]
Admission Date: [2201-2-27] Discharge Date: [2201-3-10] Date of Birth: [2122-4-8] Sex: F Service: MEDICINE Allergies: Morphine / Oxycodone / Dilaudid Attending:[First Name3 (LF) 1674] Chief Complaint: Delerium Major Surgical or Invasive Procedure: None History of Present Illness: 78 y/o F with PMHx of CAD s/p MI/PTCA & recent BMS [1-17], systolic HF (LVEF 45-50%, MGUS, recent c.diff infxn, seen by her PCP on day of admission and found to be delerious with labs, showing new hyponatremia (127), hypercalcemia (12.2), and acute on chronic renal failure (Cr 2.4 up from baseline Cr 1.8-2.0). She was sent to ER where family also reported worsening back pain, also some cough with white "spit". The family reported to the PCP that the patients mental status had been clouded for several months and that the presentation was typical of this new baselin. Denied any fever, chills, or SOB prior to admission. At the time of admission she reported no dysuria, N/V, abd pain, hematuria, or diarrhea. Recently her oncologist had been concerned about development of multiple myeloma. In the ED she was afebrile, and VSS were stable. CXR showed a ? LLL infiltrate vs atelectasis, wbc count normal. She was given Levaquin 750mg IV and admitted to the floor. Past Medical History: 1) HTN 2) CAD s/p MI with PCTA in [2190] @ [Hospital1 2025], s/p PCI [2198] with stent to LAD, RCA totally occluded and filled by collaterals 3) Breast cancer B Masectomy in [2175] 4) B/L ORIF 5) R Olecranon fracture 6) Ulnar nerve surgery x 3 7) Pulmonary stenosis s/p valvuloplasty in [2183] 8) s/p appendectomy 9) MGUS BM in [3-15] nml flow with 5% plasma cells; receives transfusion on regular basis 10) H/o anxiety 11) Hypercholesterolemia 12) GERD 13) Recent c.dif infection treated with Flagyl/PO Vanco ([1-/2201]) 14) CRI - baseline Cr 1.8-2.0 Social History: Significant for the absence of current tobacco use. There is no history of alcohol abuse. 1 daughter in CT and 1 daughter in [Name2 (NI) ]. Family History: Father died of heart disease in this 40s. Sister-congenital pulmonary stenosis Physical Exam: ON ADMIT T:98.0 BP:134/79 P:111 RR:20 O2 sats:100% on RA Gen: Elderly, frail female in Resp distress, on NRB, confused, +rigors HEENT: NCAT, PERRL, EOMI, Anicteric, MM dry Neck: JVP difficult to assess [3-14] rigors CV: Reg, nml s1,s2. Resp: Crackles throughout (anteriorly) Abd: Soft, NTND, NABS Ext: No c/c/e Neuro: Oriented to person, but not place/time Pertinent Results: Stool: positive for c diff CXR: possible consolidation atelectasis SPEP consistent with multiple myeloma Serum viscosity within normal Skeletal survey with many lytic lesions MRI of l and t spine and CT of L spine and pelvis without fracture. Diffuse myelomatous invasion of bones (entire spinal cord, pelvis) Serum lambda and kappa pending Brief Hospital Course: #C diff colitis: No response to Flagyl and so started on po vancomycin with good response. Plan to continue vancomycin with taper. #Pneumonia: On hospital day # 3 became sob and febrile. At same time pt was in acute chf, as well as septic, though possibly from c diff colitis. Given CXR with consolidation v atelectasis and severity of illness, started on zosyn for possible HAP. Planned 10 day course of Zosym with final day on [3-11]. Midline placed for access. #Acute on chronic systolic CHF: On hospital day #3 pt became hypoxic after blood transfusion (receives chronic transfusions for anemia assoc w/ MGUS), transferred to ICU for monitoring, did not require intubation; managed well with IV lasix daily. # Delerium: Multifactorial, hypercalcemia, sepsis, and finally from dexamethosone treatment for multiple myeloma; resolved with treatment. # Multiple myeloma: Spep/upep c/w new dx of multiple myeloma. Heme/onc team consulted and recommended to start treatment with dexamethasone 40 mg q wk. Pt received first treatment of dexamethasone [2201-3-4]. Follow up to be arranged via. pt.s oncologist, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2539] - this discussed with oncology team and with pt.s daughter and health care proxy. Instructions below. # Pain - pain team consulted. No focal area on imaging indicating indication or utility of focal, palliative, irradiation, or injection. Recommended fentanyl patch. # High TSH low T4, during acute illness. Will need repeat check once acute infectious process treated and resolved; as TFTs not reliably interpretable in acute illness. Medications on Admission: asa 325mg daily colace furosemide 20mg daily saline nasal spray prn senna Lidoderm Lipitor 80mg daily MVI tylenol prn metoprolol SR 150mg daily pantoprazole 40mg daily propoxyphene 65mg q6hrs -hold if lethargic Discharge Medications: 1. Dexamethasone 4 mg Tablet Sig: Forty (40) mg PO Q Wednesday for 3 doses. Disp:30 tablets Refills:0 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) u Injection at bedtime. 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for low back pain: apply to area of pain over the right SI joint. Adhesive Patch, Medicated(s) 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for pain. 9. pipercillin-tazobactam 2.25g IV q 8 hours with last day of treatment [2201-3-11] 10. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 12. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [6-20] MLs PO Q6H (every 6 hours). 14. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed. 15. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 16. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO twice a day for 35 days: as follows: 1 capsule [Hospital1 ] for 7 days; 1 capsule QD for 7 days; 1 capsule QOD for 7 days; 1 capsule Q 3 days for 14 days. 17. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 19. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 20. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 21. Furosemide 10 mg/mL Solution Sig: Two (2) mL Injection DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 1294] Discharge Diagnosis: multiple myeloma widely metastatic to bones diffusely heart failure (acute on chronic systolic) acute renal failure c diff colitis Discharge Condition: stable Discharge Instructions: Please call your PCP with increasing shortness of breath, fever, dizziness, or other concerning symptoms. Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1239], [Name Initial (NameIs) ].O. Phone:[Telephone/Fax (1) 719] Date/Time:[2201-3-13] 9:30 Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] of oncology will contact pt's daughter [Name (NI) 5627] directly during the week of [3-8] - [3-13] to notify her of appointment time/day, and name of her assigned physician in [Name9 (PRE) 20722]; if you have not heard from him, call Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2539] to find out when and who will be following up with you, at: ([Telephone/Fax (1) 16387]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 1677]	[ "5849", "486", "2761", "4280", "41401", "40390", "5859", "2720", "53081" ]
Admission Date: [2123-2-26] Discharge Date: [2123-3-3] Date of Birth: [2052-2-14] Sex: F Service: MEDICINE Allergies: Penicillins / Tegretol / Insulin,Beef / Insulin,Pork / Zaroxolyn Attending:[First Name3 (LF) 759] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: 71M with MMP including CHF, afib, CAD, and COPD and multiple admissions to [Hospital1 18] (recently D/C'd [2-15] from [Hospital Unit Name 196]/MICU for admission for CHF/chest pain) found at HebReb to have change in MS and O2 sat 76-80% RA. In [Name (NI) ], pt initially placed on 3L O2: 91% then dropped to 86%. ABG initially 7.3/44/66, pt placed on bipap: 7.24/50/90. Per previous DC summaries, pts base ABG is nl (no hypercarbia). She was noted to have thick yellow sputum. At some pt in ED, BP dropped and ED team unable to find pulse. LIJ attempted, but unsuccessful. R groin line placed and pt started on dopamine and levophed. Lactate in ED 1.5. UA positive and pt started on empiric coverage with Vanc, Levo, flagyl. CXR showed CHF. Cr elevated at 2.9 from baseline 0.8-1.2. Pt was transferred to the [Hospital Unit Name 153] on [2-25], where she was treated for her hypotension with pressors and IVF (7 L). She was also continued on vanc/levo/flagyl for emperic treatment of sepsis while cultures were pending. Pt was off pressors on [2-28] and transferred to medical floor. During medical evaluation pt revealed that she may have had diarrhea for 2 weeks prior to admission, however, [Hospital ] rehab was unable to corroberate since no evidence that pt had diarrhea there. During this hospitalization, pt was found to be c. difficile toxin positive. Past Medical History: 1. CHF diastolic dysfunction (EF 65% 1/05 MIBI normal) DRY WEIGHT 194 lbs 2. DM 2 on insulin 3. Atrial Fibrillation 4. Anemia 5. CAD s/p PTCA x 3 (RCA '[09], LCx '[10], RCA '[13]) 6. Pulmonary HTN 7. Hypercholesterolemia 8. COPD/[Year (2 digits) 105496] on home O2 (sometimes on home O2) 9. Thyroid CA s/p resection/now hypothryoid 10. Myoclonic tremors 11. H/O PE 12. OSA on CPAP (started last admission) 13. Depression/Anxiety 14. h/o MRSA/VRE. ICU admit x 2 for MRSA aortic valve endocarditis and pseudomonal sepsis (secondary to wound infection), status post intubation x 2. 15. S/p laproscopic cholecystectomy [34]. s/p right throcoscopy and decortication. Right lung bx. 17. s/p right hip ORIF 18. s/p right ankle ORIF Social History: Pt is divorced with three children. Former CPA. Quit smoking in [2104] after a history of 1 ppd x 15 years. No etoh. No drugs. Family History: F: Died at 47 of MI; M: Colon ca; brother with DM Physical Exam: Physical exam upon transfer to medical floor: WEIGHT 204 V/S Tm 99.7 BP 109-169/50-70 P 95-120 RR 24 O2 sat 88-99%, at time of transfer 91% on 4L Gen: awake, alert, oriented x 3, REJ in place Lungs: scattered wheezing in all lung fields Heart: irregularly irregular Abd: obese, soft, +bs, mild tenderness in all quadrants ext: bilateral hyperpigmentation of LE, 1+ pitting edema, L 1st toe ulcer, L heel ulcer, RLE shin ulcer Pertinent Results: INR on [3-2]- 3.0 on 2mg coumadin CXRAY [2123-2-27]- The cardiac silhouette is mildly enlarged, but stable. There is upper zone [Month/Day/Year 1106] redistribution, perihilar haziness, and a bilateral interstitial pattern which has progressed in the interval compared to the previous study. There is a small right pleural effusion. at admission: EKG: Atrial fibrillation with a controlled ventricular response. [2123-2-25] 10:25PM WBC-6.4 RBC-3.47* HGB-9.5# HCT-29.6# MCV-85 MCH-27.3 MCHC-32.0 RDW-15.4 [2123-2-25] 10:25PM ALBUMIN-3.1* [2123-2-25] 10:25PM LIPASE-23 [2123-2-25] 10:25PM ALT(SGPT)-42* AST(SGOT)-69* ALK PHOS-100 AMYLASE-14 TOT BILI-0.2 [2123-2-25] 10:25PM GLUCOSE-121* UREA N-46* CREAT-2.9# SODIUM-130 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-23 ANION GAP-14 Brief Hospital Course: Pt is a 71 yo female with mult medical problems including afib, chf, CAD, DM who presents from the [Hospital Unit Name 153] with resolved hypotension, and hypoxia. Now treat for C.diff colitis (most likely from recent tx with levaquin). Diarrhea- cdiff + -po flagyl (continue for six days post discharge) -IV vanco/flagyl and levaquin d/c'd after transfer to medical floor -we did not give IV fluid since she looked overloaded on exam Hypoxia- was on 4L NC in [Hospital Unit Name 153] weaned down to 2l on floor. She was placed on bipap at night (10,5,3L) in [Hospital Unit Name 153] but refused it on the medical floor. -d/c'd levaquin since did not seem to have clinical pneumonia -given nebulization treatments to help with the her sob/wheezing with good result The initial hypoxia that brought her to the hospital was never revealed, perhaps as a result of refusing bipap although in house her saturation was okay without bipap at night. Sepsis is a possibility- perhaps from her picc line that was placed many months ago -PICC was d/c'd on this admission Hypertension- on ace and bb as outpt, held due to hypotension initially but restarted bb and ace when on medical floor Afib- was continued on amioderone, beta blocker, coumadin ARF- Cr now normalized with fluids (baseline .8-1.2) -we restarted lasix on transfer to medical floor CHF- noted to have JVD, 1+ pitting edema so lasix was restarted Leg ulcers- chronic superficial ulcer on right calf, left big toe, and l heel, +MRSA -tx'd with vit c/zinc/collagenase -dressing changes and bactroban -wound care consult was familiar with pt and recommended aquacell ag, adaptic on left big toe, dry dressing on L heel -podiatry cut her toenails since they were causing skin breakdown S/p thryoidectomy for thyroid ca -continued synthroid Neuro/pain- -we continued fentanyl patch -we also continued oxycodone, neurontin (renally dosed), topomax DM -was placed on insulin ss, lantus Code on this admission was DNI, but pt DOES want to be resuscited. Medications on Admission: Meds on admission: 1. Aspirin 325 mg PO qD 2. Amiodarone HCl 200 mg PO qD 3. Simvastatin 20 mg PO qD 4. Gabapentin 900 mg Capsule PO BID 5. Ferrous Sulfate 325 (65) mg PO qd 6. Lansoprazole 30 mg PO qD 7. Citalopram Hydrobromide 60 mg PO qD 8. Multivitamin Capsule qD 9. Topiramate 25 mg PO qD 10. Methylphenidate HCl 10 mg PO qAM 11. Methylphenidate HCl 5 mg PO qnoon 12. Levothyroxine Sodium 200 mcg PO qD 13. Warfarin Sodium 3.5 mg PO qHS 14. Lisinopril 5 mg PO qD 15. Furosemide 40 mg PO qD 16. Miconazole Nitrate 2 % Powder TP [Hospital1 ] 17. Metoprolol Tartrate 25 mg PO TID 18. Oxycodone HCl 5-10 mg PO Q4-6H prn 19. Albuterol INH q6 prn 20. Ipratropium Bromide INH q6 prn 21. Fentanyl 25 mp patch q 72h 22. Insulin Glargine 15U qHS 23. Insulin Lispro SS Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - LTC Discharge Diagnosis: Primary diagnoses 1. c. difficile diarrhea 2. hypoxia Secondary diagnoses. 1. CHF diastolic dysfunction (EF 65% 1/05 MIBI normal) 2. DM 2 on insulin 3. Atrial Fibrillation 4. Anemia 5. CAD s/p PTCA x 3 (RCA '[09], LCx '[10], RCA '[13]) 6. Pulmonary HTN 7. Hypercholesterolemia 8. COPD/[Year (2 digits) 105496] on home O2 (sometimes on home O2) 9. Thyroid CA s/p resection/now hypothryoid 10. Myoclonic tremors 11. H/O PE 12. OSA on CPAP (started last admission) 13. Depression/Anxiety 14. h/o MRSA/VRE. ICU admit x 2 for MRSA aortic valve endocarditis and pseudomonal sepsis (secondary to wound infection), status post intubation x 2. 15. S/p laproscopic cholecystectomy [34]. s/p right throcoscopy and decortication. Right lung bx. 17. s/p right hip ORIF 18. s/p right ankle ORIF Discharge Condition: stable Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2L Please take all your medications as prescribed. You have been treated for c. difficile infection with flagyl. Please call your doctor immediately if you have diarrhea. Please come to the ED if you have chest pain, shortness of breath or any other concerning symptoms. Followup Instructions: Please check your INR each week Please follow up with Dr. [Last Name (STitle) ] in 1 week Call [Telephone/Fax (1) 250] for an appointment as soon as you leave the hospital. Other appointments: Provider: [Name10 (NameIs) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SURGERY Where: [Last Name (NamePattern4) ] SURGERY Date/Time:[2123-3-2] 10:30 Completed by:[2123-3-4]	[ "5849", "42731", "5990", "25000", "V5867" ]
Admission Date: [2164-6-3] Discharge Date: [2164-6-5] Date of Birth: [2086-10-6] Sex: M Service: TRAUMA SURGERY HISTORY OF THE PRESENT ILLNESS: The patient is a 77-year-old male status post a fall off a bicycle over the handlebars, hitting his face and head with loss of consciousness, hemodynamically stable on transfer. The only complaint is facial pain and lip pain. No abdominal pain or chest pain. No extremity pain. PAST MEDICAL HISTORY: 1. Hypertension. 2. Atrial fibrillation. 3. Status post cardioversion. 4. Mild aortic insufficiency. 5. History of recurrent prostatitis. PAST SURGICAL HISTORY: Cyst removal as a child, per the patient. ADMISSION MEDICATIONS: 1. Aspirin 325 mg p.d. 2. Univasc 7.5 mg q.d. 3. Atenolol 12.5 mg q.d. 4. Prozac 10 mg p.o. q.d. 5. Citrucel p.r.n. 6. Ciprofloxacin p.r.n. 7. Multivitamins. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient is a nonsmoker, nondrinker. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: The vital signs were stable. The patient had multiple facial lacs and lip lacerations. Chest: Clear. Heart: Regular rate and rhythm. Abdomen: Soft. Extremities: Positive pulses. No deformities noted. Rectal: Normal tone. Grossly positive Guaiac. Back: Mild lumbar tenderness. No deformities noted. Neck: Nontender. Neurologic: GCS 15. No defects noted. LABORATORY/RADIOLOGIC DATA: White count 7.3, hematocrit 37.3, platelets 236,000. Electrolytes were within normal limits as were his coagulations. Amylase slightly elevated at 113. The patient was tox negative. The U/A was 69 red blood cells, [2-22] white blood cells, occasional bacteria. The chest x-ray was negative. Pelvic was negative. Head CT had a small subarachnoid bleed, anterofrontal bilaterally. CT of the spine was negative. Abdominal CT was negative. T&L spine was negative. HOSPITAL COURSE: Neurosurgery was consulted and recommended neurologic checks and repeat CT scan of the head which showed that the subarachnoid hemorrhage was not worsened. A CT of the face was done which showed no fractures. The patient's diet was advanced. The patient was with good p.o. pain control and ambulating well. The patient was felt to be ready for discharge with a follow-up. The patient is to be following up with Dr. [Last Name (STitle) 665] in one week for workup for Guaiac positive stool. Also, Dr. [Last Name (STitle) ] for Cardiac Services for reevaluation. Trauma Surgery Clinic with Dr. [Last Name (STitle) ] for suture removal and Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]/Dr. [First Name (STitle) ] for neurology follow-up. DISCHARGE MEDICATIONS: 1. Bacitracin to apply topically to his facial wounds t.i.d. 2. Standard over the counter pain medications. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSIS: 1. Status post traumatic closed head injury after a fall from a bicycle. 2. Small subarachnoid hemorrhage. 3. Lip laceration. 4. Multiple small lacerations and contusions. 5. Transient hyperamylasemia. 6. Other comorbidities as above, including atrial fibrillation, recurrent prostatitis, hypertension, coronary artery disease with aortic insufficiency, and cyst removal as a child, and paroxysmal atrial fibrillation. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2213], M.D. [MD Number(1) 2214] Dictated By:[Name8 (MD) 5915] MEDQUIST36 D: [2164-6-8] 04:55 T: [2164-6-16] 19:43 JOB#: [Job Number ] cc:[Last Name (STitle) 93361]	[ "42731", "4241", "4019" ]
Admission Date: [2178-7-29] Discharge Date: [2178-8-1] Date of Birth: [2127-1-11] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1271] Chief Complaint: s/p mechanical fall Major Surgical or Invasive Procedure: None History of Present Illness: Called by ED to see this pt s/p fall for occipital hemorrhage. ED resident explains that pt was sweeping out the back of his pick up truck and he was a witnessed fall off of the truck striking his head. He was with ? LOC. He stood up and then was able to walk up two flights to his apt unassisted. He then was seen coming out of the bathroom and fell again / not striking his head at this time. There is also report of a witnessed seizure. He was brought to [Hospital ] hospital. There he was combative and after CT results they decided to intubate him for transport to [Hospital1 18] for neurosurgical eval. Per report the wife states he is on an HIV cocktail and a medication for GERD. She does not know the names and is not here in the ED at this time. Past Medical History: HIV HEP C IVDA Social History: Married / history of IVDA-Heroin use within 24hrs of admit Family History: NC Physical Exam: O: T: af BP: 99/ 73 (was 160-170 sys at OSH) HR: 67 R 22 O2Sats 100% intubated Gen: WD/Thin male / intubated with OGT in place / hard collar in place/ with soft restraints in place. MAE to lab draws HEENT: Pupils: [4-1] (right eye with subconjunctival hemorrhage) pupils midposition / conjugate gaze / no nystagmus or gaze preference / no hemotymapnum . no csf rhinorrhea/ possible battle sign - early vs pressure from collar / + raccoon eyes with minimal swelling. / + blood to scalp in occipital region/ minimal / no [Last Name (un) 2043] step off Neck: In hard collar / Neuro: INTUBATED / off sedation / possibly still post-ictal + grimace to noxious / no EO / no commands / extensor postures to LE's without stim / with stim he does NOT localize / he does withdraw his extremity equally without focal weakness...he does withdraw his lowers to noxious, he also has some spontaneous LE movement / knee bending / no clonus. Pertinent Results: CT MaxFace [7-29]: Multiple nasal bone fractures with opacification of the ethmoidal air cells. Right frontal pneumocephalus. While no discrete right frontal bone fracture is seen, an occult fracture is not excluded. Left occipital fracture again seen, extending to the level of the jugular foramen, as noted on the concurrent head CT. Internal jugular vein injury can not be excluded and can be further evaluated for on MRV/CTV. CT Head [7-29]: Left occipital fracture extending through the left occipital condyle and extending to the level of the left jugular foramen. Cannot exclude an internal jugular vein injury which could be further evaluated with MRV/CTV if necessary. There is also a small left occipital extra-axial focus of hemorrhage at the level of the bony fracture. Additionally, there is a small right frontal subdural hematoma and small left parafalcine subdural hematoma. There are also foci of right frontal hyperdensity which are likely foci of subarachnoid hemorrhage versus small contusions. Small right pneumocephalus of unknown etiology, an occult frontal bone fracture is not excluded. Left nasal bone fractures. CT Torso [7-29]: 1. Endotracheal tube is located at less than 1 cm from the carina and withdrawing/repositioning of this tube is recommended. Findings and recommendation had been discussed with Dr. [First Name8 (NamePattern2) 636] [Last Name (NamePattern1) 5850] on [2178-7-19]. 2. Nasogastric tube distal tip at the gastroesophageal junction and further advancement is recommended so that it is well within the stomach. Finding and recommendation had been discussed with Dr. [First Name8 (NamePattern2) 636] [Last Name (NamePattern1) 5850] on [2178-7-19]. 3. Bilateral dependent atelectasis with possible aspiration. 4. No evidence of acute traumatic injury in the chest, abdomen, or pelvis. Brief Hospital Course: Patient was admitted to [Hospital1 18] Surgical ICU after beign trasnferred from an OSH where he was intubated and placed [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] cervical collar after a fall. He remained stable in the ICU overngiht and scans of his head, face, sinus, mandible, and torsos were obtained. He was found to have multiple nasal fractures and an occipital bone fracture in addition to his intracranial blood. On the mornign of [7-30] he was deemed fit for extubation and it was noted after conversation with his wife that he had within at least the last 24 hours if not more recently used heroin. As a result the ICU placed him on Methadone [Hospital1 ] for withdrawl prophylaxis. Pt had a repeat CT that evening which showed stable parafacline SDH and R frontal contusions. He was extubated without incident. On [7-31], he was transferred to floor in stable condition. Social work was consulted on [8-1] due to active heroin abuse however patient refused to meet with social work. He also refused the option of methadone clinic initially stating that he wasn't allowed back to the [Location (un) 89246] clinic and subsequently stating that it wouldn't help his addiction. It was explained to him that without adequate followup in methadone clinic or with a specialist he would not be given a prescription for methadone. He intitially entertained the option of a suboxone treatment program but then refused based on his HIV medication status. He became increasingly agitated and demanded to be discharged as soon as possible. At the time of discharge the patient is afebrile, VSS, and neurologically stable. Patient's pain is well-controlled and the patient is tolerating a good oral diet. He was cleared by PT for discharge home in stable condition and will follow-up accordingly. Medications on Admission: -kaletra (lopinavir/ritonavir) 200-50 mg two tabs PO BID -epzicom (abacavir sulfate/lamivudine) 600-300 mg PO QHS -omeprazole 20 mg PO HS -amitriptyline HCl 25 mg 1-2 tabs PO HS PRN Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain fever. 2. lopinavir-ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. abacavir 300 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. lamivudine 150 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO QHS (once a day (at bedtime)). 6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:30 Patch 24 hr(s) Refills:2 8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:10 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Frontal Contusion/SDH Seizure Left Cerebellar Contusion Nasal bone fracture Left occipital bone fracture Substance abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: ?????? Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [Last Name (STitle) 739], to be seen in 4 weeks. ?????? You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. - You refused discussion with social work during this admission and refused the option of a methadone clinic and suboxone center at this time. Please contact your PCP or Mental Health Services at [Hospital1 18] at [Telephone/Fax (1) 26838] should you wish to pursue these options at a later time. [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2178-8-1]	[ "51881" ]
Admission Date: [2173-6-14] Discharge Date: [2173-6-23] Date of Birth: [2102-11-22] Sex: M Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: This is a 70-year-old male with no known previous diagnosed coronary artery disease and a history of diabetes mellitus who was transferred from [Hospital6 27375] for cardiac catheterization after he developed shortness of breath with difficulty breathing. He had been noticing increasing dyspnea on exertion. When he presented to [Hospital 4199] Hospital he was found to be in congestive heart failure. He was then started on Lasix, an ACE inhibitor and enteric coated aspirin. It was thought that the shortness of breath was secondary to ischemia. The patient was transferred to [Hospital6 2018] on the [2-14] for a cardiac catheterization for subsequent work up after he had an electrocardiogram that showed recent T-wave inversions in V4 to 6. The patient had noticed a prior episode about two weeks before presentation and again six months prior. The patient had had no chest pain, palpitations, diaphoresis, nausea or vomiting. PAST MEDICAL HISTORY: 1. Diabetes mellitus 2. Hypertension 3. Hypercholesterolemia 4. Vitiligo 5. Chronic renal insufficiency 6. Anxiety MEDICATIONS ON PRESENTATION: 1. Lipitor 20 mg q hs 2. Enalapril 25 mg [Hospital1 ] 3. Metoprolol 50 mg [Hospital1 ] 4. Aspirin 325 mg po qd 5. Lorazepam prn 6. Lovenox 80 mg [Hospital1 ] PHYSICAL EXAM: VITAL SIGNS: His temperature was 97.3??????, pulse 66, blood pressure 175/85, saturating 97% on three liters O2 by nasal cannula. APPEARANCE: Pleasant middle aged white male lying comfortably in bed. NECK: Jugular venous distention about 7 cm, no carotid bruits. LUNGS: Slight basilar crackles bilaterally. HEART: Regular rate and rhythm. ABDOMEN: Soft, nontender, 2+ groin pulses, no bruits. EXTREMITIES: Trace bilateral edema. LABS: His white blood count was 9.0, hematocrit 36.5, platelets count 163. PT 13.3, PTT 41.9, INR 1.2, calcium 8.8, magnesium 1.7, phosphate 3.9. ALT 9, AST 9. His troponin was 0.22. His CKs were negative. IMAGING: Electrocardiogram showed normal sinus rhythm, no ischemic STs. Echocardiogram done on the [2-15] showed an ejection fraction of 30% with left ventricular hypertrophy. Cardiac catheterization done the [2-15] showed three vessel coronary artery disease. He was taken to the Operating Room on [2173-6-17] where a five vessel coronary artery bypass graft was performed. He tolerated the procedure well. It was found postoperatively that the patient was found postoperatively to have some upper and lower extremity weakness with decreased bilateral hand grips. Over the course of the next few days, his neurologic status noted some improvement, however he continued to have some clumsiness on his left side. Neurology was consulted and he was thought to have had a perioperative stroke. Head CT was performed and he a had a bilateral complex duplex study done. Head CT showed multiple chronic lacunar infarcts with a possible lesion in the right parietal area. Carotid duplex showed greater than 90% right ICA stenosis with significant plaque and 60% to 69% stenosis on the left internal carotid artery with moderate plaque. The patient was continued on aspirin which he had been on pre and postoperatively. He was transfused to keep his hematocrit above 30 and blood pressure was managed above 140 systolic. The patient otherwise had an uncomplicated postoperative recovery with respect to his cardiac status and is found to be stable for discharge to an acute rehabilitation facility. DISCHARGE DIAGNOSES: 1. Status post five vessel coronary bypass grafting 2. Perioperative stroke 3. Diabetes mellitus 4. Hypertension 5. Hypercholesterolemia 6. Vitiligo 7. Chronic renal insufficiency FOLLOW UP: The patient is to follow up with vascular surgery in three weeks and follow up with neurology, Dr. [Last Name (STitle) 623], #[Telephone/Fax (1) ], in six to eight weeks. The patient is to follow up with Dr. [First Name (STitle) 10102] in three to four weeks. DISCHARGE MEDICATIONS: 1. Lipitor 20 mg q hs 2. Enalapril 25 mg [Hospital1 ] 3. Aspirin 325 mg po qd 4. Lovenox 80 mg subcutaneous [Hospital1 ] 5. Colace 100 mg po bid 6. Captopril 12.5 mg po qid 7. Lopressor 75 mg po bid 8. Tylenol 650 mg po q4h prn pain 9. Milk of Magnesia 30 mg po q hs prn 10. Lorazepam 0.5 mg po q8h prn anxiety The patient has been accepted at the On [Location (un) ] Nursing and Rehabilitation Center which should receive a copy of this dictation. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 13625] Dictated By:[Last Name (NamePattern1) 27376] MEDQUIST36 D: [2173-6-23] 11:39 T: [2173-6-23] 12:39 JOB#: [Job Number 27377] cc:[Location (un) 27378]	[ "41401", "4280", "25000" ]
Admission Date: [2125-10-10] Discharge Date: [2125-10-31] Date of Birth: [2072-11-5] Sex: F Service: ADDENDUM: DISCHARGE MEDICATIONS: Synthroid 100 micrograms po q.d., vitamin E 400 units po q day, Protonix 40 mg po q.d., Colace 100 mg po q.d., Miconazole powder b.i.d. to affected areas. Regular insulin sliding scale, NPH 18 units subQ b.i.d., Haldol 1 to 2 mg po intravenous IM q 2 to 4 hours prn agitation. Tylenol 650 mg po q 4 to 6 hours prn. Benadryl 25 mg po q 4 to 6 hours prn. The patient will follow up with her outpatient psychiatrist Dr. [First Name (STitle) ] [Name (STitle) 67071] in two weeks. The patient will also follow up with her primary care physician [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4610] in one to two weeks after discharge from rehab. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 97811] Dictated By:[Last Name (NamePattern1) 5246] MEDQUIST36 D: [2125-10-31] 11:41 T: [2125-10-31] 11:45 JOB#: [Job Number 96089]	[ "5849", "486", "5990", "2762", "25000" ]
Admission Date: [2131-5-20] Discharge Date: [2131-5-24] Date of Birth: [2064-6-17] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern4) 290] Chief Complaint: Gastrointestinal bleed Major Surgical or Invasive Procedure: Right Internal Jugular central line placement and removal History of Present Illness: Mr. [Known lastname 916] is a 66 year old man with DM, CAD, s/p recent STEMI, Ischemic cardiomyopathy LEVF 25%, errosive gastritis, and colon polyps who is admitted from [Hospital ] rehabilitation for 1 week of black stool, and a slow hct drop. According to the report HCT trend: 30 ([5-15]) -> 27 ([5-19])->22 today and he was transferred to the emergency department. . In the ED, initial vs were: T: not recorded, P:92 BP:120/69 RR:28 Sa02:100% FiO2: 40%. He subsequently spiked to T:102.6. Labs were remarkable for HCT 20.9, WBC 6.7 83.2% Lactate 2.4, Cr 1.5, UA positive. Patient was given Vanc/zosyn, pantoprazole drip and 80mg bolus, and a RIJ was placed, GI was consulted who recommended non-urgent scope, and to continue pantoprazole 40mg IV BID vs drip. Not transfused in the ED. VS prior to transfer: T99.8 HR 84 122/67 22 on vent 100% AC 450x12 Peep 5 fi02 50% . On arrival to the ICU, T:99.9 BP: P:84 R: 18 O2:100% AC 450x12 50% FiO2. He reported that his breathing is comfortable, denies chest pain. He complained of pain at the site of his saccral decubitis. . Review of sytems: (+) Per HPI (-) Denies fever, chills. Denied shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting. . Of note patient was hospitalized recently in the MICU [Date range (1) 29015]. He was admitted for STEMI, urosepsis and hypotension. STEMI was medically managed with heparin, plavix, asa, statin, ECHO showed newly depressed EF to 25% with wide LV hypokinesis. He grew VRE from blood and urine and was treated with daptomycin, meropenem and linezolid. He was intubated for increased work of breathing and treated for heart failure and VAP however the MICU team was unable wean him off of the vent, he is s/p trach and PEG. Hospital course was also complicated by pulseless VT x4 managed with synchronized cardioversion and amiodarone. Goals of care at end of hospital course were DNR, do not escalate care Past Medical History: Ventilator dependent last vent settings PSV 12/5 ATC 40% Fio2 Coronary Artery Disease c/b STEMI [4-/2131] medically managed Ventricular tachycardia s/p cardioversion Ischemic cardiomyopathy LVEF 25% [4-/2131] Erosive esophagitis c/b recurrent GI bleeds Bilateral CEA Diabetes mellitus Sacral Decubitis BL heel pressure ulcers Chronic kidney disease baseline creatinine 1.4-1.6 PVD: mild-moderate aorto-[Hospital1 ]-ilac disease as noted in [2119] GERD Colonic polyps VRE UTI MRSA Pneuomonia Hyperlipidemia Macular Degeneration Chronic back/leg pain secondary to DJD Essential Tremor Peripheral Neuropathy s/p Left and Right Total hip replacements COPD Depression Social History: Denies current tobacco use (h/o 20+ pack year, quit 15-20 years ago) Admits to approximately 2+ beers most nights of the week. Denies h/o illicit drug use. Resident at [Hospital1 ] health. Family History: Non-contributory Physical Exam: ADMISSION EXAMINATION Vitals: T:99.9 BP: P:84 R: 18 O2:100% AC 450x12 50% FiO2 CVP:16 General: Alert; follows simple commands HEENT: Tracheostomy in place on ventilator tube in place; MMM, PERRL Neck: supple, JVP elevated at 10cm, Right IJ catheter in place Lungs: Left basilar rales, otherwise clear to auscultation in posterior lung fields. CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Back: Deep sacral decubitis ulcer with packing in place GU: Foley in place Ext: Right lower ext cool to touch, left warm to the touch. Radial pulses 1+ BL. Bilateral R>L heel ulceration with granular base and eschar; no exudates/purulence visible; 1+ pedal edema Pulses: Right PT palpated, DP not dopplerable Left PT and DP dopplerable DISCHARGE EXAM: T96.2, HR66 BP135/69, RR21, 100% on pressure support 8cm/5cm, RR20,Fi02 40% General: Alert; follows simple commands HEENT: Tracheostomy in place on ventilator tube in place; MMM, PERRL Neck: supple, Right IJ catheter in place Lungs: Bibasilar rales on anterior/lateral auscultation CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Cool, 1+ radial pulses, bandages over heels b/l, trace pedal edema Pertinent Results: ADMISSION LABS: [2131-5-20] 06:45PM BLOOD WBC-6.7 RBC-2.17* Hgb-6.9* Hct-20.9* MCV-96 MCH-31.7 MCHC-33.0 RDW-17.9* Plt Ct-157# [2131-5-20] 06:45PM BLOOD Neuts-83.2* Lymphs-11.4* Monos-4.3 Eos-0.7 Baso-0.5 [2131-5-20] 06:45PM BLOOD PT-14.3* PTT-37.1* INR(PT)-1.2* [2131-5-20] 06:45PM BLOOD Glucose-155* UreaN-82* Creat-1.5* Na-147* K-3.8 Cl-99 HCO3-36* AnGap-16 [2131-5-20] 06:45PM BLOOD ALT-96* AST-73* LD(LDH)-249 CK(CPK)-22* AlkPhos-125 TotBili-0.4 [2131-5-20] 06:45PM BLOOD Calcium-8.3* Phos-5.3# Mg-2.7 [2131-5-20] 06:45PM BLOOD Hapto-380* [2131-5-20] 07:08PM BLOOD Lactate-2.4* CARDIAC ENZYMES [2131-5-20] 06:45PM BLOOD CK-MB-1 cTropnT-0.49* . DISCHARGE LABS: [2131-5-24] 03:17AM BLOOD WBC-8.5 RBC-3.36* Hgb-11.2* Hct-32.3* MCV-96 MCH-33.2# MCHC-34.6# RDW-17.8 Plt Ct-175 [2131-5-24] 03:17AM BLOOD Plt Ct-175 [2131-5-24] 03:17AM BLOOD PT-14.3* PTT-38.7* INR(PT)-1.2* [2131-5-24] 03:17AM BLOOD Glucose-74 UreaN-66* Creat-1.6* Na-148* K-3.3 Cl-104 HCO3-31 AnGap-16 [2131-5-24] 03:17AM BLOOD Calcium-8.0* Phos-4.3 Mg-2.3 [2131-5-21] 04:29AM BLOOD Lactate-1.1 . IMAGING: [5-20] CXR 1. Interval placement of right internal jugular central venous catheter terminating in the proximal to mid SVC, without evidence of pneumothorax. 2. Bilateral layering pleural effusions, increased, with overlying atelectasis, underlying consolidation not excluded. Additional peripheral right upper lobe patchy opacity may be due to additional site of infection and/or aspiration. Pulmonary edema. Cardiomegaly. . [5-21] TTE The left atrium is mildly dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (LVEF= 25-30 %) secondary to akinesis of the inferior and posterior walls, and hypokinesis of the interventricular septum. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with depressed free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Severe (4+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (images reviewed) of [2131-4-9], there has been marked progression of mitral and tricuspid regurgitation (both of the functional ischemic classification) consistent with the natural history of this patient's recently documented untreated extensive inferior posterior and right ventricular myocardial infarction. Brief Hospital Course: HOSPITAL COURSE 66yo chronically-ventilated M PMH recent STEMI, ischemic cardiomyopathy LEVF 25%, errosive gastritis, a/w slow upper gastrointestinal bleed and PNA, bleeding stabilized without surgical/endoscopic intervention, started on high-dose cefepime for MDR psuedomonal PNA, clinical status improving with patient discharged to ECF. . ACTIVE # GI Bleed: Patient w h/o errosive gastritis on EGD [2-/2131], who presented w downtrending HCT (30 to 20.9), guaiac + stool. Patient received 3 units pRBCs w stabilization of Hct in low 30s. Patient was continued on IV PPI and started on carafate. HCT stabilized (>48 hours) without invasive intervention and GI service opted not to scope. . # Respiratory Failure [3-7] PNA and Chronic Systolic CHF: Ventilator dependent patient [3-7] MRSA pneumonia [4-/2131] and heart failure, with pulmonary infiltrates on admission. Sputum grew out psuedomonas with sensitivities demonstrating carbapenem resistance. Per ID recommendations, patient was started on high dose extended infusion cefepime. ID fellow [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 6137] agreed to follow up further micro data on patient. He was continued on home lasix, nebulizers. . # Coronary artery disease c/b ischemic cardiomyopathy: Patient with recent STEMI [4-/2131] that was medically managed (given his prior bleeds) with ASA, plavix, and a statin, who was w/o signs ischemia on admission, but w signs c/w worsening failure. Given some hypotension on admission, metoprolol dosing was decreased. TTE demonstrated LVEF 25%, 4+MR. Cardiology was consulted, who recommended started ACE-I. If he remained stable, they also recommended starting spironolactone (not started at discharge, recommended to start at ECF). . INACTIVE # h/o VT: Patient was continued on amiodarone. . # DM: Patient was continued on standing glargine and sliding scale insulin . # Thrombocytopenia: Patient continued to have thrombocytopenia on this admission. Heparin antibody was negative in prior admission. On discharge platelets 175. . # Sacral decubitis: Patient with deep sacral decubitis, bilateral heel ulcers. Followed by wound care during inpatient stay. Should be followed at rehab center. . TRANSITIONAL 1. Code status: Patient remained DNR for duration of hospital stay 2. Pending: At time of discharge, additional sensitivities for psuedomonas (doripenem and colistin) were pending. ID fellow [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 6137] would follow-up. 3. Transition of Care: Patient discharged to [Hospital1 ], with follow-up planned with heart failure clinic. 4. Barriers to Care: Recurrent GI bleeds have had major effect on patient management (rehospitalizations, inability to manage STEMI w cath), and may necessitate recurrent transfusions or future readmissions Medications on Admission: acetaminophen 650 mg/20.3 mL Oral Soln Q6H PRN albuterol sulfate HFA 90 mcg 6 puffs Q6-8 hrs PRN amiodarone 400 mg daily ascorbic acid 500 mg daily atorvastatin 80 mg Daily Chlorhexedine 0.12% 12mL Q12H Diphenhydramine 25mg Q4H PRN itching Diphenhydramine cream 1appl Q8H PRN Docusate 100mg [Hospital1 ] Glucerna 1.2 tube feed 75ml/H furosemide 80 mg IV BID collnaagese clostridium histolyticum 250 unit/g Ointment Topical [Hospital1 ] insulin glargine 14 QHS insulin regular Sliding scale Ipratropium/Albuterol 3mL Q2H PRN Lorazepam 1mg Q8H PRN metoprolol tartrate 75 mg Q8H pantoprazole 40 mg IV BID sucralfate 1 gram 4x daily Polyethylene glycol 17g daily free water 200cc Q6H Discharge Medications: 1. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. acetaminophen 650 mg/20.3 mL Solution Sig: Six [Age over 90 1230]y (650) mg PO Q6H (every 6 hours) as needed for pain. 3. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO once a day. 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 5. Pantoprazole 40 mg IV Q12H 6. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane TID (3 times a day). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 8. cefepime 2 gram Recon Soln Sig: Two (2) grams Injection Q12H (every 12 hours): to be infused over 3 hours. 9. Furosemide 80 mg IV BID Hold for SBP<90; please contact MD if going to hold. 10. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) Inhalation q2h as needed for shortness of breath or wheezing. 11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 12. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Tablet(s) 14. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 16. insulin glargine 100 unit/mL Solution Sig: Fourteen (14) units Subcutaneous at bedtime. 17. Sliding Scale Regular Insulin Sliding Scale Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: PRIMARY Hospital Acquired Pneumonia SECONDARY GI Bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Mr. [Known lastname 916], It was a pleasure taking care of you at [Hospital1 827]. You were admitted with decreasing blood levels, likely due to bleeding from your gastrointestinal tract. You were transfused with red blood cells. Your blood levels returned to [Location 213] levels, and remained stable for 3 days. We discussed your care with gastroenterologists who felt that you did not need to have an endoscopy as long as your blood levels remained stable. Given your recent history of a heart attack and heart failure, we discussed your case with cardiologists, who felt that certain medications should be started to help your heart function. You were found to have a pneumonia with a very resistant bacteria called psuedomonas. You were seen by infectious disease doctors, who started you on a strong antibiotic called cefepime that you will need to continue for 2 weeks. During the course of this hospitalization, the following changes were made to your medications: -DECREASED metoprolol to 50mg [Hospital1 ] -STARTED cefepime (to be continued for 13 days) -STARTED captopril -STARTED aspirin -STARTED sucralfate Followup Instructions: Name: [Last Name (LF) ], [Name8 (MD) ] NP Location: [Hospital1 18] DIVISION OF CARDIOLOGY Address: [Location (un) ], E/RW-453, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 62] We are working on a follow up appointment with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] NP within 1-2 weeks. You will be called with the appointment. If you have not heard from the office within 2 days or have any questions, please call the number above. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "5990", "2760", "2851", "41401", "4280", "25000", "53081", "5859", "2875", "496", "40390", "2724", "4240", "311", "V5867" ]
Admission Date: [2179-3-24] Discharge Date: [2179-3-27] Date of Birth: [2106-5-17] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2724] Chief Complaint: HEADACHE Major Surgical or Invasive Procedure: LEFT BURR HOLE EVACUATION OF SDH History of Present Illness: Mr [Known lastname 80675] started with a headache 3 weeks ago. He fell down(slipped on the ice twice) in 2 consecutive days. It was dull,holocraneal. He did not take any medications and it wore off onits own. He did have 2 to 3 events qwk. His daughter states he had minor concentration problems last weekend while having a conversation and attempting to continue with a concomitant task.He has had no nausea or vomiting. There have been no new motor or sensory deficits. He ambulates w/o a cane. He is IADL. As far as his headaches were not subsiding, he visited his PCP 48h ago. He decided to performed an MRI CNS w/o contrast today at [Location (un) 620] that evidenced LARGE LEFT CEREBRAL HEMISPHERIC SUBDURAL HEMORRHAGE WITH midline shift and no hydrocephalus. Took celebrex yesterday (only once). Past Medical History: Seasonal allergies. He has on colonoscopy had diverticuli in [2174]. He did have a right total knee replacement in [2174]. Raynaud's phenomenon. He does have 50% carotid blockage on ultrasound in [2172]. Recent exercise stress test in which he was only able to perform 5 minutes of exercise stopping with a maximal heart rate of 132 with dyspnea and a maximal blood pressure of 210/78. No EKG changes with exercise. Emphysema Social History: Social Hx: cigarette smoking but stopped smoking 10 years ago. He used to work in electronic repair. He is married and lives with his wife. [Name (NI) ] does not smoke at present and uses alcohol infrequently. There is a history of mom[Name (NI) 12823] blindness occurring after being stung with wasps in the past but there is no allergic history. There is no history of allergy to drugs. Family History: FH: His father died prematurely of throat cancer. His father's family died in their 70s. His mother died at age [Age over 90 ] with a stroke at age [Age over 90 ]. She did have Alzheimer's disease and carotid vascular disease. He has lost a brother and a sister to trauma.He has a brother and sister who are alive with no history of stroke and no history of coronary disease. He works presently in delicatessen. Physical Exam: PE: VS: 140/ 69, 76 bpm, RR 12 SO2 100% RA. GCS 15. Gen: Lying in bed, NAD. HEENT: NC/AT, moist oral mucosa Neck: supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: Soft, nontender, non-distended. No masses or megalies. Percussion within normal limits. +BS. Ext: no edema, no DVT data. Pulses ++ and symmetric. Neurologic examination: No meningismus. No photophobia. MS: General: alert, awake, normal affect Orientation: oriented to person, place, date, situation Attention: 20 to 1 backwards +. Follows simple/complex commands. However digit span backwards is impaired. Speech/Language: fluent w/o paraphasic errors; comprehension, repetition, naming: normal. Prosody: normal. Memory: Registers [3-2] and Recalls [3-2] when given choices at 5 min Praxis/ agnosia: Able to brush teeth. No field cuts. CN: I: not tested II,III: VFF to confrontation, PERRL 3mm to 2mm in the LEFT and 4 to 2 mm on the RIGHT to direct and consensual light, fundus w/o papilledema. III,IV,VI: EOMI, no ptosis. No nystagmus V: sensation intact V1-V3 to LT VII: Facial strength intact/symmetrical VIII: hears finger rub bilaterally IX,X: palate elevates symmetrically, uvula midline [Doctor First Name 81]: SCM/trapezeii [5-4] bilaterally XII: tongue protrudes midline. Rinne: R ear: AC>BC, LEFT ear AC> BC [Doctor Last Name 15716]: central. Motor: Normal bulk. Tone: mildly increased on the RIGT hemibody. No tremor, no asterixis or myoclonus. No pronator drift: Delt;C5 bic:C6 Tri:C7 Wr ext:C6 Fing ext:C7 Left 5 5 5 5 5 Right 5 5 5 5 5 IP: Quad: Hamst: Dorsiflex: [Last Name (un) 938]:Pl.flex Left 5 5 5 5 5 Right 5 5 5 5 5 Deep tendon Reflexes: Bicip:C5 Tric:C7 Brachial:C6 Patellar:L4 Toes: Right 2 2 2 2 DOWNGOING Left 1 1 1 1 DOWNGOING Sensation: Intact to light touch, vibration, and temperature. Propioception: normal. Coordination: Finger-nose-finger mild dysmetria on the LEFT Rapid Arm Movements normal. Fine finger tapping: clumpsier than expected on the LEFT hand Heal to shin: normal. Romberg: drifting toward LEFT. Uthemberg: drifting toward LEFT. Unable to perform heel to toe. Regular gait: narrow based, tentative, normal arm swing, cadence normal, stride normal. Turns are normal. Trunk is not in flexion. Pertinent Results: MRI at [Location (un) ] on 3/ 25/ 09: Very large, mixed signal intensity subdural hemorrhage extending over the entire left frontal and parietal lobes, and which appears to terminate caudally at approximately the level of the left sylvian fissure. There is a small component of this hemorrhage overlying the left occipital lobe. The maximal thickness of the subdural hemorrhage is 27 mm. There is pronounced effacement of the adjacent cortical sulci and approximately 7 mm right-sided subfalcine herniation,as well as compression of the left lateral ventricle. There does not overt uncal or hippocampal herniation at this time. on the FLAIR images are numerous subcentimeter areas of elevated T2 signal within the white matter of both cerebral hemispheres, somewhat more prominent on the right side. While nonspecific in etiology, given patient age, chronic small vessel infarcts would appear the most probable diagnosis, as opposed to postinflammatory residua. There is no overt extracranial abnormality detected. [2179-3-24] 01:25PM GLUCOSE-95 UREA N-18 CREAT-0.9 SODIUM-140 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-24 ANION GAP-14 [2179-3-24] 01:25PM WBC-7.8 RBC-4.77 HGB-15.4 HCT-43.9 MCV-92 MCH-32.3 MCHC-35.2* RDW-14.0 [2179-3-24] 01:25PM NEUTS-66.6 LYMPHS-26.3 MONOS-5.0 EOS-1.7 BASOS-0.4 [2179-3-24] 01:25PM PLT COUNT-262 [2179-3-24] 01:25PM PT-12.3 PTT-25.1 INR(PT)-1.0 Brief Hospital Course: Pt was admitted to the ICU for close neurologic monitoring he remained stable. He was started on antiseizure prophylaxis. He was readied for the OR. On [3-25] he was brought to the OR where under general anesthesia he underwent left burr hole evacuation of subdural hematome. He tolerated this procedure well, was extubated and transferred back to the ICU. Post op CT showed decrease in SDH and decreased shift. His wounds were clean and dry with staples. His diet and activity were advanced. He remained neurologically intact. He was seen and evaluated by PT and cleared for discharge to home. Medications on Admission: Home Meds: Simvastatin unknown dose Discharge Medications: 1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:2 2. Simvastatin Oral Discharge Disposition: Home Discharge Diagnosis: SDH Discharge Condition: NEUROLOGICALLY STABLE Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair beginning [2179-3-29] ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. for one week. ?????? You have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in 7 days and fax results to [Telephone/Fax (1) 87]. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR. [Last Name (STitle) ] TO BE SEEN IN 4 days (patient says that this is when Dr [Last Name (STitle) 548] wanted him seen next). If you do not see Dr [Last Name (STitle) 548] until 4 weeks from now, please make appt to come in in 10 days for staple removal. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST Completed by:[2179-3-29]	[ "V1582" ]
Unit No: [Numeric Identifier 70045] Admission Date: [2130-12-16] Discharge Date: [2131-1-12] Date of Birth: [2130-12-16] Sex: F Service: NB HISTORY: [First Name9 (NamePattern2) ] [First Name8 (NamePattern2) ] [Known lastname 5936]-[Known lastname ] was born at 32 and 5/7 weeks and admitted to the newborn intensive care unit with respiratory distress and prematurity. She was born at 32 and 5/7 weeks to a 37-year-old gravida 2, para 0, 2, 2 mother. [Name (NI) ] [2131-2-5]. Prenatal labs included a blood type A negative, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune and group B strep negative. Pregnancy was intrauterine insemination assisted resulting in a di-di twin gestation. Pregnancy was uncomplicated until mother presented on [12-3], with premature prolonged rupture of membranes. She was found to be having preterm contractions without cervical change and was admitted for bed rest. She was treated with magnesium sulfate, betamethasone and erythromycin C for latency. She had some transient elevations in blood pressures but was without proteinuria. Ultrasound remained reassuring. Biophysical profile 8 out of 8. On the evening prior to delivery, the mother developed increased preterm contractions, uterine tenderness and a mildly elevated fetal heart rate. Due to concern for developing chorioamnionitis, she was brought for cesarean section delivery. There were no interpartum antibiotics. At delivery this twin, twin B, emerged with moderate tone and weak cry, responding to stimulation and blow-by oxygen. Apgars were 7 at 1 and 8 at 5 minutes with mild respiratory distress and the infant was transported to the NICU. PHYSICAL EXAMINATION: Weight 1665 grams, 25th to 50th percentile; head circumference 29 cm, 25th percentile; length 43 cm, 25th to 50th percentile. GENERAL: A well developed premature infant, active with examination. Moderate respiratory distress at rest. Overall appearance consistent with estimated gestational age. HEENT: Mild positional deformity of left side concavity, fontanel soft and flat. Sutures approximate. Ears, nares normal. Nondysmorphic, intact palate, positive red reflex noted bilaterally. NECK: Supple. No lesions. CHEST: Coarse symmetric moderate aeration. Mild grunting. Mild retractions. CARDIAC: Regular rate and rhythm. No murmur or gallop. Femoral pulses of 2+ and equal. ABDOMEN: Soft. No hepatosplenomegaly. No masses. Quiet bowel sounds. Three-vessel cord. GENITOURINARY: Normal female. Anus patent. EXTREMITIES: Hips and back normal. No lesions. NEUROLOGIC: Appropriate tone and activity for gestational age. Symmetric Moro. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: [Month (only) ] demonstrated mature lungs and remained comfortable in room air from admission to the NICU. She developed apnea of prematurity and had up to 2 to 3 apneic episodes daily which resolved spontaneously without the use of methylxanthine. She has been spell free for 5 days. CARDIOVASCULAR: She remained hemodynamically stable with AP's 130s to 160s, blood pressure 60/32 with a mean of 42. Infant has had an intermittent murmur, which was not appreciated on discharge exam today but will need to be followed. Infant initially had an IV access via double lumen UVC line which was placed upon admission and remained in place through day 6 for parenteral nutrition administration. FLUIDS, ELECTROLYTES AND NUTRITION: Initially [Month (only) ] was maintained NPO, total fluids of 80 per kg with PN and D10W. She was euglycemic upon admission and remained so as feeds were advanced and IV fluids were decreased. She started feeding on day of life 1 with expressed breast milk or Similac Special Care 20 and increased 10 cc per kg twice a day reaching full enteral volume by day of life 7. Thereafter calories were increased to a maximum of breast milk 26 calories with Beneprotein utilizing human milk fortifier and MCT oil. On day of life 13 she was noted to have some frank blood in her stool. She had a KUB at that time which was normal. CBC and blood culture were drawn which were reassuring and feeds were reassumed, however 2 days later, on day of life 15, there was gross blood in the stools. [Month (only) ] was again made NPO. CBC and blood culture were obtained. There was mild temperature elevation to 100.1. CBC showed increased I to T ratio with a white blood cell count of 6.4, 41 polys, 9 bands, 31 lymphs and 5 metamyelocytes. Hematocrit was 35% and platelets were mildly elevated at 715,000. Serial KUBs were obtained which remained normal. She was kept NPO for a period of 48 hours on repeat CBC demonstrated significant eosinophilia with resolved bandemia. Given the presentation and the eosinophilia, it was felt that the bloody stools were due to milk protein allergy. Therefore feeds were resumed with breast milk and fortified with Nutramigen powder. These have been well tolerated and the stools have been heme negative since that time. Of note the mother is a vegetarian and has a diet that is with a large concentration of dairy products which she has been instructed to modify. Discharge weight is 2210g. GASTROINTESTINAL: The baby was treated with single phototherapy from day 2 through day 5 with a peak bilirubin of 7.1/0.3. With initiation of phototherapy, this problem is now resolved. HEMATOLOGY: [Month (only) ] was started on supplemental iron when full feeds were achieved and continues on that at the time of discharge with a dose of 0.4 cc po q day. INFECTIOUS DISEASE: Initially a CBC and blood culture were drawn. There was relative neutropenia with an ANC of 612 which resolved on subsequent CBC on day of life 2. Blood cultures remained sterile. Ampicillin and gentamycin were administered for the first 48 hours and discontinued at that time. As aforementioned when [Month (only) ] was made NPO on day of life 15, a repeat sepsis assessment was undertaken during which time she received 48 hours of ampicillin and gentamycin, discontinued for negative cultures and improved clinical course. NEUROLOGIC: [Month (only) ] has remained appropriate for gestational age in terms of her examination. SENSORY: Audiology, hearing screen was performed with automated auditory brain stem responses which was passed. OPHTHALMOLOGY: An eye examination was not indicated at this gestational age. PSYCHOSOCIAL: Mother is married and quite involved and invested in these twin girls. The sister of this baby was discharged a few days ago and is doing well at home. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: To home. NAME OF PRIMARY PEDIATRICIAN: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 66546] of [Hospital ] Pediatrics. CARE RECOMMENDATIONS: 1. Feed at the time of discharge is breast milk fortified with Nutramigen powder to 24 calories per ounce. 2. Medications: Fer-In-[Male First Name (un) ]. Elemental iron 0.4 ml by mouth each day. 3. Car seat position screening was done and the baby passed this screening test as well. 4. State newborn screen was done on day of life 3 and more recently on day of life 14 which was [12-30]. REsults are pending and will need to be followed by the pediatrician. 5. Immunizations received: Initial Hepatitis B vaccine given on [1-7]. 6. Immunizations Recommended: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following three criteria. 1. Born at less than 32 weeks. 2. Born between 32 and 35 weeks with two of the following: daycare during the RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school age siblings or with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. Follow up appointments recommended are: 1) primary pediatrician on Monday. 2) hip ultrasound at 4-6 weeks of age due to breech in utero positioning 3) VNA on Sunday. [2131-1-14] DISCHARGE DIAGNOSES: 1. Premature twin No. 2 at 32 and 5/7 weeks. 2. Sepsis suspect ruled out. 3. Presumed Milk protein allergy. 4. Breech presentation at risk for congenital hip dysplasia. 5. Physiologic jaundice, resolved 6. Anemia of prematurity, resolved [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 56662] Dictated By:[Last Name (NamePattern1) 61558] MEDQUIST36 D: [2131-1-11] 22:36:14 T: [2131-1-12] 00:00:12 Job#: [Job Number 70046]	[ "7742", "V290", "V053" ]
Admission Date: [2166-11-7] Discharge Date: [2166-11-8] Date of Birth: [2108-5-7] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 78] Chief Complaint: elective admission Major Surgical or Invasive Procedure: cerebral angiogram with stent and coiling of aneurysm History of Present Illness: thisis a 58 year old man who was electively admitted for coiling of basilar aneurysm Past Medical History: basilar aneurysm Social History: Works as a window installer; primary language is Portuguese Family History: Unknown Physical Exam: on the day of admission10/12/[2166]: neurologically intact On the day of discharge10/13/[2166]: neurologically intact - angio site right groin intact no eccymosis, or hematoma, pedal pulses are present. patient ehibits full strength sensation intact pupils equal and reactive face symetric Pertinent Results: [2166-11-7] 10:45AM PT-12.0 PTT-29.3 INR(PT)-1.1 [2166-11-7] 10:45AM PLT COUNT-337 [2166-11-7] 10:45AM WBC-7.8 RBC-4.95 HGB-15.5 HCT-43.8 MCV-89 MCH-31.4 MCHC-35.5* RDW-12.8 Brief Hospital Course: The patient is a 58 year old man who was electively admitted on [2166-11-7] for a cerebral angiogram and coiling and stenting of his basilar aneurysm. The procedulre was performed by Dr [Known firstname ] and tolerated well. The patient was recovered in the intensive care unit and stayed there overnight on a heparin intravenous gtt. The patient was initiated on Aspirin 325 mg daily and plavix 75 mg daily for his coiling and stent. The heparin gtt was discontinued in the morning. The patient remained neurologically intact throughout his hospital course. The patient was able to tolerate a regular diet and ambulate independently and was discharged to home. Medications on Admission: unknown Discharge Medications: 1. Aspirin 325 mg PO DAILY first dose tonight RX aspirin 325 mg 1 tablet(s) by mouth once a day Disp #60 Tablet Refills:5 2. Atorvastatin 10 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY for 1 month post coiling and stenting of aneurysm Duration: 30 Days RX clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 4. Docusate Sodium (Liquid) 100 mg PO BID RX docusate sodium [Colace] 100 mg 1 capsule by mouth twice a day Disp #30 Capsule Refills:0 5. Finasteride 5 mg PO DAILY 6. Senna 1 TAB PO BID:PRN Constipation RX sennosides [senna] 8.6 mg 1 capsule by mouth twice a day Disp #30 Capsule Refills:0 7. Methocarbamol 500 mg PO TID 8. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain RX oxycodone 5 mg [1-27] tablet(s) by mouth q 6-8 Disp #40 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: basilar aneurysm Discharge Condition: the patient is neurologically intact strength is full sensation is full pupils are equal and reactive face is symetric patient is alert and oriented to person/place and time Discharge Instructions: Angiogram with Embolization and Stent placement Dr. [First Name8 (NamePattern2) ] [Known firstname ] Medications: ?????? Take Aspirin 325mg (enteric coated) once daily indefinitely. ?????? Take Plavix (Clopidogrel) 75mg once daily for 1 month. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Followup Instructions: please call Dr [First Name8 (NamePattern2) ] [Known firstname ] office for an appointment to be seen in 2 months with a MRI/MRA per Dr [Known firstname ] protocol You may call to make an appointment at [Telephone/Fax (1) 1669]. Completed by:[2166-11-8]	[ "2724", "4019", "53081" ]
Admission Date: [2116-10-19] Discharge Date: [2116-10-21] Date of Birth: [2043-3-17] Sex: F Service: MEDICINE Allergies: No Allergies/ADRs on File Attending:[First Name3 (LF) 99] Chief Complaint: Post-cardiac arrest Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname 12129] is a 73yoF with h/o bipolar d/o on Lithium who is transferred from OSH s/p cardiac arrest. Patient is currently unable to provide history, therefore details of HPI are obtained from family and OSH records. Per pt's family, pt had c/o flu-like sx a week ago, with URI sx and cough. Had also had progressive DOE for past few weeks, to the point that she became dyspneic when walking from her apartment to parking lot (~100 feet). No h/o cardiac disease, however recently had stress test which was reportedly negative and was scheduled to see cardiologist this week. Today the elevator in her apartment building was broken, and when walking up 2 flights of stairs to her apartment she became extremely SOB and called for help. EMS was called, started CPAP but she did not tolerate it, became agitated, then became bradycardic and suffered asystolic arrest. CPR was started and she receieved epi 1mg x3 and lidocaine 100 in field then was taken to OSH. At OSH ED received atropine x2 and additional epi x4. Total time to ROSC estimated 25 minutes. She received chilled saline at OSH and was transferred to [Hospital1 18], with T 33.9 en route. In the ED, initial VS were T 33F, HR 85, BP 90/40 on dopa 20mcg and epi 12.5mcg. GCS 3, not responding to commands but withdrawing to painful stimuli. Labs were notable for pH 6.94, pCO2 64, HCO3 15, lactate 9.9. EKG showed sinus rhythm with LAD and RBBB, low voltage. (Of note initial ECG at OSH had anterior STE, but resolved.) Bedside TTE showed no RV enlargement, global hypokinesis with depressed LVEF, c/w post-arrest. No significant valvular disease. FAST exam negative. CTA showed no PE but large bibasilar consolidations c/w aspiration pna. Post-arrest consult team was consulted for initiation of arctic sun cooling protocol. Epi gtt was increased to max, and she was started on neo gtt. She received IV vancomycin 1g x1, IV cefepime 2g x1, and IV levofloxacin 500mg x1. She was admitted to MICU for arctic sun cooling protocol. . On arrival to the MICU, she is intubated and sedated. Vitals T 32.2F, HR 103, BP 97/70, O2 sat 94% on 100% FIO2. Past Medical History: -Bipolar disorder -Severe asthma requiring hospitalizations years ago, no exacerbations for many years (not currently treated) Social History: Per family, pt lives in [Hospital3 4634] but is very independent with ADLs. Occ smoking (1 pack per month), no EtOH or drug use. Family History: Notable for CAD in patient's parents and siblings, but no known h/o sudden cardiac death. Physical Exam: Admission Exam: Vitals T 32.2F, HR 103, BP 97/70 (on dopamine/epi/neo gtt), O2 sat 94% on 100% FIO2. HEENT: NCAT, pupils fixed at 5mm bilaterally Chest: Quiet breath sounds anteriorly, symmetric Cardiovascular: RRR, nl S1 S2, no m/r/g Abdominal: soft NTND, RUQ surgical incision scar Extremities: Cool, no clubbing/cyanosis/edema Neuro: Not following commands, not responsive to painful stimuli Pertinent Results: Admission Labs: [2116-10-19] 07:00PM BLOOD WBC-15.6* RBC-3.80* Hgb-12.1 Hct-41.2 MCV-108* MCH-31.8 MCHC-29.4* RDW-11.5 Plt Ct-276 [2116-10-20] 01:42AM BLOOD Neuts-86* Bands-5 Lymphs-8* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [2116-10-19] 07:00PM BLOOD PT-15.1* PTT-60.5* INR(PT)-1.3* [2116-10-20] 01:42AM BLOOD Glucose-364* UreaN-19 Creat-1.1 Na-139 K-4.4 Cl-112* HCO3-14* AnGap-17 [2116-10-20] 01:42AM BLOOD ALT-189* AST-348* AlkPhos-77 TotBili-0.4 [2116-10-20] 09:56PM BLOOD ALT-430* AST-515* LD(LDH)-1438* AlkPhos-28* TotBili-0.4 Cardiac enzymes: [2116-10-20] 08:45AM BLOOD CK(CPK)-1424* [2116-10-20] 04:32PM BLOOD CK(CPK)-1221* [2116-10-20] 08:45AM BLOOD CK-MB-87* MB Indx-6.1* cTropnT-1.48* [2116-10-20] 04:32PM BLOOD CK-MB-77* MB Indx-6.3* cTropnT-0.96* Lithium Level: [2116-10-20] 08:45AM BLOOD Lithium-0.4* Serum tox: [2116-10-19] 07:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG IMAGING: CT HEAD W/O CONTRAST [2116-10-19] FINDINGS: There is no evidence of acute hemorrhage, edema, mass effect, or recent infarction. The ventricles and sulci are age appropriate in appearance. Areas of periventricular and subcortical white matter hypodensity likely reflect sequela of chronic small vessel ischemic disease. No concerning osseous lesion or fracture is identified. There are air-fluid levels within the nasopharynx and mild mucosal thickening of the ethmoid air cells, compatible with intubation. The mastoid air cells are grossly clear. There is minimal mucosal thickening of the right maxillary sinus. IMPRESSION: No evidence of acute intracranial process. CTA CHEST [2116-10-19] FINDINGS: There are massive bilateral dependent consolidations. Additionally, within the aerated portions of the lungs, there are bilateral ground-glass opacities extending from the hila. Additional nodular opacities are likely related to acute process, though no prior exams are available for comparison. A small amount of free air is noted along the left base. While this is not clearly localized, there is suggestion on coronal images (601B:24-26) that the collection is above the diaphragm and within the pleural space. The pulmonary arterial tree is well opacified and no filling defect to suggest pulmonary embolism is seen. No evidence of acute aortic syndrome is identified. There are coronary artery calcifications. No pericardial effusion is seen. The patient is intubated with the endotracheal tube tip low lying at the level of the carina. Additionally, the balloon of the endotracheal tube appears hyperinflated. There is a left-sided subclavian central venous catheter with tip reaching the SVC. An esophageal catheter is in place, incompletely imaged; however, coursing to the stomach at least. No lymphadenopathy is identified. The left thyroid lobe is enlarged. Limited views of the upper abdomen demonstrate at least two calcified splenic artery aneurysms. Bone windows demonstrate a nondisplaced sternal fracture (602B:34), which may be related to chest compressions. IMPRESSION: 1. Massive bilateral dependent consolidations, compatible with aspiration. Ground-glass opacities consistent with pulmonary edema. 2. Air collection at the left base felt more likely above the diaphragm representing small pneumothorax vs bulla as opposed to contained within the peritoneum. In comparison with prior radiographs of the chest, it appears this was present prior to placement of central line. 3. Low-lying endotracheal tube with tip at the level of the carina and hyperinflation of the endotracheal tube balloon. 4. Enlargement of the left thyroid lobe. 5. Non-displaced sternal fracture may be related to chest compressions. TTE [2116-10-20] Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with distal septal hypokinesis. The remaining segments contract normally (LVEF = 45%). The right ventricular cavity is moderately dilated with focal hypokinesis of the apical free wall. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Dilated right ventricle with mild systolic dysfunction. Mild regional left ventricular systolic dysfunction. Mild mitral regurgitation. Moderate pulmonary hypertension. Brief Hospital Course: Primary Reason for Hospitalization: 73yo F with history of bipolar d/o transferred from OSH s/p asystolic cardiac arrest, likely secondary to respiratory etiology. Brief Hospital Course: Ms. [Known lastname 12129] presented after witnessed episode of respiratory distress of unclear etiology which progressed to asystolic cardiac arrest. Per EMS records, CPR was started in field and ROSC occured after 25 minutes of pulselessness. Post-cardiac arrest hypothermia protocol was initiated at OSH and she was transferred to [Hospital1 18] for continued management. On arrival to [Hospital1 18] she was intubated, cooled to 33 degrees F and was requiring maximum dose of 3 pressors (neo, levo, VPA) to maintain blood pressure. She became progressively hypoxic and acidotic on CMV ventilation despite max vent support with 100% FIO2 and PEEP 24. Rewarming was started at 1600 on [10-20]. She had continuous EEG monitoring per hypothermia protocol which showed evidence of seizure activity, and she was loaded with IV keppra. On [10-21] she became bradycardic and was noted to be pulseless. A code blue was called for pulseless arrest and CPR was initiated. Rhythm showed asystole, received epi 1mg x3, 1 amp NaHCO3. Attending physician met with patient's family, who decided to terminate resuscitation. Time of death was declared at 1:39AM. [Location (un) 511] Organ Bank notified, declined patient as donor. Medical examiner was notified and declined autopsy. Medications on Admission: lithium carbonate 300 mg Tab Oral 1 Tablet(s) [Hospital1 ] -> recently changed to daily lorazepam 0.5 mg Tab Oral 1 Tablet(s) Once Daily, at bedtime fluvoxamine 50 mg Tab Oral 1 Tablet(s) Once Daily -> just discontinued nabumetone 500 mg Tab Oral 1 Tablet(s) as directed propranolol 10 mg Tab Oral 1 Tablet(s) Twice Daily Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Respiratory arrest Cardiac arrest Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A	[ "5070", "2762", "49390" ]
Admission Date: [2166-1-3] Discharge Date: [2166-1-6] Date of Birth: [2116-4-12] Sex: M Service: CSU Mr. [Known lastname ] is a 49-year-old man with known mitral valve disease, referred for cardiac catheterization, which was done on [2165-12-30], and showed no angiographically-apparent coronary artery disease with a EF (ejection fraction) of 67 percent. There is 3+ MR (mitral regurgitation, no pulmonary hypertension with an LVEDP (left ventricular end diastolic pressure) of 19 and a wedge of 13. The index was 4.6 liters per minute. HISTORY OF PRESENT ILLNESS: This is a 49-year-old HIV positive man with a history of mitral valve disease followed over the years, last echo showing an EF of 60 percent with an LV that was moderately dilated and trace AI (aortic insufficiency), moderate to severe mitral prolapse and 4+ MR (mitral regurgitation) and trivial TR (tricuspid regurgitation). A cardiac MR done in [2165-8-1] showed an EF of 61 percent with an effective forward EF of 40 percent, bileaflet mitral valve prolapse with moderately severe MR, moderately enlarged left and right atriums. The patient reports that he has been asymptomatic and is feeling well. He has a history of hypertension, HIV and mitral valve disease. No known drug allergies. MEDICATIONS: Sustiva 600 q.day, Neurontin 300 q.day, Epival 300 q.day, Diovan 80 q.day, Pepcid p.r.n., albuterol p.r.n. and Viread 300 mg q.day. SOCIAL HISTORY: Single, lives alone. Works in fund raising. PHYSICAL EXAM: Height 6 feet, 3 inches, weight 195 pounds. GENERAL: In no acute distress. NEUROLOGIC: Alert and oriented x3. Moves all extremities. Nonfocal exam. RESPIRATORY: Clear to auscultation bilaterally. CARDIAC: S1-S2. There is a diastolic murmur. ABDOMEN: Soft, nontender, nondistended with normal active bowel sounds. EXTREMITIES: Warm and well-perfused with no edema or varicosities. LABORATORY DATA: White count 7, hematocrit 38.6, platelets 148, sodium 141, potassium 5.1, chloride 104, CO2 31, BUN 14, creatinine 1.0, glucose 71. Chest x-ray showed no evidence of acute pulmonary disease. Urinalysis was negative. Following catheterization, the patient was discharged to home and scheduled to return as an outpatient for minimally invasive repair of mitral valve, as stated. The patient is a direct admission to the operating room. Please see the OR report for full details and summary. He had a minimally invasive mitral valve repair with a No. 32 [Last Name (un) 3843]-[Doctor Last Name ] annuloplasty band. He tolerated the operation well and was transferred from the operating room to the cardiothoracic intensive care unit. At the time of transfer, the patient was in a sinus rhythm at 70 beats per minute with a mean arterial pressure of 62 and a CVP of 14. He had propofol at 40 mics/kilogram/minute and epinephrine at 0.03 mics/kilogram/minute. The patient did well in the immediate postoperative period. His anesthesia was reversed. He was weaned from the ventilator and successfully extubated. On postoperative day 1, the patient remained hemodynamically stable. He was weaned from all IV cardioactive medications, transitioned to oral medications, all central lines were removed, as was his Foley catheter and he was transferred from the Cardiothoracic Intensive Care Unit to 52 for continuing postoperative care and cardiac rehabilitation. Additionally on postoperative day 1, the patient's chest tubes were removed. Over the next 2 days, the patient's activity level was increased with the assistance of the nursing staff as well as physical therapy staff. He otherwise had an uneventful postoperative course. On postoperative day 3, it was decided that the patient was stable and ready for discharge to home. At the time of this dictation, the patient's physical exam is as follows: Vital signs temperature 98.9, heart rate 67 sinus rhythm, blood pressure 95/52, respiratory rate 18, O2 sat 94 percent on room. Weight preoperatively 89 kg, at discharge is 96.9 kg. PHYSICAL EXAM: GENERAL: No acute distress. Neurologically alert and oriented x3. Moves all extremities. Follows commands. Nonfocal exam. PULMONARY: Clear to auscultation bilaterally. CARDIAC: Regular rate rhythm, S1-S2 with no murmur. Incision is a right thoracic minimally evasive incision with Steri-Strips, is open to air, clean and dry without erythema or drainage. ABDOMEN: Soft, nontender, nondistended with normal active bowel sounds. EXTREMITIES: Warm and well-perfused with no edema. The patient is to be discharged to home with visiting nurses. CONDITION AT TIME OF DISCHARGE: Good. FO[Last Name (STitle) ]P: In the [Hospital 409] Clinic in 2 weeks and with Dr. [Last Name (Prefixes) ] in 4 weeks. DISCHARGED DIAGNOSES: 1. Mitral regurgitation, status post minimally invasive mitral valve repair with a No. 32 [Last Name (un) 3843]-[Doctor Last Name ] annuloplasty band. 2. Hypertension. DISCHARGE MEDICATIONS: Include aspirin 81 mg q.day, Colace 100 mg b.i.d., Neurontin 300 mg q.day, Percocet 5/325 1-2 tablets q.[5-7] h. p.r.n., ibuprofen 800 mg q.8 h., metoprolol 25 mg b.i.d, Epival 300 mg q.day, Sustiva 600 mg q.day, and Viread 300 mg q.day. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 1288] Dictated By:[Last Name (NamePattern4) 1718] MEDQUIST36 D: [2166-1-6] 17:48:24 T: [2166-1-7] 03:29:44 Job#: [Job Number 13352]	[ "4240", "4019" ]
Admission Date: [2140-6-1] Discharge Date: [2140-6-5] Date of Birth: [2112-11-14] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 330] Chief Complaint: diabetic ketoacidosis Major Surgical or Invasive Procedure: none History of Present Illness: 27 yo male with T1DM admitted with DKA. Unclear precipitant--had sudden onset abd pain/diarrhea/n/v this morning. No fever/chills. States compliant with insulin but has not seen his [Name8 (MD) ] MD since [2137] Past Medical History: T1DM on 75/25 split mix 50 units qam and 40-50 units q supper gastroparesis -- gastric emptying study in [2137] GERD Social History: lives with roomate Family History: noncontributory Physical Exam: Gen- no acute distress HEENT-anicteric, oral mucosa moist CV-rrr, no r/m/g resp-clear to auscultation bilaterally abdomen- soft, nontender, nondistended, good bowel sounds extremities- no edema Pertinent Results: [2140-6-1] 08:30AM PLT SMR-NORMAL PLT COUNT-241 [2140-6-1] 08:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2140-6-1] 08:30AM NEUTS-92.6* BANDS-0 LYMPHS-4.6* MONOS-2.7 EOS-0 BASOS-0.1 [2140-6-1] 08:30AM WBC-11.7# RBC-4.70 HGB-13.6 HCT-40.0 MCV-85 MCH-28.9 MCHC-34.0 RDW-11.9 [2140-6-1] 08:30AM CALCIUM-10.0 PHOSPHATE-3.3# MAGNESIUM-1.9 [2140-6-1] 08:30AM GLUCOSE-479* UREA N-26* CREAT-1.6* SODIUM-135 POTASSIUM-5.7* CHLORIDE-96 TOTAL CO2-18* ANION GAP-27* [2140-6-1] 08:43AM LACTATE-2.2* [2140-6-1] 08:55AM LACTATE-1.5 K+-4.3 [2140-6-1] 08:55AM TYPE-ART PO2-96 PCO2-31* PH-7.39 TOTAL CO2-19* BASE XS--4 COMMENTS-ADD ON K+ [2140-6-1] 08:55AM TYPE-ART PO2-96 PCO2-31* PH-7.39 TOTAL CO2-19* BASE XS--4 COMMENTS-ADD ON K+ [2140-6-1] 09:45AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [2140-6-1] 09:45AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2140-6-1] 09:45AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.026 [2140-6-1] 09:45AM URINE GR HOLD-HOLD [2140-6-1] 09:45AM URINE UHOLD-HOLD [2140-6-1] 09:45AM URINE HOURS-RANDOM [2140-6-1] 09:45AM URINE HOURS-RANDOM [2140-6-1] 01:00PM CALCIUM-9.1 PHOSPHATE-2.7 MAGNESIUM-1.8 [2140-6-1] 01:00PM GLUCOSE-213* UREA N-23* CREAT-1.3* SODIUM-142 POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-22 ANION GAP-16 [2140-6-1] 04:42PM %HbA1c-10.9* [Hgb]-DONE [A1c]-DONE [2140-6-1] 06:14PM CALCIUM-9.3 PHOSPHATE-3.1 MAGNESIUM-2.0 [2140-6-1] 06:14PM GLUCOSE-227* UREA N-20 CREAT-1.4* SODIUM-138 POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-20* ANION GAP-18 Brief Hospital Course: 27yo M with Type I DM and gastroparesis presented with DKA. He was on insulin drip for several day for aggressive control of anion gap. He remained nauseous and unable to take po intake until the anion gap is well controlled. IV fluid with dextrose was used while patient was NPO. As soon as the anion gap was well controlled, patient resumed extremely good appetite and was able to be transitioned to sc insulin [First Name8 (NamePattern2) ] [Last Name (un) ] reccomendation. Of note, patient also has domented gastroparesis on gastric emptying study and this also may have contributed to the nausea. Reglan was increased, LFTs and Ultrasound of the abdomen were normal. Of note, he was also hypertensive with sbp running 170-180 systolic. He was on ACE inhibitor a few years ago according to [Last Name (un) 387] records but has discontinued that due to insurance issue. ACE inhibitor was restarted while he was in the hospital. Social work consult was obtained to help him handle the medical insurance issue. As mentioned above, he had not seen a doctor for years and has discontinued/not compliant with medication. On the day of discharge, patient insisted on leaving. The ICU team explained to him that he had just been transitioned to sc insulin at that time and would need to stay for the afternoon for observation. He seem to have understood at the time of discussion and was very agreeable. However, he left without telling any medical staff shortly after that. Effort was made to contact him by phone but to no avail . Medications on Admission: 75/25 insulin anzamet Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:120 Tablet(s) Refills:2 3. Compazine 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for nausea. Disp:20 Tablet(s) Refills:0 4. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Diabetic ketoacidosis Discharge Condition: Left hospital AMA without telling staff. Condition was Good at time of last assessment by nursing personnel. Discharge Instructions: please return to the hospital or call your doctor if your blood sugar is out of control, if you have dizziness, nausea/vomiting or if there are any other concerns Please make sure you follow up with a PCP You have just been started on lisinopril for your blood pressure, you will need to have close follow up of your electrolytes Followup Instructions: Please call [Telephone/Fax (1) 250] to schedule an appointment with a PCP of your choice within 1 weeks of your discharge. Please call the [Hospital ] CLinic for follow up appointment within 2 weeks of discharge Completed by:[2140-6-22]	[ "5849", "53081", "V5867" ]
Admission Date: [2144-10-3] Discharge Date: [2144-10-6] Date of Birth: [2064-12-3] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Codeine / Ranitidine Attending:[Doctor Last Name 10493] Chief Complaint: syncope Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname 24214] is a 79 F with h/o seizures now transferred from neurosurg service for workup of syncope. Pt was in USOH on [2144-10-3] when had apparent syncope while grocery shopping. She remembers purchasing groceries and walking outside and seeing her car. Next thing she remembers is waking up on ground near her car surrounded by people. No aura/prodrome. No postictal confusion, no incontinence or tongue biting. There were many people around; no reported tonic-clonic activity. No HA, fever, palpitations, N/A, weakness, numbness. Notes that it was a hot day and she had not had much to eat or drink. . Pt has history of 2 or 3 prior seizure events, last more than 20 years ago. Has been on Dilantin for many years. During prior seizures she was observed to have GTC activity, aura, post ictal confusion, +/- urinary incontinence. She does not feel that this particular episode was similar to her prior seizures. She does have a history of atrial tachycardia to 160's during prior admission, asymptomatic. She also notes one month history of intermittent regularly irregular heartrate (skipped beats, see [9-11] PN from Dr. [Last Name (STitle) 1007]. Notes this when feeling her pulse but is otherwise asymptomatic. She also had a mechanical fall down stairs at her house about 1 week PTA. States she fell on her hip; did not hit her head but did hit the back of her neck. No LOC. . In [Name (NI) ] pt found to have subdural hematoma and admitted to neurosurgery. By CT hematoma has shown stability. Transferred to medicine for workup of her syncope. Past Medical History: Seizure disorder, last Sz about 20 y ago, on dilantin. Chronic HA OA Osteopenia Endometrial polyp h/o atrial tachycardia during admit [3-/2137] Tricuspid regurg (mod-severe on echo) Social History: Retired social worker. Denies EtOH, illicits. Past h/o smoking, quit 20 years ago. Family History: Cousin with Sz disorder, mother with MI, father with COPD Physical Exam: VS: T 96, P 71, R 18, BP 118/64, O2 sat 98% Orthostatics: Lying 110/66; sitting 120/72; standing 132/74 General: Thin, elderly female, NAD HEENT: Ecchymosis/edema under L orbit. Healing skin tear at hairline of L forehead, no active bleeding. PERRL, EOMI. OP clear. No oral trauma. MMM. Neck: full ROM, no carotid bruit Chest: CTA bilat Heart: RRR with occ early then skipped beat (~one out of [1-9] beats). S1 S2, 2/6 systolic murmur at LLSB. Abdomen: +BS, slightly distended, soft, NT. Tympanic throughout, no shifting dullness. Extrem: Thin, no edema. Normal muscle tone, bulk. Neuro Exam: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [3-28] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [5-30] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally No pronator drift Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Pertinent Results: [2144-10-3] WBC-5.3 HGB-12.5 HCT-35.8* MCV-96 RDW-14.0 PLT-271 NEUTS-69.7 LYMPHS-24.3 MONOS-4.2 EOS-1.2 BASOS-0.5 PT-12.7 PTT-27.3 INR(PT)-1.1 GLUCOSE-103 UREA N-12 CREAT-0.5 SODIUM-134 POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-28 ANION GAP-13 CALCIUM-8.8 PHOSPHATE-3.4 MAGNESIUM-2.4 PHENYTOIN-13.2 ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG . CT head: Right subdural hematoma (3.1 x 1.1), appearing partially organizing, with local mass effect, as described above. Mixed density in the adjacent subdural space may represent hyperacute-on-acute bleeding or acute-on-chronic bleeding. Superficial soft tissue swelling along the left frontal region. There is local mass effect, without shift of normally midline structures. . CT head (repeat [10-4]) No increase in size in the right subdural hematoma.It may be slightly decreased in size. . CT head (repeat [10-5]) Stable right-sided subdural hematoma . CXR: No displaced rib fracture or acute cardiopulmonary process. . ECG: Sinus rhythm at 71. Frequent ventricular premature beats. Left axis deviation with left anterior fascicular block. . CT spine: Prevertebral soft tissue structures are normal. Advanced degenerative changes are present at C5 through C7 with anterior osteophytes, subchondral sclerosis, and joint space narrowing. Multilevel degenerative changes are present in the facet joints. No acute fracture or dislocation is identified. . Echo ([2142-4-6]): The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is no pericardial effusion. . Review of telemetry: No Vtach. Frequent PVCs, no couplets, at times trigeminy or every fourth beat is PVC. Brief Hospital Course: A&P: Ms. [Known lastname 24214] is a 79 F with h/o seizure disorder on Dilantin, multiple PVCs on telemetry, h/o atrial tachycardia; initial admit to neurosurgery with subdural hematoma (now stable); transfer to medicine for syncope workup. . # Syncope: Pt's fall and LOC seemed most consistent with syncope (vs. seizure). Although she had h/o seizure disorder, this episode was not c/w priors. No prodrome, no postictal confusion, no incontinence/tongue biting. Stated that she did not remember good chunk of time prior to her LOC. Other DDx included vasovagal, cardiac arrhythmia, orthostasis, mechanical fall with concussion. Her orthostatics were normal. Carotid dopplers were normal. She had a normal EEG. Echo was unchanged from previous (normal EF, no aortic stenosis). She had frequent PVCs here (frequently in trigeminy) but no NSVT or couplets. EP was consulted and saw no evidence of syncope due to arrhythmia. Could be vasovagal (hot weather, etc). No known toxins/electrolyte abnormalities. Neurology was also consulted and autonomic tilt table testing was done (report pending). She also had some unsteadiness on her feet (unclear how much of this was due to the SDH) with occasional falls at home. It was also quite likely that she had a mechanical fall with head trauma severe enough to cause mild retrograde amnesia. She was instructed not to drive until seeing her PCP [Name Initial (PRE) ]/or neurologist. . # Subdural hematoma: Initially admitted to neurosurgery. She had serial CT scans to evaluate progression and the hemorrhage continued to show stability/improvement. There was no neurologic deficits. She will followup with neurosurgery as an outpatient. . # Seizure disorder. She had had no seizure x 20 years but has continued on dilantin mainly because she has felt uncomfortable off antiepileptics. Dilantin level was within range. She had a neurology consult and EEG as above. . # Osteopenia: contined Fosamax. Also encouraged her to take calcium and vitamin D. . # Anemia: Normocytic, near baseline and stable. . # Hyperlipidemia: continued atorvastatin Medications on Admission: Dilantin 300 mg QAM, 400 mg QPM Fosamax 35 mg Qweek Lipitor 10 mg QHS Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Alendronate 35 mg Tablet Sig: One (1) Tablet PO QMON (every Monday). 3. Phenytoin Sodium Extended 100 mg Capsule Sig: [2-29] Capsules PO BID (2 times a day): Please take Dilantin as per prior dosing (200 mg twice daily alternating with 200 mg in AM and 300 mg in PM). Discharge Disposition: Home Discharge Diagnosis: Subdural hematoma Syncope Seizure disorder Discharge Condition: Stable Discharge Instructions: You were admitted for an episode of falling with a related head injury. There was a small amount of bleeding inside your head (subdural hematoma) that has not changed while we have been monitoring you. You will followup with the neurosurgeons in the future. We also tried to figure out why you had this fall. We looked at your heart rhythms and brain rhythms to look for abnormalities. So far we have not been able to uncover a definite reason for why you had this fall. . Please DO NOT DRIVE until you followup with your primary care physician and your neurologist. . Please return to the hospital if you have further episodes of fainting, seizure, dizziness, palpitations, difficulty with memory or confusion, or any new symptoms that you are concerned about. . Please keep all of your appointments with your doctors and take [Name5 (PTitle) ] of your medications as prescribed. Followup Instructions: Please call Dr. [Last Name (STitle) 1007] ([Telephone/Fax (1) 10492]) to schedule a followup appointment in 1 week. . We would like you to followup with Dr. [Last Name (STitle) 2442] again regarding your seizures and Dilantin. Please call ([Telephone/Fax (1) 5563] to schedule an appointment with him in [2-29] weeks. . The neurosurgery team (Dr. [Last Name (STitle) ] will be in contact with you to schedule a followup appointment. Please call ([Telephone/Fax (1) 88] if you do not hear from them within one week. . You also have the following upcoming appointments at [Hospital1 18]: Provider: [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 2226] Date/Time:[2144-12-3] 2:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 24672], MD Phone:[Telephone/Fax (1) 24673] Date/Time:[2145-4-1] 2:00 [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 10491] MD, [MD Number(3) 10495]	[ "2720", "2859" ]
Admission Date: [2176-11-19] Discharge Date: [2176-11-24] Date of Birth: [2104-3-2] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) / Fentanyl / Lipitor Attending:[First Name3 (LF) 1505] Chief Complaint: Shortness of breath, palpitations, chest pressure and worsening fatigue Major Surgical or Invasive Procedure: s/p ASD closure History of Present Illness: 70 year old woman with history of shortness of breath, palpitations, chest pressure and worsening fatigue who was worked up by her PCP for dysphagia. As part of workup, she had a transesophageal echocardiogram that showed an atrial septal defect with normal pulmomary veins. Cardiac catheterization showed normal coronary arteries. Past Medical History: Dyslipidemia Thyroid cancer s/p ablation with radioactive iodine Hiatal hernia Enterogastric ulcers Migraines Skin cancer s/p c-section x3 s/p right femoral hernia repair s/p TAH Social History: Retired and lives with her husband in [Name (NI) 17566]. She never smoked and consumes alcohol rarely. Family History: Non-contributory Physical Exam: Admission: HR 72 Right BP 142/76 Left BP 122/64 Height 5'5" Weight 66KG General: no acute distress Neck: supple with full range of motion, no JVD Chest: lungs clear to auscultation bilaterally COR: regular rate and rhythm. III/VI systolic ejection murmur. Abdomen: soft and nontender without rebound or guarding Extremities: warm without edema. 2+ peripheral pulses Neuro: grossly intact Pertinent Results: ECHO [2176-11-19] Pre- Bypass: 1. The left atrium is normal in size. The right atrium is dilated. A two secundum atrial septal defects present with bidirectional flow. 2. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). with mild global free wall hypokinesis. 3. There are simple atheroma in the descending thoracic aorta. 4. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 5. The mitral valve leaflets are myxomatous.Trace mitral regurgitation is seen. 6. There is no pericardial effusion. Post-Bypass: 1. Left and right ventricular function is preserved. 2.The aorta is intact. 3.Both of the ASDs are repaired with minimal bidirectional flow across the repaired atrial septum is seen. 4. Dr. [Last Name (STitle) ] was notified of these results intraoperatively. [2176-11-24] 06:45AM BLOOD WBC-4.2 RBC-3.06* Hgb-10.2* Hct-28.8* MCV-94 MCH-33.2* MCHC-35.4* RDW-13.0 Plt Ct-223 [2176-11-24] 06:45AM BLOOD Glucose-105 UreaN-16 Creat-0.9 Na-137 K-4.1 Cl-102 HCO3-28 AnGap-11 Brief Hospital Course: Mrs [Known lastname 80232] was brought to the operating room on [2176-11-19] and underwent an ASD closure with Dacron Patch per the ususal routine (please see operative note for further details). She was transferred to the CVICU post-operatively for invasive monitoring. She was extubated within a few hours and was transferred to the floor on POD 1. She was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with her postoperative strength and mobility. She developed atrial fibrillation on [2176-11-21] with hypotension. She was transferred back to the intensive care unit for closer monitoring. Amiodarone was started. The patient converted back to sinus rhythm before discharge. She was continued on oral amiodarone, as well as beta blocker. Anticoagulation was not initiated. By the tiem of discharge on POD 5, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. Medications on Admission: Levoxyl 75 mcg po daily Ambien 5mg po QHS PRN Fiorinal MVI daily Protonix 40 mg po daily ASA 325 mg po daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:60 Tablet(s) Refills:0 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): 200mg 2x/day for 2 weeks, then 200mg daily. Disp:60 Tablet(s) Refills:0 6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 8. Ambien 5 mg Tablet Sig: One (1) Tablet PO hs prn as needed for insomnia. Disp:20 Tablet(s) Refills:0 9. Multivitamin Capsule Sig: One (1) Capsule PO once a day. Disp:30 Capsule(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: s/p ASD closure with dacron patch Dyslipidemia Thyroid Cancer s/p thyroidectomy Migraines Hiatal hernia Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Dr. [Last Name (STitle) ] in 4 weeks ([Telephone/Fax (1) 170]) please call for appointment Dr. [First Name (STitle) ] in 1 week please call for appointment Dr. [First Name (STitle) 1075] in [3-10] weeks please call for appointment Wound check appointment [Hospital Ward Name 121] 2 as instructed by nurse ([Telephone/Fax (1) 3071]) Completed by:[2176-11-24]	[ "42731", "2724", "2449" ]
Admission Date: [2138-11-21] Discharge Date: [2138-11-23] Date of Birth: [2062-7-21] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: This is a 76-year-old male with severe coronary artery disease involving three vessels, hypercholesterolemia, diabetes mellitus, status post coronary artery bypass graft in [2132], and multiple follow-up catheterizations who presented to [Hospital1 190] for elective percutaneous transluminal coronary angioplasty and stent of the right coronary artery. Since the patient's 4-vessel coronary artery bypass graft in [2132] he has had recurrent exertional angina that is relieved by rest and nitroglycerin. He has had six catheterizations since the surgery, but no interventions. His most recent catheterization was in [2138-4-13] that showed an ejection fraction of 73%, mild inferobasal hypokinesis, severe 3-vessel disease with 60% to 80% proximal left anterior descending artery occlusion, and complete distal left anterior descending artery occlusion, diffuse left circumflex disease with middle stenosis of approximately 50%, with 90% stenosis at third obtuse marginal, and significant right coronary artery disease with serial 70% stenoses proximal and midway through the vessel as well as total occlusion of the distal third of the right coronary artery. These findings represented essentially no change since the prior study performed in [2136]. Also, the patient had a stress thallium in [2138-4-13] that showed defects in an inferoapical distribution as well as with upper septal defects. This was worse than the prior test which was performed one year earlier. Therefore, he was admitted for elective catheterization and right coronary artery intervention. During his cardiac catheterization an right coronary artery stent was placed that resulted in a perforation of the middle right coronary artery. He remained hemodynamically stable. A [Doctor First Name ]-Med covered stent was placed with filling of the perforation. Subsequently, a small guide wire perforation was noted in the distal posterior descending artery. This was treated with reversal of heparin and prolonged balloon inflations. A post procedure echocardiogram was performed that showed no pericardial effusion. The patient was brought to the holding area where approximately half an hour after the procedure he experienced substernal chest pain, and electrocardiogram at that time revealed ST elevations in leads V1 through V3. He was brought back to the catheterization laboratory where he underwent an additional catheterization. A total right coronary artery stent occlusion was seen. A stent thrombectomy was performed with Angio-Jet and proximal and distal stents were placed. The patient tolerated this procedure well and given the complicated procedure he was admitted to the Coronary Care Unit for observation and for monitoring for possible development of tamponade in the setting of coronary vessel rupture. PAST MEDICAL HISTORY: 1. Diabetes mellitus. 2. Hypertension. 3. Coronary artery disease, status post 4-vessel coronary artery bypass graft involving left internal mammary artery to the left anterior descending artery, saphenous vein graft to first obtuse marginal, saphenous vein graft to the distal right coronary artery, and saphenous vein graft to the acute marginal. 4. Gastroesophageal reflux disease. 5. Hypercholesterolemia. MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o. q.d., Zocor 80 mg p.o. q.i.d., Imdur 30 mg p.o. q.d., Elavil 75 mg p.o. q.h.s., Glucophage 850 mg p.o. t.i.d., glyburide 10 mg p.o. b.i.d., atenolol 25 mg p.o. q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He smoked 15 years ago but has not smoked since. No ethanol history. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs were afebrile, blood pressure 122/55, pulse 78, respirations 14, oxygen saturation 98% on 3 liters. In general, an elderly gentleman in no acute distress, lying in bed. HEENT revealed pupils were equal, round, and reactive to light. Extraocular movements were intact. Neck had no jugular venous distention. Pulmonary revealed lungs were perfectly clear to auscultation. Heart had a regular rate and rhythm, normal S1 and S2. No murmurs, rubs or gallops. The abdomen was soft, nontender, and nondistended, positive bowel sounds. His extremities had no clubbing, cyanosis or edema, and good pulses bilaterally. The groin was notable for absence of hematoma. LABORATORY DATA ON PRESENTATION: White blood cell count 7.3, hematocrit 37.5, platelets 278. Sodium 136, potassium 4.8, chloride 98, bicarbonate 28, BUN 16, creatinine 0.8, glucose 135. RADIOLOGY/IMAGING: Electrocardiogram showed normal sinus rhythm, inferior Q wave consistent with an old inferior myocardial infarction. There was diffuse T wave flattening. The ST elevations seen in leads V1 through V3 that were present on the electrocardiogram immediately after catheterization were completely resolved. IMPRESSION: This is a 76-year-old male with severe 3-vessel disease and a history of coronary artery bypass graft in [2132] who presented for elective catheterization, where he received a stent to the right coronary artery complicated by right coronary artery bleed, placement of [Doctor First Name ]-Med stent and distal posterior descending artery bleed treated with percutaneous transluminal coronary angioplasty. Post catheterization course complicated by chest pain found to be secondary to stent thrombosis. A thrombectomy was performed and additional stents were placed with complete resolution of symptoms and electrocardiogram changes. HOSPITAL COURSE BY SYSTEM: 1. CARDIOVASCULAR: (a) Coronaries: The patient had no further angina at rest of evidence of stent instability following the second cardiac catheterization. An electrocardiogram was done that showed complete resolution of the ST elevations that had been seen in V1 to V3 in association with a stent thrombosis. Aspirin was continued. Plavix was given at the time of catheterization and was continued at 75 mg p.o. q.d. and should be continued for 30 days. ReoPro was given for 18 hours after catheterization. We held his Imdur and Norvasc. He was given Lopressor after catheterization, and this was tolerated well so it was switched back to his home dose of atenolol 25 mg p.o. q.d. (b) Pump: There were no signs or symptoms of congestive heart failure or tamponade post procedure. (c) Rate and rhythm: The patient was in a normal sinus rhythm and there were no acute issues from a rate and rhythm perspective. 2. PULMONARY: The patient was weaned off oxygen quickly after his cardiac catheterization and did well from a pulmonary standpoint. There were no acute issues. 3. ENDOCRINE: The patient was treated with a regular insulin sliding-scale and once he was tolerating p.o. food he was restarted on his oral hypoglycemics. 4. GASTROINTESTINAL: The patient was treated with Protonix for his known gastroesophageal reflux disease. 5. CODE STATUS: He was full code. 6. DISCHARGE DISPOSITION: The patient was stable in the Coronary Care Unit, and on the second day after admission was transferred to the Cardiology Medicine floor. DISCHARGE STATUS: He was discharged to home. CONDITION AT DISCHARGE: Discharge condition was good. DISCHARGE FOLLOWUP: He was instructed to follow up with his primary care cardiologist, Dr. [Last Name (STitle) 10439], in one week. MEDICATIONS ON DISCHARGE: 1. Glyburide 10 mg p.o. b.i.d. 2. Glucophage 850 mg p.o. b.i.d. 3. Elavil 75 mg p.o. q.h.s. 4. Atenolol 25 mg p.o. q.d. 5. Plavix 75 mg p.o. q.d. for 30 days. 6. Aspirin 325 mg p.o. q.d. 7. Zocor 80 mg p.o. q.d. Imdur and Norvasc were both held given good blood pressure control. DISCHARGE DIAGNOSES: 1. Stent of right coronary artery complicated by stent thrombosis and thrombectomy. 2. Hypertension. 3. Diabetes mellitus. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 2057] Dictated By:[Name8 (MD) 2734] MEDQUIST36 D: [2138-11-26] 12:35 T: [2138-11-27] 12:52 JOB#: [Job Number 10440] (cclist)	[ "41401", "25000", "53081", "V4581" ]
Admission Date: [2195-5-11] Discharge Date: [2195-6-2] Date of Birth: [2166-9-28] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 99] Chief Complaint: jaundice and fatigue Major Surgical or Invasive Procedure: Paracentesis, diagnostic Paracentesis, therapeutic History of Present Illness: 28 year old man with hx of chronic etoh use presenting with fatigue, jaundice and found to be anemic. He stated that ~[12-10] months ago he noticed that he was more fatigued with increasing abdominal girth, leg swelling and fatigue. He denies abdominal pain, chest pain, cough, dysuria, rash, or headache. He denied bloody or black stools, as well as no grey stools. He was encouraged by his mother to come to the hospital for evaluation. He initially presented to [Hospital3 ] where he was hemodynamically stable with markedly elevated bilirubin and Hct ~15. He was guaiac negative x1. Prior to transfer he received vitamin K po, and lactulose 30 g as well as a banana bag of IVF . In the ED, his initial vital signs were 101.5 122 144/63 30 95%RA. He received zosyn IV x1 and motrin 600 mg po x1. He had a diagnostic para that showed no evidence of SBP. He was guaiac negative x 1. He received 1 unit of pRBCs and admitted to the ICU. In ICU he was continued on CTX because of fevers x 24 hours and defervesced. Past Medical History: tooth abscess ([8-16]) car accident at age 17 (received blood transfusion) Social History: divorced. 5 kids (10 year old son and 8 year fraternal twins (boy and girl) with ex-wife. 5 year old son, 2 year old girl with present girlfriend. works small construction jobs. incarcerated in [2194-7-9]. Family History: sister with HepC. dad with heavy etoh use. mom with anxiety/depression Physical Exam: VS: 99.7 118 138/57 32 100%NRB GEN: marked jaundice and distended abdomen HEENT: AT, NC, PERRLA (5->2mm bilat), EOMI, no conjuctival injection, icteric, OP clear, dental depression in left 2nd mandibular molar, MMM, Neck supple, no LAD, no carotid bruits CV: regular tachy, nl s1, s2, no m/r/g PULM: CTAB, no w/r/r with good air movement throughout ABD: marked distension with ascites, NT, + BS, no HSM, no caput. marked penile and scrotal swelling EXT: warm, +2 distal pulses BL, no femoral bruits, marked peripheral edema NEURO: alert & oriented x3, coherent response to interview, CN II-XII intact, 5/5 strength throughout. No sensory deficits to light touch appreciated. asterixis PSYCH: appropriate affect Pertinent Results: [2195-5-11] 05:15PM WBC-15.6* RBC-1.28* HGB-5.2* HCT-14.8* MCV-116* MCH-41.0* MCHC-35.3* RDW-23.5* [2195-5-11] 05:40PM HGB-5.2* calcHCT-16 O2 SAT-90 [2195-5-11] 07:10PM WBC-19.7* RBC-1.39* HGB-5.5* HCT-15.7* MCV-113* MCH-39.7* MCHC-35.1* RDW-25.5* [2195-5-11] 05:15PM ASA-NEG ETHANOL-193* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2195-5-11] 05:15PM NEUTS-77* BANDS-15* LYMPHS-2* MONOS-3 EOS-1 BASOS-0 ATYPS-0 METAS-2* MYELOS-0 NUC RBCS-2* [2195-5-11] 05:15PM HYPOCHROM-3+ ANISOCYT-3+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-1+ TARGET-1+ SCHISTOCY-1+ BURR-1+ TEARDROP-1+ ACANTHOCY-1+ [2195-5-11] 05:15PM PT-26.4* PTT-43.6* INR(PT)-2.6* [2195-5-11] 05:15PM ALBUMIN-2.5* CALCIUM-7.7* PHOSPHATE-3.3 MAGNESIUM-1.9 [2195-5-11] 05:15PM calTIBC-142* VIT B12-GREATER TH FOLATE-14.9 HAPTOGLOB-<20* FERRITIN-1374* TRF-109* [2195-5-11] 05:15PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc Ab-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE [2195-5-11] 05:15PM GLUCOSE-104 UREA N-22* CREAT-0.8 SODIUM-122* POTASSIUM-5.7* CHLORIDE-90* TOTAL CO2-22 ANION GAP-16 [2195-5-11] 06:10PM ASCITES TOT PROT-0.5 GLUCOSE-135 LD(LDH)-177 AMYLASE-18 ALBUMIN-LESS THAN [2195-5-11] 06:10PM ASCITES WBC-13* RBC-4100* POLYS-95* BANDS-0 LYMPHS-5* MONOS-0 EOS-0 [2195-5-11] 07:10PM RET MAN-15.0* . RUQ ultrasound: IMPRESSION: 1. Constellation of findings, consistent with longstanding liver disease, including splenomegaly and portal vein flow reversal. 2. Gallbladder contains sludge, no evidence of acute cholecystitis. . CXR: IMPRESSION: No acute cardiopulmonary process. . CT abd/pelvis: IMPRESSION: 1. Extremely limited exam due to lack of IV and oral contrast. 2. Splenomegaly and shrunken liver consistent with cirrhosis. Multiple varices are incompletely identified on this study. 3. Extensive amount of intra-abdominal and pelvic ascites with a small layering fluid level. 4. Extensive anasarca and scrotal edema. 5. Large ill-defined left gluteal hematoma as described above. 6. Multiple ground-glass nodules at the lung bases. This may be infectious etiology. Brief Hospital Course: 28 year old man with history of chronic etoh use presenting with fatigue found to have marked hepatic dysfunction and gastrointestinal bleed. Hepatic failure most likely secondary to alcoholic cirrhosis. Patient not a transplant candidate due to continued EtOH use. Patient with signs of worsening hepatic function including increasing abdominal girth, leg swelling, fatigue and jaundice for which he presented to [Hospital3 3583]. He was transferred from [Hospital3 ] for his markedly elevated bilirubin and Hct ~15. He received 1 unit of pRBCs in the ED and was admitted to MICU Green, where he received 3 units pRBCs, Hct improved to 21. Got therapeutic tap of 8L performed on [5-14] without complications or signs of infection. Transferred to [Doctor Last Name 3271]-[Doctor Last Name 679] on [5-14]. Started on prednisone; furosemide increased to 80 qday; albumin 50 gm started [2195-5-16]. On [2195-5-18] patient experienced hematemesis of 700 ml on the floor, was transferred to MICU [Location (un) ], where NG suctioned out 1.5 L of blood. Patient was emergently intubated. Given 5 units of pRBCs, 4 units of FFPs, 1 bag of platelets, vasopressin, octreotide. Patient felt to have fulminant hepatic failure with poor prognosis as after his transfer to MICU [Location (un) ] he remained he hemodynamically unstable with active bleeding at oropharynx/UGI, IV sites, via Foley and lower gastrointestinal tract bleeding requiring several units blood and FFP daily. The patient was also felt to have hepatic encephalopathy. Patient also had a fever with no clear source of infection, but was treated empirically with ceftriaxone. In this setting patient required intubation for airway protection. He also developed hepatorenal syndrome non responsive to fluids, octreotride, or midrodrine. The patient also developed a lactic acidosis likely from his liver failure with global hypoperfusion. Given the patient's multisystem organ failure and the fact that he was not a candidate for a transplant, a family meeting was held with his mother. The decision was made to shift the patient's goals of care to comfort measures. He was started on iv morphine. Organ bank notified and will intervene and meet with family to discuss organ donation in more detail. The patient died from complications of his liver disease. Medications on Admission: none Discharge Medications: Discharge due to death Discharge Disposition: Expired Discharge Diagnosis: Fulminant Hepatic Failure due to Alcoholic Cirrhosis Hepatorenal syndrome with renal failure Hepatic Encephalopathy Hematemesis due to Variceal Bleed Coagulopathy with lower gi bleed due to liver failure Respiratory Failure Discharge Condition: Dead Discharge Instructions: Discharge due to death Followup Instructions: Discharge due to death Completed by:[2195-6-12]	[ "5849", "2851", "51881", "5070" ]
Admission Date: [2199-5-26] Discharge Date: [2199-5-28] Service: MICU CHIEF COMPLAINT: Respiratory distress. HISTORY OF PRESENT ILLNESS: This is an 84-year-old woman with a history of tracheobronchiomalacia and chronic respiratory failure who was transferred to the [Hospital1 346] from [Hospital3 672] Hospital. The patient originally had her respiratory failure following an episode of aspiration pneumonia back in [Month (only) 404], at which time she had failed attempts at stenting of her tracheobronchiomalacia and required tracheostomy and PEG tube placement for her chronic respiratory failure. She has been at [Hospital3 672] Hospital since that time and has been unable to wean from the ventilator. Her usual vent settings are SIMV, respiratory rate of 8, tidal volume of 500, pressure support of 15, PEEP of 5, FIO2 of 0.3. The patient had been doing well and had been gradually weaned off the ventilator until the day of admission. At that time she was noted to be in respiratory distress. She was tachypneic and short of breath. Two saturations decreased to 90%. She went from CPAP back to IMV. Arterial blood gas was 7.23/70/123/30/96%. Breath sounds were noted to be distant and chest x-ray could not be obtained for a significant period so she was sent to [Hospital1 188] for further evaluation. In the Emergency Department the patient was bagged and suctioned. No obvious mucous plugs were removed and Lasix 60 mg IV x 1 was given. The patient's symptoms improved and she was transferred to the medical intensive care unit for further evaluation. PAST MEDICAL HISTORY: 1. Diabetes mellitus type 2. 2. Hypertension. 3. Tracheobronchiomalacia as above. 4. Anemia. 5. Moderate to severe mitral regurgitation. ALLERGIES: The patient has no known drug allergies. MEDICATIONS: 1. Protonix 40 mg p.o. q.d. 2. Ritalin 5 mg p.o. q.d. 3. Zoloft 50 mg p.o. q.d. 4. Albuterol p.r.n. 5. Subcutaneous heparin 5,000 mg subcutaneous b.i.d. 6. Ativan 0.25 mg p.o. q. 8 hours p.r.n. 7. Lasix 40 mg p.o. q.d. on hold x 1 week. FAMILY HISTORY: Unknown. SOCIAL HISTORY: The patient is currently a resident at [Hospital3 672] Hospital. She has some family members who are involved in her care. She has no known history of tobacco or drug use. PHYSICAL EXAMINATION: Vital signs were 98.8, heart rate 82, blood pressure 92/47, respiratory rate 18, 100% bagged. In general she was an obese, confused woman who was in no acute distress at the time of the medical intensive care unit evaluation. HEENT: Left eye cataract with some ptosis. Oropharynx was noted to have thrush, otherwise dry. Neck: No jugular venous distension, no lymphadenopathy. Tracheostomy in place. Cardiac: Regular rate and rhythm, no murmurs, gallops, or rubs. Lungs: Rhonchi noted diffusely with decreased breath sounds at the bases bilaterally, occasional expiratory wheezes. Abdomen: Soft, nontender, distended abdomen, positive bowel sounds. PEG in place with [Initials (NamePattern4) ] [Last Name (NamePattern4) 1356] clamp. Extremities: No cyanosis, clubbing or edema, warm with good pulses, no calf tenderness, no palpable cord. Neurological: The patient was able to move all extremities, decreased hearing and unable to communicate or take p.o. LABORATORY DATA: White blood count 18.2, hematocrit 36.4, platelet count 425, and 87.5, no bands. Sodium 132, BUN 49, creatinine 1.1, glucose 231. Urinalysis had large blood, greater than 50 white blood cells, [12-5] red blood cells, nitrite negative, leukocyte esterase moderate. HOSPITAL COURSE: 1. Pulmonary: The patient was admitted with respiratory distress of unclear etiology. She was given Lasix initially for congestive heart failure, although this was unlikely to be congestive heart failure. The patient was thought to have a mucous plug given the rapid improvement of her symptoms after suctioning. The patient had follow-up chest x-ray which demonstrated right middle lobe pneumonia and question of pneumonia at the left base. The patient was initially started on ceftriaxone and azithromycin in the Emergency Department, but was then changed to vancomycin and Zosyn to cover a ventilator-associated pneumonia. The patient was then put back on her [Hospital3 672] Hospital ventilator settings and her white count decreased. She continued to have low-grade temperatures which were thought to be due to her lack of adequate antibiotics. Sputum culture showed greater than 25 polys, less than 10 epithelial cells with mixed flora and final culture is pending at the time of this dictation. 2. Cardiac: The patient was treated empirically in the Emergency Department for congestive heart failure. She underwent transthoracic echocardiogram to evaluate her ejection fraction given possible congestive heart failure. This demonstrated left atrium with moderate dilatation, right atrium with moderate dilatation, mild left ventricular hypertrophy, minimal aortic stenosis, 1+ aortic regurgitation, mild to moderate mitral regurgitation, impaired ventricular relaxation. It was not clear if the patient was in any congestive heart failure and she was not given Lasix. This can be restarted should her symptoms worsen. 3. Weakness: On hospital day number one the patient was noted to have some left-sided weakness. It is unclear exactly what her baseline is. She was able to move all four extremities, however she had some flaccidity and hyperreflexia in the left upper and lower extremities. She underwent CT scan of the head which demonstrated no acute changes but chronic microvascular changes and atherosclerosis of the internal carotid and vertebral arteries. Given the patient's condition and unclear age of her findings, no additional work-up was undertaken. 4. Endocrine: The patient was maintained on fingersticks q.i.d. and a Regular Insulin sliding scale for her diabetes mellitus. This should be maintained at her discharge for optimal blood sugar control during her time of infection. 5. Anemia: The patient's blood counts decreased from admission of 36 down to 26 on hospital day number two. Some of this was thought to be dilution as the patient did receive some intravenous fluids during her admission. She was guaiac negative and did not have any signs of active bleeding. Blood count is stable at the time of her discharge. She did not have a history of coronary artery disease so no packed cells were given. Should her hematocrit decreased to less than 24, blood transfusion may be of benefit to her. 6. Access: The patient had a PICC line placed for intravenous antibiotics to complete a 14-day course of vancomycin and Zosyn. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient was discharged back to [Hospital3 ] Hospital for continued weaning and intravenous antibiotic therapy. DISCHARGE DIAGNOSES: 1. Ventilator-associated pneumonia. 2. Cerebrovascular accident of unclear duration. 3. Mitral regurgitation. 4. Anemia. 5. Diabetes mellitus. 6. Urinary tract infection: Positive urinary tract infection with Gram-negative rods and beta streptococcus. DISCHARGE MEDICATIONS: 1. Vancomycin 1 gram q. 48 hours started on [2199-5-27] to receive a 14-day course. 2. Zosyn 2.25 grams IV q. 6 hours started on [2199-5-27] to complete a 14-day course. 3. Sertraline 50 mg p.o. q.d. 4. Methylphenidate 5 mg p.o. b.i.d. 5. Albuterol nebulizer inhaled q. 6 hours p.r.n. 6. Atrovent 2 puffs inhaled q.i.d. 7. Heparin 5,000 mg subcutaneous b.i.d. 8. Fluticasone 110, 2 puffs inhaled b.i.d. 9. Regular Insulin sliding scale. 10. Fluconazole 100 mg p.o. q. 24 hours for thrush to complete four additional doses. 11. Lansoprazole 30 mg via nasogastric tube q.d. 12. Ativan 0.25 mg p.o./IV t.i.d. p.r.n. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3795] Dictated By:[Name8 (MD) 17420] MEDQUIST36 D: [2199-5-28] 10:50 T: [2199-5-28] 11:03 JOB#: [Job Number 46668]	[ "486", "5990" ]
Admission Date: [2155-3-1] Discharge Date: [2155-3-4] Date of Birth: [2111-3-24] Sex: M Service: MEDICINE Allergies: Valium Attending:[First Name3 (LF) 1162] Chief Complaint: hyperglycemia Major Surgical or Invasive Procedure: This is a 43 yo M who presents with increased urinary frequency x one week, found to have new onset [Hospital 23051] transferred to MICU for management on HONC. He complained of urinary incontinence and episodic R-sided weakness. He reports 3 falls at home in last week. He woke up on the floor, not remembering how he got from the bed to the floor. . In the ER he was given a regular insulin bolus of 4 units (0.05 u/kg of ideal weight) at 4 units insulin gtt (0.05u/kg/hr) at 1 a.m. At 4:30 am he received a 10 unit bolus with 6 units/hr gtt. EKG showed worsening ST depressions in leads 2, 3, 4, and v4-v6. He received 325 mg of ASA. Head CT and CXR were negative. UA negative for infection and ketones. IVF were given via 20g IV. The IV team was unable to obtain second IV. He was given 1.5 grams of amoxicillin. History of Present Illness: This is a 43 yo M who presents with increased urinary frequency x one week, found to have new onset [Hospital 23051] transferred to MICU for management on HONC. He complained of urinary incontinence and episodic R-sided weakness. He reports 3 falls at home in last week. He woke up on the floor, not remembering how he got from the bed to the floor. . In the ER he was given a regular insulin bolus of 4 units (0.05 u/kg of ideal weight) at 4 units insulin gtt (0.05u/kg/hr) at 1 a.m. At 4:30 am he received a 10 unit bolus with 6 units/hr gtt. EKG showed worsening ST depressions in leads 2, 3, 4, and v4-v6. He received 325 mg of ASA. Head CT and CXR were negative. UA negative for infection and ketones. IVF were given via 20g IV. The IV team was unable to obtain second IV. He was given 1.5 grams of amoxicillin. Past Medical History: -Type A Aortic Dissection Repair (hemiarch and ascending aorta repair, aortic valve repair) - [1-/2152] -Strokes: several peri-procedural embolic strokes involving bilateral hemispheres. -chronic renal insufficiency (ARF due to ATN during admission for aortic dissection in [2151] and required transient HD); cr baseline 2.0-2.2 -bilateral peroneal neuropathies -chronic low back pain -peripheral neuropathy -hypertension -prurigo nodularis -Hypercholesterolemia -Asthma -Sarcoid -h/o ishemic hepatitis s/p celiac stent along with L CIA/EIA stent -h/o Klebsiella UTI Social History: lives with wife, no ETOH, no drugs, no tobacco Family History: Non-contributory. Physical Exam: Vitals: 99.6 89 125/70 21 94% RA GEN: Morbidly obese male in NAD, breathing comfortably HEENT: Sclera anicteric, OP clear with dry MM Neck: thick, unable to assess JVP CV: RRR, S1/S2 with mechanical click. no MRG Resp: CTAB Abd: Obese, soft, NT/ND, +BS Ext: No peripheral edema Skin: xerosis to LE Neuro: PERRLA, EOMI intact, L Amblyopia (previously noted), +Horizonal Nystagmus bilaterally, CN otherwise intact. Decreased sensation to light touch on bilateral lower extremities. 4+ strength og R LE, otherwise 5/5 strength throughout. Pertinent Results: Head CT [2-28]: No evidence of acute intracranial pathology. Please note that MRI with diffusion-weighted sequences is more sensitive for detection of acute ischemia. . CXR [3-1]: No pneumonia or CHF. Improving right discoid atelectasis. . EKG [2-28]: NSR @ 87, nl axis/intervals, STD in II, III, aVF, V4-V6 (new since [11-11]) . . [2155-2-28] 09:50PM WBC-7.3 RBC-4.49* HGB-15.0 HCT-47.1 MCV-105* MCH-33.4* MCHC-31.9 RDW-15.1 [2155-2-28] 09:50PM NEUTS-64.0 LYMPHS-30.4 MONOS-2.3 EOS-2.8 BASOS-0.6 [2155-2-28] 09:50PM PLT COUNT-192 . [2155-2-28] 09:50PM CK-MB-3 cTropnT-0.02* [2155-2-28] 09:50PM CK(CPK)-197* [2155-3-1] 08:49AM CK-MB-3 cTropnT-0.03* [2155-3-1] 10:12PM CK-MB-4 cTropnT-0.03* [2155-3-1] 10:12PM CK(CPK)-194* . [2155-2-28] 09:50PM GLUCOSE-989* UREA N-45* CREAT-3.9# SODIUM-120 POTASSIUM-4.4 CHLORIDE-75* TOTAL CO2-30 ANION GAP-19 [2155-3-1] 08:49AM GLUCOSE-250* UREA N-42* CREAT-3.5* SODIUM-134 POTASSIUM-3.0* CHLORIDE-92* TOTAL CO2-26 ANION GAP-19 . [2155-2-28] 10:53PM URINE RBC-0-2 WBC-[4-9] BACTERIA-RARE YEAST-RARE EPI-[7-15] [2155-2-28] 10:53PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2155-2-28] 10:53PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.026 . [2155-3-1] 02:25PM TYPE-ART PO2-82* PCO2-49* PH-7.40 TOTAL CO2-31* BASE XS-3 INTUBATED-NOT INTUBA [2155-3-1] 02:25PM LACTATE-1.8 [2155-2-28] 10:53 pm URINE Site: CLEAN CATCH FINAL REPORT [2155-3-2] URINE CULTURE (Final [2155-3-2]): NO GROWTH. Brief Hospital Course: A/P: 42 yoM with MMP, including morbid obesity, aortic dissection s/p repair and complicated by h/o multiple embolic strokes, CKD who presents with hyperglycemia now on insulin gtt. . 1) Hyperglycemia: the patient was given IV insulin, aggressive IVF and placed in the [Hospital Unit Name 153] for further care. A TLC was placed given the patient's poor IV access. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] consult was obtained for titration of lantus and humalog. The patient's BG trended down and he was transitioned to sc regimen without difficulty. He was transferred to the floor with diabetic teaching. He will follow up with [Last Name (un) ] the day after discharge for further care. 2) Altered Mental Status: combination of hyperglycemia and uremia. head CT was unremarkable. This resolved with adequate control of BG. 3) History of aortic dissection: No active issues. - Continue lopressor . 4) Status post CVA: No active issues. - Continue ASA, lopressor, trileptal . 5) Peripheral neuropathy: No active issues. - Continue amitryptiline, vitamin B12 6) Hypertension: The patient's HCTZ was held during the admission as he was admitted with severe volume depletion and ARF that improved with IVF. The HCTZ will need to be restarted by his PCP as an outpatient. Medications on Admission: albuterol IH prn wheezing amitriptyline 50 mg QHS androgel 1.25g transdermal QDay aspirin 81 QD calcitriol 0.25 mcg TIW cyanocobalamin [2147] mcg QDay gabapentin 600 mg TID hydrochlorothiazide 25 mg QDay Lopressor 200 mg [Hospital1 ] amlodipine 10 mg QDay Trileptal 300 mg [Hospital1 ] Xalatan 1 drop OU daily - amoxicillin 500 mg PO QDay x 3 days (for recent dental procedure) Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Metoprolol Tartrate 50 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO three times a week. 8. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every 4-6 hours as needed. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:1 10. Lantus 100 unit/mL Solution Sig: One (1) 40 Subcutaneous at bedtime. Disp:1 bottle Refills:5 11. Humalog 100 unit/mL Solution Sig: One (1) as directed by sliding scale Subcutaneous four times a day. Disp:2 bottles Refills:5 12. Syringe (Disposable) Syringe Sig: One (1) Miscellaneous four times a day. Disp:1 box Refills:5 13. Lancets,Ultra Thin Misc Sig: One (1) Miscellaneous four times a day. Disp:1 box Refills:2 14. Humalog sliding scale Please see attached sliding scale for your Humalog dose. You should check your blood sugar four times daily (prior to each meal and once at bedtime). Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: Diabetes Type II, insulin dependent hyperglycemia HTN dyslipidemia asthma ARF Discharge Condition: stable Discharge Instructions: You were admitted with hyperglycemia and diagnosed with diabetes Type 2. You will need careful follow up in the future from both your PCP and the [Name9 (PRE) ] Clinic. Please call your PCP if you develop increased urinary frequency, thirst, dizziness, or new symptoms. Followup Instructions: [Hospital ] Clinic [Telephone/Fax (1) 2384] with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3640] [2155-3-5] at 2:30 PM Provider: [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2334], M.D. Phone:[Telephone/Fax (1) 253] Date/Time:[2155-3-7] 9:45 Provider: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Name (STitle) ] Phone:[Telephone/Fax (1) 612] Date/Time:[2155-4-1] 1:45 Provider: [Name8 (MD) 23218],MD Phone:[Telephone/Fax (1) 1091] Date/Time:[2155-4-10] 9:10 Your hydrochlorathiazide is currently on hold until your renal function improves.	[ "5849", "5859", "40390", "2720" ]
Admission Date: [2183-5-20] Discharge Date: [2183-5-23] Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 1838] Chief Complaint: Intraparenchymal hemorrhage Major Surgical or Invasive Procedure: None - intubated in the field and initially admitted to the ICU History of Present Illness: Patient is a 90 RHW with HTN and afib on coumadin presents from OSH. She is intubated and HPI obtained from family who was at bedside. She is very healthy at baseline, lives alone and is independent. She works as a volunteer at [Hospital ] Hospital. She was at work this morning, and didn't appear her usual self this am. She was somewhat confused at the front desk at work. Around noon, she was found down in the restroom and was confused. After fall, when asked by family when they reached OSH ED, she denies seizure and didn't recall how she fell. BP on arrival at OSH :187/75 which became 206/98 shortly. Labs at OSH showed CBC 8.2, 13.9/40, 226. Chem 7 was normal. INR was 3.4. She became drowsy and was intubated after 10 mg vit K, 2 FFP, 1 gram dilantin, 5 lopressor, with lido/eto/succ/ and put on propofol. INR after the FFP was 2.3. She was then sent to [Hospital1 18] ED. Past Medical History: 1.Hypertension 2. Atrial fibrillation on Coumadin 3. Osteoporosis Social History: Lives alone and volunteers at the hospital gift shop. Denies smoking, EtOH. Full code. Family History: Mother had stroke. Physical Exam: Physical Exam on Admission: Vitals: 98.4 76 136/84 14 99% 2L Nasal Cannula General: Intubated HEENT: NC/AT, no scleral icterus noted, Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Clear Cardiac: [Last Name (un) ] Rare rhythm nl. S1S2, no M/R/G noted Abdomen: soft, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: intubated, off propofol follows commands on the left side, doesnt follow on right side. -CN: PERRL 3 to 2mm and brisk. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. face appears symmetric though limited by intubated status. -Motor: moves left side spontaneously and to pain. doesnt move right side even to painful stimuli. -DTRs: [Name2 (NI) ] in arms but none for patellar or achilles. Plantar response was extensor on right and flexor on left -Coordination: Intact FNF. -Gait: Defd. Pertinent Results: [2183-5-21] 02:22AM BLOOD WBC-10.0 RBC-3.81* Hgb-12.5 Hct-35.8* MCV-94 MCH-32.9* MCHC-35.0 RDW-14.2 Plt Ct-233 [2183-5-21] 02:22AM BLOOD Glucose-126* UreaN-11 Creat-0.6 Na-134 K-4.3 Cl-99 HCO3-24 AnGap-15 [2183-5-20] 11:00PM BLOOD Calcium-8.4 Phos-2.1* Mg-1.6 [2183-5-22] 07:45AM BLOOD %HbA1c-5.7 eAG-117 [2183-5-21] 02:22AM BLOOD Triglyc-86 HDL-62 CHOL/HD-2.7 LDLcalc-91 [2183-5-20] 05:30PM URINE RBC-3* WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 [2183-5-20] 05:30PM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-300 Ketone-40 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG CT C-spine: 1. No evidence of fracture or malalignment. 2. Multilevel degenerative changes of the cervical spine, as described above. 3. Mild pulmonary edema. CT head: Stable 2 x 1 x 1.6-cm left thalamic acute-to-subacute intraparenchymal hemorrhage is surrounded by stable mild edema. There is hemorrhagic extension into the ventricular system with blood layering in the left occipital [Doctor Last Name 534]. There is no hydrocephalus. No new intracranial hemorrhage. No significant mass effect or shift of normally midline structures. The [Doctor Last Name 352]-white matter differentiation is well preserved. There are no suspicious lytic or sclerotic bony lesions. There are mild aerosolized secretions in the left sphenoid sinus, likely related to endotracheal and nasogastric intubation. The patient is status post bilateral lens replacement. IMPRESSION: Unchanged left thalamic hemorrhage with intraventricular extension. Brief Hospital Course: Patient is a 90 RHW with HTN and afib on coumadin presents from OSH. Patient was working at [Hospital ] Hospital, where she has been volunteering at the gift shop for the past 30 years. She reportedly collapsed at the hospital and was intubated in the field. She was found to have R sided weakness and CT showed left BG hemorrhage with minimal intraventricular extension. She was also reportedly hypertensive upto 200/90. Patient received vitamin K and FFP before the transfer. Patient was admitted to the ICU and repeat head CT here showed stable L BG hemorrhage. Given the location of blood and her BP, this is most consistent with hypertensive hemorrhage. She was able to be extubated the day after admission to ICU and she was transferred out to the neurology floor on hospital day #2. Patient's exam is consistent with left basal ganglia hemorrhage - mild R facial droop with right sided weakness of arm and leg. Patient underwent repeat scan which shows stable hemorrhage with no further expansion. Given the hemorrhage, patient remained off Coumadin or heparin during this admission. Patient is to start ASA 81mg on [5-27] for stroke prevention given her atrial fibrillation. Then Coumadin needs to be started on [5-30] with ASA 81mg daily bridging until INR >2.0. Goal INR is between 2~3 for stroke prevention given her atrial fibrillation. Possibility of dabigatran instead of Coumadin was discussed with Dr. [Last Name (STitle) 23246] (cardiologist) but given the lack of strong evidence in her age group and no known reversing [Doctor Last Name 360], the decision was made to restart Coumadin on [5-30] rather than switching. Patient was evaluated per PT and OT who recommend discharge to acute rehabilitation facility for inpatient physical and occupational therapy. Medications on Admission: coumadin 2.5 mg po daily except on wed and saturday metoprolol 25 mg po bid hctz 25 mg po daily alendronate 20mg po weekly calcium and D 2 xs per day Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain fever. 4. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day for 1 weeks: Please start ASA 81mg daily on [2183-5-27] and stop once INR > 2.0 with Coumadin. 8. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: goal INR 2~3 and please stop ASA 81mg daily once INR > 2.0. 9. alendronate 10 mg Tablet Sig: Two (2) Tablet PO once a week. 10. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO twice a day. 11. heparin (porcine) 5,000 unit/mL Cartridge Sig: One (1) Injection TID (3 times a day): can stop once patient ambulating regularly. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Left basal ganglia hemorrhage witn minimal intraventricular extension Atrial fibrillation Hypertension Discharge Condition: Mental Status: Clear and coherent about self and hospital. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Neuro deficits: Alery and mostly oriented to self and place. Fluent speech with intact repetition. Mild R facial droop with right sided weakness of R arm and leg in upper motor neuron pattern. Discharge Instructions: You were transferred from [Hospital ] Hospital after being intubated and found to have left basal ganglia hemorrhage. Your blood pressure was elevated up to 200/90 per field report. Given the location of hemorrhage and blood pressure, your hemorrhage is most likely due to hypertension. You were successfully extubated the day after your admission and you were transferred out of the intensive care unit on your hospital day #2. You have slight right facial droop and right sided weakness due to your hemorrhage. Notably, your INR was within therapeutic range and you are recommended to restart Coumadin for your on [2183-5-30]. You will be started on ASA 81mg daily on [5-27] as bridging therapy and please remain on ASA 81mg until your INR is therapeutic (INR > 2.0). Please stop ASA once INR > 2.0. You were evaluated per physical and occupational therapy and recommended to go to acute rehabilitation facility. You are also scheduled to follow-up with Dr. [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], neurologist who ovesaw your care during this admission. Followup Instructions: Please follow-up with your primary health care providers 1~2 weeks after your discharge from rehabilitation facility including Dr. [Last Name (STitle) 23246] (cardiologist) and Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 911] (PCP). Provider: [First Name8 (NamePattern2) ] [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) 3445], MD Phone:[Telephone/Fax (1) 2574] Date/Time:[2183-7-25] 2:30 Please call [Telephone/Fax (1) 10676] to complete registration and you will need a referral from your PCP before the scheduled appointment as listed above. Completed by:[2183-5-23]	[ "42731", "V5861", "4019" ]
Admission Date: [2119-3-31] Discharge Date: [2119-4-7] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 783] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: ICU stay History of Present Illness: 88 yo F w/COPD, Emphysema, HTN, remote h/o endometrial CA with ? pulm mets recent admission [Date range (1) 93122] for weakness sent to rehab, now admitted for weakness, fever at home 102, increasing SOB and cough. Pt was discharged from rehab on [3-30] to home, at baseline able to ambulate with walker. On [3-30] felt relatively weak, per [Name (NI) 269] unable to get up from toilet, no episodes of syncope or fall at home. Overnight she slept on cough without changing her clothes. In am, her housekeeper found her sleeping on her couch. Temp taken 102, given weakness, fever, SOB and cough since thursday pt was sent into ED. Pt is unable to recall events in terms of why she was sent into ED. She did c/o some DOE, wheezing and cough, she is not O2 dependent at home. Sick contacts from rehab, no recent travelling. No GI symptoms, no N/V/Abdominal pain, no diarrhea, no dysuria, no BRBPR, no melena, no hematuria. Pt with poor PO intake. Per pt no HA, confusion, visual changes. No changes in her meds. Past Medical History: - endometrial cancer, s/p TAH [2097] - spinal stenosis - hypertension - emphysema - deviated septum - hemorrhoids (recent colonoscopy [11-10])- - s/p left shoulder replacement - s/p right hip replacement - right rotator cuff tear - hyperlipidemia Social History: Lives alone at [Street Address(2) ], senior center. She has a lifeline. Her daughter is close by and very involved. She moved from New Jersey one year ago. She quit tobacco in [2097] (smoked for 50 years). Very rare EtOH. Family History: NC Physical Exam: VS: 96.0 BP 120/66 HR 83 RR 17 97% 2L NC; pulsus=5 GEN: NAD HEENT: Dry MM, PERRL RESP: Distant breath sounds with minimal exp wheeze, no crackles CV: Reg Nml S1, S2, no M/R/G ABD: soft ND/NT +BS EXT: no peripheral edema, warm, 2x3cm blister on foot-no drainage, no lesions, no warmth/erythema NEURO: A&O x3, no focal deficits, following commands appropriately, strength 3/5 LE, [4-8] UE b/l, normal sensation, dop DP pulses b/l Pertinent Results: [2119-3-31] 12:15PM BLOOD WBC-8.2 RBC-5.12 Hgb-16.4# Hct-46.7 MCV-91 MCH-32.0 MCHC-35.1 RDW-12.3 Plt Ct-225 [2119-4-1] 03:55AM BLOOD WBC-4.9 RBC-4.37 Hgb-13.4 Hct-40.5 MCV-93 MCH-30.7 MCHC-33.2 RDW-12.4 Plt Ct-184 [2119-4-6] 06:30AM BLOOD WBC-9.3 RBC-4.55 Hgb-14.0 Hct-41.8 MCV-92 MCH-30.8 MCHC-33.6 RDW-12.4 Plt Ct-286 [2119-4-7] 06:54AM BLOOD WBC-10.9 RBC-4.83 Hgb-14.7 Hct-44.5 MCV-92 MCH-30.4 MCHC-33.0 RDW-12.9 Plt Ct-329 [2119-3-31] 12:15PM BLOOD PT-13.2 PTT-26.7 INR(PT)-1.1 [2119-4-7] 06:54AM BLOOD PT-12.5 PTT-57.3* INR(PT)-1.1 [2119-3-31] 12:15PM BLOOD Glucose-132* UreaN-18 Creat-0.8 Na-137 K-3.6 Cl-95* HCO3-29 AnGap-17 [2119-4-1] 03:55AM BLOOD Glucose-155* UreaN-18 Creat-0.7 Na-142 K-3.1* Cl-108 HCO3-27 AnGap-10 [2119-4-2] 06:33AM BLOOD Glucose-97 UreaN-21* Creat-0.7 Na-139 K-4.5 Cl-106 HCO3-25 AnGap-13 [2119-4-7] 06:54AM BLOOD Glucose-80 UreaN-26* Creat-0.7 Na-140 K-4.0 Cl-97 HCO3-32 AnGap-15 [2119-3-31] 12:15PM BLOOD CK(CPK)-303* [2119-4-3] 06:30AM BLOOD ALT-19 AST-23 LD(LDH)-239 AlkPhos-42 TotBili-0.3 [2119-3-31] 12:15PM BLOOD CK-MB-3 cTropnT-<0.01 [2119-3-31] 12:15PM BLOOD cTropnT-<0.01 [2119-3-31] 08:37PM BLOOD CK-MB-4 cTropnT-<0.01 [2119-3-31] 12:15PM BLOOD Calcium-9.0 Phos-3.4 Mg-1.7 [2119-4-1] 03:55AM BLOOD Calcium-7.5* Phos-3.4 Mg-1.6 [2119-4-1] 03:55AM BLOOD TSH-0.27 [2119-3-31] 12:15PM BLOOD Cortsol-28.5* [2119-3-31] 12:15PM BLOOD CRP-40.0* [2119-3-31] 12:19PM BLOOD Lactate-1.9 K-3.5 CTA 1. No evidence of aortic dissection, pulmonary embolism, or etiology for acute shortness of breath identified. No interval change in multiple metastatic nodules within the chest. 2. Marked atherosclerotic disease involving the aorta and coronary circulation. 3. Unchanged appearance of sclerotic foci within the thoracic vertebral bodies which are worrisome for metastatic disease. 4. Reidentification of a left adrenal nodule with Hounsfield units suggesting that it is a benign adenoma. If alteration clinical management will occur this can be further evaluated with dedicated CT adrenal protocol or MRI. ECHOCARDIOGRAM The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Brief Hospital Course: INFLUENZA / SEPSIS Ms. [Known lastname 93123] was initally admitted to the intensive care unit from the emergency department with sepsis, fever, hypotension. The patient did have CTA which showed no e/o PE and also had serial cardiac enzymes which showed no new MI. She was found to be influenza A positive, and treated with oseltamivir for five day course. She was called out to the floor after brief stay. She did not require mechanical ventilation or vasopressor support. COPD The patient was treated for COPD exacerbation in the setting of influenza. She received po pulse of prednisone for five days. She received azithromycin for five days. She required frequent nebulizer treatments that became less frequent over time. She was still on 1L NC for sats in the low 90s. She should be titrated to range of 89-94%, as higher O2 sats can worsen COPD. HYPERTENSION The patient was hypertensive in setting of steroids requiring PRN hydralazine, worse at night. This improved after steroids. She is being discharged on her most recent outpatient medications. LUNG NODULES The patient has suspicious lung nodules on CT and history of endometrial cancer. She had recent bronchoscopy last admission, which was negative for malignancy. However, this was not a very sensitive test. Our team felt that if the patient desired, she should be seen in thoracic oncology clinic. Thoracic [Hospital ] Cancer Center [Hospital1 18] ([2119] Her prior oncologist was [Initials (NamePattern4) ] [Last Name (NamePattern4) 2406] at [Hospital1 112] per patient. Medications on Admission: 1. Acetaminophen 500 mg q6hr prn 2. Tiotropium Bromide 18 mcg daily 3. Aspirin 81 mg daily 4. Sucralfate 1 gram Tablet qid 5. Ezetimibe/simvastatin 10/20mg daily 6. Zinc Oxide-Cod Liver Oil 40% PRN 7. Cyanocobalamin 100mcg daily 8. Hexavitamin 1 daily 9. Metoprolol Succinate 25 mg DAILY 10. Benazepril 20 mg [Hospital1 ] 11. Levofloxacin 250mg daily for 5 days. 12. Albuterol Q4HR prn 13. Fluticasone-Salmeterol 100-50 mcg/Dose [Hospital1 ] Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): While in [Location (un) ] Home to be given if not ambulatory . 2. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 6. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 7. Vytorin [10-23] 10-20 mg Tablet Sig: One (1) Tablet PO once a day. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [5-13] MLs PO Q6H (every 6 hours) as needed for cough. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Sodium Chloride 0.65 % Aerosol, Spray Sig: [1-4] Sprays Nasal QID (4 times a day) as needed. 12. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 13. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 14. Benazepril 20 mg Tablet Sig: One (1) Tablet PO once a day. 15. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 16. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Topical once a day as needed. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: PRIMARY COPD Influenza SECONDARY h/o endometrial cancer Hypertension Discharge Condition: Improved but still on 1L NC Discharge Instructions: You were admitted with shortness of breath and found to have influenza. This exacerbated your emphysema/COPD. You were briefly in the intensive care unit. You were treated with Tamiflu for five days. Your blood pressure was elevated during your stay. You are being discharged on your home blood pressure medications. Please discuss your blood pressure with your primary care physician. If you develop fevers, chills, worsening shortness of breath or other concerning symptoms, please call your doctor and return to the hospital. Followup Instructions: Please follow-up with your primary care physician [Name9 (PRE) ],[Name9 (PRE) ] [Name Initial (PRE) ]. [Telephone/Fax (1) 608] Please follow-up with the thoracic oncolocy. [First Name11 (Name Pattern1) 734] [Last Name (NamePattern1) 735] MD, [MD Number(3) 799]	[ "4280", "4019", "2724" ]
Admission Date: [2111-8-4] Discharge Date: [2111-8-9] Service: SURGERY Allergies: Penicillins / Lyrica Attending:[First Name3 (LF) 4748] Chief Complaint: Right lower extremity rest pain with non-healing right toe ulcer Major Surgical or Invasive Procedure: Right femoro-peroneal bypass graft with lesser saphenous vein graft History of Present Illness: This patient is an 85 year old male with a history of severe coronary artery disease s/p myocardial infarction, congestive heart failure, hypertension who presents with chronit unremitting right lower extremity rest pain and a non-healing right toe ulcer. The patient received an extensive coronary work-up prior to presentation and was felt to be a poor operative candidate given his other co-morbidities. This poor candidate status was discussed at length with the patient and his family, who remained quite insistent that, despite the high risks, we procede with a limb-saving intervention Past Medical History: CAD,MI ,CHF,HTN,hypercholestremia,DUJd of rt. hip,hx TISs/p left CEA [2094]'s,BPH s/p turn-now w frequency/nocturia Social History: Remote history of smoking, quit 40 years ago, social ETOH use. Physical Exam: Awake and alert, NAD RRR w/ SEM at base Crackles at lung bases on auscultation bilaterally Abdomen soft, obese, non-tender Pulse exam: DP/PT dopplerable bilaterally Brief Hospital Course: The patient was admitted to the hospital and started on IV antibiotics to treat his non-healing ulcer. Cultures were taken, and ultimately grew out gram-positive cocci and gram-negative rods. He was taken to the operating room on [8-6] for a right femoro-peroneal bypass graft with lesser saphenous vein. The patient initially tolerated this procedure well and was taken to the vascular surgery ICU for recovery. On the morning of post-operative day #2, the patient began to complain of chest pain and was found to have a systolic blood pressure of 85 with elevated pulmonary artery pressures of 60/30. This picture was concerning for an active coronary event. The patient was immediately transferred to the cardiovascular surgery ICU for further monitoring and treatment. An electrocardiogram showed new lateral precordial ST-segment elevation. Troponins were checked and were found to be rising to 0.67. At 2:30am on post-operative day #3, the patient was found to be tachypnic and tachcardic. Lasix was given emperically, however, soon after the patient became unresponsive and asystolic. ACLS protocol was initiated and the patient was coded for 30 minutes without return of cardiac function. The patient was pronounced deceased at 3:57am. Medications on Admission: lasix 80mgm qam,lasix 40mgm qpm,plavix 75mgm',kcl 20meq",atorvastatin 40mgm',lopressor25mgm"percoset Discharge Disposition: Expired Discharge Diagnosis: Coronary artery disease, s/p myocardial infarction Peripheral vascular disease Congestive heart failure Hypercholesterolemia Benign prostatic hyperplasia Carotid stenosis s/p carotid endarterectomy Discharge Condition: Expired	[ "4280", "4241", "41401", "412", "2720" ]
Admission Date: [2181-12-19] Discharge Date: [2182-4-10] Date of Birth: [2127-4-15] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6075] Chief Complaint: ICH Major Surgical or Invasive Procedure: Intraventricular drain placement History of Present Illness: 54 yo man with PMH of HTN, but otherwise unknown who was at work today whe he collapsed atound 1330. Was noted to have right themiparesis, aphasia and MS changes. Rapidly lost consciousness and was taken to [Hospital ] Hospital. CT there showed 5.5cm left lentiform nucleus bleed with 14mm shift and intraventricular spread. He was intubated and transfered to [Hospital1 18]. In the ED, neurosurgery placed an intraventricular drain. Past Medical History: HTN Social History: Wife is [Name (NI) 8003] speaking only therefore an interpreter was present and assisted wife with calls to family members to update them. Social work met a second time with wife, daughter, son-in-law and neuro-med re: possible outcomes, family able to confirm their understanding and request that trach, peg and rehabilitation be pursued. Wife seemed unable to speak to what the pt would consider as quality of life, rather stated her commitment to caring for her husband and her knowledge of people who have been given poor prognosis and "are out walking in the street now". Supported wife's decisions and assisted her with completion of paper work for NH Medicaid and [Social Security Number 76688]social security disability. Family History: NC Physical Exam: BP- 225/118 HR- 63 RR-16 O2Sat 100 vented Gen: intubated and off propofol for 10 minutes HEENT: NC/AT, moist oral mucosa with some blood Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Neurologic examination: Mental status: intubated and off sedation 10 minutes now. Does not follow commands. Moves trunk and arms weakly, right>left to nox stim. DOes not withdraw legs. No spont movements. Cranial Nerves: Pupils equally round and slugglishly reactive to light, 2.5 to 2 mm bilaterally. No occulocephalics. Corneals intact weakly bilatearlly. intubated. Motor: Normal bulk bilaterally. Tone normal. Right arm postures to nox stim and left arm withdraws weakly. Legs do not withdraw. Sensation: withdraws right arm > left Reflexes: +1 and symmetric at Biceps. no reflexes in LE. Toes mute bilaterally Coordination: NA Pertinent Results: [2181-12-19] 05:40PM BLOOD WBC-7.6 RBC-4.24* Hgb-11.1* Hct-35.3* MCV-83 MCH-26.2* MCHC-31.5 RDW-13.8 Plt Ct-244 [2181-12-21] 03:17AM BLOOD WBC-8.7 RBC-4.04* Hgb-10.8* Hct-32.6* MCV-81* MCH-26.8* MCHC-33.2 RDW-14.1 Plt Ct-230 [2181-12-19] 05:40PM BLOOD PT-12.8 PTT-24.3 INR(PT)-1.1 [2181-12-20] 03:00AM BLOOD PT-12.8 PTT-26.0 INR(PT)-1.1 [2181-12-19] 05:40PM BLOOD Glucose-174* UreaN-13 Creat-0.8 Na-138 K-4.9 Cl-107 HCO3-19* AnGap-17 [2181-12-19] 05:40PM BLOOD cTropnT-<0.01 [2181-12-20] 03:06AM BLOOD CK-MB-6 cTropnT-<0.01 [2181-12-20] 10:51AM BLOOD CK-MB-5 cTropnT-<0.01 [2181-12-19] 05:40PM BLOOD Albumin-3.7 Calcium-7.8* Phos-3.3 Mg-1.8 [2181-12-20] 10:51AM BLOOD Triglyc-46 HDL-71 CHOL/HD-2.3 LDLcalc-84 [2181-12-20] 12:29PM BLOOD %HbA1c-5.8 [2181-12-19] 05:40PM BLOOD Phenyto-7.7* [2181-12-19] 05:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ================================ Head CT [12-19]: Stable size of left basal ganglia hemorrhage with intraventricular extension, associated mass effect, subfalcine and uncal herniation. Interval ventricular shunt placement with mild decompression of the ventricles. --------- HEAD CT [12-20]: There is no change in the left basal ganglia bleed, which extends into the centrum semiovale superiorly and has surrounding vasogenic edema. There is persistent compression of the ventricles and midline shift and residual uncal herniation. No fractures are identified. There is opacification of the sinuses consistent with intubation. The intraventricular drain tip lies in the thalamus. --------- HEAD AND NECK CTA [12-20]: The carotid and vertebral arteries and their major branches are patent with no evidence of stenosis. There is no evidence of aneurysm formation or other vascular abnormality. Impression: Peristent left basal ganglia hemorrhage and mass effect. No aneurysm or other vascular abnormality. Final addendum to follow when volume- rendered images are available for evaluation. --------- CT-head [2182-1-2]: IMPRESSION: 1. Ventriculostomy catheter terminates in the third ventricle with unchanged appearance of the known intraparenchymal hemorrhage and 9 mm of rightward midline shift. 2. Right scalp soft tissue swelling and fluid collection measuring 12 mm thick, likely secondary to recent ventriculostomy catheter revision. --------- CT head [2182-1-9]: IMPRESSION: Since [2182-1-2], minimal decrease in size of the hyperdense component of the left basal ganglia/centrum semiovale hemorrhage but with minimal worsening of the surrounding edema which is causing minimal worsening of the left to right shift of the normally midline structures, now measuring approximately 7 mm. Tiny amount of blood layering within the occipital [Doctor Last Name 534] of the right lateral ventricle. Basal cisterns are still patent. There is diffuse effacement of the left cerebral sulci. ----- CT head ([2182-2-2]): IMPRESSION: 1. No hydrocephalus or evidence of shunt malfunction is identified. 2. Hypoattenuation without evidence of acute hemorrhage in the region of old intraparenchymal hemorrhage within the left basal ganglia/centrum semiovale ----- CT head ([2182-2-27]): IMPRESSION: No intracranial hemorrhages. No change in ventricular size. ----- CT head ([2182-3-5]): IMPRESSION: No short interval change. No intracranial hemorrhages and stable ventricular size. ----- CT head ([2182-3-13]): CONCLUSION: No interval change in the appearances of the ventricular system post-stent placement. No new abnormality. ====== Video Oropharyngeal Swallow ([2182-2-8]): IMPRESSION: Mild-to-moderate impairment of oral phase; however, there is no penetration or aspiration. For further details, see speech and swallow evaluation from the same date. ===== Renal ultrasound ([2182-2-27]): IMPRESSION: Non-obstructing left renal stone. No evidence of hydronephrosis. Nearly symmetric size and flow of the kidneys. =============== ECHO [2181-12-21]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Dilated thoracic aorta. ======================== EEG [2181-12-24]: This is an abnormal portable EEG due to the disorganized, low voltage, and slow background consistent with a marked/severe encephalopathy which suggests dysfunction of bilateral subcortical or deep midline structures. Medications, metabolic disturbances, infection, and anoxia are among the common causes of encephalopathy but there are others. The increased voltage amplitude seen about the C4-P4 and P4-O2 electrode channels likely represent a breach rhythm from a skull defect. There were no epileptiform features. No electrographic seizure activity was noted. ---- EEG ([2182-3-9]): IMPRESSION: This is an abnormal portable EEG due to an intermittent asymmetry between the two hemispheres, with loss of faster frequencies and more prominent delta slowing noted broadly over the left side. Findings are consistent with an underlying region of cortical and subcortical dysfunction on the left. In addition, the background was disorganized, poorly modulated and slow with frequent bursts of generalized slowing. This constellation of findings is consistent with a moderate global encephalopathy, due to dysfunction of bilateral subcortical or deep midline structures. Medications, metabolic disturbances, and infection are among the common causes of infection. There were no epileptiform features and no electrographic seizure activity was noted. ----- EEG ([2182-3-14]): IMPRESSION: This is an abnormal routine EEG due to the low voltage fast and disorganized background with intermittent bursts of moderate amplitude generalized mixed frequency slowing consistent with a mild encephalopathy suggesting dysfunction of bilateral subcortical or deep midline structures. Medications, metabolic disturbances, and infection are among the common causes of encephalopathy but there are others. There were no areas of prominent focal slowing although encephalopathic patterns can sometimes obscure focal findings. There were no epileptiform features. ======= Brief Hospital Course: Mr. [Known lastname 6633] was admitted to the ICU and subsequently transferred to the floor. His hospital course by problem is as follows: 1) Neuro / L basal ganglia bleed: - He was very hypertensive and his mechanism for bleeding was felt to be likely secondary to this. A CTA showed no vascular abnormalities. His blood pressure was initially maintained between 120-170 with a MAP of less than 130. He was also maintained normothermic and normoglycemic. His blood pressure was somewhat difficult to control requiring metoprolol 100 TID, lisinopril 40mg daily, norvasc 10mg daily and HCTZ 25mg daily. His LDL and A1c were checked and were WNL. - upon arrival to the floors, multiple adjustments were made to her blood pressure medications and proper control was eventually obtained. - sustained clonus was noted on multiple occasions on the right side and occasionally misinterpreted as seizure activity, but this was then followed by some reports of facial twitching and an EEG was obtained. The EEG was not suggestive of epileptiform activity, but due to increasing somnolence (thought to be in part related to depression from being in the hospital for so long)that could have been related to seizure activity (that might be too deep to have been picked up by EEG), the decision was made to start him on Keppra. - Provigil was trialed with regard to his increasing somnolence, but there was no benefit from this. He was also started on lexapro and psychiatry team was consulted. Lexapro provided little benefit, and psychiatry believed that a lack of response to ritalin made one lean away from the diagnosis of depression and more toward a diffuse encephalopathic state entered after his large hemorrhage. 2) The patient had an extraventricular drain (EVD) placed by the neurosurgical service for hydrocephalus. An attempt was made to clamp and remove the EVD, but the pressure rose steeply to 30 cmH20. The drain was reopened and the patient was taken for a ventriculoperitoneal shunt placment. The patient tolerated this well. 3) The patient's decreased arousal prevented him from taking adequate nutrition. A PEG tube was placed. He was started on tube feeds. Eventually he alerted enough to taking more PO feeds. He passed his speech and swallow study and was then started on PO feeds. 4) The patient's decreased arrousal and decreased mobility was felt to put him at risk for an aspiration event. He had a tracheostomy performed to prevent aspiration. He required oxygen via trachmask for a significant proportion of his stay. Eventually, his trach was decannulated and he remained stable on room air. 5) Hypertension was also a major area of concern during this admission. Etiology of this was not well known, and further workup included a renal ultrasound in order to rule out renal artery stenosis (found to be negative). 6) There were considerable insurance impediments to appropriate discharge. He stayed on the floor for >90 days awaiting insurance issues. Please refer to the documentation from Social Work and the Case Manager. He was markedly abulic and barely interactive, with terse answers and limited interaction, and a stable, dense R hemiplegia. There were no further in-hospital complications. 7) He was evaluated by psychiatry on [2182-3-11] for a question depression, and it was felt that depressive symptoms more often seen in left hemisphere strokes. Aphasia by itself can lead to depression especially if too many motor deficits elements given the frustration of not being able to communicate one's thoughts and feelings in words. He was started on Lexapro, eventually up to 20 mg QD, but efficacy may not be evident until 6 - 8 weeks out. Regarding activating medication like Provigil, it was of no effect and discontinued - as outlined above. 8) He was notoriously constipated during this admission and was kept on an intense bowel regimen. PS The patient has his BIRTHDAY in 5 days ([4-15]). The nurses were planning on a party. Medications on Admission: unknown Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet [Month/Year (2) ]: One (1) Tablet PO three times a day. Tablet(s) 2. Docusate Sodium 50 mg/5 mL Liquid [Month/Year (2) ]: One (1) 10 mL PO BID (2 times a day). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Month/Year (2) ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Heparin (Porcine) 5,000 unit/mL Solution [Month/Year (2) ]: One (1) mL Injection TID (3 times a day). 5. Acetaminophen 325 mg Tablet [Month/Year (2) ]: One (1) Tablet PO Q6H (every 6 hours) as needed for fever. 6. Hydrochlorothiazide 12.5 mg Capsule [Month/Year (2) ]: One (1) Capsule PO DAILY (Daily). 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 8. Amlodipine 5 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO DAILY (Daily). 9. Escitalopram 10 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO DAILY (Daily). 10. Senna 8.6 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). 11. Lactulose 10 gram/15 mL Syrup [Last Name (STitle) ]: Thirty (30) ML PO BID (2 times a day) as needed. 12. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day). NOTE THAT THERE IS PLENTY OF ROOM TO GO UP ON THE METOPROLOL, HE WAS ON 100 MG TID AT SOME POINT IN TIME Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: Primary 1. Left basal ganglia hemorrhage. Secundary 2. Hypertension. 3. Abulia 4. Major Disposition Problem Discharge Condition: Vital signs stable. The patient interacts minimally with the examiner. There is a right facial droop. The right side of the body is densely paretic with increased tone. Discharge Instructions: Please take all your medications excactly as directed and please attend all your follow-up appointments. Please report to the nearest ER or call 911 or your PCP immediately when you experience recurrence of weakness, numbness, tingling, problems with vision, speech, language, walking, thinking, headache, or difficulties arousing, or any other signs or symptoms of concern. Followup Instructions: Please arrange for obtaining a primary care physician in [Name9 (PRE) ] [Name9 (PRE) ] for this patient. Completed by:[2182-4-10]	[ "4019" ]
Admission Date: [2189-10-9] Discharge Date: [2189-10-14] Date of Birth: [2104-1-18] Sex: M Service: MEDICINE Allergies: Aspirin / Penicillins Attending:[Doctor First Name 3290] Chief Complaint: Transfer for ERCP Major Surgical or Invasive Procedure: ERCP. History of Present Illness: 85 year old male w/ h/o HTN, GERD, Gout who is transferred to [Hospital1 18] from [Hospital3 ] for ERCP for rising tbili, ERCP aborted today b/c of hypoxia and laryngeal spasms, now transferred to [Hospital Unit Name 153] for further management. . Patient was in usual state of health [10-7], went to PCP at VA, and reportedly had normal labs (including t bili). When he arrived home, his wife describes pt having chills. The following day [10-8], pt experienced mid epigastric abdominal pain and presented to OSH. In the ED, he was febrile w/ tmax 102. He had an US of the abdomen by ED physician reportedly negative. His labs on admission was notable for WBC 10.8, w/ 83.6% PMN, hct 47 (trended to 37.4 on [10-9]), Cr 1.6, t bili 3.2 (trended 5.6 on [10-9]), AP 98, AST/ALT 167/184, lipase 730 (trended to 54), and trop I 0.01. UA + leuk est, nit, wbc, bacteria. Blood cx reportedly positive for GNR. There he had a CT abdomen w/o contrast that showed unremarkable liver, tiny calcifications in the gallbladder representing small stones, pancreas w/ fatty infiltrations of the head, CBD not dilated, ileus vs enteritis w/o evidence of obstruction and 3.5cm AAA. There was concern for possible passed gallstone, concern for cholangitis and gallstone pancreatitis. He was started on iv levo, flagyl, aztreonam and transferred to [Hospital1 18] for ERCP. . Patient went to ERCP. On introduction of EGD scope pt desatted to low 80s while in prone poisition and c/o L sided chest pain. He was also noted to have laryngeal spasms and so procedure was stopped. Positioned pt upright and desats resolved. He was given dilaudid for pain, zofran for nausea, and started on lactate ringer. Post procedure his HR remained in 90s, RR 20s, O2 mid 90s on nc. An ECG was checked and notable for nl axis, pvc, hr 99, sinus rhythm, twi in III, no st changes. CXR w/ hilar fullness. . He was transferred to the medical floor once medically stable, and ERCP with stone extraction and sphicterotomy done and was successful. The [Hospital3 3583] lab faxed micro data that showed his blood cultures initially grew out pan-sensitive [Last Name (LF) ], [First Name3 (LF) ] he was put on cipro and flagyl once on the medical floor. Past Medical History: HTN Gout GERD MI, medically managed in his 40s Social History: - Tobacco: quit 50 yrs ago, but smoked 3ppd - Alcohol: rare - Illicits: unknown Former plumbing contractor Family History: Mother w/ alzheimer dementia, Father w/ AAA Physical Exam: Vitals: T: 99.6 - febrile initially, but deferevesced during the course of the admission BP: 133/63 P: 95 R: 15 O2: 99% on RA General: Alert, oriented to self/place and time, very pleasant HEENT: Sclera anicteric, dry MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: CTAB, anterior breath sounds clear, No stridor CV: Regular rate, normal S1 + S2, no murmurs, rubs, gallops Abdomen: distended, tender though w/o guarding or rebound tenderness, +BS Ext: warm, well perfused, palpable pulses, no clubbing, cyanosis or edema Pertinent Results: [2189-10-9] 06:14PM PT-14.9* PTT-23.7 INR(PT)-1.3* [2189-10-9] 06:14PM PLT COUNT-122* [2189-10-9] 06:14PM WBC-9.4 RBC-4.70 HGB-14.7 HCT-42.3 MCV-90 MCH-31.2 MCHC-34.7 RDW-14.3 [2189-10-9] 06:14PM CALCIUM-9.1 PHOSPHATE-2.0* MAGNESIUM-1.9 [2189-10-9] 06:14PM CK-MB-5 cTropnT-<0.01 [2189-10-9] 06:14PM LIPASE-226* [2189-10-9] 06:14PM ALT(SGPT)-170* AST(SGOT)-128* LD(LDH)-197 ALK PHOS-109 AMYLASE-169* TOT BILI-6.7* [2189-10-9] 06:14PM estGFR-Using this [2189-10-9] 06:14PM GLUCOSE-142* UREA N-27* CREAT-1.3* SODIUM-136 POTASSIUM-3.4 CHLORIDE-97 TOTAL CO2-25 ANION GAP-17 [2189-10-9] 09:11PM URINE HYALINE-1* [2189-10-9] 09:11PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 [2189-10-9] 09:11PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-40 BILIRUBIN-SM UROBILNGN-4* PH-6.0 LEUK-NEG [2189-10-9] 09:11PM URINE COLOR-AMBER APPEAR-Clear SP [Last Name (un) 155]-1.022 [2189-10-9] 09:11PM URINE OSMOLAL-909 [2189-10-9] 09:11PM URINE HOURS-RANDOM UREA N-1153 CREAT-134 SODIUM-137 CHLORIDE-143 Brief Hospital Course: 85 year old male w/ h/o HTN, GERD, [Hospital ] transferred to [Hospital1 18] from [Hospital3 3583] with choledocholithiasis, gram negative sepsis, gallstone pancreatitis and ? of cholangitis. 1. Initial ERCP unsuccessful because of laryngeal spasm, but repeat procedure successfully completed on [10-11]. Ducts swept, stone removed and sphincterotomy done. Patient tolerated procedure well, and abdominal pain largely resolved soon afterwards. Lipase continued to trend downwards. Patient was put on aztreonam and flagyl initially, but this was changed to cipro and flagyl once it became clear that the [Month/Year (2) 14594] in his blood was pan sensitive. He had diarrhea through much of his hospital course, but it became worse on cipro/flagyl, and he developed nausea as well. Flagyl was stopped, and he had a flexible sigmoidoscopy to look for evidence of cdiff, of which there was none. The cipro was held when he was markedly symptomatic. He was discharged with levaquin for five additional days, to complete a 10 day course of antibiotics for gram negative sepsis. Levaquin was chosen as cipro gave him rather severe antibiotic associated diarrhea. 2. Choledocholithiasis: Patient met with surgeon [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] who will contact him after discharge to set up an appointment for cholecystectomy. 3. Hypertension: Meds held initially, but patient advised to resume them on return home has sbp in 140-150 range. Medications on Admission: pantoprazole 40mg iv daily levo 750mg iv q48hr zofran 4-8mg prn morphine 3-4mg prn allopurinol 100mg daily flagyl 500mg iv q8hr dilaudid 1mg/1ml trazadone 50mg daily aztreonam 2gm q8hr Discharge Medications: 1. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:5 Tablet(s) Refills:0 Patient advised to resume home meds for gout and hypertension. Discharge Disposition: Home Discharge Diagnosis: 1. Choledocholithiasis 2. Gram negative sepsis 3. Antibiotic associated diarrhea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were transferred to [Hospital1 18] because a gallstone was stuck in your bile dict. You had a procedure called ERCP in which they removed the stone. You also were found to have bacteria in the blood at [Hospital3 3583]. You were started on antibiotics for this bacteria, but then you developed severe diarrhea. You had a flexible sigmoidoscopy to make sure that you did not have another infection in the bowel. We will give you a prescription for an additional 5 days of antibiotics, as it important to re-attempt them given that you had bacteria in your blood. If you find that your diarrhea and gas becomes unbearable on the antibiotic, please contact me (Dr [First Name (STitle) ] with the contact information on my business card. You also need to have your gallbladder removed in the near future. You were evaluated by Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] while you were hospitalized, and her office will call you with an appointment time to schedule your gallbladder surgery. Followup Instructions: Please make an appointment to see your primary care doctor at the VA to discuss the details of this admission.	[ "4019", "53081", "2875", "V1582", "412" ]
Admission Date: [2152-12-6] Discharge Date: [2152-12-29] Date of Birth: [2098-6-11] Sex: F Service: SURGERY Allergies: Ivp Dye, Iodine Containing / Tetracycline Attending:[First Name3 (LF) 371] Chief Complaint: MVA Major Surgical or Invasive Procedure: Ex-Fix RLE [12-5] ORIF R tib-fib [12-7] Ex-Fix LLE prox fib and distal fib pilon fx [12-7] Intracranial pressure monitor (bolt) placed [12-5] and removed [12-7]. IVC Filter placed [12-7] and removed [12-29] TTE, intra-operative, [12-7]. Gracilus flap and STSG RLE [12-11] STSG LLE over ex-fix [12-22] History of Present Illness: 54yo F unrestrained driver in MVA with ejection. +LOC with subsequent GCS 15. Brought in by EMS to trauma plus. Pt could not recall events leading to accident. Past Medical History: Lupus asthma COPD Social History: family very involved, daughter, sister, brother, son Family History: unknown Physical Exam: Afebrile, HR 105, BP 110/palp, RR 18, O2 sat 100% A&Ox3, GCS 15. PERRL Neck: no c-spine step off, NT CTAB NT ND. FAST negative. DRE: nl tone, guaiac negative R open tib-fix fx, L superficial abrasion over shin. R forearm abrasion. BL palp DP. ABI: L 1.1, R 1.3 neuro grossly intact Pertinent Results: [2152-12-5] 07:09PM BLOOD WBC-14.7* RBC-3.97* Hgb-12.6 Hct-37.2 MCV-94 MCH-31.6 MCHC-33.7 RDW-12.5 Plt Ct-339 [2152-12-6] 12:58AM BLOOD WBC-13.7* RBC-2.58# Hgb-7.9# Hct-25.1# MCV-97 MCH-30.6 MCHC-31.5 RDW-12.8 Plt Ct-206 [2152-12-6] 04:17AM BLOOD Hct-36.1# [2152-12-5] 07:09PM BLOOD PT-12.5 PTT-25.5 INR(PT)-1.0 [2152-12-5] 07:09PM BLOOD Plt Ct-339 [2152-12-6] 12:58AM BLOOD Glucose-117 UreaN-10 Creat-0.7 Na-134 K-3.2* Cl-105 HCO3-24 AnGap-8 [2152-12-5] 07:09PM BLOOD Amylase-40 [2152-12-6] 12:58AM BLOOD CK(CPK)-491* [2152-12-6] 12:58AM BLOOD Calcium-6.6* Phos-3.3 Mg-1.3* [2152-12-5] 07:09PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2152-12-7] 04:10PM BLOOD Glucose-114* Lactate-1.2 Na-136 K-4.1 Cl-111 [2152-12-17] 04:36AM BLOOD Glucose-137* UreaN-16 Creat-0.3* Na-137 K-4.4 Cl-103 HCO3-26 AnGap-12 [2152-12-25] 10:30AM BLOOD WBC-10.1 RBC-3.47* Hgb-10.4* Hct-32.4* MCV-93 MCH-29.9 MCHC-32.0 RDW-14.7 Plt Ct-842* [2152-12-25] 10:30AM BLOOD Plt Ct-842* [2152-12-29] 05:37AM BLOOD Plt Ct-612* CT ABD/PELVIS 1/4/5 IMPRESSION: IMPRESSION: 1. Bilateral sacral alar fractures extending into the neural foramen. S1, and probably L5 transverse process fracture on the right. 2. Right rib fractures with small right pulmonary contusion. Repeat 1) Comminuted sacral fractures as previously described, with mildly increased presacral hematoma and thickening adjacent to the psoas muscles. Otherwise unchanged abdominal and pelvic exam from four hours prior. The examination is somewhat limited by the lack of IV contrast. CT head 1/4/5 IMPRESSION: Findings suspicious for a small left subdural hematoma. CT Cspine 1/4/5 IMPRESSION: There are fractures of the C6 right posterior foramen transversarium and transverse process, the right C7 transverse process, the right medial first and second ribs and transverse processes. Degenerative change, multilevel. There is also a fracture of the right medial clavicle. Tib Fib B/L 1/4/5 IMPRESSION: 1). Oblique fractures of the distal right tibia and fibula, with moderate displacement and override. 2). Ill-defined lucencies overlying the bones of the right mid and hindfoot are inadequately evaluated due to overlying cast material. 3). Oblique fracture of the proximal left fibula and comminuted fracture of the distal left tibia, mildly displaced. RUE 1/4/5 IMPRESSION: 1. No fracture of the right elbow. 2. Comminuted fracture of the left fifth metacarpal, with extension of fracture line to the CMC joint articular surface. 3. Polygonal density adjacent to the base of the right first metacarpal. Tiny avulsion fragment versus foreign body cannot be entirely excluded. CT T spine 1/8/5 IMPRESSION: Tiny fracture involving the T3 spinous process which is associated with cortication of the donor site and is most likely chronic. Alternatively, this could represent ligamentous calcification as well. Brief Hospital Course: 54yo W bib EMS to trauma bay for trauma plus where underwent thorough evaluation by trauma and ER staff. Notable injuries included R open tib-fib fracture with intact distal pulses, stable vitals, and a GCS 15. Ortho consult was obtained and the R foot was splinted. Pt was placed in C-collar and stabilized. She was taken for emergent radiography notable for Head CT showing small ? L SDH, nl Chest CT, Abd-Pel showed BL sacral alar fx's but no acute abdominal pathology, and extremity plain films showed the R tib-fix fx, a L Maissonerve fx, a L distal tib fx, and a L 5th metacarpal fx. Later reads also revealed multiple rib fx's, a pulmonary contusion, and a clavicular fx. Injury also significant for C7 transverse process fx and C6 transverse process/ posterior foramen fracture. Neurosurgery consult was obtained for the L SDH and who recommended frequent neuro checks; it was decided therefore to place an epidural for anesthesia for Ortho's RLE ex-fix and LLE splint. Towards the end of the case, the patient experienced a seizure. Apparently, she became hypertensive, was given a b-blocker, went into bronchospasm (possibly related to her asthma), significantly retained CO2, had a seizure with a blown pupil, got stat intubated, given propafol and dropped her BP. A femoral a-line was placed by anesthesia. She was urgently returned to the CT scanner; Head CT showed mild cerebral edema and no L SDH as previously noted. An Abd-Pel CT also obtained for ? tense abdomen was also negative. She was brought to the the T-SICU in intubated and critical condition. Neurosurgery placed a bolt for intracranial monitoring at the bedside. She was hypotensive 90s/50s, given volume fluid resuscitation, and transfused 2 units PRBCs for a Hct 25 (down from 37 on presentation). She required neo for BP support for 24 hours, and a R subclavian triple-lumen was placed. Ortho splinted the L hand. The abdomen was soft. She was placed on stress dose steroids with taper to her home daily dose, given mannitol for ICP control, given dilantin loading dose and then tid, and Ancef/Gent for Abx. On HD 2 a swan-ganz catheter was placed in the L subclavian but resulted in a L pneumothorax. A L chest tube was placed, this had a mild air leak. Serial Hcts were performed revealing a slowly downtrending Hct. On HD 3 the intracranial bolt was removed. She was taken to the OR for an IVC filter for PE prophylaxis as the pt could not receive heparin nor could pneumoboots be applied to her LE because of her orthopedic injuries. Ortho performed an ORIF for the RLE and an Ex-Fix LLE. An intraoperative TTE revealed no aortic injury and an EF 65%. Transferred to the floor after CT removal in stable and improving condition on HD 11. A plastic surgery consult was obtained for the RLE degloving injury- throughout hospital course the plastic surgery team completed a gracilis flap and split thickness skin grafts to RLE and LLE (HD 7, 17). Throughout hospitalization, pt continued to improve steadily. Tolerating POs well, maintained on PO pain meds, converted to lovenox for anticoagulation, IVC filter removed, moving bowels, and OOB to chair as tolerated. She was transferred to rehab on HD# 25 for continued physical therapy within her limitations of PWB for transfer only RLE and NWB LLE, and ROM exercises for LUE. She was given instructions for followup with Neurosurgery (2weeks for Cspine eval, hard collar at all times), Ortho (5 weeks for LLE exfix removal), Plastics (1 week for graft eval), and Trauma (2 weeks for interval fup). Medications on Admission: Prednisone 20mg po qd ? plaquinel Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed. Disp:qs Refills:0 2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q2-3H (every 2-3 hours). Disp:qs Refills:0 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:qs Refills:0 6. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H () as needed. Disp:30 Tablet(s) Refills:0 8. Hydroxychloroquine Sulfate 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for for agitation/sleep. Disp:30 Tablet(s) Refills:0 10. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:120 Tablet(s) Refills:0 11. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:30 Tablet(s) Refills:0 12. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). Disp:qs Refills:0 13. Phenol-Phenolate Sodium 1.4 % Mouthwash Sig: One (1) Spray Mucous membrane Q4H (every 4 hours) as needed. Disp:qs Refills:0 14. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours). Disp:20 Capsule(s) Refills:0 15. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous [Hospital1 ] (2 times a day). Disp:qs Refills:0 16. Dolasetron Mesylate 12.5 mg IV Q4-6H:PRN nausea Discharge Disposition: Extended Care Facility: [Hospital6 979] - [Location (un) 246] Discharge Diagnosis: MVA L frontal SDH, small BL sacral alar fx c presacral hematoma R 7th posterior rib fx c contusion R 3rd anterior rib fx R 1st and 2nd rib fxs R distal tib-fib fx L proximal fibula and distal tibia fx. L 5th metacarpal fx S1/L5 transverse process fx R medial clavicle fx R C6 transverse process / posterior foramen fx R C7 transverse process fx bronchospasm seizure Discharge Condition: stable Discharge Instructions: -Regular diet as tolerated -Continue to wear the cervical collar at all times. -Non-weight-bearing Left leg at all times. [Month (only) 116] weight-bear Right leg for transfers only, otherwise non-weight-bearing Right leg for ambulation. Followup Instructions: 1. Follow-up with Orthopedics, Dr. [Last Name (STitle) 1005], for removal of your external fixation device (left leg) in 5 weeks after discharge. Call [Telephone/Fax (1) 4845] for an appointment. 2. Follow-up with Plastic Surgery [Telephone/Fax (1) 23144] for [Hospital 2974] clinic next week to evaluate your skin grafts and your left hand fracture. 3. Follow-up with Neurology, [Telephone/Fax (1) 1690], for further evaluation of your closed head injury 4. Follow-up with Neurosurgery, Dr. [Last Name (STitle) 739], in 2 weeks for evaluation of your cervical collar. Call [Telephone/Fax (1) 1669] for an appointment.	[ "2762", "4019" ]
Admission Date: [2169-4-5] Discharge Date: [2169-4-16] Date of Birth: [2125-10-11] Sex: F Service: MEDICINE Allergies: E-Mycin / Penicillins / Codeine Attending:[First Name3 (LF) 689] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 43F H/O IPF, COPD/Asthma (Multiple Intubations), Current Smoking, Schizoaffective Disorder/Depression with URI symptoms and dyspnea. Patient was well until about one week ago when she developed rhinorrhea, productive cough of yellow sputum, chills, fevers, mild right ear pain, fatigue and then increased dyspnea, PND, orthopnea and decreased exercise tolerance. There was no rash, headache, sore throat, nausea, vomiting, diarrhea, constipation, chest pain, leg pain, but has chronic mild swelling. She saw her PCP and had mild improvement with nebulizers. Her symptoms then worsened and she called EMS. ED Course: Afebrile. OS85%RA. Peak flow at 250 (baseline of 350). CXR showing perihilar haziness with asymmetric hilar fullness and no definite infiltrate. Started on Levofloxacin, Nebs and admitted to Medicine. Past Medical History: 1. IPF: DIP, transthoracic lung bx ([2166]) negative 2. COPD/Asthma: Spirometry ([5-/2164]) FVC 2.48 (67%), FEV1 1.96 (68%), FEV1/FVC 101%, DLCO ([4-/2163]) 51%, Lung vol ([4-/2163]): TLC 64%, FRC 48%, RV 49%, ERV 47%, multiple admissions, intubation x 1 [2163] 3. Current Smoking 4. Schizoaffective Disorder (VH/AH/Paranoia/Olfactory Hallucinations) 5. Depression 6. H/O Heavy ETOH Use and DTs 7. TLE (Most Recent Sz five years ago) 8. H/O VRE/MRSA 9. PPD Positive S/P INH 10. H/O Meningitis 11. S/P Ex Lap 12. Hyperlipidemia 13. DM Social History: She lives alone and is a jewlery maker. She currently smokes and has 30 pack-years. She is detemited to quit smoking today. She used marijuana, cocaine and LSD as a teenager but has not used drugs since then. She rarely drinks ETOH. Family History: No lung or known autoimmune disease (such as SLE, Rh or Sjogrens). Her father and mother died from MIs at ages 55 and 63, resp. Her siblings had MIs in their 40s. Physical Exam: T100.3 HR115 BP144/69 OS95%2L. GEN - NAD. SPEAKING IN FULL SENTENCES. EATING. HEENT - MMM. CLEAR OP. ANICTERIC. RESP - B/L EXP WHEEZES WITH POOR AIR MOVEMENT. Improving with peak flows > 300 and minimal wheezes by discharge. CV - TACHY AND REGULAR. NML S1/S2. NO MGR. ABD - S/NT/ND. POS BS. EXT - TRACE PEDAL EDEMA. NEURO - A&OX3. CNII-XII GROSSLY INTACT. STRENGTH AND [Last Name (un) ] TO LT INTACT THROUGHOUT. Pertinent Results: [2169-4-16] 07:00AM BLOOD WBC-13.0* RBC-4.51 Hgb-12.4 Hct-36.5 MCV-81* MCH-27.4 MCHC-33.9 RDW-14.7 Plt Ct-313 [2169-4-9] 05:33AM BLOOD PT-13.4 PTT-22.9 INR(PT)-1.1 [2169-4-16] 07:00AM BLOOD Glucose-121* UreaN-11 Creat-0.6 Na-142 K-4.0 Cl-103 HCO3-33* AnGap-10 [2169-4-15] 07:00AM BLOOD Calcium-9.5 Phos-3.5 Mg-2.0 [2169-4-11] 04:13PM BLOOD Type-ART O2 Flow-50 pO2-110* pCO2-56* pH-7.38 calHCO3-34* Base XS-6 Intubat-NOT INTUBA [2169-4-9] 03:12AM BLOOD Glucose-141* Lactate-0.9 Na-138 K-3.6 Cl-99* [2169-4-9] 03:47PM BLOOD O2 Sat-94 Brief Hospital Course: 43F H/O IPF, COPD/Asthma (Multiple Intubations), Current Smoking, Schizoaffective Disorder/Depression with URI symptoms and dyspnea - presumed atypical PNA and COPD exacerbation in setting of poor lung substrate. 1) Dyspnea: Likely multifactorial and includes Atypical PNA, COPD/Asthma and underlying IPF. Stable on 2L NC. WBC mildly elevated and afebrile. - Continue Levofloxacin 500 mg PO Q24H for typical and atypical coverage. - Continnue Fluticasone Propionate 110mcg 2 PUFF IH [Hospital1 ], Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H, Ipratropium Bromide Neb 1 NEB IH Q6H, Albuterol 0.083% Neb Soln 1 NEB IH Q3H, and Guaifenesin [5-23] ml PO Q6H:PRN. - Prednisone Taper: Prednisone 60 mg PO DAILY. - Smoking Cessation; counseled at bediside. Providing Nicotine 14 mg TD DAILY. 2) DMII: Continue SSI/FS QID, Pioglitazone HCl 30 mg PO DAILY and Glipizide 10 mg PO BID. 3) Psychosis/Depression: Stable now without symptoms or SI/HI. - Continue Clozapine 100 mg PO QAM and 400 mg PO HS. - Continue Risperidone 1 mg PO HS and Fluoxetine HCl 40 mg PO DAILY. 4) TLE: Most recent seizure five years ago. - Continue Gabapentin 600 mg PO TID. 5) PPx: PPI, Colace/Senna, Heparin SQ. 6) Code: Full. 7) Access: pIV. 8) FEN: Diabetic/Consistent Carbohydrate. 43F with history of IPF, COPD/Asthma (multiple admissions and intubation x1), current smoking, Schizoaffective Disorder and Depression who was originally admitted to the general medicine floor on [2169-4-5] with fevers, URI symptoms and dyspnea. She was started on levofloxacin for atypical pneumonia and nebulizers (peak flow 250, BL 350). On the floor, the patient was given corticosteroids, albuterol and atrovent nebs, fluticasone and continued on levofloxacin (given a penicillin allergy). Her oxygen saturations ranged 89-98% and it was thought that she was generally improving. Alas, she took a turn for the worse as she had desaturation to high 80s thought [2-15] mucous plugging. She was noted to have hypercarbia on ABG (7.40/54/71). [Hospital Unit Name 153] team evaluated the patient and encouraged increased frequency of nebs with frequent evals by Respiratory Therapy. She did well until that evening when she was found to be somnolent and difficult to arouse. Her oxygen saturation was in the high 90s. An ABG revealed 7.39/58/72. Nursing was concerned and the patient was transferred to unit for closer monitoring. While in the unit, she was noted to have a combined respiratory acidosis and metabolic alkalosis. She was started on BiPAP and gradually weaned down. She was transferred to the floor for further management of her pulmonary disease. By [2169-4-15] the patient was feeling much better with stable SpO2 >94% on 2L oxygen, and dramatically improved peak flow >300 and minimal wheezing on exam. The patient was stable for discharge on [2169-4-16], with minimal wheezing. She has home O2 set up from previous use, and will be discharged with home services. During [2169-4-15] patient had elevated FBS readings 200-300. She was initiated on a glargine / humalog insulin regimen, with 15 units glargine qPM giving improved control. She will go home with this regimen (glargine + humalog sliding scale tid), and understands that this will need to be adjusted as she discontinues her steroid medication. Ms. [Known lastname 5923] will receive a slow prednisone taper over one week, and follow up with her primary care physician and pulmonology. Medications on Admission: Albuterol / atrovent Protonix Risperidone 2 mg qd Clozapine 100 mg qAM, 400 mg qhs Fluoxetine 40 mg po qd Fluticasone Metformin / Glipizide NPH 4U [Hospital1 ] Home O2 Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever, pain. 2. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) Units Subcutaneous at bedtime. Disp:1 vial Refills:0 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Clozapine 100 mg Tablet Sig: One (1) Tablet PO twice a day: Take ONE tablet (100mg) in morning, and take FOUR tablets (400mg) in evening. (100 mg qAM, 400 mg qPM). Disp:150 Tablet(s) Refills:0 7. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One (1) inhaled Inhalation Q12H (every 12 hours). Disp:2 discs Refills:0 8. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:0 9. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Disp:180 Capsule(s) Refills:0 10. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). Disp:2 inhalers Refills:0 11. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:30 Patch 24HR(s) Refills:0 12. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: Five (5) ML PO Q6H (every 6 hours) as needed. 13. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. Disp:90 Capsule(s) Refills:0 14. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q6H (every 6 hours) as needed for cough. 15. Prednisone 10 mg Tablet Sig: As written Tablet PO once a day for 8 days: Take 4 tablets for two days (starting and including [4-17]), then 3 tablets for two day, then 2 tablets for two days, then 1 tablet for two days, then discontinue use. Disp:20 Tablet(s) Refills:0 16. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 2 doses. Disp:2 Capsule(s) Refills:0 17. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer treatment Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. Disp:50 nebulizer treatment Refills:0 18. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 19. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:30 Cap(s) Refills:0 20. Fluoxetine HCl 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). Disp:90 Capsule(s) Refills:0 21. Humalog 100 unit/mL Solution Sig: As written Subcutaneous three times a day: Take with meals according to written sliding scale. Disp:2 vials Refills:2 Discharge Disposition: Home With Service Facility: [Hospital3 6012] Discharge Diagnosis: Pneumonia, asthma, diabetes Discharge Condition: Good Discharge Instructions: Patient will need home O2, start 2L/min. Please follow up with your primary care physician, [Last Name (NamePattern4) ]. [First Name (STitle) ] [Name (STitle) 1395], early this week. You will likely have to reduce your insulin dose as you reduce your steroid medication (prednisone.) Followup Instructions: Please follow up with pulmonary service and your primary care physician. [Name10 (NameIs) ] is essential that you see your PCP this week.	[ "486", "51881", "2762", "3051", "311", "25000", "V5867" ]
Admission Date: [2198-2-13] Discharge Date: [2198-2-22] Date of Birth: [2119-4-4] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 4765] Chief Complaint: cardiopulmonary arrest Major Surgical or Invasive Procedure: pulmonary intubation central line placement History of Present Illness: 78yo male with history of COPD found by nursing home staff to be unresponsive. . The patient was in his usual state of health until yesterday when he went into atrial fibrillation with shortness of breath. He was treated with propanolol, digoxin, prednisone, and azithromycin but looked somewhat worse this morning. Shortly afterwards, he was found to be unresponsive. A code blue was called and CPR was initiated at 1035am. It is unclear if he was wearing is oxygen prior to this event. AED applied and delivered a shock at 1038am with CPR afterwards. EMS arrived at 1040am and CPR was stopped, patient with agonal breathing and bradycardic rhythm. Patient intubated, given epinephrine and atropine, and taken to the ambulance at 1044am, which transported him to [Hospital 8125] Hospital. He was thought to be down for about 10 minutes before ACLS was initiated. . On arrival to OSH, central line was placed and he was started on levophed and given amiodarone load and hydrocortisone 100mg IV. He was then transferred to [Hospital1 18] for further management. . On arrival to [Hospital1 18] ED, patient was intubated and sedated. Post-arrest team consulted and ArticSun protocol was initiated. Head CT demonstrated no acute process. Patient transferred to CCU for further management. Past Medical History: 1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: - CABG: - PERCUTANEOUS CORONARY INTERVENTIONS: - PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: -Atrial fibrillation (? if this is accurate) -COPD- on home oxygen -Pulmonary hypertension -CKD- stage III (baseline Cr 1.5-1.6) -GERD -Hypothyroidism -Psoriasis -Renal cysts -Hyperlipidemia -Hx of diverticulitis Social History: Widower, quit smoking cigarettes 6 years ago. Smoke rare tobacco pipe. Does not drink alcohol. Lives with a nephew. [Name (NI) ] ADLs. Has daughter [Name (NI) ] who is very involved in his care. Family History: Positive for COPD secondary to smoking and asbestos exposure. - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: VS: T=90.5 BP= 109/46 HR= 68 RR= 15 O2 sat=100% (intubated) GENERAL: Intubated, sedated. HEENT: Pupils 2+ and sluggish. NECK: Supple with JVP of 16 cm. CARDIAC: RRR, normal S1, S2. No m/r/g. LUNGS: Bilateral wheezes, scattered crackles, wheezes or rhonchi. ABDOMEN: Soft, non-distended. Cooling pads in place EXTREMITIES: 2+ edema bilaterally, cool to touch. SKIN: PULSES: Right DP/PT- dopplerable . Discharge exam: Vitals - Tm 97.9/97.9 BP: 99-122/60-69 P: 58-89 RR 20 SaO2 88-94% 4L NC Weight: 82 (82.9) . Tele: run or AF, RVR at 0600, lasting 10 minutes. Otherwise SR. . GENERAL: 78 yo M in no acute distress HEENT: mucous membs moist, JVD at 12 cm CHEST: faint crackles BB, tubular BS overall. CV: S1 S2 Normal in quality but distant. RRR ABD: soft, non-tender, non-distended, BS normoactive. EXT: wwp, 2+ pitting edema 1/2 up calf. NEURO: Memory impaired with short term events but clearer today. Speech clear. 4/5 strength in U/L extremities. SKIN: no rash, PIV OK PSYCH: A/O Pertinent Results: Labs on Admission: [2198-2-13] 12:57PM BLOOD WBC-8.6 RBC-5.15 Hgb-15.5 Hct-46.6 MCV-91 MCH-30.1 MCHC-33.2 RDW-13.3 Plt Ct-158 [2198-2-13] 12:57PM BLOOD Neuts-85.3* Lymphs-7.7* Monos-4.8 Eos-1.0 Baso-1.3 [2198-2-13] 12:57PM BLOOD PT-13.4* PTT-28.2 INR(PT)-1.2* [2198-2-13] 12:57PM BLOOD Glucose-129* UreaN-53* Creat-2.1* Na-137 K-4.6 Cl-109* HCO3-16* AnGap-17 [2198-2-13] 12:57PM BLOOD ALT-218* AST-231* AlkPhos-58 TotBili-1.2 [2198-2-13] 12:57PM BLOOD Albumin-2.8* Calcium-7.0* Phos-7.3* Mg-2.0 Cardiac Enzymes: [2198-2-13] 06:45PM BLOOD CK-MB-11* MB Indx-13.1* cTropnT-0.26* [2198-2-14] 12:52AM BLOOD CK-MB-13* MB Indx-15.9* cTropnT-0.23* [2198-2-14] 12:12PM BLOOD CK-MB-15* MB Indx-20.5* [2198-2-14] 06:34PM BLOOD CK-MB-16* MB Indx-22.9* [2198-2-15] 12:32AM BLOOD CK-MB-14* MB Indx-24.1* [2198-2-15] 05:28AM BLOOD CK-MB-13* MB Indx-24.1* TTE [2-13]: The left atrium is elongated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is severe global left ventricular hypokinesis (LVEF = 15-20 %). There is no ventricular septal defect. The right ventricular cavity is moderately dilated with severe global free wall hypokinesis. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate to severe pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Biventricular systolic dysfunction. Dilated RV. Mild AR. Mild TR. At least moderate to severe pulmonary artery systolic hypertension. CT Head [2-13]: IMPRESSION: 1. No acute intracranial process. 2. Region of encephalomalacia in the left frontal lobe, subjacent to the craniotomy site 3. Bilateral proptosis. LENI [2-14]: IMPRESSION: Normal Doppler evaluation of both lower extremities. No evidence of deep venous thrombosis. TTE [2-16]: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 40 %). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. . ECG [2198-2-21]: Sinus rhythm. Atrial ectopy. Left axis deviation. Right bundle-branch block with left anterior fascicular block. Compared to the previous tracing of the same day there is no significant change. Intervals Axes Rate PR QRS QT/QTc P QRS T 85 160 158 386/429 56 -107 56 . Labs at discharge: [2198-2-22] 06:45AM BLOOD WBC-13.3* RBC-5.64 Hgb-16.1 Hct-48.5 MCV-86 MCH-28.6 MCHC-33.2 RDW-14.2 Plt Ct-206 [2198-2-22] 06:45AM BLOOD Glucose-88 UreaN-60* Creat-1.8* Na-138 K-4.2 Cl-95* HCO3-34* AnGap-13 [2198-2-22] 06:45AM BLOOD Calcium-9.8 Phos-3.8 Mg-2.1 Brief Hospital Course: ASSESSMENT AND PLAN- 78yo male with history of COPD found to be unresponsive s/p cardiopulmonary arrest. . # Cardiopulmonary arrest- Unclear etiology at this time but thought [2-8] severe hypoxia at rehabilitation causing a possible VF or PEA event. Patient with no known coronary artery disease and extensive history of COPD. EKG on arrival to hospital demomstrated LAD, RBBB, STD V1-V4, TWI aVL, V4-V5. Previous EKG ([1-18]) revealed RBBB and left axis deviation. Other contributing factors are new medications (digoxin, propanolol) and bradycardic-induced VT/VF is also possible in this situation. Given history of COPD and pulmonary hypertension, cor pulmonale is a definite possibility. He had no further episodes of bradycardia or arrhythmia on telemetry and was aggressively diursed to prevent further severe hypoxia. At discharge, he would desat to the mid 80's on 4L NP. He underwent an artic sun protocol and his mental status has improved greatly over his hospital course. OT evaluated pt and felt he had mild short term memory defecits only. . # Acute on Chronic Systolic CHF with right heart failure: Pt was aggressively diuresed over his hospital stay and transitioned to PO lasix today. His dry weight is 180 pounds. IV furosemide has been added prn for use with weight gain more than 3 pounds in 1 day or 5 pounds in 3 days. Despite apparant dry weight, pt continues to have 2+ pitting edema [1-8] way up LE that is thought [2-8] right heart failure. TEDS stockings and leg elevation is recommended. Consider repeat ECHO as an outpt. Should also consider ACEi or [Last Name (un) ] for CHF once kidney function is improved as it has been held for a high creatinine here. . #Atrial fibrillation: He has had 3 spisodes of AF/RVR. This appears to be a new rhythm for him and he was started on warfarin 4mg daily. His tachycardia was treated wtih increasing doses of metoprolol. . # HLD- continue home statin . # COPD- patient with extensive smoking history and known COPD s/p recent exacerbation in [1-18]. His medical regimen was optimized with increased dose of Advair, slow prednisone taper and nebulizeer treatement. He currently has a non productive wet sounding cough. Azithromycin course has been completed. He will need continuing monitoring of his oxygen level, especially with ambulation. As his cardiac arrest is thought [2-8] hypoxia, treatment for his COPD and CHF is paramount. . # Hypothyroidism - continue home levothyroxine . # Acute on Chronic Kidney disease- baseline Cr 1.5-1.6. His Creatining high was 2.7 thought [2-8] ATN, now 1.8. . #Transaminitis. LFTs stably elevated. Likely [2-8] right heart failure. Medications on Admission: 1. Digoxin 0.125mg daily (recently initiated for episode of RVR a few days prior to presentation) 2. Propanolol 20mg [Hospital1 ] 3. Trazadone 25mg qHS 4. Liquid antacid 30ml PO q4h prn 5. Milk of magnesia- 30ml PO daily prn 6. Albuterol 2.5mg neb via INH q6hr prn SOB 7. Azithromycin 500mg daily x 3 days (day 1- [2-12]) 8. Levothyroxine 75mg daily 9. Calcitriol 0.25mg daily 10. Spiriva INH 1puff daily 11. Advair 250/50 1 puff q12hr 12. Simvastatin 10mg qHS 13. Guaifenisin q12hr 14. Lasix 40mg daily x 2 days (day 1- [2-12]) 15. Prednisone 10mg q8hr x 5 days (day 1- [2-12]) 16. MVI daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 3. Milk of Magnesia 400 mg/5 mL Suspension Sig: Ten (10) cc PO at bedtime as needed for constipation. 4. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) vial Inhalation Q6H (every 6 hours). 6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 7. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO once a day. 8. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 9. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 11. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for pain. 12. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day: Stop once prednisone is finished. 13. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): give pm dose at 1500. 14. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 15. prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 2 days. 16. prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day for 3 days: [2-26], 21 and 22. 17. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: [3-1], 24 and 25, then d/c. 18. furosemide in 0.9 % NaCl 100 mg/100 mL (1 mg/mL) Solution Sig: Forty (40) mg Intravenous twice a day as needed for for weight gain of more than 3 pounds in 1 day or 5 pounds in 3 days. 19. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: Then check INR and adjust dose. Discharge Disposition: Extended Care Facility: [Hospital 5503] [Hospital ] Hospital - [Location (un) 5503] Discharge Diagnosis: Acute on chronic systolic congestive heart failure Sudden cardiac death Chronic Obstructive pulmonary disease on home O2 Acute on Chronic kidney injury Atrial fibrillation with rapid ventricular response Pulmonary hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Your heart stopped and you needed to be shocked to restore a normal heart rhythm. You were transferred to [Hospital1 18] for treatment and was placed on a cooling protocol to help you recover. You were on a ventilator and medicines to keep your blood pressure up. We have given you medicine to get rid of extra fluid, we think that may be why you became so sick. You continued to have episodes of atrial fibrillation at a rapid rate and we have adjusted your medicines to keep your heart rate low and help your heart pump better. . We made the following changes to your medicines: 1. START taking furosemide 40 mg twice daily to prevent fluid from building up again. IV furosemide may be needed if your weight is increasing. You should wear TEDS stockings every day as well. 2. STOP taking digoxin and propanolol 3. INCREASE the Advair to 500/50 dosing 4. INCREASE Furosemide to 40 mg twice daily 5. TAPER prednisone as noted 6. START aspirin to prevent a stroke in the setting of atrial fibrillation 7. START omeprazole to protect your stomach from the prednisone. You can stop this once the prednisone is finished 8. START Metoprolol to lower your heart rate and help your heart pump better. 9. START warfarin to prevent a stroke because of your atrial fibrillation. You will need to have this monitored closely by your primary care doctor after you get out of rehabilitation. . Weigh yourself every day once you are home. Your goal weight is 180 pounds. Followup Instructions: Name: [Last Name (LF) 3321], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Address: [Doctor Last Name 37166], [Location (un) ],[Numeric Identifier ] Phone: [Telephone/Fax (1) 5315] Please schedule an appointment to see Dr. [Last Name (STitle) 3321*] within 2 weeks.	[ "5845", "2762", "4168", "4280", "40390", "496", "53081", "2449", "V1582", "42731" ]
Admission Date: [2141-10-11] Discharge Date: [2141-10-18] Date of Birth: [2079-1-26] Sex: M Service: C-MEDiCINE HISTORY OF PRESENT ILLNESS: The patient is a 63 year old male with type 1 diabetes mellitus times 36 years, coronary artery disease, status post coronary artery bypass graft in [2133], who presented to the Emergency Department with a two day history of nausea, vomiting and fingerstick glucose of greater than 500 by home monitor. Two days prior to admission, the patient was seen in Pain Clinic for worsening of chronic low back pain and was given a prescription for Percocet. Since that time, the patient experienced nausea and vomiting with six to seven episodes of nonbloody, nonbilious vomiting associated with mild shortness of breath and mild diffuse abdominal pain. The patient denied chest pain or diaphoresis (of note, the patient has never had chest pain). The patient noted at this time fingerstick glucose of greater than 500 by home monitor with associated polyuria, On review of systems, the patient denied any fever, chills, headaches, cough, diarrhea, bright red blood per rectum, melena, changes in medications other than starting Percocet, recent illness or sick contact. The patient called his primary care physician about his elevated fingerstick and was told to go to the Emergency Department. In the Emergency Department, the patient had temperature of 95.2, pulse 79, blood pressure 111/42, oxygen saturation 97% in room air, negative orthostatics. Initial laboratories were notable for a pH of 7.2, bicarbonate 11, anion gap of 31, and white blood cell count of 20.4. The patient was given two liters of normal saline and started on an insulin drip. Initial cardiac enzymes showed a CPK of 224 with troponin of 1.9, cycle #2 showed CPK 302 with troponin of 3.4. Electrocardiogram showed normal sinus rhythm with old Q waves in aVF, II and III with new 1.[Street Address(2) 2811] depression in V4 through V6. The patient was given Aspirin, Lopressor 5 mg intravenously and started on continuous infusion of Aggrestat and Heparin. PAST MEDICAL HISTORY: 1. Type 1 insulin dependent diabetes mellitus for 36 years with insulin pump began in [2138]. Diabetes mellitus complicated by neuropathy and retinopathy. 2. Coronary artery disease, status post silent myocardial infarction, and status post coronary artery bypass graft times four in [2131]. Persantine Sestamibi in [2141-8-16], showed an ejection fraction of 55%. Old inferior myocardial infarction and mild fixed inferior wall perfusion defect and mild inferior wall hypokinesis. 3. Status post abdominal aortic aneurysm repair in [2131]. 4. Status post aortopopliteal bypass in [2131]. 5. Hypertension. 6. Hypercholesterolemia. 7. History of gastrointestinal bleed in [2140]. 8. Chronic gastritis/colitis. 9. Chronic low back pain with L5 to S1 disc space narrowing. 10. Status post left eye cataract surgery in [2141-8-16]. MEDICATIONS ON ADMISSION: 1. Lopressor 25 mg p.o. b.i.d. 2. Insulin pump. 3. Lipitor 10 mg p.o. q.d. 4. Zestril 20 mg p.o. q.d. 5. Aspirin 81 mg p.o. q.d. 6. Neurontin 300 mg p.o. q.d. 7. Vioxx. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives at home with his wife, worked for the [Name (NI) 2318], now retired. Ninety pack year history of tobacco, quit 30 years ago. No alcohol. LABORATORY DATA: On admission. White blood cell count 20.4, hematocrit 32.9, platelets 206,000. Urinalysis greater than 1000 glucose, no white blood cells. Sodium 125, potassium 6.1, anion gap 33, creatinine 2.0, blood urea nitrogen 65, glucose 925. ALT 108, AST 102, amylase 33, total bilirubin 0.5, CPK #1 224, CPK #2 302, CPK #3 1557. Anemia workup - Iron 22, TIBC 200, ferritin 383, transferrin 154, reticulocyte count 0.9, Vitamin B12 1735, folate 8.5. Microbiology - Urine culture and blood cultures from admission showed no growth. Chest x-ray - no acute cardiopulmonary process. HOSPITAL COURSE: 1. Endocrine - The patient was admitted with diabetic ketoacidosis with peak anion gap of 37 and initial blood gas showing pH of 7.2 and bicarbonate of 14. The patient was given two liters normal saline in the Emergency Department and started on an insulin drip. Electrolytes were repleted as necessary. On hospital day two, the patient's anion gap decreased to 5.0 and the patient was restarted on his insulin pump. The patient's anion gap subsequently rose to 14 with blood glucose of 583 and the patient was restarted on an insulin drip. On testing of the insulin pump, it was noted that the battery pump had died. The battery was replaced and the day prior to discharge the insulin pump was restarted with good control of blood sugar. 2. Cardiovascular - The patient ruled out in non Q wave myocardial infarction with peak CPK of 2189 and electrocardiogram showing 1.[Street Address(2) 2811] depressions in V4 through V6. In the Emergency Department, the patient was given Aspirin and started on continuous infusion of Aggrestat and Heparin. The patient subsequently went for cardiac catheterization which found occlusion of saphenous vein graft to posterior descending artery with widely patent saphenous vein graft to diagonal and OM. The patient underwent percutaneous transluminal coronary angioplasty with stent placement of saphenous vein graft to posterior descending artery anastomotic site with no residual stenosis. After the procedure, the patient remained hemodynamically stable and without chest pain. 3. Hematology - On admission, the patient had a hematocrit of 32.0 which decreased to 28.0 with hydration. The patient was transfused one unit of packed red blood cells with increased hematocrit to 32.0. Anemia laboratories were sent which showed a low iron, low TIBC and high ferritin consistent with anemia of chronic disease. Vitamin B12 and folate levels were both within normal limits. The patient's hematocrit remained stable at 32.9 at the time of discharge. 4. Gastrointestinal - On admission, the patient had a transaminitis of unclear etiology. The patient's Lipitor was discontinued with resolution of transaminitis at the time of discharge with an AST of 34 and ALT of 60. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient is discharged to home with follow-up with primary care physician in one week. DISCHARGE DIAGNOSES: 1. Diabetic ketoacidosis. 2. Myocardial infarction, status post percutaneous transluminal coronary angioplasty with stent. 3. Anemia. MEDICATIONS ON DISCHARGE: 1. Aspirin 81 mg p.o. q.d. 2. Vitamin E 400 international units p.o. q.d. 3. Neurontin 300 mg p.o. q.h.s. 4. Atenolol 50 mg p.o. q.d. 5. Zestril 30 mg p.o. q.d. 6. Plavix 75 mg p.o. times 25 days. 7. Eye drops. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 12978], M.D. [MD Number(1) 12979] Dictated By:[Last Name (NamePattern1) 1297] MEDQUIST36 D: [2141-10-18] 16:13 T: [2141-10-21] 08:44 JOB#: [Job Number 19119]	[ "41071", "4280", "2859" ]
Admission Date: [2115-3-8] Discharge Date: [2088-4-12] Date of Birth: [2046-10-19] Sex: M Service: ADMISSION DIAGNOSIS: 1. Myocardial infarction. 2. Ventricular tachycardia. HISTORY OF THE PRESENT ILLNESS: The patient is a 68-year-old male who was taking his garbage out to the curb when he had the sudden onset of severe chest pain associated with diaphoresis and shortness of breath. It was described as similar to chest pain he had during a CHF exacerbation at [Hospital1 18] in [2112-7-14]. The patient contact[Name (NI) ] the EMS System who found him in ventricular tachycardia and he was cardioverted in the field to sinus and brought in and referred to an outside hospital. There, he was given aspirin, Lopresor, and transferred to [Hospital1 18]. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post MI in his 30s. 2. Status post cardiac catheterization with LAD stenting in [2112]. 3. Ejection fraction 23%. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Aspirin q.d. 2. Toprol XL 50 mg q.d. 3. Zantac 150 mg b.i.d. 4. Cozaar 25 mg q.d. 5. Lasix 20 mg q.d. 6. Coenzyme Q. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Heart rate 69, blood pressure 110/62, respirations 14, saturations 96%. General: The patient was in no acute distress. HEENT: EOMI. PERRL, anicteric. The throat was clear. Chest: There were coarse breath sounds bilaterally with right greater than left. Cardiovascular: Regular rate and rhythm without murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended, without masses or organomegaly. Extremities: Warm, noncyanotic, nonedematous times four. Neurological: Grossly intact. ADMISSION LABORATORY DATA: CBC 7.8/42.5/111. Chemistries: 136/4.0/97/28/12/1.2/288. CKs 154 with an MB of 14.9 and troponin of 9.4. The chest x-ray showed only mild atelectasis at the right lower lobe, no acute CHF picture. HOSPITAL COURSE: The patient was initially on a lidocaine drip for his ventricular tachycardia. He was admitted to the ICU for close monitoring. On hospital day number two, the patient was transferred down to the floor. At that time, he was stabilized in preparation for cardiac catheterization and possible ablation. The patient did rule in for an MI, although there were no ST elevations detected on the EKG. The Electrophysiology Service was consulted in regards to his episode of ventricular tachycardia. VT ablation versus ICD were discussed and both were possibilities. Catheterization was performed on [2115-3-11] which revealed an ejection fraction of 20%, as well as diffuse disease of a right dominant system. It was felt that the patient would benefit from revascularization. It was also noted that the patient had a very large abdominal aortic aneurysm greater than 7 cm at this time. The patient was recommended further delineation of CT angiography for sizing of the aorta as well as possible endostenting. The patient went for VT ablation later that day. The patient continued, however, to have an episode of ventricular tachycardia postprocedure. It was asymptomatic and identical to the episode described three days prior. Cardiothoracic Surgery was consulted for the patient's three vessel disease. Vascular Surgery was also consulted for his large AAA. The patient underwent CABG times three on [2115-3-13] with LIMA to diagonal artery, saphenous vein graft to LAD and acute marginal. Postoperatively, the patient was taken to CRSU for closer monitoring. It was complicated only by having to reopen to remove a lap pad. The patient was extubated on the evening of postoperative day number zero and tolerated this well. He continued to have recurrent ventricular tachycardia status post ablation and the patient remained A-paced using temporary pacing wires. The patient also had multiple episodes of NSVT and Amiodarone bolus was given as well as Amiodarone drip. The patient had recurrent prolonged runs of NSVT on postoperative day number two and the EP Service continued to follow. It was felt with the patient's multiple arrhythmias the patient would most likely benefit from implantation of an AICD. The patient was transitioned to p.o. Amiodarone which did not seem to be as effective as a drip. He was restarted on the Amiodarone drip. On postoperative day number three, the patient's chest tubes were removed and the insulin drip was weaned to off. Physical Therapy began seeing the patient. The patient did begin ambulating some. The patient's Cordis was changed over a wire to a lumen CVL on postoperative day number five. By postoperative day number five, the patient was seen to be stable overnight and the patient was transferred to the floor. On the floor, the patient had a largely unremarkable course and was preopped appropriately for the Vascular Service. The rest of this dictation summary will be completed either by Vascular Surgery or the other subsequent services to have this patient. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Last Name (NamePattern1) 5745] MEDQUIST36 D: [2115-3-26] 05:49 T: [2115-3-26] 18:04 JOB#: [Job Number 31997]	[ "41071", "4280", "5990", "41401", "412", "V4582" ]
Admission Date: [2123-3-9] Discharge Date: [2123-3-15] Date of Birth: [2042-11-1] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2123-3-10] - AVR (23mm [Company 1543] Mosaic Porcine) History of Present Illness: 80 year old female with history of hypertension and hyperlipidemia with known aortic stenosis for 6 months who presents for evaluation for aortic valve replacment. The patient is limited by dyspnea on exertion that has affected her daily activities. Past Medical History: Past Medical History: Hypertension Hyperlipidemia Aortic Stenosis History of falls Osteoporosis Past Surgical History: s/p Right hip replacement S/p left hip plate and screw s/p THS and BSO 30 years ago s/p Tonsillectomy Social History: Family History:NC Race: Causasian Last Dental Exam: Full dentures Lives with: Senior living center (estranged from husband; has 2 grown sons) Occupation: none Tobacco: denies ETOH: denies Family History: None Physical Exam: Pulse: 89 Resp: 16 O2 sat: 97 B/P Right: 136/75 Left: 128/66 Height:5'0" Weight:138 lbs General: well-developed elderly female in no acute distress Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur 4/6 systolic Abdomen: Soft [X] non-distended [] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema Varicosities: None [X] Neuro: Grossly intact [X] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right/Left: transmitted murmur Pertinent Results: [2123-3-10] ECHO Pre Bypass: The left atrium is mildly dilated and elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic root, aortic arch, and the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. No mitral regurgitation is seen. Post Bypass: Patient is in sinus rhythm with pac's on phenylepherine infusion. Preserved biventricular function LVEF >55%. There is a bioprosthetic valve in the aortic position (#23 mosaic per surgeons) without AI or perivalvular leaks. Peak gradient 7 mm Hg, mean 6 mm Hg on aortic valve. Aortic contours intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. [2123-3-9] Cardiac Catheterization Clean coronaries Brief Hospital Course: Ms. [Known lastname ] was admitted to the [Hospital1 18] on [2123-3-9] for a cardiac catheterization in preparation for an aortic valve replacement. Her cardiac catheterization revealed clean coronaries and severe aortic stenosis. She was worked-up in the usual preoperative manner. On [2123-3-10] she was talken to the operating room where she underwent an aortic valve replacement with a bioprosthesis. Please see operative note for details. Postoperatively she wastaken to the intensive care unit for invasive hemodynamic monitoring. Over the next 24 hours, she awoke neurologically intact and was extubated. She was transferred to the stepdown unit on POD#2. She was started on betablockade and diuresed toward her pre-operative weight. Her chest tubes and temporary pacing wires were removed per protocol. She was evaluated by physical therapy for strength and conditioning and rehab was recommended. She was cleared for discharge on POD#5 by Dr. [Last Name (STitle) ]. Medications on Admission: Fosamax Lipitor 10mg qd Lisinopril 2mg qd Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Until at pre-op weight of 59kg. Then chnage to home diuretic HCTZ. 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily): while on lasix. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. Discharge Disposition: Extended Care Facility: [Hospital3 13990] Health Care Center Discharge Diagnosis: AS s/p AVR Hypertension Hyperlipidemia History of falls Osteoporosis Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call to schedule appointments Surgeon Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Primary Care Dr.[Last Name (STitle) 15942] in [1-30] weeks Cardiologist Dr. [Last Name (STitle) 10543] in [1-30] weeks Completed by:[2123-3-15]	[ "4241", "4019", "2724", "2875" ]
Admission Date: [2118-3-17] Discharge Date: [2118-3-31] Date of Birth: [2056-4-15] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 13256] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: EDG [Last Name (un) ] placement Tracheal intubation TIPS procedure CPR Transfusion of blood products History of Present Illness: 61 YOM with history fo HCV genotype 2 cirrhosis complicated by mild encephalopathy and varices s/p EGD with banding 3 weeks ago presets to ED with CC of melena. Patient reports that over the last 3-4 days he has had increasing dark stools. This morning he had some mild epigastric discomfort and rpesented to the ED for eval. No hematemsis, no BRBPR. No Dyspnea. + Light heasded ness this afternoon. . With regards to his HCV cirrhosis, He has remote IVDU history int he 60s' as well as a period of heavy drinking in the [2096]'s. In [2115] he had a major Gi bleed requiring banding. In [2107] he apprently bled while in [State 622]. . He was seen by GI in [Month (only) ] who scheduled him for EGD on [2118-2-25]. He underwent the procedure with visualization of grade 2 varices. Was banded and discharge din stable condition. . In the ED he underwent NG lavage wtih 100cc of BRB returned but nothign further. He had no other episodes of bleeding and was HD stable. He was transferred to te MICU in stable condition with plans for EGD in the evening or AM. . VS prior to transfer VS HR 90 BP 135/70 T 97.6 RR 18 Sattign 100% RA . A Loquacious gentleman, nn arrival to the MICU, he is stable with no complaints or distress. Past Medical History: Chronic hepatitis C, genotype 2. Cirrhosis. Portal hypertension with a history of esophageal varices. Tonsillectomy at age ten. Social History: Former smoker, quit 25 years ago. Occasional EtOH once every other week but drank [9-23] drinks/night in late [2096]/early [2106] for [3-18] yrs. IV drug use in late [2066]. Works in a Nucor Plant. Travels in US by RV. Family History: Denies FH of diabetes, CAD, liver disease, liver cancer Physical Exam: ADMISSION EXAM: VS: T 98, HR 70, BP 116/65, RR 19, POx 97%RA General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Abdominal: Tender: epigastric, splenomegaly Extremities: Right lower extremity edema: Trace, Left lower extremity edema: Trace Skin: Not assessed Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed . DISCHARGE EXAM VS: 97.6 108/64 74 20 96% RA I/O 1280/800 BM x 2 GENERAL: Comfortable, appropriate. NECK: Supple with JVP 6 cm CARDIAC: RRR, S1 S2 without murmurs, rubs or gallops. LUNGS: Resp were unlabored. crackles bilaterally to 1/3 up back ABDOMEN: Distended but Soft, non-tender to palpation. EXTREMITIES: Warm and well perfused. 2+ [Location (un) ] bilaterally to knees. NEURO: CN II-XII intact grossly, strength 5/5 on L [5-19] on R Pertinent Results: ADMISSION LABS: [2118-3-17] 10:45PM BLOOD WBC-4.9 RBC-3.45* Hgb-11.1* Hct-31.2* MCV-90 MCH-32.1* MCHC-35.5* RDW-15.3 Plt Ct-94* [2118-3-17] 10:45PM BLOOD Neuts-73.7* Lymphs-19.4 Monos-4.0 Eos-2.3 Baso-0.6 [2118-3-17] 10:45PM BLOOD PT-14.2* PTT-33.8 INR(PT)-1.3* [2118-3-17] 10:45PM BLOOD Glucose-122* UreaN-21* Creat-0.7 Na-134 K-5.7* Cl-104 HCO3-24 AnGap-12 [2118-3-17] 10:45PM BLOOD ALT-151* AST-267* AlkPhos-68 TotBili-1.3 [2118-3-17] 10:45PM BLOOD Albumin-3.3* Calcium-9.0 Phos-3.0 Mg-2.0 [2118-3-17] 10:50PM BLOOD Lactate-1.7 [2118-3-18] 01:08PM BLOOD Glucose-201* Lactate-3.8* K-4.2 [2118-3-18] 03:15PM BLOOD Glucose-112* Lactate-1.6 Na-139 K-4.1 Cl-110* . DISCHARGE LABS [2118-3-31] 04:21AM BLOOD WBC-4.5 RBC-3.26* Hgb-10.5* Hct-30.3* MCV-93 MCH-32.2* MCHC-34.7 RDW-18.5* Plt Ct-104* [2118-3-31] 04:21AM BLOOD PT-20.6* PTT-35.9 INR(PT)-2.0* [2118-3-31] 04:21AM BLOOD Glucose-100 UreaN-10 Creat-0.7 Na-136 K-4.0 Cl-109* HCO3-24 AnGap-7* [2118-3-31] 04:21AM BLOOD ALT-99* AST-202* LD(LDH)-251* AlkPhos-210* TotBili-19.9* [2118-3-31] 04:21AM BLOOD Albumin-2.4* Calcium-7.8* Phos-2.3* Mg-2.1 . CXR [2118-3-18]: Endotracheal tube is seen terminating at least 2.5 cm from the carina while neck is in flexion. Right-sided catheter sheath is seen entering the right IJ and terminating within the superior vena cava. Proximal end of this sheath is kinked. . [2118-3-24] As compared to the previous radiograph, there is no relevant change. The monitoring and support devices are in constant position. Constant size of the cardiac silhouette. Moderate pulmonary edema with bilateral areas of pleural effusions and subsequent areas of atelectasis. Interval appearance of focal parenchymal opacity suggesting pneumonia. . AXR [2118-3-18]: Cross-table lateral and supine frontal views of the abdomen are obtained. Note is made of Sengstaken-[Last Name (un) ] tube, with esophageal and gastric balloons inflated. There is large gaseous distention of the colon and small bowel in a pattern suggesting ileus. There is no evidence of pneumoperitoneum on the cross-table lateral image. . CT head [2118-3-23] IMPRESSION: Multifocal hypodensities in the right frontal, left occipital, and cerebellar regions concerning for subacute infarction given the clinical history. If there is no contraindication, MRI of the brain is recommended for further characterization. . MRI/MRA head and neck There are bilateral multiple foci of restricted diffusion, predominantly in the cortex of the frontal and parietal lobes. There is also some involvement of the temporal lobes. No abnormality is noted in the hippocampi or the basal ganglion. Focal restricted diffusion is also seen in the right occipital lobe which could represent an acute infarction. Intracranial flow voids are maintained. MRA of the circle of [Location (un) 431] demonstrates the proximal vasculature to be patent. The study is technically limited for evaluation of the distal branches. No aneurysm is noted. There is a hypoplastic left A1. The left distal vertebral artery is not visualized and may terminate as a PICA. MRA of the neck demonstrates mild plaquing at bilateral ICAs. No high-grade stenosis is seen. Both vertebral arteries are patent. The origins of the vertebral arteries are not well visualized due to technique. The left distal vertebral artery is hypoplastic. There is a probable lipoma in the right suboccipital region. IMPRESSION: Hypoxic injury in the bilateral cerebral cortices. Acute ischemia in the right occipital lobe. No vascular abnormalities. . CT Abdomen Pelvis [2118-3-23] 1. TIPS is patent. 2. Thrombosed right posterior portal vein branch is seen secondary to covering of the origin of that vessel by the stent. 3. Subacute/chronic SMV thrombosis. 4. Liver cirrhosis. 5. Splenomegaly. 6. Gallbladder sludge and stones are seen. 7. Bilateral small pleural effusion with secondary atelectases . RUQ US 1. Patent TIPS shunt with normal-appearing flow and pulse Doppler waveforms. No evidence of portal vein thrombosis. 2. Cirrhotic liver with splenomegaly. 3. Gallstones but no bile duct dilatation. . TTE The left atrium is elongated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . MICROBIOLOGY blood cultures negative [3-17], [3-19], [3-20] Urine culture negative [3-19], [3-20] GRAM STAIN (Final [2118-3-20]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [2118-3-22]): RARE GROWTH Commensal Respiratory Flora. Brief Hospital Course: 61 YOM with history of HCV cirrhosis complicated by 2 prior variceal bleeds and intermittent hepatic encephalopathy, s/p banding of known grade 2 varices on [2118-2-25] presenting on [2118-3-17] with melena and NG lavage demonstrating BRB. . # GI bleed: Upper source. Concern for sentinal bleed from varix vs arterial bleed from ulcer in the setting of recent banding. Admission Hct was 31 from baseline 39. Pt was intubated for airway protection after active bleeding was found on EGD on [3-18], during the second attempt following intubation he became hypotensive and had a PEA arrest. Pt was resuscitated and received massive transfusion (10 units PRBC, 4 units FFP, 1 bag platelets, 2 bags cryoprecipitate); [Last Name (un) ] was placed and emergent TIPS was performed, with gradient reduction from 11-->4 mm Hg. The balloons were deflated on [3-19] and the [Last Name (un) ] was removed on [3-21]. Pt had melenic stool but no further evidence of GI bleed following TIPS. Octreotide drip was continued from [Date range (1) 71218]. Patient was transferred to the floor where HCT remained stable and stools were noted to be guaiac negative. He was initially given an IV PPI and was transitioned to PO PPI prior to discharge. His home lasix restarted at 40 mg daily however with instructions to hold this medication if systolic blood pressure is less than 90. Nadolol was started at a low dose in place of his home propanolol . # Possible aspiration pneumonia: Pt was intubated in the setting of EGD on [3-18] (as above). Developed fever to 101.2, GNR on sputum gram stain; 8 day course of vanc/zosyn was started on [3-20]. WBC and fever curve trended down [3-21], [3-22], sputum culture grew only commensal flora, CXR improved following diuresis [3-21]. Pt was successfully extubated morning of [3-22]. He remained afebrile without signs of infection throughout the remainder of his hospitalization. . # Abnormal LFTs: Pt has had transaminitis throughout admission (ALT/AST 151/267 on admission, discriminant function 16). Transaminases peaked [3-20] with ALT/AST 226/348, trending down since. Tbili trending up after TIPS, from 1.3 on admission to 14.3 (11.8 direct) on [3-22]. TIPS patent per abdominal CT [3-23] and RUQ US on [3-29]. There was also no evidence of bilary dilitation on US to suggest obstructive etiology. Fracination demonstrated a direct hyperbilirubinemia making hemolysis unlikely. Possible etiology for the elevation includes relative liver hypoperfusion in ther setting of TIPS placement. Bili was noted to trend downward and was 19.9 at discharge from a peak value of 22.6. Patient will need a repeat EGD in 1 month. . # Peripheral/pulmonary edema- Patient received a large amount of volume in the setting of massive transfusion. He was markedly volume overloaded on exam. He was initially diuresed in the ICU with 10 mg IV lasix boluses. Diuresis on the floor was complicated by hypotensions. Patient was still net negative for length of stay at the time of discharge. His weight was 214Ibs from a baseline of 207.6 lbs. It was felt given his recent bleed initiation of nadolol was more important than diursis as his respiratory status was stable. His home lasix was restarted at the time of discharge as above. The patient will follow-up with Dr. [Last Name (STitle) ] regarding restarting this medication. . # HCV Cirrhosis: Was on lactulose intermittently and propranolol at home, has never been on rifaximin or SBP prophylaxis at home. On vanc/zosyn as inpatient. Developed encephalopathy s/p TIPS (and PEA arrest) which improved with lactulose and rifaximin. He will likely require evaluation for possible liver transplant as an outpatient. . # Stroke: CT head was performed on [3-22] to look for watershed infarcts after PEA arrest given L>R arm and leg strength, slow recovery of mental status. Imaging revealed multifocal hypodensities concerning for subacute infarcts R frontal, L occipital, bilateral cerebella. TTE was performed to look for embolic source and showed no evidence of vegitation or septal defects. Patient underwent MRI/MRA which demonstrated bilateral multiple foci of restricted diffusion, predominantly in the cortex of the frontal, parietal, and occipital lobes, in addition to ,mild plaquing of bilateral ICAs but with other vessels patent. He was evaluated by neurology who felt presentation was most consistent embolic events in the setting of PEA arrest. They did not recommend anti-coagulation as the patient had a recent severe [Hospital1 ] bleed. Patient will follow-up with neurology as an outpatient. . TRANSITIONAL ISSUES - Patient will follow-up at the liver clinic and with neurology - Patient possibly require evaluation for liver transplant - Patient will discuss restarting diuretics with Dr. [Last Name (STitle) ] - Patient was full code throughout this admission Medications on Admission: 1. Lasix 40 mg p.o. daily. 2. Hydromorphone 2 mg p.r.n. pain. 3. Lactulose 10 gram/15 mL solution titrating to one to two bowel movements a day. 4. Propranolol 10 mg p.o. three times a day. 5. Omeprazole Discharge Medications: 1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 3. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for sob/whz/bronchospasm. 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: please hold for SBP < 90. Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Primary Diagnosis Upper GI bleed [Hospital ] Hospital Acquired Pneumonia . Secondary diagnosis Chronic hepatitis C cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname ], It was a pleasure participating in your care while you were admitted to [Hospital1 69]. As you know you were admitted because you were having bleeding from one of the vessels in your esophagus. You had a large amount of bleeding and required intubation to protect your airway. You also developed a pneumonia for which you were treated with anti-biotics. You experienced some weakness and a MRI of your head showed that you had a small stroke. You were seen by the neurologists who did not feel that there was anyhting that needed to be done right now. Our physical therapist did feel you would benefit from a stay at a rehab facility and therefore you were discharged to rehab. We made the following changes to your medications 1. STOP lasix 40 mg dialy (you should discuess restarting this medication with Dr. [Last Name (STitle) ] 2. START nadolol 20 mg daily 3. STOP propanolol 4. START tramadol as needed for pain You should continue to take all other medications as instructed. Please call with any questions or concerns Followup Instructions: Department: LIVER CENTER When: THURSDAY [2118-4-7] at 11:15 AM With: [Name6 (MD) ] [Last Name (NamePattern4) 2424], MD [Telephone/Fax (1) 2422] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: NEUROLOGY When: MONDAY [2118-5-23] at 2:30 PM With: [First Name8 (NamePattern2) ] [Name8 (MD) 162], MD [Telephone/Fax (1) 2574] Building: [Hospital6 29] [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "2760", "5070", "51881", "2851", "V1582" ]
Admission Date: [2194-7-26] Discharge Date: [2194-7-27] Date of Birth: [2167-7-22] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 8961] Chief Complaint: seizure and hypoglycemia Major Surgical or Invasive Procedure: None. History of Present Illness: This is a 27 yo M with a past medical history significant for ESRD secondary to HTN on HD, beginning in [2192]. He reports one previous incident of seizure also in the setting of a hypoglycemic episode following HD. He presents today with hypoglycemia following a witnessed seizure in his cousin's car after HD. HD today was uncomplicated, though he states that more fluid was removed and faster than usual (3L in 2.5 hours). He denies any recent illnesses or ingestions. . He states that before these seizures he experiences an aura in which he "blacks out" and cannot see anything. He frequently has these auras during or immediately after dialysis, but without the seizures. He receives dialysis on Tues/Thurs/Sat at [Location (un) 105764]. Kidney Center. . In the ED, his neuro exam was felt to be nonfocal. He was given 1 amp of D50 x 1 to which he responded from a FS of 57 to a FS of 120. Following eating, however, his glucose began to drift downwards once again to a nadir in the 60's, for which he was given another amp of D50. He is admitted to the MICU for frequent blood glucose monitoring and to initiate further work-up for hypoglycemia in a non-diabetic. Past Medical History: HTN - diagnosed [2191] (?"small stroke" per [State ] OSH) ESRD - diagnosed [2191], felt [2-15] HTN (dx [2191] also). pt on dialysis since [12/2192] (kidney center, comme ave, [Telephone/Fax (1) ], nephrologist [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], on transplant list, s/p failed R AVF, with L AVF placed [10/2192], usual dialysis day Tu/Th/Sa). seizure presumed to be [2-15] hypoglycemia [1-20] (seen by neuro, no intervention) Seizures as noted above Social History: worked in construction, now on disability, denies tobbacco, alcohol, or IVDU. Family History: denies family history of premature cad, dm, htn, or seizures. Father has psoriasis. Grandmother died of cancer, type unknown. Physical Exam: Vitals - T 98.4 BP 153/102 HR 76 RR 18 99%RA GENERAL: laying in bed, NAD SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, MMM, good dentition, supple neck, no LAD, no JVD CARDIAC: regular rate. III/VI holosystolic murmur heard at the LUSB, radiating up to clavicle on left, but not to carotids. Breast: Left breast with subareolar mass, about 2x2cm, tender to palpation, no discharge, no skin changes LUNG: CTAB no w/r/r ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally. thrill over fistula L arm. NEURO: CN II-XII intact, strength 5/5 bilaterally, sensation to light touch in tact bilaterally. A&Ox3. Normal speech, prosidy, cerebellar function. Normal gait. Pertinent Results: Admission Labs: WBC-8.5 Hgb-14.3 Hct-44.8 MCV-94 MCH-29.9 Plt Ct-204 Neuts-67.2 Lymphs-25.6 Monos-4.8 Eos-1.9 Baso-0.6 UreaN-28* Creat-16.0# Na-143 K-3.9 Cl-89 HCO3-17* ALT-19 AST-31 AlkPhos-81 TotBili-0.4 Lipase-59 Calcium-9.7 Phos-5.5* Mg-3.1* [2194-7-27] 02:54AM BLOOD Cortsol-18.0 [2194-7-27] 04:31AM BLOOD Cortsol-32.1* . Studies: [2194-7-26] CT FINDINGS: Non-contrast head CT. There is no intra-axial or extra-axial hemorrhage, mass effect, shift of normally midline structures, or evidence of major vascular territorial infarction. [Doctor Last Name ]-white matter differentiation is preserved. There is no hydrocephalus. Paranasal sinuses are well aerated as are the mastoid air cells and middle ear cavities. The surrounding calvarium and soft tissue structures are unremarkable. IMPRESSION: No acute intracranial process. Brief Hospital Course: 27 yo M with history of ESRD on HD with history of seizures in the setting of hypoglycemia, who presents with hypoglycemia after a witnessed seizure. . 1. Hypoglycemia: Unclear etiology, however he is clearly symptomatic given seizure in this setting. Etiologies in a non-diabetic include insulinoma, adrenal insufficiency, and malignancy. Adrenal insufficiency is unlikely given high blood pressures, cosyntropin stim test performed with good response. His blood sugars remained entirely normal with q1 hour fingerstick monitoring. - c peptide checked and pending - ultrasound of breast mass, as outpt. . 2. Seizure: No further seizures following admission and thought to have occurred in the setting of hypovolemia and hypoglycemia. CT head was negative for bleed and mass. As below, he was advised to eat prior to each dialysis session. Hypoglycemia evaluation pending as above. . 3. AG Metabolic Acidosis: Likely uremia exacerbated by s/p seizure. Lactate normal at 1.3. . 4. ESRD: Continue HD as outpatient. Patient advised to make sure to eat prior to hemodialysis. . 5. HTN: Home antihypertensives continued. . 6. FEN: Low Na diet. . 7. PPx: Heparin sc for DVT prophylaxis Medications on Admission: Labetalol 300 mg PO BID Felodipine SR 2.5 mg PO QAM Catapres 2 patch QWeek Lisinopril 5 mg PO QD Calcium Acetate 667 mg capsules, 2 PO TID Acetaminophen prn Discharge Medications: 1. Labetalol 200 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:90 Tablet(s) Refills:2 5. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Catapres-TTS-2 0.2 mg/24 hr Patch Weekly Sig: One (1) Transdermal once a week. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Hypoglycemia Seizure Hypertension End-stage renal disease on hemodialysis Discharge Condition: Stable, normoglycemic. Discharge Instructions: You were admitted to the hospital because of a seizure associated with a low blood sugar after hemodialysis. You were monitored in the medical ICU with frequent blood sugar checks, all of which were normal. You should always eat something when you have hemodialysis. Also, you should schedule an appointment with your physician, [Last Name (NamePattern4) ]. [Last Name (STitle) ], to follow-up on the results of the tests that were done while you were in the hospital. You should also make an appointment to have the mass in your breast further evaluated. You should continue to take your home medications, especially your phosphate binders (Calcium acetate or Phoslo) as your phosphate level is high. In addition, you should also take the phosphate binder Sevelamer or Renagel. If you have any additional seizures, low blood sugar, or other concerning symptoms, you should contact your physician or return to the hospital. Followup Instructions: You should schedule an appointment to see Dr. [Last Name (STitle) ] within the next week or two. You should make an appointment to have the mass in your breast evaluated as you were instructed when you were seen in the Emergency Department a few days ago. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 8965]	[ "40391", "2762" ]
Admission Date: [2115-8-9] Discharge Date: [2115-8-19] Date of Birth: [2048-9-18] Sex: M Service: Thoracic Surgery HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old with a history of acute myeloplastic leukemia diagnosed in [2114-10-1] who was treated with Ara-C but complicated by infection and myelosuppression. The patient was readmitted on [8-9] for an acute myeloplastic leukemia relapse. The patient has been complaining of right pleuritic chest pain, cough, and fevers. A chest CAT scan was done on [8-10] which revealed a right upper lobe consolidation. A biopsy of this consolidation showed that it was a mucoid mycosis, and consequently Thoracic Surgery was consulted on [8-14] to evaluate the need to resect the right upper lobe. The patient was started on AmBisome and Levaquin while he was admitted on the Oncology Service. PAST MEDICAL HISTORY: (His past medical history was significant for) 1. Questionable aspergillus pneumonia in [2115-11-1] which was treated with four weeks of AmBisome. 2. He also has a history of hypertension. 3. Recurrent acute myelogenous leukemia. 4. Gout. 5. Prostate cancer 10 years ago. SOCIAL HISTORY: The patient has a social history significant for cigarette smoking; although he quit. He also has a history of asbestos exposure four years ago and possible tuberculosis exposure since he was working in a tuberculosis institute. FAMILY HISTORY: His family history is significant for father and brother both having prostate cancer. ALLERGIES: The patient is allergic to PENICILLIN, DEMEROL, ASPIRIN. MEDICATIONS ON ADMISSION: He was admitted on Ambien, allopurinol, hydroxyurea, colchicine, Paxil, multivitamin, Tylenol, Ativan. The patient was placed on Levaquin and AmBisome by the Oncology Service on admission. PHYSICAL EXAMINATION ON PRESENTATION: On examination, the patient's temperature was 100.6, pulse was 112, respirations were 20, blood pressure was 140/80, 98% on 35% shovel mask. He saturated 88% on room air. His head, eyes, ears, nose, and throat examination was significant for lymphadenopathy in the cervical and submandibular region. His sclerae were anicteric. No evidence of jugular venous distention or carotid bruits. His pupils were equally round and reactive. Chest examination revealed the patient was noted to right inspiratory and expiratory wheezes with rales. His left chest was clear to auscultation. He was also noted to have palpable axillary lymph nodes including one that was significantly enlarged in the left axilla. His heart was regular rate and rhythm. First heart sound and second heart sound were present. No murmurs or gallops were appreciated. The abdomen was soft and nontender, though moderately protuberant. Extremities were warm with palpable distal pulses. No evidence of edema. Neurologically, he was alert and oriented, and no focal neurologic deficits were noted. PERTINENT LABORATORY DATA ON PRESENTATION: His white blood cell count was 36.1, with a hematocrit of 25.7, and platelets were 44. His electrolytes revealed sodium was 141, potassium was 4.4, chloride was 106, bicarbonate was 27, blood urea nitrogen was 20, creatinine was 1, and blood glucose was 110. RADIOLOGY/IMAGING: He had a chest CT which revealed a right upper lobe opacity measuring 6.7 cm X 8.7 cm; which was increased from his previous CT scan of 4.1 cm X 4.5 cm. There was extensive mediastinal and hilar lymphadenopathy. A CAT scan of his abdomen also showed right basilar nodules in the right base of his lung measuring approximately 8 mm. There was also lymphadenopathy at the porta hepatis and the retroperitoneum. HOSPITAL COURSE: He has been receiving chemotherapy during his admission to the Oncology Service. A biopsy of his left axilla lymph node showed that there was no evidence of disseminated fungal infection. Therefore, discussion with the patient as well as his family was started to determine whether or not they would wish to have this consolidation in his right upper lobe removed. A discussion was also carried in conjunction with the Oncology Service. After much discussion, the decision was made to go ahead with this thoracotomy and resection of his right upper lobe. The patient was then consented for this procedure and was taken to the operating room on [2115-8-16]. Intraoperatively, an initial attempt to remove the patient's right upper lobe appeared to be difficult, and the patient had a significant amount of blood loss intraoperatively. He lost approximately 3 liters of blood, requiring a 5-liter transfusion. The patient also received multiple units of platelets. Moreover, it was determined that it was necessary intraoperatively to perform a complete right pneumonectomy. Postoperatively, the patient was transferred to the Recovery Unit in stable condition, though remained intubated. The next morning the patient was transferred to the Cardiac Surgery Recovery Unit where it became extremely difficult to ventilate the patient. Initially, the patient's ventilator was placed on pressure control ventilation, trying to control his airway pressures so that the stump of the side where the pneumonectomy was performed would not be blown out. However, despite a pressure of 30 with a positive end-expiratory pressure of 5, leaving a plateau pressure of around 35, it was very difficult to ventilate the patient. The patient's PCO2 increased precipitously to the 90s. At this point, the patient was then switched over to assist control which temporarily improved his ventilation. However, the patient's creatinine increased from 1 to 1.9. Moreover, his blood pressure began to drop, requiring the addition of Neo-Synephrine to maintain an adequate mean arterial pressure. However, the patient's respiratory status continued to deteriorate despite the fact that we ventilated him. His oxygenation then became a problem requiring high FIO2 of up 100%. We attempted to wean this down slightly to 80%; however, the patient did not tolerate this and required going back to 100%. Next, his blood pressure became an issue again requiring the addition of a second [Doctor Last Name 360]; we added Levophed to maintain his blood pressure. Fluid boluses did not appear to help his blood pressure or his perfusion. The patient became progressively acidotic. Moreover, his renal function also deteriorated with his creatinine increasing to 3.7 the next morning, which quickly increased to over 5 the same afternoon. In the morning of [8-19], the patient's systolic blood pressure dropped to the 70s despite very high doses of Neo-Synephrine and Levophed. Moreover, his kidney stopped making urine, and his oxygenation became a main issue since the patient was unable to get rid of any of the fluids that he had been receiving. His oxygen saturation dropped into the 80s despite being on 100% FIO2. At this point, the family was then contact[Name (NI) ] as well as the attending to explain that the patient was not doing well and may not survive. At this point, the family decided to make the patient do not resuscitate; however, they did not withdraw care. Nevertheless; at 7:55 a.m. on [2115-8-19], the patient's blood pressure continued to drop, followed by his heart rate, and finally he became asystolic and expired at exactly 7:55 a.m. on [2115-8-19]. CONDITION AT DISCHARGE: The patient expired. DISCHARGE STATUS: The patient expired. DISCHARGE DIAGNOSES: 1. Disseminated acute myelogenous leukemia. 2. Status post right pneumonectomy. 3. Multiple organ failure. [Known firstname 177] [Last Name (NamePattern4) 178], M.D. [MD Number(1) 179] Dictated By:[Name8 (MD) 20292] MEDQUIST36 D: [2115-8-19] 08:31 T: [2115-8-24] 21:24 JOB#: [Job Number 21208]	[ "5849", "V1582" ]
Admission Date: [2134-5-16] Discharge Date: [2134-6-1] Date of Birth: [2068-12-28] Sex: M Service: MEDICINE Allergies: Penicillins / Shellfish Attending:[First Name3 (LF) 594] Chief Complaint: leg swelling, DOE Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy Colonoscopy Tracheostomy PICC line placement Arterial line placement Trauma line placement History of Present Illness: 65yo M with a PMH of afib on coumadin, diabetes, HIV, HTN and CHF BIBA after calling 911 for several months of increasing LE edema x2months and concerns that he was not doing well at home w/ lightheadness, DOEx4days, disorientation. Upon further questioning he does note DOE x4days and several weeks of dark malodorous loose stool with intermittent BRBPR in the toilet bowl. Does recall some mild abdominal pain 4 days ago that has resolved. States he has had a colonoscopy and EGD previously at [Hospital1 2025], does not know why, states he does not remember being told anything was wrong. Denies ETOH use, occasional Aleve use. Of note, he states his VNA stopped checking his blood levels about 1 month ago. He continued to take his coumadin as previously instructed (1.5pills/day, unknown dose). Denies F/C/CP/SOB at rest/N/V/hematemesis, diaphoresis. Noted LE edema has worsened over the last 2 days. In the ED, initial VS were Temp 98 HR 148 BP 98/58 RR 15 sat 100% 3LNC. He was noted to be pale appearing and tachycardic with guaiac positive black stool on rectal exam. Labs were significant for a hct of 12.8 (last noted to be 37.4 in [2121]), hgb 3.6, INR 14.2, plts 216, Cr 2.7 (last noted to be 1.2 in [2121]) with a BUN of 73, Bicarb 20, glucose 216, trop 0.07, lactate 1.3, LFTs normal, Alb 3.6. Repeat Hct 1.5hrs later was stable at 12.4 prior to PRBC transfusions. Blood cultures were sent. ECG showed afib with RVR (HR120s) and poor baseline. CXR showed mild cardiomegaly, clear lungs without acute process. Patient received 1 liter NS with improvement in his SBP from 80s to 100s and HR from 140s to 120s. Patient was ordered for 4PRBCs ad 3 units FFP, however only the first unit of FFP had been completed prior to transfer. Patient was receiving the second unit of FFP on arrival and had not received any PRBCs. He received pantoprazole 40mg IV and vitamin K 10mg IV. GI was consulted and plans to do EGD and colonoscopy early this week, when hct is >25 and INR is therapeutic. Admitted with a presumed diagnosis of subacute lower GI bleed. VS on transfer HR 120-130 BP94/60 rr16 100% RA. On arrival to the MICU, he is comfortable lying in bed without chest pain, SOB, lightheadedness. C/o trembling. Past Medical History: afib on coumadin (CHADS 3, denies h/o strokes) diabetes on oral hypoglycemics HTN HL CHF CAD s/p MI 15yrs ago (denies PCI or CABG) CKD (unknown baseline) HIV, pt reports undetectable viral load s/p right hernia repair Social History: Retired, lives in [Location 669]. States an old girlfriend gave him HIV many yrs ago. - Tobacco: 1/2ppdx10yrs, quit 20yrs ago - Alcohol: none, quit 30yrs ago (used to drink on the weekends) - Illicits: denies Family History: Mother w/ HTN. Father w/ HTN and h/o MI. Denies DM, CVA, cancers including stomach and colon cancer. Physical Exam: Admission Exam: Vitals: T: 98.4 BP: 117/66 P: 133 R: 18 O2: 100%2LNC General: Alert, oriented, no acute distress, pleasant and interactive HEENT: Sclera anicteric, MMM, oropharynx clear w/ dentures, EOMI, PERRL Neck: supple, JVP could not be assessed [12-24] large neck, no LAD, trauma line in right JVP with moderate hematoma posteriorly CV: rapid irreg irreg, normal S1 + S2, no murmurs, rubs, gallops appreciated Lungs: Clear to auscultation bilaterally with mild rales at the bases bilaterally, no wheezes, rhonchi Abdomen: Obese, soft, non-tender, mildly distended, bowel sounds present- normoactive, unable to assess for organomegaly. healed scar to the right of the umbilicus GU: no foley Ext: [11-23]+ symmetric edema to knees bilaterally, warm, well perfused, 1+ pulses, no clubbing, cyanosis, verucous lesions on anterior shins bilaterally Neuro: A&Ox3, CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred Discharge Exam: General: Awake, sitting in chair, interactive, following commands. HEENT: PERRL, anicteric sclera. CV: S1S2 RRR w/o m/r/g??????s. Lungs: CTA bilaterally w/o crackles or wheezing. Ab: Positive BS??????s, NT/ND, no HSM. Ext: Brawny LE skin changes. Neuro: Alert and interactive. Moving all extremities. No focal motor deficits noted. Pertinent Results: Admission Labs: [2134-5-15] 11:10PM BLOOD WBC-6.2# RBC-1.33# Hgb-3.6# Hct-12.8# MCV-97 MCH-27.3# MCHC-28.3# RDW-17.4* Plt Ct-216 [2134-5-15] 11:10PM BLOOD Neuts-75.1* Lymphs-18.3 Monos-6.1 Eos-0.3 Baso-0.2 [2134-5-15] 11:10PM BLOOD PT-136.7* PTT-45.9* INR(PT)-14.2* [2134-5-16] 03:06AM BLOOD Fibrino-217 [2134-5-15] 11:10PM BLOOD Glucose-216* UreaN-73* Creat-2.7# Na-143 K-4.5 Cl-114 HCO3-20* AnGap-14 [2134-5-15] 11:10PM BLOOD ALT-11 AST-8 AlkPhos-114 TotBili-0.1 [2134-5-15] 11:10PM BLOOD cTropnT-0.07* [2134-5-16] 03:06AM BLOOD Calcium-7.6* Phos-3.5 Mg-2.2 [2134-5-15] 11:10PM BLOOD Albumin-3.6 [2134-5-16] 03:17AM BLOOD Type-[Last Name (un) ] pH-7.30* [2134-5-15] 11:25PM BLOOD Lactate-1.3 [2134-5-15] 11:25PM BLOOD Hgb-3.9* calcHCT-12 [2134-5-16] 03:17AM BLOOD freeCa-1.02* [2134-5-16] 05:59AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.009 [2134-5-16] 05:59AM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [2134-5-16] 05:59AM URINE RBC-2 WBC-6* Bacteri-NONE Yeast-NONE Epi-<1 [2134-5-16] 05:59AM URINE Hours-RANDOM UreaN-616 Creat-84 Na-43 K-27 Cl-33 [2134-5-31] 03:51AM BLOOD WBC-8.0 RBC-2.80* Hgb-7.9* Hct-25.0* MCV-89 MCH-28.1 MCHC-31.5 RDW-16.4* Plt Ct-369 [2134-6-1] 05:39AM BLOOD WBC-7.8 RBC-2.75* Hgb-7.9* Hct-24.5* MCV-89 MCH-28.7 MCHC-32.1 RDW-16.6* Plt Ct-366 [2134-5-27] 03:15AM BLOOD PT-12.0 PTT-24.4* INR(PT)-1.1 [2134-5-29] 12:58AM BLOOD PT-13.6* PTT-26.7 INR(PT)-1.3* [2134-5-30] 04:01AM BLOOD PT-16.5* PTT-25.0 INR(PT)-1.6* [2134-5-31] 03:51AM BLOOD PT-19.9* PTT-29.2 INR(PT)-1.9* [2134-5-29] 12:58AM BLOOD Glucose-153* UreaN-36* Creat-1.8* Na-150* K-3.0* Cl-112* HCO3-28 AnGap-13 [2134-5-29] 12:00PM BLOOD Na-149* K-3.5 Cl-114* [2134-5-29] 11:13PM BLOOD Glucose-180* UreaN-31* Creat-1.7* Na-145 K-3.4 Cl-110* HCO3-25 AnGap-13 [2134-5-30] 04:01AM BLOOD Glucose-139* UreaN-29* Creat-1.6* Na-145 K-3.7 Cl-111* HCO3-27 AnGap-11 [2134-5-31] 03:51AM BLOOD Glucose-112* UreaN-25* Creat-1.5* Na-146* K-3.8 Cl-110* HCO3-26 AnGap-14 [2134-5-31] 10:04PM BLOOD Glucose-120* UreaN-18 Creat-1.5* Na-147* K-3.6 Cl-112* HCO3-24 AnGap-15 [2134-6-1] 05:39AM BLOOD Glucose-90 UreaN-17 Creat-1.5* Na-147* K-4.0 Cl-112* HCO3-27 AnGap-12 [2134-6-1] 05:39AM BLOOD Calcium-8.4 Phos-2.4* Mg-2.0 [2134-6-1] 05:35AM BLOOD HERPES SIMPLEX (HSV) 1, IGG-PND [2134-6-1] 05:35AM BLOOD HERPES SIMPLEX (HSV) 2, IGG-PND [2134-5-28] 03:56PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.012 [2134-5-28] 03:56PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD [2134-5-28] 03:56PM URINE RBC-1 WBC-12* Bacteri-NONE Yeast-NONE Epi-0 [2134-5-28] 3:56 pm URINE Site: NOT SPECIFIED Source: Line-PICC line. URINE CULTURE (Preliminary): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [2134-5-25] 4:00 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT [2134-5-26] C. difficile DNA amplification assay (Final [2134-5-26]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). ECG Study Date of [2134-5-15] 11:12:34 PM Atrial fibrillation with rapid ventricular response rate of 126 beats per minute. Multifocal premature ventricular complexes. Delayed R wave transition. Non-specific ST segment changes in the lateral and high lateral leads. No previous tracing available for comparison. CT ABD & PELVIS W/O CONTRAST Study Date of [2134-5-17] 10:29 AM FINDINGS: CT OF THE ABDOMEN WITHOUT CONTRAST: Although this study is not tailored for the evaluation of supradiaphragmatic contents, the visualized lung bases show bilateral consolidations/collapse on the right greater than the left with air bronchograms and trace bilateral pleural effusions on the right greater than the left. Diffuse ground-glass opacification in the aerated portions of the lung bases is also noted. No pulmonary nodules are seen. Limited imaging of the heart shows moderately enlarged size without pericardial effusion. The visualized portion of the descending thoracic aorta is slightly tortuous in its course. The esophagus contains an enteric tube and otherwise appears unremarkable. Evaluation of the solid organs is limited without intravenous contrast. Within these limitations, no gross abnormality is detected within the liver. There is trace perihepatic fluid. No intrahepatic or extrahepatic biliary ductal dilatation is seen. The gallbladder contains several calcified gallstones in the dependent portion measuring up to 6 mm in size. No gallbladder wall thickening, edema, or pericholecystic fluid is seen. The pancreas is unremarkable. The spleen contains a 2.1-cm hypodensity with internal fluid density of 19 Hounsfield units, likely representing a splenic cyst. The spleen is otherwise unremarkable. The bilateral adrenal glands and kidneys are within normal limits. The stomach contains an enteric tube in the distal body. The intra-abdominal loops of small and large bowel are unremarkable without evidence of wall thickening or obstruction. The appendix is normal in appearance. Minimal fluid is noted tracking along the left paracolic gutter. There is no large volume abdominal ascites or retroperitoneal fluid collection. No free air is present. No mesenteric or retroperitoneal lymphadenopathy is noted, although there are scattered small retroperitoneal and iliac lymph nodes which do not meet CT size criteria for lymphadenopathy. The abdominal aorta is normal in caliber throughout. CT OF THE PELVIS WITHOUT CONTRAST: The urinary bladder is decompressed by Foley catheter in appropriate position. The prostate and seminal vesicles are unremarkable. A small amount of simple free fluid is noted superior to the urinary bladder, within the superior pelvis. The rectum and sigmoid colon are unremarkable. Several prominent pelvic side wall and inguinal lymph nodes are noted measuring up to 12 mm in short axis. OSSEOUS STRUCTURES AND SOFT TISSUES: There is a compression fracture deformity at the L5 vertebral body which is indeterminate in age. No suspicious lytic or sclerotic lesions are detected in the bone. There is mild generalized anasarca. No focal fluid collections are noted within the soft tissue to suggest hematoma. IMPRESSION: 1. No evidence of retroperitoneal or subcutaneous fluid collection to suggest hematoma. Mild generalized anasarca and minimal perihepatic and pelvic ascites is noted. 2. Bibasilar consolidation/collapse of the lungs, on the right greater than the left, with trace pleural effusions. 3. Cholelithiasis. 4. Nonspecific prominent pelvic side wall and inguinal lymph nodes. TTE (Complete) Done [2134-5-24] at 10:56:45 AM FINAL The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([11-23]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild-moderate mitral regurgitation. Pulmonary artery hypertension. PORTABLE ABDOMEN Study Date of [2134-5-31] 11:51 AM * UNAPPROVED (PRELIMINARY) REPORT * !! WET READ !! Preliminary report has not yet been released for viewing. CHEST (PORTABLE AP) Study Date of [2134-5-28] 2:50 PM NG tube tip is in the stomach. Tracheostomy tube is in the standard position. Left PICC tip is in the mid-to-lower SVC. Moderate cardiomegaly is stable. There is mild vascular congestion. Bibasilar opacities, larger on the left side are unchanged, could be due to atelectasis and/or pneumonia. There are no new lung abnormalities. EGD [2134-5-17] Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated his understanding and signed the corresponding consent forms. A physical exam was performed. The patient was administered General anesthesia. A physical exam was performed prior to administering anesthesia. Supplemental oxygen was used. The patient was placed in the left lateral decubitus position and an endoscope was introduced through the mouth and advanced under direct visualization until the third part of the duodenum was reached. Careful visualization of the upper GI tract was performed. The vocal cords were visualized. The procedure was not difficult. The patient tolerated the procedure well. There were no complications. Findings: Esophagus: Mucosa: Esophagitis with no bleeding was seen in the GE junctoin, compatible with mild esophagitis. Stomach: Mucosa: Erythema of the mucosa with no bleeding was noted in the antrum. These findings are compatible with mild gastritis. Other linear erosion on the greater curvature of the stomach consistent with NG tube trauma Duodenum: Mucosa: Normal mucosa was noted. Impression: Esophagitis in the GE junctoin compatible with mild esophagitis Linear erosion on the greater curvature of the stomach consistent with NG tube trauma Erythema in the antrum compatible with mild gastritis Normal mucosa in the duodenum Otherwise normal EGD to third part of the duodenum Recommendations: No clear explanation for the patient's GI bleed from this EGD. Will need colonoscopy when more stable Additional notes: The attending was present for the entire procedure. The patient's home medication list is appended to this report. FINAL DIAGNOSIS are listed in the impression section above. Estimated blood loss = zero. No specimens were taken for pathology. Bronchoscopy [2134-5-26] Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated his understanding and signed the corresponding consent forms. A standard time out was performed as per protocol. The procedure was performed for diagnostic and therapeutic purposes at the operating room. A physical exam was performed. The bronchoscope was introduced through an endotracheal tube and advanced under direct visualization until the tracheobronchial tree was reached.The procedure was not difficult. The quality of the preparation was good. The patient tolerated the procedure well. There were no complications. Recommendations: Admit to ICU Additional notes: Patient medication list was reconciled. Attending was present for the entire procedure. FINAL DIAGNOSES are listed in the impression section above. Estimated blood loss = 25 ml. No specimens were taken for pathology. Colonoscopy [2134-5-31] Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated his understanding and signed the corresponding consent forms. The efficiency of a colonoscopy in detecting lesions was discussed with the patient and it was pointed out that a small percentage of polyps and other lesions can be missed with the test. A physical exam was performed. The patient was administered moderate sedation. The physical exam was performed prior to administering anesthesia. Supplemental oxygen was used. The patient was placed in the left lateral decubitus position.The digital exam was normal. The colonoscope was introduced through the rectum and advanced under direct visualization until the cecum was reached. The appendiceal orifice and ileo-cecal valve were identified. Careful visualization of the colon was performed as the colonoscope was withdrawn. The colonoscope was retroflexed within the rectum. The procedure was not difficult. The quality of the preparation was fair. The patient tolerated the procedure well. There were no complications. Findings: Protruding Lesions Three sessile non-bleeding polyps of benign appearance and ranging in size from 5 mm to 6 mm were found in the ascending, descending, sigmoid. Excavated Lesions A single circular ulcer was found in the rectum. A single linear ulcer was found in the rectum. Impression: Polyps in the ascending, descending, sigmoid Ulcer in the rectum Ulcer in the rectum Otherwise normal colonoscopy to cecum Recommendations: Colonoscopy in 6 mos. Additional notes: The procedure was performed by the fellow and the attending. The attending was present for the entire procedure. Degree of difficulty 1 (5 most difficult) FINAL DIAGNOSES are listed in the impression section above. Estimated blood loss = zero. No specimens were taken for pathology Brief Hospital Course: 65yo M with a PMH of afib on coumadin, diabetes, HIV, HTN, and CHF admitted to the ICU with likely subacute GIB, with hct 12.8 in the context of supratherapeutic INR at 14.2. Originally he was hypotensive secondary to significant blood loss. Patient was noted to have SBPs in the 80s on admission, was responsive to IVF bolus. He then receivied 6 units PRBCs and FFP with a massive transfusion protocol with SBPs in the 100s with a trauma line that was placed. All his at home antihypertensives were held clonidine, monixidil, isosorbide dinitrate. His atrial fibrillation normally treated with coumadin and diltiazem at home became Afib with RVR likely 2ndary to anemia (rates in the 120s to 140s). Patient then became agitiated and went into flash pulmonary edema. he was intubated and then was stablaized. He failed 3 extubation attmepts, 1 planned and 2 self attmepts. He then got a tracheosomty placed. He improved afterwards and was able to breath off of the ventilator without hemodynamic compromise. # Anemia [12-24] gastrointestinal bleeding: Patient reports a history of weeks of dark stools and was noted to have dark guaiac positive stool on rectal exam. He does not carry a diagnosis of liver disease or known GI pathology, however he has also not seen a GI physician and has not had an EGD or colonoscopy previously. LFTs are normal, MCV normal. Hcts stabilized, then dropped again and he was transfused another 2 more units. His EGD showed esophagitis in the GE junctoin compatible with mild esophagitis, linear erosion on the greater curvature of the stomach consistent with NG tube trauma, erythema in the antrum compatible with mild gastritis. He had a colonoscopy that showed several rectal ulcers and polyps in the ascending, descending, and sigmoid colon. No clear explanation of the GI bleed was discovered and a colonscopy was recommened in 6 months. # Supratherapeutic INR: patient is on coumadin for atrial fibrillation. It is currently unclear how or for how long his INR has been supratherapeutic. He was given vitamin K 10mg IV and multiple units of FFP. Patient is a poor historian and may have inadvertantly taken more than recommended. He was continued without anticoagulation due to the GIB. At the end of the hospitalization his coumadin was restarted at his home dose and will be continued to be montiored and managed as an outpatient. #A. fib. with RVR on multiple occasion led to flashing during the extubation attempts. He was managed as above for coumadin and rate controlled with diltiazem and metoprolol. #CHF Pt required large doses of iv lasix and lasix drips to treat vol overload and lost over 19 kilograms during the hospitalization likely due to a fluid overloaded state and LE edema that resolved by the time of discharge. #Hypertension: History of htn he was treated before with clonidine, Isosorbide Dinitrate, Lisinopril, Diltiazem ER, Metoprolol, and Minoxidil. He was treated with clonidine, diltiazem, metoprolol mainly, but several medicines were used on a prn basis including hydralazine and a nitroglycerin drip. We discharged him with lisinopril, metoprolol, clonidine, and isosorbide dinitrate. # [Last Name (un) ]/CKD: It is unknown whether the patient carries a diagnosis of CKD, however he does related that he has been told his kidneys do not work well. States he does not urinate a lot as well. Admission Cr is 2.7. Last known Cr is 1.2 from [2121]. [Last Name (un) ] could be due to renal hypoperfusion [12-24] acute/subacute blood loss. Final Cr during hospitalization 1.5. # Elevated troponin: Likely due to demand ischemia [12-24] tachycardia and significant anemia. Following trops flat. Outpatient management should be continued. # Diabetes: Blood glucose 216 on admission. Patient managed on oral hypoglycemics as an outpatient. Managed with 10 units of glargine and a sliding scale, may be continued as an outpatient or transitioned to oral medications. # HIV: patient reports an undetectable viral load. Inactive issue during this hospitalization. -continued home meds and needs to continue outpt followup Hypernatremia -Pt required free water flushes to resolve his hypernatremia. This issue resolved in the hospitalization. UTI- He was found to have a E.Coli UTI and we decided to treat for 7 days with ceftriaxone staring on [2134-6-1]. End dat [2134-6-8]. Transitional issues: Colonoscopy with GI within 6 months Gi says the flexiseal- would be best to avoid, but can continue for patient comfort/ skin issues. [Month (only) 116] start glipizide when taking PO, now discharging on insulin per regimen in the hospital Diet per Page 1: pureed and nectar thick with cuff deflated, no PMV Discharged on subq heparin for dvt prophylaxis will read address the issue of anticoagulation as an outpatient Pt was send out on 7 days on ceftriaxone for a UTI end on [2134-6-8]. PICC line Hypertension medications may need uptitration Holding lasix as patient diuresed during hospitalization over 20 pounds and was borderline hypernatremic at time of discharge, during cardiology appointment, reconsideration of restarting lasix. Blood cultures pending Emergency contact [Name (NI) ] [Telephone/Fax (1) 28767] Sister [Name (NI) ] [Name (NI) 28768] [Telephone/Fax (3) 28769], not official emergency contact. Full code during this admission Medications on Admission: Unable to obtain information regarding preadmission medication at this time. Information was obtained from dc list from [Hospital1 2025] in [3-4]. 1. Abacavir Sulfate 600 mg PO HS 2. Efavirenz 600 mg PO HS 3. LaMIVudine 150 mg PO HS 4. Azithromycin 250 mg PO Q24H 5. Diltiazem Extended-Release 240 mg PO DAILY 6. Metoprolol Succinate XL 100 mg PO DAILY 7. Lisinopril 40 mg PO DAILY 8. Isosorbide Dinitrate 20 mg PO TID 9. Minoxidil 5 mg PO BID 10. CloniDINE 0.4 mg PO BID 11. Furosemide 40 mg PO DAILY 12. Furosemide 20 mg PO PRN lower extremity edema 13. Pravastatin 40 mg PO DAILY 14. Aspirin 81 mg PO DAILY 15. Warfarin 5 mg PO DAILY16 16. GlipiZIDE 5 mg PO DAILY take 30 minutes before a meal 17. traZODONE 25 mg PO HS 18. Calcitriol 0.25 mcg PO MWF 19. Cyanocobalamin 1000 mcg PO DAILY 20. Doxazosin 8 mg PO HS 21. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain 22. Omeprazole 40 mg PO DAILY 23. Docusate Sodium 100 mg PO BID 24. Polyethylene Glycol 17 g PO DAILY:PRN constipation 25. Lactulose 15 mL PO Q8H:PRN constipation 26. Senna 1 TAB PO BID:PRN constipation Discharge Medications: 1. Abacavir Sulfate 600 mg PO HS 2. CloniDINE 0.4 mg PO BID 3. Efavirenz 600 mg PO HS 4. Isosorbide Dinitrate 40 mg PO TID HOLD for SBP<100 5. LaMIVudine 150 mg PO HS 6. Senna 1 TAB PO BID:PRN constipation 7. Warfarin 5 mg PO DAILY16 8. Diltiazem Extended-Release 240 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Heparin 5000 UNIT SC TID 11. Lisinopril 20 mg PO DAILY 12. Glargine 10 Units Dinner Insulin SC Sliding Scale using REG Insulin 13. Omeprazole 40 mg PO DAILY 14. Metoprolol Tartrate 100 mg PO TID hold for SBP < 100, HR < 60 15. Aspirin 81 mg PO DAILY 16. Calcitriol 0.25 mcg PO MWF 17. Cyanocobalamin 1000 mcg PO DAILY 18. Lactulose 15 mL PO Q8H:PRN constipation 19. Polyethylene Glycol 17 g PO DAILY:PRN constipation 20. Pravastatin 40 mg PO DAILY 21. traZODONE 25 mg PO HS:PRN Sleep aide 22. Quetiapine Fumarate 50 mg PO Q12H:PRN agitation 23. CeftriaXONE 1 gm IV Q24H Duration: 7 Days Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Lower gastrointestinal bleed Congestive heart failure Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [Known lastname ], It was our pleasure to care for you at [Hospital1 18]. You were treated in the hospital for low blood pressures likely from a gastrointestinal bleed in the setting of a high INR, which is a measure of the thinness of your blood on coumadin. You received several blood transfusions. You were also seen by the gastroenterology doctors who recommended a colonoscopy that showed rectal ulcers, which may be where the bleed was coming from. You should have another colonoscopy in 6 months. Because you stopped bleeding your coumadin was restarted on discharge. Because you were critically ill, you were treated in the intensive care unit and were intubated for several days due to fluid in your lungs. Since you had the breathing tube in for several days and it had been replaced several times, we changed your tube to a tracheostomy, which is the breathing tube that was placed in your neck. As you improve this may be able to be removed in the future. Since you cannot eat safely right now, you have a feeding tube in as well which can be removed when you can safely swallow. Changes to your medications: STOP taking minoxidil STOP taking doxazosin. STOP taking glipizide STOP taking azithromycin STOP taking Lasix CHANGE dose of lisinopril to 20 mg daily CHANGE dose of isosorbide dinitrate to 40 mg three times a day CHANGE metoprolol to three times daily START taking heparin shots three times a day. This can help prevent blood clots. START taking lantus insulin 10 units at night and insulin sliding scale with meals. START taking seroquel 50 mg twice a day as needed START taking ceftriaxone 1 g daily x 7 days, starting [2134-6-1], given in the ICU. Followup Instructions: Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [2134-6-16] at 1 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 463] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage Department: CARDIAC SERVICES When: THURSDAY [2134-6-24] at 8:40 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: WEST PROCEDURAL CENTER When: THURSDAY [2134-8-5] at 1:30 PM With: WPC ROOM THREE [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	[ "5849", "2760", "2762", "40390", "5990", "51881", "2851", "42731", "25000", "V5861", "41401", "412", "5859", "4280" ]
Admission Date: [2128-11-27] Discharge Date: [2128-12-4] Date of Birth: [2086-10-4] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 20506] Chief Complaint: Status epilepticus Major Surgical or Invasive Procedure: Intubation (at outside hospital) Extubation History of Present Illness: The pt is a 42 year-old man, with a past medical history significant for TBI and seizure disorder, reported EtOH use, who presents after being found down at or around his house, and then taken to an OSH where he was intubated and sedated out of concern for status. There is not a great deal of information known about this patient. All information is obtained throughout the [Hospital3 ] chart and EMS report. He had an address without a phone number listed, there was no contact information otherwise and could not find a number for the given address. What is known is that EMS was called to his house where he was found lying on the floor breathing, presumed post ictal from a seizure. At first he was given Narcan because there was a concern that there was an overdose, but here was no effect. fter learning the patient has a seizure d/o he was given ~4mg of Ativan in the field and taken to [Hospital6 ]. There he was noted on exam to have brainstem reflexes, but minimal withdrawal to pain. A head CT was obtained but did not show any acute pathology. He had levels of the two AEDs he is reportedly on (PHT and VPA), pHT was 12 and VPA 44, but it is not clear if these are pre or post load. He may have gotten 2 more mg of Ativan at this point. He was seen by neurology at the outside hospital who felt that he was still not very responsive and that this may be due to "subtle" status, and recommended intubating the patient, he was bolused 500mg PHT and started on a versed gtt and transferred to BIMDC for further neurological management. Past Medical History: Traumatic brain injury Epilepsy Previous alcohol dependence Social History: He lives with his mother who is [Name8 (MD) ] RN at [Hospital 1263] Hospital. He smokes (unclear amount), and has not drunk any alcohol for many years. Family History: non-contributory Physical Exam: Physical Exam: Vitals: T: 99 P: 100 R: 16 BP: 136/92 SaO2: 100 General: Intubated/sedatated HEENT: NC/AT, no scleral icterus noted, MMM, Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds Extremities: No C/C/E bilaterally, Neurologic: -Mental Status: Intaubted and sedated, grimaces and slightly opens eyes to deep sternal rub. Pulls away from painful stimulus. No tracking. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. III, IV, VI: VOR intact V, VII: corneal intact IX, X: gag -Motor: Normal bulk, tone throughout. Withdraws to pain at all 4 ext -Sensory: feels pain at all 4 -DTRs: [Name2 (NI) ] Tri [Last Name (un) 1035] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. No clonus -Coordination and gait: not tested Pertinent Results: [2128-11-27] 08:15PM GLUCOSE-98 UREA N-10 CREAT-0.6 SODIUM-145 POTASSIUM-4.7 CHLORIDE-111* TOTAL CO2-23 ANION GAP-16 [2128-11-27] 08:15PM cTropnT-<0.01 [2128-11-27] 08:15PM CALCIUM-8.2* PHOSPHATE-4.4 MAGNESIUM-2.0 [2128-11-27] 08:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2128-11-27] 08:15PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2128-11-27] 08:15PM WBC-9.5 RBC-4.03* HGB-14.0 HCT-38.6* MCV-96 MCH-34.8* MCHC-36.4* RDW-13.4 [2128-11-27] 08:15PM NEUTS-77.5* LYMPHS-15.9* MONOS-5.5 EOS-0.7 BASOS-0.4 [2128-11-27] 08:15PM PLT COUNT-196 [2128-11-27] 08:15PM PT-12.7 PTT-25.0 INR(PT)-1.1 [2128-11-27] 08:15PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.006 [2128-11-27] 08:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-25 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2128-11-29] EEG showed no epileptiform features Brief Hospital Course: Initial Impression / Hospital Course: The pt is a 42 year-old man, with a past medical history significant for TBI and seizure disorder, reported EtOH use, who presents after being found down at or around his house, and then taken to an OSH where he was intubated and sedated out of concern for status. The patient was found down after a presumed seizure, and he received 4-6mg of Ativan on route to the local hospital (it is not clear why so much was given). At the OSH he was noted to have brainstem reflexes but not much response to pain. He had two AEDs level drawn which indicated he was slightly subtherapuetic . A neurologist saw the patient at [Hospital3 ] and was concerned that the patient had not returned to baseline and was possibly in status, so was given more Ativan, intubated and placed on a versed gtt. AT [Hospital1 18], on exam he is more rousable then before. He moves and grimaces to pain, withdraws at all fours to pain. This patient is currently intubated and will need admission to the ICU and an EEG to help determine if he is in sub-clinical status. Given the patient history of EtOH/drug, his sub-therapeutic AEDs level were likely provoking factors. Mr. [Known lastname ] was admitted to the ICU. His tox screen was negative except for benzos. He was weaned off of versed and then extubated and transferred to the ICU. His AEDs were adjusted. He received 1 gram fosphenytoin for low dilantin level, and then was maintained on Dilantin 500mg QHS. Due to the difficulty in maintaining therapeutic dilantin levels with Valproate, his valproate was decreased to 500mg [Hospital1 ]. Valproate was not completely removed due to need for mood stabilization. He was started on Zonegran, which is titrating up. Currently the dose is at 200mg QHS, but will continue to increase as an outpatient to 300mg QHS. Infectious work-up was negative. Medications on Admission: He was on Depakote and Dilantin but the drug doses were not the same as what his neurologist prescribed, as his doses were checked with his pharmacy. The patient was non-compliant with his meds so the actual drug dose was unclear. [Name2 (NI) ] was supposed to be on Dilantin 400 mg QHS and Depakote 1 g [Hospital1 ] as per his neurologist Dr. [Last Name (STitle) 35852]. Discharge Medications: 1. divalproex 500 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a day). Disp:60 Tablet Sustained Release 24 hr(s) Refills:2 2. phenytoin sodium extended 100 mg Capsule Sig: Five (5) Capsule PO QHS (once a day (at bedtime)). Disp:150 Capsule(s) Refills:2 3. zonisamide 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). Disp:60 Capsule(s) Refills:2 4. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for agitation. Discharge Disposition: Home Discharge Diagnosis: Primary Generalized seizure Secondary Traumatic brain injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were found unresponsive, likely after having a generalized seizure. You were taken to an outside hospital, intubated, before transfer to [Hospital1 18] for further management. Your stayed in the ICU briefly. On the floor service, we adjusted your anti-epileptic medications (Dilantin and Depakote). We also started a new anti-epileptic medication called Zonisamide. Followup Instructions: Please follow-up with your outpatient neurologist Dr. [Last Name (STitle) ] [Last Name (NamePattern4) 35852] (tel:([Telephone/Fax (1) 88263]) in one week, he requested that you call to schedule an appointment. Your Dilantin level at the time of discharge was 10.3.	[ "3051" ]
Admission Date: [2170-12-2] Discharge Date: [2170-12-14] Date of Birth: [2090-3-5] Sex: M Service: MEDICINE Allergies: Ceftazidime Attending:[First Name3 (LF) 3984] Chief Complaint: Increased respiratory secretions and inability to swallow meds. Major Surgical or Invasive Procedure: None. History of Present Illness: 80 y.o. man with P.D., s/p 2 admissions over last month for falls. Pt was just discharged to rehab yesterday, but is now returning with inability to take PO meds, requiring frequent suctioning. When pt was here last he was admitted after a witness fall and injured his left elbow. On that admit, he was witness to aspirate with meds, food, and liquids but family was refusing NGT or PEG tube. Therefore, pt was discharged with rehab with understanding that he could take food and meds but was at high risk of aspiration and ensuing complications. This morning at [Hospital 599] rehab in [Location (un) ], pt was noted to have increased resp secretion requiring q30min suctioning. He also could not swallow his medications. Though pt did pass swallow study at [Hospital1 5595] about 2 weeks ago, he was clearly witnessed to aspirate over last 2 days while here. .. Currently, pt denies pain, SOB, CP, cough. He understands why he is here. Past Medical History: 1. CAD s/p CABG [2165]-3VD--CABG by [Last Name (un) 2230] -[2146] IMI (Rx'd with SK), CATH with 75% mid RCA. -Noted to have VEA and ?PAF, Rx'd with quinidine and later digoxin. [11/2153] normal ETT, [2158] 10" ETT/neg EKG/neg Sx. - [10/2160] admitted for eval palpitations, MI R/O, HOLTER with VEA, quinidine/dig stopped, atenolol begun. 2. hypercholesterolemia 3. HTN 4. parkinson's 5. colon cancer -S/P RESECTION [2158] WITH CLEAR MARGINS (R-colon), f/u colonoscopies negative [12/2160], [6-/2161]; [6-/2163]; [6-/2165]- two small (4mm) sessile adenomatous polyps were identified and removed 6. anemia 7. hx hip fracture w/right total hip replacement 8. actinic keratoses, SCC on forehead, s/p MOHS excision 9. h/o PAF Social History: SH: Has been at [Hospital 599] rehab in [Location (un) ] x2 days since last admission. Son and family live nearby. Son heavily involved in pt's care and is healthcare proxy. Former [Name2 (NI) 1818] (+20 pack year h/o), quit 25 years ago. Seldom EtOH, no drugs. No longer able to ambulate secondary to frequent falls and rigidity from Parkinson's. He passed a speech and swallow eval at [Hospital 100] Rehab ~1 month; he was taking his Parkinson's Meds at that time. Family History: FH - CAD, HTN Physical Exam: 97.8---91---102/72---17---95%RA Gen: cogwheeling tremor, pt in no resp distress. HEENT: Pupils min reactive to light. Anicteric. OP clear with dry MM. Neck: supple Lungs: b/l rhonchi and occ insp and exp wheezing. CV: irreg irreg rhythm, nml S1S2, no m/r/g Abd: soft, NT, ND, na BS Ext: no edema, Left elbow wrapped but nontender. Neuro: A&Ox2 (not date), cogwheelng tremor of left hand mostly. Gait not tested. Pertinent Results: [2170-12-1] 07:20AM WBC-5.8 RBC-3.50* HGB-11.2* HCT-32.9* MCV-94 MCH-32.1* MCHC-34.1 RDW-14.2 [2170-12-1] 07:20AM NEUTS-78.8* LYMPHS-18.1 MONOS-1.3* EOS-1.4 BASOS-0.4 [2170-12-1] 07:20AM PLT COUNT-195 [2170-12-1] 07:20AM GLUCOSE-102 UREA N-12 CREAT-0.8 SODIUM-138 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13 [2170-12-1] 07:20AM CALCIUM-8.9 PHOSPHATE-3.4 MAGNESIUM-2.1 [2170-12-1] 01:42AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [2170-12-1] 01:42AM URINE RBC-5* WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 CXR: no acute infiltrate. EKG: poor baseline, irregular, likely AF with nml vent response, Qs inf (old), no ST changes. Brief Hospital Course: 80 y.o. man with Parkinson disease, h/o recent aspiration presenting with increasing resp secretions and now worsening dysphagia. . # MRSA aspiration pna: Patient developed respiratory failure in the MICU from MRSA aspiration pna. He was maintained on Levo, Vanco, and Flagyl. He initially was afebrile, with normal WBC and clear CXR. Inability to swallow and take his PD regimen is the likely reason that his dysphagia worsened. Over the hospital stay, the patient developed aspiration pna. PD sublingual meds were attempted, but were not successful. Patient had an NGT placed for administration of his meds, but placement attempts failed because of anatomical variant in his pharynx. Pulmonary and GI both attempted to place the NGT without success. . Patient was frequently suctioned, underwent chest PT, and had nebs. Oxygen saturation were in the high 90s on nc until the last two days before passing. The patient's son was called to patient's bedside for desaturation to 80s for the first time, and code status was changed from full to DNR/DNI, consitent with the patient's previously expressed wishes. With the focus of care on patient [Last Name (LF) ], [First Name3 (LF) ] infusion of morphine was used to provide relief of pain and airhunger. The patient passed away in the MICU, with the patient's son by his bedside. [Name (NI) ] son [Name (NI) 382] did not wish to have an autopsy. . # C diff diarrhea: Patient was being treated for C diff with IV flagyl. . # AFIB with RVR: Patient was rate controlled on digoxin, and was anticoagulated on heparin gtt. . # CAD with CABG: Hct was maintained at > 30, on digoxin, well controlled. . # Parkinson disease: Continued on sinemet and mirapex. Medications on Admission: 1. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO qid (). 2. Carbidopa-Levodopa 25-100 mg One Tablet PO TID. 3. Zoloft 100 mg Tablet Sig: One (1) Tablet PO once a day. 4. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY 6. Multivitamin Capsule Sig: One (1) Cap PO DAILY 7. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO DAILY Discharge Medications: 1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO tid (). Discharge Disposition: Extended Care Discharge Diagnosis: Deceased Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] Completed by:[2171-2-18]	[ "5070", "42731", "51881", "0389", "99592", "5849", "V4581", "4019" ]
Admission Date: [2115-10-20] Discharge Date: [2115-11-1] Date of Birth: [2039-9-25] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 613] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: none History of Present Illness: 76 yo male w/ severe COPD (FEV1 28%) p/w acute worsening of dyspnea this PM, called 911, brought by EMS to [Hospital1 18] ED. Pt reports that he did not have any precipitating symptoms to note such as fevers/chills/cough/allergies but that this "has happened before. He denies CP/orthopne/N/V/Abd Pain/hemoptysis/diarrhea. IN ED the patient was tachtpneic to the 30's, he was placed on a non-rebreather w/ nebs every hour. He was also given solumedrol and a dose of levofloxacin w/ good improvement. Past Medical History: 1. COPD ?????? Pt with severe COPD. His last PFTs on [2115-9-25] were consistent with marked obstructive defect. Measurements included a FVC of 59% predicted, FEV1 28% predicted, and FEV1/FVC of 48% predicted. There was no significant change since a prior study from [2115-8-12]. Pt is on 3 L home O2. 2. Asthma ?????? Diagnosed in [2104]. 3. Crohn??????s disease ?????? Diagnosed in [2104] 4. Steroid-induced NIDDM ?????? Present for two to three years. 5. Peripheral Neuropathy 6. Hypertension 7. Osteoarthritis 8. Osteoporosis 9. Cervical spinal stenosis 10. BPH s/p TURP 11. GERD Social History: Former banker. Retied since [2104]. Wife is deceased; patient lives alone at home. Has four children ?????? 2M, 2F.EtOH: Denies use Tob: 25 pack-year prior historyDrugs: Denies use Family History: Brother ?????? NIDDM Sister ?????? ??????Chest cancer?????? Physical Exam: On admission: Temp BP 106-193/59-101 RR 25 O2 sat 95% NRB Gen: able to speak in complete sentences HEENT: + pursed lips when breathing, anicteric, dry mm, EOMI, Neck: JVP 8 cm CV: Tachycardic no m/r/g Resp: scattered diffuse expiratory wheezes Ext: no c/c/e Neuro: grossly intact . On transfer out of MICU VS: t96.5, p93, 115/59, rr24, 100%4Lnc Gen- Alert and oriented. Able to speak in full sentences. Appears mildly uncomfortable but reports that he is at his respiratory baseline. Cardiac- RRR. Pulm- Poor air movement bilaterally. Diffuse wheezing. Pt using ascesory muscles which he reports is baseline for him. Abdomen- Soft. NT ND. Positive BS. Extremities- No c/c/e. Neuro- Alert and oriented. 5/5 strength in upper and lower extremities bilaterally. Pertinent Results: [2115-10-20] 01:45AM WBC-13.3* RBC-4.19* HGB-12.1* HCT-36.5* MCV-87 MCH-28.9 MCHC-33.1 RDW-13.6 [2115-10-20] 01:45AM PLT COUNT-360# [2115-10-20] 01:45AM NEUTS-63.6 LYMPHS-29.2 MONOS-5.8 EOS-1.2 BASOS-0.2 . [2115-10-20] 01:45AM GLUCOSE-228* UREA N-17 CREAT-1.1 SODIUM-141 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-22 ANION GAP-16 [2115-10-20] 09:25AM CALCIUM-9.0 PHOSPHATE-3.0 MAGNESIUM-2.0 . [2115-10-20] 01:45AM CK(CPK)-154 [2115-10-20] 01:45AM CK-MB-15* MB INDX-9.7* cTropnT-0.08* [2115-10-21] 01:26AM BLOOD CK(CPK)-162 [2115-10-21] 01:26AM BLOOD CK-MB-16* MB Indx-9.9* cTropnT-0.13* [2115-10-21] 06:25AM BLOOD CK(CPK)-71 [2115-10-21] 06:25AM BLOOD CK-MB-NotDone cTropnT-0.09* [2115-10-21] 04:29PM BLOOD LD(LDH)-774* TotBili-0.3 [2115-10-21] 04:29PM BLOOD CK-MB-15* cTropnT-0.15* [2115-10-21] 10:46PM BLOOD CK(CPK)-140 [2115-10-21] 10:46PM BLOOD CK-MB-13* MB Indx-9.3* cTropnT-0.21* [2115-10-22] 05:03AM BLOOD CK(CPK)-127 [2115-10-22] 05:03AM BLOOD CK-MB-12* MB Indx-9.4* cTropnT-0.18* . [2115-10-20] CXR portable CHEST X-RAY, PORTABLE AP: Comparison is made to prior study of [2115-7-29]. The heart is at the upper limits of normal in size. The aorta is calcified. There is increased density in the right middle lobe and left suprahilar region which has been demonstrated on multiple prior studies and is likely chronic. No new infiltrates are seen. There is stable blunting of the left costophrenic angle. There is no pneumothorax. . IMPRESSION: Stable appearance of the chest from [2115-7-29]. No acute pulmonary process. No pneumothorax. . [2115-10-22] CXR: CHEST X-RAY, PORTABLE AP: Comparison is made to prior study of [2115-7-29]. The heart is at the upper limits of normal in size. The aorta is calcified. There is increased density in the right middle lobe and left suprahilar region which has been demonstrated on multiple prior studies and is likely chronic. No new infiltrates are seen. There is stable blunting of the left costophrenic angle. There is no pneumothorax. IMPRESSION: Stable appearance of the chest from [2115-7-29]. No acute pulmonary process. No pneumothorax. . Echo ([2115-10-22])- Mild symmetric LVH with LVEF of 40 to 45%. NOrmal RV chamber size and wall motion. Severely thickened/deformed aortic valave leaflets with severe AS. Aortic valve area is 0.7 cm2 with a peak gradient of 82 and a mean of 52. 1+ AR and 2+ MR. [First Name (Titles) ] [Last Name (Titles) ] regurgitation. Trivial/physiologic pericardial effusion. . [2115-10-27] CXR: AP SEMI-ERECT PORTABLE CHEST @ 3:40 P.M.: Compared to prior study on [2115-10-25], there appears to be increased interstitial markings in the left lung and at the right base sparing the right upper lung zone. This pattern may be seen in interstitial edema in a patient with emphysema. . Brief Hospital Course: Floor course 1: Pt was initially admitted to the floor service for further care of a COPD exacerbation. On the evening of admission ([10-21]), pt had an episode of [7-9] left sided CP with concurrent SOB that improved with SL NTG. Pt's troponin and CK were subsequently positive (0.13 and 162) and EKG had lateral ST depressions so he was started on a heparin drip. A cardiology consult was obtained on [10-21] and further medical management was initially presued. On the evening of HD #1, the pt developed acutely worsening SOB with tachypnia to the 40s. ABG showed 7.24/57/222 so he was transferred to the MICU for management of hypercarbic respiratory failure including noninvasive ventilation. . MICU course: In the MICU, pt's respiratory status improved with noninvasive ventilation, continuous nebs, IV steroids, and lasix. Anxiety related SOB was also been an issue for which pt received klonipin. Pt continued to be followed by cardiology for his NSTEMI and had a peak troponin of 0.21 at 10:46 PM on [10-21]. Echo was done on [10-22] showing a LVEF of 40 to 45% with severe AS. Pt continued to have severe respiratory distress requiring continuous BIPAP and persistent troponin elevation thought to bue due to secondary demand ischemia. A cardiac cath was not obtained as it would have required intubation which the pt did not desire. TPN was started for nutritional support on [10-24]. Pt was weaned off of noninvasive ventilation on the evening of [10-26] and has been having an oxygen sat of 100% on 6L NC. He was also started on an insulin drip on [10-26] secondary to persistently elevated blood glucose levels. Insulin drip was weaned off prior to being transferred to the floor for further care; pt was continued on NPH and insulin sliding scale. . Floor course 2: . 1. Respiratory- On the floor, pt continued to have good O2 saturations ranging from 97-100% on 1-2Lnc. Pt was continued to be aggressively treated for COPD with standing and prn albuterol nebs, atrovent nebs, montelukast, azithromycin, and steroid taper. Pt was seen by pulmonary consult. From their recommendations, we discontinued atrovent and started spiriva. We also switched from azithromycin to bactrim. Azithromycin has anti-inflammatory properties, but there is still little good evidence for its benefit in COPD. Pulmonary felt that Bactrim would be a better antibiotic, in the the setting of long-term steroids since it has PCP [Name Initial (PRE) 21150]. Advair was added the the regimen. Prednisone taper was continued. The taper is to be as follows: Prednisone 50 x 7 days, 40mg x 7 days, 30mg x 7days, then continue with 20mg. Klonipin which was given for anxiety was discontinued secondary to lethargy. Pt will follow-up with outpatient pulmonologist Dr. [First Name4 (NamePattern1) ] [Known firstname ]. . 2. CAD/[Name (NI) 102410] Pt had a NSTEMI on [10-21] which was felt to be most probably due to demand but acute coronary syndrome could not be absolutely excluded. He was on heparin for 5 days and was d/c'ed in setting of left subconjunctival hemorrhage. Since pt is just recovering from his COPD exacerbation, we felt that it would be safer to defer cardiac cath as an outpatient. Pt agreed with this plan and stated his wish not to be cath'ed during this admission. Cardiology was okay with this plan and they plan to re-evaluate him in 4 weeks. In the meantime, pt was continued on with medical management. He was continued on diltiazem for rate control (beta blocker not used in order to avoid it's bronchospastic effects). However, diltiazem was unable to be titrated up secondary to blood pressure intolerance; pt's HR remained in 90-110 range. Pt was continued on captopril, but most doses were held secondary to blood pressure intolerance. For now, we will discontinue ACEi; please add it back on as tolerated. Pt was continued on aspirin and statin. . 3. Severe aortic stenosis- Pt found to have severe aortic stenosis on echo during this admission. The plan to be have cardiac cath as an outpatient after pulmonary rehab for a formal assessment of the aortic valve. We avoided beta blocker and nitoglycerin. . 4. Steroid induced diabetes mellitus- Pt was continued on NPH and sliding scale. Oral [Doctor Last Name 360] glipizide was added. Pt is on Metformin as an outpatient, but we did not restart that since pt may be at increased risk for lactic acidosis in the setting of hypoxia or cardiac ischemia. Please continue to titrate up glipizide and adjust NPH as indicated. . 5. [Name (NI) 12329] Pt had a difficult time tolerating diltiazem and ACEi given his low blood pressures ranging from 90-100 systolic. We will continue diltiazem for rate control and hold ACEi for now. Please titrate up dilt for better rate control. If BP tolerates, can consider restarting ACEi . 6. Subconjunctival hemorrhage- Occurred in setting of IV heparin and noninvasive positive pressure. There was slow resolution of the hemorrhage. Pt was continued on erythromycin ointment qid. Ophtho stated that it may take 2 weeks for the hemorrhage to resolve. After then, pt should be safe for elective cardiac cath. Should anti-coagulation be urgently indicated prior to resolution of hemorrhage, ophtho feels the hemorrhage should not be an absolute contraindication. Pt will f/u with [Hospital ] clinic one week after discharge. . 7. [Name (NI) 14983] Pt was continued on PPI. . 8. Crohn's disease- Stable Pt was continued on mesalamine DR. . 9. FEN- Was on TPN in MICU which was discontinued. Pt was continued on cardiac, [Doctor First Name ] diet. . 10. Proph- SC heparin; PPI; bowel regimen. . 11. Access- PICC line ([10-22]) . 12. Code- DNR/DNI. Medications on Admission: Meds on admission: 1. Prednisone 20mg qd 2. Prozac 3. Azithromycin 250mg qd 4. Singulair 10mg qhs 5. Alb/Atrovent tid 6. Glucophage 850mg [Hospital1 ] 7. Univasc 7.5mg qd 8. Hytrin 9. Asacol 400mg qd 10. Serevent [Hospital1 ] . Meds on transfer from MICU: 1. Albuterol nebs IH Q4H 2. ASA 325 mg PO daily 3. Atorvastatin 40 mg PO daily 4. Azithromycin 250 mg PO daily 5. Captopril 6.25 mg PO TID 6. Clonazepam 1 mg PO BID 7. Diltiazem 30 mg PO QID 8. Docusate 100 mg PO BID 9. Erythromycin 0.5% opth oint 0.5 in OU QID 10. Famotidine 20 mg PO BID 11. SC heparin 5000 units TID 12. Ipratropium bromide neb IH Q6H 13. Mesalamine DR 400 mg PO TID 14. Montelukast sodium 10 mg PO daily 15. Prednisone 50 mg PO daily 16. Senna PRN 17. Bisacodyl PRN 18. Albuterol neb PRN 19. Tylenol PRN 20. Insulin- being weaned off drip Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Sodium Chloride 0.65 % Aerosol, Spray Sig: [11-30] Sprays Nasal QID (4 times a day) as needed. 7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheezing. 8. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4 times a day). 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 13. Prednisone 10 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily) for 2 days: Last day is [11-3]. 14. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days: From [11-4] to [11-10]. 15. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day for 7 days: From [11-11] to [11-17]. 16. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day: Start [11-18] and continue. 17. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 19. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed. 20. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 21. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 22. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 23. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Capsule, w/Inhalation Device Inhalation qd (). 24. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 25. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. 26. Morphine Sulfate 2 mg/mL Syringe Sig: One (1) Injection q4h prn as needed for air hunger, pain. 27. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO qhs prn as needed for aggitation, anxiety: Hold for sedation or for RR<12. 28. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 29. Insulin NPH Human Recomb 100 unit/mL Syringe Sig: One (1) Subcutaneous twice a day: 24U qAM 12U qPM. 30. Insulin Regular Human 300 unit/3 mL Syringe Sig: One (1) Subcutaneous four times a day: Please follow insulin sliding scale QID. Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: COPD exacerbation s/p NSTEMI severe AS steroid induced DM Discharge Condition: Stable Discharge Instructions: If you develop difficulty breathing or chest pain, call your doctor or return to the emergency room. Followup Instructions: Follow up with Ophthamology on: [2121-11-17]:15am with Dr. [Last Name (STitle) ] located in [Hospital Ward Name 23] [Location (un) 442] follow up with your primary care doctor : [Name6 (MD) ] [Name8 (MD) ], MD Where: [Hospital6 29] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2115-11-19], 10am Provider PULMONARY BREATHING TEST Where: [Hospital6 29] PULMONARY FUNCTION LAB Phone:[Telephone/Fax (1) 612] Date/Time:[2115-12-23] 9:45 Provider [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 5265], M.D. Where: [Hospital6 29] Phone:[Telephone/Fax (1) 5091] Date/Time:[2115-12-4] 10:30 Follow up with cardiology on [12-2] with Dr. [Last Name (STitle) ] at 11am located in [Hospital Ward Name 23] [Location (un) 436]. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "41071", "4241", "4280" ]
Unit No: [Numeric Identifier 66861] Admission Date: [2196-4-22] Discharge Date: [2196-8-1] Date of Birth: [2196-4-22] Sex: F Service: NB HISTORY: Baby girl [Known lastname 30041], twin A was a 748 gram product of a 25 and [4-8] week gestation born to a 36-year-old G7, P4, now 7 mom. Prenatal screens - B positive, antibody negative, hepatitis surface antigen negative, RPR nonreactive, rubella immune, and GBS unknown. This was a spontaneous di-di twin gestation. Mother had some early bleeding and shortening of cervix. Mother was transferred from [Hospital3 ] with preterm labor. She received betamethasone prior to delivery. She was also treated with antibiotics prior to delivery. The infant was delivered by cesarean section. She emerged with a nuchal cord, was given positive pressure ventilation, intubated in the delivery room. Apgars were 6 at 1 minute, and 8 at 5 minutes. PHYSICAL EXAMINATION: Birth weight 748 grams, 25th to 50th percentile; head circumference 24 cm, 25th percentile; length 32 cm, 25th to 50th percentile. Neck supple. Lungs shallow respirations with intercostal retractions. CARDIOVASCULAR: Regular rate and rhythm. No murmurs. Femoral pulses palpable. Abdomen soft. No bowel sounds appreciated. No masses or organomegaly. GENITOURINARY: Normal preterm female. Anus patent. Spine midline but no dimples. Hips stable. Clavicles intact. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: [Known lastname 18488] was intubated in the delivery room for management of respiratory distress syndrome. On admission to the newborn intensive care unit, the infant received a total of 3 doses of surfactant therapy for management of respiratory distress syndrome. The infant remained ventilated for a total of 38 days on a combination of conventional ventilation and high frequency ventilation. Her maximum respiratory support included high frequency ventilation with a mean airway pressure of 16 and amplitude of 26. She was exutbated and then transitioned to CPAP. She remained on CPAP for a total of 21 days at which time she transitioned to nasal cannula oxygen. She currently is stable on nasal cannula oxygen flow between 13 to 25 ml per minute and is otherwise stable. [Known lastname 18488] was treated with caffeine citrate until [2196-7-11] for management of apnea bradycardia of prematurity. She continues to have occasional apnea bradycardiac episodes with the last documented episode being on [2196-7-29]. CARDIOVASCULAR: [Known lastname 18488] is status post two courses of indomethacin therapy for patent ductus arteriosus. Following completion of her second course of indomethacin an echocardiogram documented a patent ductus arteriosus. A decision was made to have the infant ligated. A PDA ligation was completed on [2196-4-29] and the infant has been cardiovascularly stable until [2196-7-8] with the onset of an increasing blood pressure. Renal service was consulted after the infant had a renal ultrasound which demonstrated an echogenic kidney. Her urinalysis was negative at that time and her BUN and creatinine were 15 and 0.2. Renal service was consulted at that time and they suggested starting the infant in Captopril. She was started on her Captopril on [2196-7-13] with little effect. She was receiving intermittent hydralazine for immediate management of hypertension. On [7-23], the infant continued to received hydralazine around the clock in addition to her Captopril dosing. Recommendations were made by renal to start the infant on Lasix. She was started on her Lasix therapy on [2196-7-23] at 2 mg per kg per day. At the same time she was receiving Captopril at 0.2 mg per kg per day and hydralazine 0.5 mg per kg per dose. She demonstrated a nice response with this therapy. Her last dose of hydralazine was on [2196-7-25]. Her Lasix was discontinued on [2196-7-28]. She is currently receiving Captopril 0.32 mg PO t.i.d which is 0.1 mg per kg t.i.d. Her blood pressure ranges have been 73/49 to 54 and has otherwise been stable. The renal team would like a post discharge follow up 1 month after discharge from [Hospital3 ] with Dr. [Last Name (STitle) 66862]. His telephone number is [Telephone/Fax (1) 50498]. They also recommend a DMSA scan during the month of [Month (only) ] as an outpatient. FLUIDS, ELECTROLYTES AND NUTRITION: The infant's birth weight was 748 grams. Her discharge weight is 3495 grams. The infant was initially started on 100 cc per kg per day of D10W via UAC, and we were unsuccessful in receiving a UVC. The infant has central percutaneous intravenous catheter placed on day of life 1 which was maintained throughout the remainder of her IV therapy needs. Enteral feedings were started on [2196-5-2]. She achieved full enteral intake by [5-14]. Her maximum enteral intake was 130 cc per kg per day of premature Enfamil 30 calorie with ProMod. She is currently receiving a 140 cc per kg per day of special care 24 calorie, working PO skills, demonstrating good weight gain. Her most recent set of electrolytes were on [2196-8-1] and they are Na 128 K 5.4 Cl 95 CO2 27. GASTROINTESTINAL: Her peak bilirubin was 6.4/0.3. She was treated with phototherapy. This issue resolved and her most recent bilirubin level was 4.8/0.4. HEMATOLOGY: Blood type is A positive, Coombs negative. Hematocrit on admission was 48.1. She received a total of 5 packed red blood cell transfusions with her most recent being on [2196-5-9]. On [2196-7-27], her hematocrit was 30.7 with a reticulocyte count of 9.2%. She is currently receiving ferrous sulfate supplementation of 0.35 mg PO once daily. INFECTIOUS DISEASE: CBC and differential were obtained on admission. CBC was benign. Blood cultures remained negative at 48 hours at which time ampicillin and gentamicin were discontinued. During her hospital course she also received 48 hour rule out of vancomycin and gentamycin secondary to increased concerns of itis. This was discontinued on [2196-5-6]. She was also treated with erythromycin ophthalmic ointment secondary to gram positive cocci culture from her eye. She completed this 7-day course on [2196-6-18]. NEUROLOGICAL: She has had several head ultrasounds which were within normal limits, most recent being on [2196-7-6]. SENSORY/AUDIOLOGY: Hearing screen is yet to be performed but should be done prior to discharge to home. OPHTHALMOLOGY: The infant has been seen and followed closely by Dr.[First Name9 (NamePattern2) ] [Name (STitle) 50313]. Most recent examination on [7-25], demonstrated immature retinal vessels to zone 3 with a recommended follow up in 3 weeks. PSYCHOSOCIAL: Parents are interested and involved and visit on a daily basis. The baby's father's name is [Name (NI) ] [Name (NI) 10269]. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To [Hospital3 ]. NAME OF PRIMARY PEDIATRICIAN: Dr. [Last Name (STitle) 23340]. Telephone No.: [Telephone/Fax (1) 37501]. CARE RECOMMENDATIONS: 1. Feeds at discharge: Continue 140 cc per kg per day of special care 24 calorie, working NPO enteral feeding. 2. Medications: Captopril 0.32 mg t.i.d, (0.1 mg per kg t.i.d). Ferrous sulfate 0.35 kg PO once daily. 3. Car seat position screening has not yet been performed. 4. State newborn screens have been sent per protocol and have been within normal limits. 5. Immunizations received: [Known lastname 18488] received Hepatitis B vaccine on [2196-5-26]. She received Pediarix on [6-26], [2196]. Pneumococcal 7-Valent on [2196-6-27]. HIV on [2196-6-27]. 6. The renal team would like a post discharge follow up 1 month after discharge from [Hospital3 ] with Dr. [Last Name (STitle) 66862]. His telephone number is [Telephone/Fax (1) 50498]. They also recommend a DMSA scan during the month of [Month (only) ] as an outpatient. DISCHARGE DIAGNOSES: 1. Premature infant, twin No. 1 born at 25 and 4/7 weeks gestation. 2. Respiratory distress syndrome. 3. Rule out sepsis with antibiotics. 4. Patent ductus arteriosus ligation. 5. Hyperbilirubinemia. 6. Apnea/ bradycardia of prematurity. 7. Anemia of prematurity. 8. Hypertension of unknown etiology. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 48738], MD [MD Number(2) 55708] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2196-7-31] 03:14:42 T: [2196-7-31] 07:28:58 Job#: [Job Number 66863]	[ "7742", "4019", "V290", "V053" ]
Admission Date: [2193-9-27] Discharge Date: [2193-10-2] Date of Birth: [2135-10-8] Sex: M HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 36633] is a 57-year-old male with a history of laryngeal cancer, status post tracheostomy and percutaneous endoscopic gastrostomy placement approximately five years ago with recent admission and [9-26] secondary to traumatic subarachnoid hemorrhage and intraventricular hemorrhage secondary to a fall caused by alcohol intoxication. He was on the Surgical Intensive Care Unit Service and subsequently was discharged to [Hospital6 6296]. He was in [Hospital6 6296] for approximately one to two [Hospital6 6296] in the setting of a temperature spike to 103. He was also noted to have increased agitation complicated by self discontinue of Foley catheter which led to hematuria. He also had one witnessed seizure episode in this setting. He was initially brought to an outside hospital where a workup included a head CT which revealed an improving right-sided hematoma and no new bleed. Chest x-ray which revealed question of right lower lobe infiltrate. The patient was empirically diagnosed with aspiration pneumonia and treated with clindamycin. He was also loaded with Dilantin with a transfer to [Hospital1 188]. At [Hospital1 69] he presented hypotensive with a systolic blood pressure in the 90s, without response to 2 liters of intravenous fluids. The workup was notable for left shift leukocytosis, negative chest x-ray, negative head CT. The patient was given one dose of vancomycin to expand antibiotic coverage, as he has a recent history of methicillin-resistant Staphylococcus aureus pneumonia, and the patient was admitted to the Medical Intensive Care Unit for supportive care for presumed sepsis. PAST MEDICAL HISTORY: 1. Laryngeal cancer. 2. Status post tracheostomy. 3. Status post percutaneous endoscopic gastrostomy. 4. Subarachnoid hemorrhage/intraventricular hemorrhage on [2193-9-11]. 5. Alcohol abuse. 6. Osteoarthritis. 7. Peripheral vascular disease. 8. Seizure disorder; unclear how old this is. 9. History of aspiration pneumonia. 10. History of detached retina. MEDICATIONS ON ADMISSION: (At [Hospital6 6296]) Lisinopril 30 mg p.o. q.d., Dilantin 100 mg p.o. t.i.d., thiamine 100 mg p.o. q.d., folate 1 mg p.o. q.d., multivitamin, Prevacid suspension 30 cc p.o. q.d., and Ultra-Cal tube feeds 75 cc per hour goal. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: Temperature 98.9, blood pressure 91/63, pulse 96, respirations 20, oxygen saturation 100% on 6-liter tracheostomy mask. In general, he was response, alert, followed commands, nontoxic, eating without difficulty. Complained of penile pain. HEENT revealed tracheostomy was in place. The patient was stable. No jugular venous distention. Lungs were clear to auscultation bilaterally. Heart had sinus tachycardia, faint S1 and S2, no extra sounds. The abdomen was soft, nontender, and nondistended, active bowel sounds. Percutaneous endoscopic gastrostomy site stable on the left side. Extremities had no edema, 2+ distal pulses. Neurologic examination revealed right-sided weakness, [12-24] in the lower extremities. Upper right extremity had [2-21]; otherwise nonfocal. LABORATORY DATA ON PRESENTATION: White blood cell count 22.3, hematocrit 32.7, platelets 233. White blood cell count differential was 89 neutrophils, 3 bands, 4 lymphocytes, and 2 monocytes. Sodium 134, potassium 4.2, chloride 97, bicarbonate 27, BUN 12, creatinine 0.6, glucose of 116. Dilantin level was 8.5 (which was low). Urinalysis had large blood, negative nitrites, small bilirubin, 11 to 20 red blood cells, 6 to 10 white blood cells, and occasional bacteria. Microbiology from previous admission revealed methicillin-resistant Staphylococcus aureus sputum culture which was sensitive to gentamicin, levofloxacin, and vancomycin. RADIOLOGY/IMAGING: Chest x-ray revealed a patchy opacity in the right lower lobe; otherwise, no infiltrates or congestive heart failure. Cardiac silhouette was within normal limits. Head CT revealed hematoma in the posterior corpus collasum extending into the right lateral ventricle which was improved since prior studies. Electrocardiogram revealed sinus tachycardia at 106 beats per minute, normal axis and intervals. No acute ST changes. HOSPITAL COURSE BY SYSTEM: 1. INFECTIOUS DISEASE: His blood cultures grew 1/4 bottles of methicillin-resistant Staphylococcus aureus; and therefore, the patient was continued on vancomycin intravenously. His Flagyl and Levaquin were stopped. A transthoracic echocardiogram was done to rule out endocarditis, which was negative. A peripherally inserted central catheter line was placed for long-term antibiotic treatment. There was no evidence of osteomyelitis or septic joints on examination throughout his hospital course. 2. PULMONARY: The patient received good tracheostomy care. He was able to tolerate being weaned from the oxygen and had no issues with his tracheostomy. 3. CARDIOVASCULAR: The patient's blood pressures were initially treated with fluid hydration and Neo-Synephrine. He was ultimately weaned off the Neo-Synephrine and was transferred to the floor. The patient's ACE inhibitor was held initially, but then was restarted before discharge. 4. GASTROINTESTINAL: The patient developed abdominal pain on hospital days two and three, and his liver function tests, and amylase, and lipase increased. When he was admitted the differential for this was between biliary stone disease, tube feed induced and shock liver. His liver function tests, amylase, and lipase returned back to normal. He also had no further complaints of abdominal pain. 5. NUTRITION: The patient's tube feeds were held in the initial setting of pancreatitis; however, they were restarted and ProMod with fiber was increased to a goal of 75 cc per hour. He tolerated this well. He received a swallowing evaluation and a video swallowing study to evaluate for aspiration, and there was evidence of Macroaspiration. Therefore, he only received a small amount of apple sauce, but was otherwise kept n.p.o., and tube feeds were continued. 6. RENAL: There were no issues. 7. ENDOCRINE: There were no issues. 8. HEMATOLOGY: There were no issues. 9. NEUROLOGY: The patient was given a loading dose of Dilantin when he came into the outside hospital, and free Dilantin level was checked which was slightly low; and, therefore, the patient's Dilantin dose was increased to 125 mg p.o. t.i.d. He was continued at this dose until discharge. He had no further seizure activity or neurologic complaints during this admission. DISCHARGE PLAN: Discharged back to [Hospital6 19936]. Outpatient transesophageal echocardiogram was arranged to definitively rule out endocarditis. CONDITION AT DISCHARGE: The patient was stable and at his current baseline. MEDICATIONS ON DISCHARGE: 1. Lisinopril 30 mg p.o. q.d. 2. Dilantin 125 mg p.o. q.8h. 3. Thiamine 100 mg p.o. q.d. 4. Folate 1 mg p.o. q.d. 5. Multivitamin. 6. Prevacid suspension 30 cc p.o. q.d. 7. Vancomycin 1 g intravenously q.12.h. times two weeks total for methicillin-resistant Staphylococcus aureus bacteremia through peripherally inserted central catheter line. DISCHARGE DIAGNOSES: 1. Methicillin-resistant Staphylococcus aureus bacteremia. 2. Question of methicillin-resistant Staphylococcus aureus pneumonia, right lower lobe. 3. Seizure disorder. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 35154], M.D. [MD Number(2) 36634] Dictated By:[Name8 (MD) 6069] MEDQUIST36 D: [2193-10-1] 16:10 T: [2193-10-1] 15:31 JOB#: [Job Number 36635] (cclist)	[ "5070" ]
Admission Date: [2114-4-23] Discharge Date: [2114-5-9] Date of Birth: [2050-4-18] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2901] Chief Complaint: CHF & severe aortic stenosis Major Surgical or Invasive Procedure: aortic valvululoplasty swan ganz catheter History of Present Illness: Mr. [Known lastname 1511] is a 64 yo man with dilated cardiomyopathy (presumed non-ischemic) and severe aortic stenosis (valve are 0.8, peak gradient 87) who was transferred from Holy [Hospital 82745] hospital for further care of his aortic stenosis. According to his initial H&P on [4-15] Mr. [Known lastname 1511] was admitted for dyspnea with minimal activity, fatigue, orthopnea, and ankle edema. He is delerius on transfer and is unable to provide any more information. Per his wife he gets dyspneic usually upon ambulating from room to room; this has worsened recently. At [Hospital3 ] he was (hct 24.7 & BUN 100) he was found to have have GI bleed; upper GI showed minimal erosions; c-scope showed residual blood & R-colon AVM that was cuaterized; he was also placed on octreotide. For an unclear reason he underwent cardiac cath today which showed EF 25%, clean coronaries. AVG 58 peak with mean 40. PCW 16, LVEDP 15, PA pressures of 85/29 & RVEDP 8. After the cardiac cath he became agitated, agressive, and was dyspneic requiring 4L. bp 79/59, He was given 80mg IV lasix for presumed CHF. He was in afib with RVR at the time in 110-130's and was given po toprol (50mg) & IV metoprolol (10mg). no temp recorded. Na 136, K 3.6, BUN 45, Cr 1.1, chloritde 105, bicarb 24. WBC increased to 15.8. VS prior to transfer: BP 160/56 HR 106 100% on 4L. RR 26-32. . Mr. [Known lastname 1511] remembers nothing of the event. Upon speaking with is wife, he was not delerious, febrile, or agitated prior to the cath. . On transfer Mr. [Known lastname 1511] is delerius and febrile to 102.3, knows he is in the hospital, unsure of which one. Thinks the year is [2049]. He cannot recall any of the symptoms leading up to his hospitalization. Currently he complains of fever and abdominal pain. He denies orthopnea, pnd, cough. He is mildly dyspneic. . Past Medical History: COPD; ?home oxygen aortic stenosis dilated CMP; last EF 25%. RV hypertrophy & hypokinesis Lumbar disc disease OSA A fib MRSA of R leg atrial fibrillation Social History: former smoker. married with 3 chilldren. Denies EtoH Family History: n/c Physical Exam: On admission - T 101.4 oral, 103.8 rectal, then T 105. RR 30-40 96% on 4L n/c. BP 92/54 with HR 120 & irregular Gen: ill-appearing, jaundiced CV: tachycardic. Very difficult to appreciate heart sounds over tachypnea Pulm: Tachypneic but CTA B Abdomen: obese, soft, non-distended diffusely TTP; maximally TTP in RUQ. + [Doctor Last Name ] sign. Extremity: 1+ BLE edema Neuro: oriented x 1. thinks it is [2049]. Knows hospital, but not [Location (un) 86] or [Hospital1 18]. No meningismus. Pertinent Results: ADMISSION LABS: [2114-4-23] 08:15PM BLOOD WBC-17.6* RBC-4.00* Hgb-10.9* Hct-34.4* MCV-86 MCH-27.2 MCHC-31.7 RDW-19.2* Plt Ct-173 [2114-4-23] 08:15PM BLOOD Neuts-94.9* Lymphs-2.2* Monos-2.6 Eos-0.1 Baso-0.1 [2114-4-23] 08:15PM BLOOD PT-18.9* PTT-38.6* INR(PT)-1.7* [2114-4-25] 01:34PM BLOOD FDP-40-80* [2114-4-23] 08:15PM BLOOD Glucose-188* UreaN-45* Creat-2.0* Na-137 K-5.1 Cl-103 HCO3-21* AnGap-18 [2114-4-23] 08:15PM BLOOD ALT-321* AST-459* CK(CPK)-39 AlkPhos-75 Amylase-22 TotBili-2.7* DirBili-1.7* IndBili-1.0 [2114-4-23] 08:15PM BLOOD Albumin-3.7 Calcium-8.8 Phos-5.5* Mg-1.8 [2114-4-23] 08:15PM BLOOD Hapto-215* [2114-4-25] 03:42AM BLOOD IgM HAV-NEGATIVE [2114-4-23] 11:19PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [2114-4-25] 02:17PM BLOOD Smooth-NEGATIVE [2114-4-23] 11:19PM BLOOD HCV Ab-NEGATIVE . cardiac cath: hemodynamics: peak gradient 59, mean gradient 40. [Location (un) 109] 0.8cm2. CO 4.73 LV pressure 135/14/17, AO 78/60/64 RA 23/26/23 RV [2098-6-26] PA 85/29/55 PCW 21/23/16 RVEDP 8 . original EKG on [4-17]: a fib with normal axis. IVCD & QRS of 91. delayed RWP. lat ST depressions (V5-6) . EKG on arrival to CCU: irregular wide complex-tachycardia, axis about 180. IVCD with QRS of 152. ?possible concordance of precordial leads. . ECHO on [2114-4-10]. EF 20%, global LV hypok. dilated with concentric hypertrophy. atrium dilated. 1+ MR. AS with [Location (un) 109] 0.88cm2. peak gradient 87, mean gradient 57. LVOT velocity 111cm/s, peak velocity 477 cm/s. 1+ TR. rheumatic aortic valve with AS, 2+ AR, rheumatic MS, 1+ MR, 1+ TR. mild PA htn CXR: no pulm edema RUQ US: no gall stones, biliary ductal dilation or cholecystitis. Neg [Doctor Last Name ] blood cultures: MSSA in [3-24] bottles on admission. negative thereafter. Brief Hospital Course: Mr. [Known lastname 1511] is a 64 yo man with dilated cardiomyopathy and severe aortic stenosis, OSA & pulmonary hypertension who was admitted to the hospital for worsening dyspnea and is transferred to [Hospital1 18] for further care. He expired after developing sepsis, renal failure, acidosis and hypotension not responsive to pressors. # Sepsis/bacteremia: Mr. [Known lastname 1511] was febrile to 105 on admission. He was empirically covered with vancomycin/cipro/flagyl on admission. A central venous line was placed and he was aggressively hydrated. He became hypotensive on the night of admission and was started on dobutamine + levophed. Admission blood cultures quickly turned positive for [3-24] MSSA. His antibiotics were changed to nafcilling. TTE and TEE were negative for endocarditis and repeat blood cultures remained negative. He completed his course of nafcillin in-house. WBC trended up and patient developed lactic acidosis in addition to his leukocytosis. Culture data was negative at the time of death. Patient was on broad spectrum antibiotics on [2114-5-7] including vancomycin and zosyn. Patient was dependent on pressors to keep MAPs greater than 55. As acidosis worsened, patient became less pressor responsive and died in the presence of his family. # Cardiogenic shock: secondary to depressed EF and severe AS. Maintained on dobutamine + levophed. Diuresed with guidance of swan-ganz catheter. Mr. [Known lastname 1511] was evaluated by Dr. [Last Name (STitle) 28946] of CT surgery for consideration of AVR, but was # Dyspnea: likely multifactorial from fever, severe pulmonary hypertension, COPD, and CHF. Swan Ganz Catheter was placed and he was found to have severe pulmonary hypertension; some of which was responsive to diuresis (at near-systemic pressures at highest). He was aggressively diuresed. # Transaminitis: From shock liver. Resolved with supportive care . # Abdominal pain: due to hepatitis. RUQ US negative and pain resolved. . # Aortic Stenosis: severe based on gradient and valve area. Patient has had symptoms of refractory heart failure, but no angina or syncope. Depressed EF alone is indication for valve repair. - consider dobutamine echo to r/o pseudo aortic stenosis . # Atrial fibrillation - given amiodarone for rate control. Had rate-related BBB . # Lower GIB: stable . # Diabetes: decrease lantus to 26 while not eating much . # hyperlipidemia: continue statin . # Access: placed chordus with RIJ CVC [2114-4-23]. Will place swan in AM . # FEN/GI: clears while unstable/poor mental status. . # Code: full Medications on Admission: torsemide 20mg po bid metolazone 2.5mg po daily lipitor 20mg po daily lisinopril 20mg po daily niaspan 500mg po daily omeprazole 20mg po daily prandin 2mg po tid coumadin metoclopramide januvia 50mg o [Hospital1 ] carvedilol 6.25mg po bid aspirin lantus advair spiriva . meds on transfer coreg 6.25mg po bid valium prior to procedure digoxin 0.25mg IV x 2 lovenox 40mg SQ daily ferrous sulfate advair daily lasix 80mg IV x 1 lisinopril 20mg po daily insulin levemir 34U QHS Toprol 50mg po daily niacin 500mg po daily octerotide 0.05mg SQ tid potassium 20mg po daily Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: primary: cardiogenic shock Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909] Completed by:[2114-5-15]	[ "99592", "5990", "5845", "2762", "4280", "2875", "496", "42731", "2724", "4168", "32723" ]
Admission Date: [2164-5-18] Discharge Date: [2164-5-25] Date of Birth: [2088-12-17] Sex: M Service: NEUROSURGERY Allergies: Neosporin Attending:[First Name3 (LF) 1271] Chief Complaint: SOB at OSH Major Surgical or Invasive Procedure: [2164-5-20] C3-5 Laminectomy and Fusion, posterior History of Present Illness: 75 y/o male with congestive heart failure, ejection fraction of 50%, CAD status post MI, hyperglycemia while on steroids,COPD on home oxygen, atrial fibrillation/flutter on Coumadin, history of lung cancer, status post resection, who presented to the [Location (un) 620] ER on [5-20], with increasing dyspnea over the last few days. He noted bilateral shoulder weakness and is unable to lift his arms over his head to the medical service at [Location (un) 620]. He reports this began approximately 2 years ago; however, it has progressively worsened over the last several weeks to days, to the point where he is unable to feed himself, especially with his right. The symptoms first started to worsen on the R side 1-2 weeks ago and in the past several days he has started having increased symptoms on the L. Past Medical History: - CHF: EF 50% 5/07 with dilated left atrium, 1+ MR. [First Name (Titles) ] [Last Name (Titles) 5348] he sleeps with 3 pillows. - COPD: on 2.5-3L NC home O2, [Last Name (Titles) 5348] 10mg prednisone daily, recent admit for exacerbation [6-13] with steroid taper. Has had [4-10] hospitalizations for COPD in last 3 years, never intubated - Atrial Fibrillation (on coumadin 2.5 mg): INR 1.6 at [Location (un) 620] - Neuropathy with chronic pain - Lung cancer, diagnosed 5 years ago, s/p resection of ?R lung per family [4-10] yrs ago - depression - hiatal hernia - Tracheobronchomalacia per previous CT - Small cystic lesions in the liver and kidneys, incompletely characterized. Social History: He lives with his wife, 60 pack-year smoking hx, quit 30 yrs ago, social drinker. Family History: Non-contributory Physical Exam: Admission: PHYSICAL EXAM: O: T: 97.5 BP: 98/60 HR:100 R 20 O2Sats 97% 3L Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs intact Neck: Supple. Lungs: Crackles right base, wheezes throughout Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T FE FF IP Q AT [Last Name (un) 938] G R 1 4 4 4 4 5 5 1 1 5 L 1 4 4 4 4 5 5 1 1 5 Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Pertinent Results: [2164-5-18] 09:54PM PT-27.0* PTT-32.1 INR(PT)-2.7* [2164-5-18] 09:54PM PLT COUNT-251 [2164-5-18] 09:54PM NEUTS-87.2* LYMPHS-8.2* MONOS-4.4 EOS-0.2 BASOS-0 [2164-5-18] 09:54PM WBC-10.2 RBC-4.60 HGB-12.3* HCT-38.3* MCV-83 MCH-26.7* MCHC-32.0 RDW-14.9 [2164-5-18] 09:54PM CALCIUM-9.5 PHOSPHATE-3.7 MAGNESIUM-2.1 [2164-5-18] 09:54PM estGFR-Using this [2164-5-18] 09:54PM GLUCOSE-96 UREA N-27* CREAT-0.9 SODIUM-138 POTASSIUM-4.1 CHLORIDE-92* TOTAL CO2-39* ANION GAP-11 Brief Hospital Course: 75 y/o male with congestive heart failure, ejection fraction of 50%, CAD status post MI, hyperglycemia while on steroids,COPD on home oxygen, atrial fibrillation/flutter on Coumadin, history of lung cancer, status post resection, who presented to the [Location (un) 620] ER with increasing dyspnea over the last few days. He noted bilateral shoulder weakness and is unable to lift his arms over his head to the medical service at [Location (un) 620]. He reports this began approximately 2 years ago; however, it has progressively worsened over the last several weeks to days, to the point where he is unable to feed himself, especially with his right. The symptoms first started to worsen on the R side 1-2 weeks ago and in the past several days he has started having increased symptoms on the L. He was treated for pneumonia, and COPD flare with antibiotics, prednisone and lasix. He was transferred to the neurosurgery service for further evaluation. On [2164-5-20] he underwent an urgent pPosterior cervical laminectomies C3, C4, C5, with instrumentation and arthrodesis from C3-C5 with lateral mass screws with approximately 900cc blood loss. Post operatively he went to the ICU where he was monitored closely and BP was kept at a normal range to perfuse his cord. He was successfully extubated on post operative day one. He was able to move his shoulders with improvement and his right arm was somewhat stronger according to the patient. On POD#2 he was moved to the floor where he remained hemodyanmically stable. His respiratory status improved and he was weaned off oxygen. A follow CXR on [5-24] showed resolved pneumonia and mild CHF he was started back on his Lasix. He was treated for a UTI on [5-20] he should complete 7 days of Levaquin his foley was dc'd and he is able to void using a condom cath. Neurologically he had at least 4+ strenght in trapezius, 4- in his deltoids and biceps on right were 4+to 5s and tricep the same on left his bicep was 3 and tricep was 4. He has previous bilateral foot drops prior to admission. He was tolerating a regular diet on discharge and had stood at the side of the bed with physcial therapy. He was fitted with a new collar on discharge. Medications on Admission: At [Location (un) 620]: Levaquin 500 mg IV daily, Lasix 80 mg IV daily, Zestril 5 mg daily, bisoprolol 2.5mg daily, Cardizem 180 mg daily, Spiriva 18 mcg daily, DuoNebs q. 6 hours as needed, Advair 250/50 one puff b.i.d., Lipitor 80mg daily,. Zoloft 50 mg daily, Nexium 40 mg p.o. daily, Neurontin 600 mg every morning, 300 mg every afternoon, 600 mg every evening. [Doctor First Name ] 120 mg daily. Percocet as needed. Fentanyl patch 50 mcg q. 72 hours. Prednisone 40 mg daily. Vitamin B-12 1000 mcg daily. Colace 100 mg. Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) as needed for in afternoon. 10. Fexofenadine 60 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 14. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 15. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 16. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours). 17. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 19. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 20. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 22. Diazepam 5 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours). 23. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 24. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 1294] Discharge Diagnosis: Cervical Spine Stenosis Discharge Condition: Neurologically stable Discharge Instructions: ?????? Do not smoke ?????? Keep wound(s) clean and dry / No tub baths or pools for two weeks from your date of surgery ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? If you are required to wear one, wear cervical collar or back brace as instructed ?????? You may shower briefly without the collar unless instructed otherwise ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. unless directed by your doctor ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits You may restart coumadin on [6-19]. Keep collar on at all times Followup Instructions: Have your staples removed on [5-31] at rehab facility PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR.[Last Name (STitle) 14074] TO BE SEEN IN [5-13] WEEKS. YOU WILL NEED XRAYS PRIOR TO YOUR APPOINMENT. [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2164-5-25]	[ "486", "5990", "4280", "412", "42731", "V5861" ]
Unit No: [Unit Number 41750] Admission Date: [2186-6-11] Discharge Date: [2186-7-20] Sex: Male Service: General Surgery HISTORY OF PRESENT ILLNESS: This is an 80 year old Caucasian male who was admitted to [Hospital3 ] from [Hospital1 1444] on [2186-6-10], with the following diagnoses of fatigue, dehydration, status post resection of gastrointestinal stromal tumor in [2185-12-26]. The patient is an 80 year old male patient with a past medical history of Crohn's and had just had tumor resected by Dr. [Last Name (STitle) 957], noninsulin dependent diabetes mellitus, metastases of the chest, status post Gleevec tumor therapy. He was readmitted, after discharge from [Hospital1 190] on [2186-6-9], on [2186-6-11], when he represented via the Emergency Department for fatigue, decreased appetite, diarrhea and came in complaining of dehydration, increased lethargy and hypotension. The patient was seen in the Emergency Department by the surgical service and was assessed to have a distended, tender and tympanitic abdomen. PAST MEDICAL HISTORY: Crohn's disease. Melanoma. Spinal stenosis. Cataract. Noninsulin dependent diabetes mellitus. PAST SURGICAL HISTORY: Small bowel resection. HOSPITAL COURSE: X-ray obtained in the Emergency Department illustrated free air with evidence of an acute abdomen and was taken to the operating room by Dr. [First Name (STitle) 2819] who was covering for Dr. [Last Name (STitle) 957] as he was out of town. The patient was found to have a perforated viscus. Please see operative note on [2186-6-11], for further information. He was seen to have a perforation at the distal transverse colon on the proximal sigmoid and he was having a transverse left end sigmoid colectomy, colostomy, Hartmann's pouch with placement of a gastrostomy tube, jejunostomy tube and take-down of the splenic flexure. The patient was admitted to the Intensive Care Unit and continued to have a complicated course. The patient received blood transfusions, as well as aggressive Intensive Care Unit care. Various services were consulted for management of this acutely ill patient including oncology service. The patient was eventually weaned off the vasopressin for support and was started on TPN for nutritional support due to his prolonged Intensive Care Unit admission. The patient was managed by the Intensive Care Unit team in the interim with consults from the general surgery service. The patient continued to oscillate in terms of his respiratory status alternating between vent settings and at times being able to support decreasing PEEP and pressure support. The patient in the beginning of [Month (only) ] continued to have hemodynamic instability and despite noninvasive imaging immediate source was not obtained. The patient was given fluid and Levophed and packed red blood cells in hopes to increase blood pressure and hemodynamic stability and was thought origin might be due to intra-abdominal sepsis and was reintubated for airway protection. CT scan of the chest illustrated bilateral pleural effusions. On [2186-6-29], thoracic surgery was consulted and chest tube was placed and 750 cc of serous fluid was obtained in the pleurovac. With this increased serous output, the patient required less Levophed and appeared to clinically improve. Over the next few days, the patient continued to have massive drainage from the chest tube and was eventually stabilized. In the beginning of [Month (only) ], the patient continued to have a few intermittent episodes of hypotension and intermittent fevers which were appropriately treated. An infectious disease consultation was obtained for management of his intermittent fevers and for further investigation of his intra-abdominal sepsis. Infectious disease made numerous recommendations which were taken into consideration. General surgery consultation was appreciated and continued to follow closely in conjunction with Dr. [Last Name (STitle) 957]. The patient continued to have hemodynamic instability despite numerous attempts to wean the patient from ventilatory support secondary to hemodynamic instability, hypovolemia and intra-abdominal sepsis. The patient was restarted on nutritional support via TPN and stopped on tube feeds. Chest tubes continued to drain considerable amount of serosanguineous fluid with the drainage from his gastrostomy tube continuing. The patient on [2186-7-9], went into atrial fibrillation with heart rates in the 110 to 130 range with blood pressure dropping to the 80s. Fluid boluses provided only transient effect. Initial Lopressor given provided no effect. The patient was cardioverted and remained in sinus rhythm and improved with two additional fluid boluses. The patient was monitored closely for additional cardiac events. The patient was tried on continuous positive airway pressure and eventually was weaned after an extended period of time and was extubated on the morning of [2186-7-11], and he appeared to be clinically improving for a few days, however, began to have some mental confusion the day after extubation on [2186-7-12]. Neurology was consulted for evaluation of a stroke. The patient was decided to become DNI on approximately [2186-7-16], after requiring multiple fluid boluses and restarted on Levophed overnight due to additional hemodynamic instability. The patient was thought to have a multifactorial cause of his confusion but could not rule out an underlying neurological cause such as stroke given his recent events. CT scan was obtained. A family meeting on [2186-7-18], was held and it was decided for the patient to be DNR/DNI. The patient continued to deteriorate hemodynamically and clinically. The patient expired on [2186-7-20], at approximately [2202]. He became apneic and asystolic on the monitor. As the patient was DNR/DNI as per family, his status was confirmed with no vital signs. Dr. [Last Name (STitle) 957] was made aware and he would contact the family personally. Death report was in progress soon after expiration. CONDITION ON DISCHARGE: Expiration. DISCHARGE STATUS: Not applicable. DISCHARGE DIAGNOSES: Hemodynamic instability requiring multiple fluid boluses and pressors. Crohn's disease. Just had tumor resection. Small bowel resection. Noninsulin dependent diabetes mellitus. Mental status changes. Intermittent episode of atrial fibrillation. MEDICATIONS ON DISCHARGE: Not applicable. FOLLOW UP PLANS: Not applicable. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], [MD Number(1) 26005] Dictated By:[Doctor Last Name 31967] MEDQUIST36 D: [2186-11-17] 08:46:48 T: [2186-11-17] 10:06:30 Job#: [Job Number 41751]	[ "5119", "2875", "0389", "2851", "2761" ]
Admission Date: [2188-5-30] Discharge Date: [2188-11-10] Date of Birth: [2160-10-29] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 613] Chief Complaint: found down Major Surgical or Invasive Procedure: 1. right craniectomy with evacuation of SDH and partial frontotemporal lobectomy 2. debridement and irrigation of craniotomy wound 3. lumbar puncture 4. endotracheal intubation 5. placement of PEG tube 6. Tracheostomy 7. central venous line placement 8. placement of ventriculoperitoneal shunt 9. right cranioplasty 10. placement of inferior vena cava filter History of Present Illness: 27 y.o. male, found down on sidewalk by EMS. At scene, pt unconscious, exibiting decorticate posturing with no response to painful stimuli. Intubated in the field and brought emergently to [Hospital1 18]. Past Medical History: none Social History: Ukranian grad student at [University/College ]; family in [Location (un) 3156] Family History: non-contributory Physical Exam: In the ED Vitals: Temp: 91.4 HR 60 BP 90/p sats 100% on BMV GCS 3T Gen: unreponsive, c-collar in place, intubated, sedated on propofol HEENT: Pupils 8mm and fixed, left periorbital contusion, large hematoma over right parietal scalp, TM clear, no obvious oralpharyngeal trauma, midface stable Neck: no crepitus, trachea midline Chest: equal BS bilaterally CV: RRR Abd: SNTND, FAST neg Rectal: nl tone, no gross blood, heme neg Pelvis: stable to AP and lateral compression Back: no step-offs on palpation of TL spine, no obvious abrasions Ext: no long-bone deformities, no abrasions, lacerations Neuro: decorticate posturing, no withdrawal to painful stimuli, no gag, no corneal reflex Pertinent Results: Study Date of [2188-6-16] ECHO: Normal LVEF CT HEAD W/O CONTRAST [2188-6-13] 10:48 AM IMPRESSION: 1) s/p craniectomy with herniation of the right cerebral hemisphere from the craniectomy defect 2) Interval resolution of the subdural hematoma. Improved grey white differentiation and reduced effacement of the sulci on the left cerebral hemisphere. 4) Widened subdural cerebrospinal fluid spaces on the right. 5) Opacification of multiple paranasal sinuses as described above. CT C-SPINE W/CONTRAST [2188-5-30] 6:28 AM IMPRESSION: Normal study. No evidence of fracture or subluxation. CT HEAD W/O CONTRAST [2188-5-30] 6:27 AM IMPRESSION: Large, acute right sided subdural hematoma with subfalcine and uncal herniation. Fractures of the right frontoparietal calvarium and left lamina papyracea. * CSF culture: [7-18]: no growth, no fungus, neg GS [9-2]: no growth, neg GS * Blood Cultures: [7-17]: mycolytic cx:[Female First Name (un) 564] parapsilosis [7-18]: mycolytic cx: Coag-negative staph, [Last Name (un) 57818] parapsilosis [7-18]: anaerobe/aerobe cx:neg x1/1 [7-19]: Mycolytic cx: coag neg staph x 1 (final) [7-19]: anaerobe/aerobe:neg x 2 (final) [7-20]: coag neg staph x 1 [7-20]: (left IV tip) coag neg staph [7-22]: anaerobe/aerobe cx:neg x 2 (final read) [7-22]: mycolytic cx: neg x 1 (final read) [7-28]: anaerobe/aerobe cx:neg x 2 [8-7]: blood cx [11-23]: coag neg staph [8-7]: mycolytic cx: coag neg staph [8-8]: blooc cx [11-23]: coag neg staph [Date range (1) ]: no growth [10-28], [10-29], [10-30], [10-31] negative x2 each set * Urine cx [7-22]: no growth [8-7]: pseudomonas and klebsiella [9-2]: no growth [9-3]: no growth [10-26], [10-27], [10-29], [10-30], [10-31], [11-1]: contamination with mixed bacterial flora * UA 9/16,9/17,[8-9]: Positive nitrite, many bacteria, but 0-2 WBC Brief Hospital Course: 1. traumatic brain injury/ right subdural hemorrhage: Pt was admitted on [2188-5-30] and was unresponsive with fixed pupils. Emergent CT revealed a large acute R subdural hematoma with subfalcine and uncal herniation, as well as fractures of the right frontoparietal calvarium and left lamina papyracea. Pt was taken to the OR for emergent evacuation. He underwent a R craniectomy with evacuation of subdural hemorrhage and frontotemporal lobectomy. He was transferred to the trauma surgery ICU for further care and was begun on mannitol to lower ICP (discontinued [6-4]) and dilantin to prevent seizure (discontinued [6-6]). Pt was closely followed but remained basically unresponsive. Sedation was weaned, but pt remained basically unresponsive and without spontaneous movement, gag, or corneal reflexes. Pt was noted to have extensor posturing to painful stimuli on upper extremities. A neurology consult was called to help evaluate for prognosis. On [6-17], an EEG showed R hemispheric subcortical dysfunction and mild encephalopathy, without evidence of ongoing seizure. It was thought that his prognosis ranged from limited verbal abilities and a dense left hemiparesis to a persistent vegetative state. Pt was transferred to the floor on [7-12], where he continued to be followed by neurology and neurosurgery. Multiple family meetings were held throughout [Hospital 228] hospital course to discuss the prognosis, both in the TSICU and on the floor, in conjunction with social work. On [7-13], pt was noted to have fluid draining from the wound site. This was felt to be necrotic brain fluid. Neurosurgery placed additional sutures on [7-16], and the issue resolved. Serial head CTs were performed to evaluate for interval changes. On [7-17], head CT showed increased size of the ventricles after the ventricular drain had been removed; neurosurgery did not believe that this represented an increase in ICP. There were intermittent changes in the amount of bulging at the R craniectomy site, thought to represent liquefaction necrosis as well as hydrocephalus. On [8-27], the amount of bulging was significantly greater, and another head CT was performed, which showed significantly worsening hydrocephalus. On [9-1], therefore, a VP shunt was placed, and a repeat head CT on [9-3] showed interval improvement of the hydrocephalus. In mid-[Month (only) 359], pt was noted to have slow improvement of mental status, and was able to respond to voice, move his R fingers, and begin to follow simple commands. His family continued to work with him, and he slowly improved. Eventually, he was able to answer yes/no questions with finger movements and to follow more commands. On [9-30], repeat head CT showed foci of relative [Name (NI) 13215] within the right temporal lobe, which could be consistent with parenchymal hemorrhage, but pt's hydrocephalus was improved. As pt was reporting headaches, another CT was performed on [10-3], which revealed an area of acute hemorrhage inferior to the frontal portion of the infarct along the inferior edge of the craniotomy, more dense than on the previous CT. Neurosurgery felt there was no indication for surgical intervention, and this remained stable on repeat head CT [10-10]. Pt had no further episodes of acute hemorrhage, and overall his neurological status continued to improve. On [10-27], pt underwent an elective R cranioplasty to repair the defect in his skull. He tolerated the procedure well. Of note, a repeat head CT on [10-30] showed no interval hemorrhage. Pt will get a repeat head CT to evaluate for interval bleed on [12-25], and will follow up with Dr. [Last Name (STitle) 739]. 2. infectious disease: A. POD #4 s/p craniotomy and SDH evacuation - [2188-5-31] - pt was febrile, and sputum grew H. influenza; was started on Zosyn for aspiration pneumonia. Repeat sputum culture [6-5] did not grow H flu. B. suspected encephalitis - Pt treated with levofloxacin [Date range (1) 57819] C. MRSA/Pseudomonas pneumonia (LLL) - vancomycin was begun on [7-4], and was given for 3 weeks given the concomitant meningitis (see below); for Pseudomonal coverage, pt was treated with ceftazidime 2g IV q8h x 10 days ([Date range (1) 57820]) D. MRSA meningitis/infection of head wound - frank pus was expressed from head wound by neurosurgery; a lumbar puncture on [7-4] eventually grew MRSA. Pt was taken to OR for washout/debridement of wound edges and subcutaneous tissue on [7-6], and a ventricular drain was placed. Tissue culture eventually grew sparse coag + Staph. For the MRSA meningitis, pt was treated with vancomycin 2g IV q12h x 21 days. Repeat LP on [7-18] showed WBC 585, RBC 8, protein 132, and glucose 38, bacterial and fungal cultures remained negative. ID felt that elevated WBC was most likely secondary to brain injury and not infection since cultures remained negative. It was felt that MRSA meningitis was resolved. E. [Female First Name (un) 564] parapsilosis fungemia - Blood cultures from [7-17] and [7-18] were positive for yeast, and Ambisome was begun. When the culture data returned with [Female First Name (un) 564] parapsilosis, pt was switched to fluconazole. Ophthalmology was consulted, and they found vitritis of the right eye, which they did not feel was specific to fungal endophthalmitis. He completed two weeks of antifungal therapy. F. Positive urine cultures for Klebsiella and Pseudomonas - this was felt to be colonization in the setting of an indwelling Foley x2 months and was not treated. G. Within 24 hours after the VP shunt was placed, pt became hypotensive and tachycardic. He was started on meropenem/vancomycin empirically, but all cultures were negative and no source found. Pt's hypotension resolved with fluids. Antibiotics discontinued. H. LOW GRADE TEMPS - found to have DVT - see below 3. Deep venous thrombosis: Bilateral LENIs on [6-11] revealed no evidence of DVT. Pt was noted to have left leg swelling back in [Month (only) 359]. However, in the setting of his traumatic subdural hemorrhage, as well as his poor neurologic prognosis at that time, the risks of anticoagulation were thought to outweigh the potential benefits, and so pt was not imaged at that time. This was discussed with the family at length. Pt was continued on subcutaneous heparin for DVT prophylaxis. However, after the elective cranioplasty on [2188-10-27], pt was noted to have daily temperature spikes. All cultures were negative including 8 sets of blood cultures, 4 urine cultures, 4 cxr with only atelectasis, Abd CT negative. Neurosurgery thought that accessing the shunt was unnecessary given his improving MS and minimal headache. At this point DVT was considered again. LENIs were performed on [10-30], which revealed L superficial femoral and L common femoral DVTs. After discussion with neurosurgery it was felt that his immediate risk of bleed is high but that it should decrease after 6 weeks or so, to the point where he may be able to be anticoagulated with coumadin. An IVC filter of intermediate duration was placed on [10-30]; this retrievable filter was placed with the plan for removal in 6 weeks if he has no further bleeding. Pt continued to have low-grade fevers, but all cultures were negative and this was attributed to the presence of DVTs, and possible atelectasis. Plans are made for followup to have the IVC filter removed in [4-29] weeks. 4. Cardiovascular, pulmonary, gastrointestinal, renal, endocrine: No acute problems since transfer to the general medical floor. 5. Supportive care: A tracheostomy was placed on [2188-6-6]. Over the course of the hospitalization, the trach size was changed to a smaller size on [10-1], and a Passy Muir valve was ultimately introduced to maximize pt's ability to speak on [10-3], which was in place only during waking hours. A PEG tube was placed on [2188-6-5], and nutrition followed pt. He was at goal tube feeds for the majority of his hospitalization, at 80cc/hr. A repeat speech and swallow evaluation on [10-7] confirmed that pt was aspirating all consistencies of liquid. However, there was concern that the family may have been feeding him, as residuals showed unexpected material once and pt with apparent crumbs all over chest the week before discharge. Pt's family was made aware of the grave danger of feeding this aspirating patient and they acknoledged the importance of not feeding him by mouth. Pt had meticulous skin care and never developed a sacral decub. Physical and Occupational Therapy continue to work with the patient, and his progress has been remarkable. Medications on Admission: none Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed. 2. Methylphenidate HCl 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 5. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 6. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [11-23] Drops Ophthalmic PRN (as needed). 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 9. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 14. Morphine Sulfate 8 mg/mL Syringe Sig: 2-4 mg Injection Q4H (every 4 hours) as needed for pain. 15. Triamcinolone Acetonide 0.025 % Ointment Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Primary: 1. subdural hemorrhage, status post right craniotomy and partial frontotemporal lobectomy, ventriculoperitoneal shunt placement, and elective cranioplasty Secondary: 1. left common femoral and left superficial femoral deep vein thrombosis 2. MRSA meningitis, now resolved 3. MRSA pneumonia, Pseudomonas pneumonia, now resolved 4. fungemia with [Female First Name (un) 564] parapsilosis, now resolved Discharge Condition: able to communicate yes and no questions, mental status good, with trach and PEG tube in place Discharge Instructions: Please let the staff know if you are in pain or have any other symptoms that are concerning to you. Followup Instructions: [Month (only) ]: Provider: [Name10 (NameIs) ] SCAN Where: [Hospital6 29] RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2188-11-26] 8:45 You have an appointment with Dr. [Last Name (STitle) 739] on [11-26] at noon, after the head CT, so that interval change can be evaluated. [Month (only) ]: Provider: [Name10 (NameIs) ] SCAN Where: CC CLINICAL CENTER RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2188-12-25] 8:00 You should not have tube feeds three hours before this study. Provider: [Name10 (NameIs) ] STUDY Where: CC CLINICAL CENTER RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2188-12-25] 8:30 You have an appointment with Dr. [Last Name (STitle) 739] (neurosurgery) at 1:30PM on [2188-12-25]. This islocated in the [Location (un) 470] (3B) of the [Hospital Unit Name ] on [Last Name (NamePattern1) ]. Phone number is ([Telephone/Fax (1) 88]. You have an appointment with Dr. [First Name (STitle) ] (interventional radiology) to discuss when the IVC filter should be removed on [2187-12-26] at 10AM. This is located on the [Location (un) 10043] of the Clinical Center on the [Hospital Ward Name 517]. Phone number is ([Telephone/Fax (1) 57821]. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "5070" ]
Admission Date: [2145-7-28] Discharge Date: [2145-7-30] Date of Birth: [2100-5-6] Sex: M Service: NEUROSURGERY Allergies: Morphine / Temodar Attending:[First Name3 (LF) 1835] Chief Complaint: recurrent right occipital tumor Major Surgical or Invasive Procedure: Right Craniotomy for resection of recurrent tumor History of Present Illness: [Known firstname ] [Known lastname 48029] is a 45-year-old right-handed man with a right parietal anaplastic oligodendroglioma with 1p & 19q chromosome deleted. He is here with his sister after a head MRI done in [Name (NI) 1727] on [2145-4-12]. This had shown new enhancement and Dr. [Last Name (STitle) 48030] referred him back to Dr. [Last Name (STitle) 724] for a treatment plan. He has remained unchanged neurologically. Denies any headaches, seizures, vision problems, or personality/memory changes. For the past several years he has noted left hand and leg tingling "twinge" that lasts seconds. He notices it most when he is not working and tends to drink more coffee those days. This has not changed. He is s/p: 1. Craniotomy [2137-6-12] at [Hospital 1727] Medical Center by Dr. [Last Name (STitle) ] 2. Monthly Temodar for one year ending [10/2139] 3. Resection of recurrence on [2143-3-13] by Dr. [Last Name (STitle) ] 4. Dose-dense temozolomide (7 on/7 off) [Date range (1) 48031]/09 5. PCV [2143-5-30] to [1-/2144] x 6 cycles Past Medical History: Past Medical History: noncontributory. Social History: Social History: He has 3 boys ages 9, 13, and 17. Works full time as a manager at Lumber Liquidators. Family History: NC Physical Exam: VITAL SIGNS: Blood pressure 126/62, heart rate of 60, respiratory rate of 16, temperature 96.8. GENERAL: Well appearing, pleasant, no acute distress. HEENT: Anicteric sclerae. Oropharynx clear. Tongue pink. Mucous membranes moist. CARDIOVASCULAR: Regular rate and rhythm; no murmurs, rubs, or gallops. RESPIRATORY: Even and unlabored respirations. Clear to auscultation bilaterally. No wheezes, crackles, or rhonchi. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: No edema. NEUROLOGIC: Cranial nerves II through XII intact. Pupils equal. No visual field defects appreciated. Strength is full in upper and lower extremities. Reflexes 1+ and symmetrical. Finger-to-nose intact bilaterally. Tandem gait intact. Negative Romberg. No pronator drift. Speech is fluent. He is alert, appears oriented. On Discharge: neuro intact, ambulatory in halls without assistance, pain well controlled, incision c/d/i, taking adequate diet Pertinent Results: CT Head Post-op Interval resection of a large right parietooccipital mass, with expected post-surgical changes, and no evidence of large post-surgical hemorrhage or large vascular territorial infarct. MRI Brain Post-op expected post-op change Brief Hospital Course: Patient presented electively on 6.22 for right sided craniotomy for resection of recurrent oligodendroglioma, he tolerated the procedure well and was extubated in the operating room and trasnferred to the ICU post-operatively. He recieved his post-op CT scan of the ehad which showed expected post-op changes and he remained stable overnight. On the morning of 6.23 he recieved his post-op MRI Brain and was deemed stable for transfer to the floor. He remained stable overnight on the floor and was ambulatory in the halls. On the morning of [7-30] he was deemed fit for discharge to home without services. He was given instructions for follow-up and prescriptions for any needed medications and discharged. Medications on Admission: Keppra 1000mg [Hospital1 ] Discharge Medications: 1. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 3. Zofran 4 mg Tablet Sig: One (1) Tablet PO q8hours as needed for nausea. Disp:15 Tablet(s) Refills:0 4. dexamethasone 2 mg Tablet Sig: per taper Tablet PO per taper: Take 3mg (1.5 tabs) every 6 hours on [7-30], Take 2mg (1 tab) every 6 hours on [7-31], take 2mg (1 tab) [Hospital1 ] on [8-1] and continue until follow-up. Disp:50 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Recurrent Right occpitital oligodendroglioma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [8-15] days (from your date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [Telephone/Fax (1) 1669]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????You have an appointment in the Brain [Hospital 341] Clinic on [8-23] at 2pm. The Brain [Hospital 341] Clinic is located on the [Hospital Ward Name 516] of [Hospital1 18], in the [Hospital Ward Name 23] Building, [Location (un) ]. Their phone number is [Telephone/Fax (1) 1844]. Please call if you need to change your appointment, or require additional directions. ??????You will not need an MRI of the brain Completed by:[2145-7-30]	[ "V1582" ]
Admission Date: [2170-7-16] Discharge Date: [2170-8-2] Service: [Hospital1 ] CHIEF COMPLAINT: Mental status change and bilateral upper extremity swelling. HISTORY OF PRESENT ILLNESS: The patient presented on [7-16] at [Hospital6 2910] with 24 hours of worsening mental status changes and bilateral upper extremity swelling. Patient has a past medical history of being a nursing home resident, dementia with behavioral disturbance/depressed features, recent admission to [Hospital 1474] Hospital with urosepsis of unknown etiology requiring intubation, and discharged on [2170-9-11], diabetes mellitus, coronary artery disease status post MI, CHF, COPD, status post pacemaker placement, which required replacement for low battery in [Month (only) 404] of this year. At the outside hospital, a chest CT with contrast was performed, which showed obstruction of the superior vena cava at the level of the origin of the SVC. A head CT was also done which was negative with no acute hemorrhage, an old left frontal infarct, and thalamic calcifications and cortical atrophy. It was uncertain what the etiology of obstruction was and ultimately the patient was started on Heparin drip and transferred to [Hospital1 69] for further evaluation and possible intervention. At the time of the arrival of the patient to the Emergency Room, the patient was slightly febrile at 101.4. Had a blood pressure of 124/84. Pulse of 105. Breathing at 30 and sating 94% on room air. Vascular Surgery evaluated the patient and recommended a venogram and a possible SVC stent at that time. Patient was admitted for further workup. PAST MEDICAL HISTORY: 1. Nursing home resident at [Hospital1 2670] in [Location (un) 5110]. 2. Dementia with behavioral disturbance and depressed features, although baseline is alert, conversant, and fairly self sufficient with activities of daily living, although requires wheelchair. 3. Recent admission at [Hospital 1474] Hospital with urosepsis of unknown etiology requiring intubation, but discharged on [2169-9-11] and admission on [2169-9-3]. 4. Diabetes mellitus. 5. Coronary artery disease status post MI. 6. CHF with recent admission with 24 hour intubation. 7. COPD. 8. Status post pacemaker placement replaced on [2169-12-7] for low battery leads and without lead transition at that time. 9. Status post traumatic brain injury. 10. GERD. 11. Hypertension. 12. Status post left knee surgery. 13. Status post appendectomy. MEDICATIONS ON ARRIVAL: 1. Nitro patch 0.2 mg q.a.m. 2. Annulose 10 mg in 30 cc q.a.m. 3. Zyprexa 5 mg p.o. q.h.s. 4. Protonix 40 mg p.o. q.d. 5. Metoprolol 50 mg p.o. q.d. 6. Magnesium oxide 40 mg p.o. t.i.d. 7. Calcium carbonate 1.2 grams t.i.d. with food. 8. Dulcolax p.o. q.a.m. 9. Procardia XL 60 mg q.d. 10. Cardura. 11. Multivitamin. 12. Artificial tears. 13. Aspirin 325 mg p.o. q.d. 14. Trazodone 50 mg p.o. q.d. 15. Albuterol. 16. Insulin. ALLERGIES: The patient reportedly had an allergy to shellfish and IVP dye, however, at the outside hospital the patient received contrast with a CT scan without any problems as well as an inpatient. Although of note, the IV dye used was nonionic ............ FAMILY HISTORY: Unknown. SOCIAL HISTORY: The patient is a former smoker, unknown alcohol use, and his surviving relatives is an elderly sister, who knows him poorly. PHYSICAL EXAM AT TIME OF ADMISSION: Generally, patient in some distress, was intermittently screaming at baseline. Patient's vital signs were a temperature of 99.7, pulse of 105, blood pressure 130/86, respiratory rate 24, and saturation 97% on 2 liters. PERTINENT PHYSICAL FINDINGS: The patient had great significant periorbital edema or facial swelling. The patient did have 3+ bilateral pitting upper extremity edema without lower extremity edema and had 2+ DP and PT pulses. The patient's heart rate was tachycardic, but regular with a normal S1, S2 with no murmurs. Lungs: Patient was making poor effort with bibasilar crackles. Chest had numerous dilated and tortuous superficial veins that were apparent. The abdomen was benign. LABORATORY STUDIES BEFORE THE PATIENT WAS ADMITTED: At the outside hospital, the patient had a CBC which had a white count of 3.7, hematocrit 32.6, and platelets of 214. Coagulation showed a PT of 13.8, PTT of 33.4, and an INR of 1.2 previous to starting Heparin. Chem-7 was significant for a potassium of 3.5, creatinine of 0.9, and bicarb of 33. LFTs were significant for an ALT of 31, AST of 27, alkaline phosphatase of 606, and total bilirubin of 1.64, direct bilirubin of 1.1, and an albumin of 2.8. Patient's CK and troponin-I were both negative. Additional laboratory studies on arrival in the Emergency Room showed a lactate of 1.8. A differential on his white count with 83% polys. A urinalysis showed a large amount of blood with trace leukocyte esterase, 150 ketones, but was otherwise negative. Electrocardiogram showed sinus tachycardia at 107 with left axis deviation and new poor R-wave progression in leads V2 through V5 with T waves consistent with normal EKG. The calcium, magnesium, and phosphorus were 9.7, 2.0, and 3.3 respectively. Uric acid and iron studies were normal. Cholesterol study was normal. TSH was 1.5. A LP was performed due to the patient's mental status change which had 175 reds, 1 white cell with a differential of 73% polys, 27% lymphocytes, total protein was 22, and glucose was 125, Gram stain was negative, and subsequent LP culture never grew out any organisms. Chest x-ray at the time of admission showed no effusion or infiltrate, but did have a tortuous aorta. HOSPITAL COURSE BY SYSTEMS: This is up to date to the evening of [8-2]. Future dictation is to be addended. 1. SVC syndrome: Patient had notable SVC syndrome on chest CT at outside hospital and the chest CT was repeated while the patient was in-house on [7-18], which was performed with contrast and showed occlusion of the SVC without obvious evidence of clot or external compression, and also of note, on the chest, the lungs were clear and the abdomen had no significant pathology. On the evening of [7-19], the patient was taken for a SVC graft and attempted wire transversal of the occlusion with theoretical stent placement. However, the SVC was found to be totally occluded above the level of the azygos and subsequently wires cannot be passed either above or below. The occlusion cannot be opened. At that time, the recommendation was made for sharp recanalization potentially some time in the future. However, at that time the patient's guardianship status arrived, and it was not until the patient's guardian was appointed and a discussion was arranged between patient's guardian and Dr. [Last Name (STitle) 2036] of Interventional Radiology. We were able to reconsider the sharp Recanalization. On [7-24], Dr. [Last Name (STitle) 2036] visited the patient and found the patient to be somewhat hesitant to have the procedure done, although his mental status was not completely clear. Consequently, we arranged for a family meeting on [7-26] with the guardian and Dr. [Last Name (STitle) 2036]. At this time, it was decided with the patient's seeming approval, the procedure should go ahead on [7-31] with sharp recanalization. However, over the following several days the patient became increasingly clear of mental function and on about [7-29], patient's expressed to the attending, Dr. [Last Name (STitle) ] that he did not want to have the procedure done. Consequently, on the 15th, Dr. [Last Name (STitle) 2036] and legal guardian were [Name (NI) 653], and it was felt that the procedure should not be performed. Specifically, Dr. [Last Name (STitle) ] talked with the guardian, and decided that procedure would be of no significant benefit to the patient at this time, and could be deferred until future. Specific argument was that a cerebral blood flow study was performed which showed no significant venous stasis, and thus, it was unclear whether or not the patient's mental function would improve after the procedure, and the patient also did not seem to be significantly bothered by his upper extremity swelling. At that time, SVC was electively not to be treated and the upper extremity swelling was noted on daily examinations, but was otherwise not treated. 2. Mental status change: By report, the patient at the outside nursing home was fairly functional with his activities of daily living, is able to carry on conversations with his problems. However, in the Emergency Room, the patient's mental status had declined to the point of intermittent screaming without provocation. Consequently, the patient was started on Haldol prn, and was maintained on this throughout his course up until the point at the time of this dictation on [8-2]. The patient's mental status gradually cleared, although there was some waxing and [Doctor Last Name 688] component. It was unclear exactly what the cause of the decline in mental status was. Multiple urinalyses showed fungus in the urine, however, it was not felt that this was significant. A cerebral blood flow study was obtained on [7-26] which showed no significant venous stasis nor retrograde flow into the jugular veins indicating no extension of the clot superior. Consequently, it was felt that the mental status was not necessarily subsequent secondary to occlusion of the jugular veins due to obstruction secondary to the SVC occlusion. Also as the patient developed MRSA bacteremia in his hospital course, the patient's mental status remained improved from the time of his admission, and the patient was able to carry on intermittent conversations. 3. Left thigh hematoma: Early on the morning of [7-18], the patient lost IV access. Consequently, a femoral line was placed in the left. Patient, at this time, was continuing to be maintained on Heparin and there was difficulty in regulating the patient's Heparin level, and there were several periods of time in which the patient's PTT was elevated greater than 150. The maximum level in which at which the test could be measured. On the morning of [7-21], the patient was noted to have a hematocrit which had dropped down to 18.9 from 25.3 the previous day, and the previous day it has actually fallen as well from 32.3. Consequently, a CT of the abdomen was obtained and this showed a bleed to the left thigh around the site of the left femoral line. The patient subsequently developed some hypotension as well as respiratory failure with worsening mental status. Consequently, was transferred to the Medical ICU. In the Medical ICU, the patient's hematocrit reached a low of 17.7 on the morning of [7-21], and consequently, the patient was transfused with 6 units of packed red blood cells and 2 units of fresh-frozen plasma, and the Heparin was obviously stopped. The patient required intubation for 24 hours due to worsening respiratory functioning in the setting of mental status decline, but was extubated uneventfully on [7-22], and was transferred back to the floor on [7-23]. The patient's hematocrits were serially drawn every 12 hours and later every 24 hours. After transfer out of the Medical ICU, the patient's remained stable in the mid 30s for the remainder of his stay up until this dictation, [8-2]. 4. Fungus in urine: The patient had numerous urinalyses performed during his hospitalization, which showed blood and urine cultures repeatedly grew out fungus, which was identified as presumptively not [Female First Name (un) 564] albicans. Patient was generally afebrile and consequently, it was felt that this was probably a spurious result. However, to be safe, the patient was transferred over to a condom catheter. The patient's fungal urine cultures were drawn after this time and found to have fungus, but presumptively not C. albicans, but again this was probably thought to be a spurious result, although it was requested that the speciation be performed and this was being completed at the time of this dictation on [8-2]. 5. MRSA bacteremia: The patient's femoral line was maintained after the time of this hematoma. Because it was his only access for blood draws and delivery of medications. However, the patient began having mild fevers over the weekend, [7-28] and 14th, and consequently, it was decided that the femoral line should be changed over wire. This was done without event maintaining sterile procedure throughout. However, the following day, the patient's blood cultures began to grow out coag positive staph, which subsequently grew out methicillin-resistant Staphylococcus aureus. The two femoral line tips were cultured and this also grew out MRSA, and in addition to Pseudomonas which was pansensitive except for ciprofloxacin. In addition, there is also a single culture which grew out coag negative staph, which was resistant to oxacillin, but sensitive to Vancomycin. Patient was started on Vancomycin on [7-31] after the blood cultures began to return positive and the patient was significantly afebrile, but this is complicated by the lack of access issue, which will be discussed in the next problem. Consequently only two doses of Vancomycin over the 16th and 17th were given and one dose of gentamicin 1 mg/kg dosing. On the evening of [8-2], no access was available and consequently the patient was given p.o. linezolid. Further events regarding his MRSA bacteria will be dictated in the near future. 6. Access: After the left femoral line was pulled, the patient's access became very difficult. A brief IV was placed in one of the varices in the patient's left chest, but this fell out after a single dose of IV Vancomycin was given. A subsequent IV was placed in the patient's left ankle, but this fell out after another dose of Vancomycin was given. The following day on [8-2], repeated IVs were attempted, but unable to be performed. Consequently, it was decided that should attempts to replace a right IJ central line. The patient was taken to the Interventional Pulmonology Procedure Unit, where there were three attempts made to place the line without success. After this, the patient was taken to the Interventional Radiology for an angiographically placed line, but this was declined on the 18th with possible repeat attempt on the 19th, and future events and this problem will be dictated in subsequent addendum. 7. Diet: The patient was initially made NPO due to his decline in mental status. On the patient's discharge for the Medical ICU on [7-23], the patient had a swallow study done, which showed the patient was able to tolerate nectar thickened liquid diets and full sized medications. Consequently, this patient was started on this diet, and maintained throughout the rest of his hospital stay up until [8-2], the time of this dictation. Nutrition was also consulted, and found the patient to be serially lacking in calorie intake and protein intake, however, it was decided that the patient would not tolerate placement of a nasogastric tube for tube feeding and that the patient's dietary intake would probably increase once he was discharged. 8. Hypertension: Patient was maintained on his baseline metoprolol 12.5 p.o. b.i.d. once he was known to be able to tolerate p.o. 9. Code status and guardianship: On the arrival, the patient was known to have only one surviving relative, whose name is [First Name4 (NamePattern1) ] [Name (NI) 10141]. This person was [Name (NI) 653]. It was found that she did not really know the patient and was unable to assess what his wants would be in terms of aggressiveness of care. At the previous hospital stay, she had been his healthcare determining person, but it was decided that she was probably inadequate for the task and consequently, legal guardianship was requested and obtained on the evening of [7-20]. The new guardian was [Name (NI) 2411] [Name (NI) 9192], phone number [Telephone/Fax (1) 10142], who wanted to reverse the patient's DNR/DNI status to full code. In addition, this person subsequently spoke with Drs. [Last Name (STitle) 2036] and [Name5 (PTitle) ] regarding sharp Recanalization procedure and maintained her guardianship status throughout the remainder of the hospital stay. Of note, the patient's legal guardian found her job difficult as she did not know the patient previously and was forced to decide what the patient's wants would be in terms through discussions with the staff and other residents at the [Hospital 228] nursing home. Disposition at the time of this dictation, [8-2] is pending treatment of the patient's infection and will be further decided upon on further dictation. As well as condition on discharge, discharge status, discharge diagnosis, discharge medications, and followup plans will all be dictated in future addendum. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 2506] Dictated By:[Last Name (NamePattern1) 10143] MEDQUIST36 D: [2170-8-2] 18:51 T: [2170-8-6] 10:57 JOB#: [Job Number 10144]	[ "4280", "496", "5849", "51881", "2851" ]
Admission Date: [2193-8-14] Discharge Date: [2193-8-23] Date of Birth: [2143-2-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2195] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Intubation/Extubation, Mechanical Ventilation History of Present Illness: 50 yo male with h/o COPD, CAD s/p STEMI, CHF, OSA, DM2 who presented with 2-3 days of increasing dyspnea, wheezing and lower extremity edema; family also reports cough, no fevers. Pt describes LE edema as acute onset on [2193-8-9], associated with intense pruritis of the soles/ankles of both feet developing into swelling. After significant encouragement from family/friends, presented to [Hospital1 18] ER on [2193-8-14] and was found to be hypercarbic and hypoxic. Pt became somnolent and was intubated in the ED for hypercarbic respiratory failure and admitted to the MICU. VS in the ED were 98.8, 136/85, 125, 26, 75% 2L NC, ABG 7.22/96/59 --> 7.11/134/77. Pt was also given solumedrol, nebs, levofloxacin, magnesium in ED for COPD exacerbation/?PNA; heparin gtt and CTA ordered for ?PE. CTA neg for PE, CT head neg for bleed. . ROS was otherwise negative for chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. No syncope, near-syncope. . MICU course: Pt remained on NIPPV [11-11] with FiO2 50% and started on Ceftriaxone/Azithromycin for ?PNA, lasix for fluid overload, nebulizers for COPD exacerbation. Solumedrol was changed to prednisone taper on [2193-8-19] starting at 30mg/day. Pt also had BAL on [2193-8-17] showing tracheobronchomalacea and mucus in LLL, sputum cx NGTD. Pt was extubated w/o issues the morning of [8-18] (day 5 of mechanical ventilation) and has remained stable since. Past Medical History: 1. CAD: 2vd s/p inferior STEMI and BMS to LCx ([2183]). cath [5-15] showed 30% stenosis of prox LAD, 60% stenosis of mid-LCx before patent OM1 stent, 100% RCA occlusion w/ good lt to rt collaterals 2. PVD s/p stenting of rt common iliac ([2183]) 3. CHF w/ preserved EF on MIBI ([4-14]) and ECHO ([1-12]) 4. COPD, FEV1 1.23 ([4-15]) 5. OSA on CPAP [11-16] 50% 6. DM2, HbA1c 7.0 ([6-15]) 7. Hypercholerolemia 8. Hypertension 9. Obesity Social History: Works in shipping/receiving. T - prev 2ppd X many years, now quit A - few beers per month D - h/o marijuana, no IVDU Family History: Father died in sleep at 59yo, h/o COPD. Mom died at 79yo, had breast cancer. Sister w/ CAD and h/o stroke Physical Exam: On admission to MICU from ED: Gen: Obese caucasian male intubated, sedated, moves to voice HEENT: blood noted around bilateral nares and around mouth; not currently oozing. NECK: Supple, No LAD, No JVD CV: RRR. NL S1, S2. No murmurs, rubs or [Last Name (un) 549] LUNGS: BS heard throughout lung fields. no wheezes ABD: normo-active BS, soft, NT, ND. EXT: 1+ edema in the feet bilaterally, DP pulses not palpable. NEURO: sedated On transfer to CC7: VITALS: T 97.4, HR 84, BP 100/66, R 20, 97% 3L NC --> 93% 2L GEN: NAD, A&O X3 HEENT: NCAT, EOMI, normal oro/nasopharynx NECK: Soft, supple, no JVD CV: RRR, no m/g/r, nl S1/S2 PULM: CTAB, no w/r/r, ?mild bilateral basilar crackles on exam ABD: soft, nt/nd, +BS (hypoactive), overweight EXT: no c/c/e, palpable 2+ DP/PT pulses bilaterally, no edema bilaterally Pertinent Results: Admit Labs WBC-13.6# RBC-5.92 Hgb-17.3 Hct-55.7 MCV-94 MCH-29.3 MCHC-31.1 RDW-12.7 Plt Ct-277 Neuts-61 Bands-16* Lymphs-10* Monos-9 Eos-0 Baso-0 Atyps-4* Metas-0 Myelos-0 Hypochr-OCCASIONAL Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-OCCASIONAL Glucose-171* UreaN-16 Creat-0.6 Na-139 K-4.0 Cl-94* HCO3-36* AnGap-13 cTropnT-<0.01 Calcium-9.1 Phos-4.1 Mg-2.2 pO2-69* pCO2-96* pH-7.22* calTCO2-41* Base XS-7 Glucose-168* Lactate-1.4 ERYTHROPOIETIN: 8.7 4.1-19.5 MU/ML JAK2 V617F NEGATIVE (r/o polycythemia [Doctor First Name ], etc) . CTA CHEST ([8-14]) - IMPRESSION: 1. No evidence of large pulmonary embolus. Evaluation of distal branches are limited. 2. Diffuse subcentimeter ground-glass nodules and more solid-appearing 6-mm nodule in the right lower lobe. Followup CT within 6 months is recommended. 3. Diffuse mediastinal and hilar adenopathy as described above. ECHO ([8-16]) - IMPRESSION: No large amounts of right-to-left shunting seen, although images are suboptimal. Normal global biventricular function. Compared with the prior study (images reviewed) of [2193-1-9], current images are technically suboptimal, so precise comparison is difficult. No ASD/PFO/VSD detected on bubble study. CXR: The ET tube tip is 8 cm above the carina. NG tube tip is in the stomach. There is no change in the left basal opacity that might represent a developing aspiration pneumonia versus infectious process in combination with atelectasis. Upper lungs are clear and there is no appreciable right pleural effusion. Small amount of left pleural fluid cannot be excluded. BAL Cx: NGTD. Neg legionella, PCP, [Name10 (NameIs) 3019], CMV Blood Cx: Neg Sputum Cx: Neg Brief Hospital Course: 50 yo male with h/o COPD, CAD s/p STEMI, CHF, OSA, DM2 who presented with 2-3 days of increasing dyspnea and was intubated emergently in ED for hypercarbic respiratory failure. Pt has since been extubated and almost back to baseline pulmonary function. Etiology remains unclear. HOSPITAL COURSE BY PROBLEM: # RESPIRATORY FAILURE. Combined hypercarbic and hypoxic respiratory failure. Etiology unclear. Chronically elevated hematocrit suggestive of some level of chronic hypoxia. Likely a combination of COPD, OSA. No obvious infection on CXR to suggest PNA. Could also have been in setting of volume overload but did not appear wet on physical exam. - Pt was given a seven day course of Ceftriaxone and five day course of Azithromycin which he finished prior to discharge. - Pt was diuresed with Lasix 40mg daily while in MICU and on the Medicine floors. Pt is to resume home dose of Lasix 20mg upon discharge. - Pt started on a Prednisone taper, 30mg X 3days, 20mg X3days, 10mg X3 days then stop - Pt was continued on Albuterol inhaler, Albuterol/Ipratropium nebs PRN. . # HYPERTENSION. Patient was normotensive during hospital stay. He did have 2 episodes of self-limited, mild hypotension with dizziness (SBP 100) with negative orthostatics. Home metoprolol was continued in house. Lisinopril was held in MICU but restarted on discharge. . # CAD. S/p inferior MI w/ BMS placement. - Continued ASA 325mg, plavix 75mg, pravastatin, metoprolol in house. Lisinopril was held in the MICU [3-11] CTA contrast dye. Lisinopril was restarted on discharge home. . # DIABETES, Type II. Well controlled during hospital stay on HISS. - Pt on metformin as outpatient and was restarted on discharge. Medications on Admission: ALBUTEROL SULFATE [VENTOLIN HFA] - 90 mcg HFA Aerosol Inhaler - 2 puffs inhaled every 6 hours as needed BENZOYL PEROXIDE - 2.5 % Gel - apply to acne on the back qday CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg Tablet - 75 Tablet(s) by mouth once a day FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose Disk with Device - 1 puff inhaled twice daily rinse mouth after use FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth once a day KETOCONAZOLE - 2 % Shampoo - apply to body and keep for 5 minutes and then wash. use for 7 days. after that can use once a week for prevention qday LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth qday METFORMIN - 500 mg Tablet - [2-8] Tablet(s) by mouth twice daily take two tabs in the morning and one tab at night METOPROLOL TARTRATE - 50 mg Tablet - 1 Tablet(s) by mouth twice a day NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s) sublingually q5min X 3 doses as needed for chest pain call 911 if no relief after 2nd pill; take up to 3 pills PORTABLE OXYGEN SYSTEM - 4L - to keep O2 sat > 87% when walking PRAVASTATIN - 40 mg Tablet - one Tablet by mouth once a day TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - one capsule inhaled daily UREA [CARMOL 40] - 40 % Cream - apply to affected areas daily Medications - OTC ASPIRIN - 325 mg Tablet - one Tablet(s) by mouth daily MELATONIN - (OTC) - 3 mg Tablet - 1 Tablet(s) by mouth taken at 8 pm nightly MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) - Tablet - 1 Tablet(s) by mouth Daily Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:2 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Melatonin 3 mg Tablet Sig: One (1) Tablet PO once a day: At 8pm. 7. Centrum Silver Tablet Sig: One (1) Tablet PO once a day. 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 9. Metformin 500 mg Tablet Sig: 1-2 Tablets PO twice a day: Take 1000mg in the morning, 500mg at night. 10. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual every 5 minutes as needed for chest pain: Do not exceed 3 doses in 15 minutes. Call 911 if chest pain persists after 3 doses. 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 13. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 14. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 15. CARMOL 40 40 % Cream Sig: One (1) application Topical once a day. 16. Benzoyl Peroxide 2.5 % Gel Sig: One (1) application to back Topical once a day. 17. Ketoconazole 2 % Shampoo Sig: One (1) Topical once a week. 18. Prednisone 10 mg Tablet Sig: Starting tomorrow, [8-24], take 20mg daily for two days * Starting [8-26], take 10mg daily for three days * Starting [8-29], do NOT take any more prednisone. Disp:10 Tablet(s) Refills:0 19. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q8H (every 8 hours) as needed for SOB. 20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 22. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB. Discharge Disposition: Home Discharge Diagnosis: Primary: Hypercarbic respiratory failure Secondary: 1. CAD: Two vessel disease s/p inferior STEMI and bare metal stent to LCx ([2183], cath [5-15]) 2. Peripheral Vascular Disease s/p stenting of right common iliac ([2183]) 3. Congestive Heart Failure w/ preserved ejection fraction on MIBI ([4-14]) and ECHO ([1-12]) 4. COPD, FEV1 1.23 ([4-15]) 5. Obstructive Sleep Apnea on CPAP [11-16] 50% 6. Type 2 Diabetes Mellitis, HbA1c 7.0 ([6-15]) 7. Hypercholerolemia 8. Hypertension 9. Obesity Discharge Condition: Improved. Vital signs are stable, patient ambulating and on 3L supplemental oxygen. Discharge Instructions: -You were admitted in acute respiratory distress which required that you be intubated, to help you breath. Your respiratory problems were likely due to a combination of COPD, usual breathing difficulties and a respiratory infection. . -It is important that you continue to take your medications as directed. We made the following changes to your medications during this admission: --> ADDED Famotidine 20mg twice daily for GERD --> ADDED Prednisone. You are to slowly decrease your daily dose of this medication as follows: * Starting tomorrow, [8-24], take 20mg daily for two days * Starting [8-26], take 10mg daily for three days * Starting [8-29], do NOT take any more prednisone. --> CONTINUE your home medications: Benzoyl peroxide 2.5% (back wash), Plavix 75mg daily, Lasix 20mg daily, Ketoconazole 2% shampoo, Carmol 40% cream daily, Lisinopril 5mg daily, Metformin 1000mg (two tablets) in the morning/500mg at night, Pravastatin 40mg daily, aspirin 325mg daily, Melatonin 3mg at 8pm daily, Centrum Silver 1 tablet daily, Nitroglycerin 0.4mg sublingual tablets as needed. --> RESUME your breathing medications: Advair 250-50mcg 1 puff twice daily, Spiriva 18mcg inhale one capsule daily, Albuterol 2 puffs every 6 hours as needed, supplemental oxygen. . -Contact your doctor or come to the Emergency Room should your symptoms return. Also seek medical attention if you develop any new fever, chills, trouble breathing, chest pain, nausea, vomiting or unusual stools. Followup Instructions: Please follow-up with your PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 6303] [Last Name (NamePattern1) ], in [3-13] weeks. You can call her office to make an appointment at: [Telephone/Fax (1) 250] . Please follow-up with your pulmonary doctor, Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in [2-8] weeks. You can call his office to make an appointment at: [Telephone/Fax (1) 612]	[ "51881", "2762", "4280", "41401", "V4582", "32723", "25000", "2720", "4019" ]
Admission Date: [2195-7-13] Discharge Date: [2195-7-18] Date of Birth: [2134-9-18] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2777] Chief Complaint: Left lower extremity ischemia with ulceration. Major Surgical or Invasive Procedure: Left SFA to TPT bypass with NRGSV History of Present Illness: This is a 60-year-old man who has left leg ulceration in the heel. Arteriogram showed occlusion of the above-knee popliteal artery with reconstitution of the below-knee popliteal artery and a single-vessel runoff via the peroneal which had a patent posterior tibial artery. Given these findings, the patient was consented for a femoral to tibial bypass to help assist him with wound healing Past Medical History: CHF with EF < 20%, global right and left ventricle hypokinesis DM2 on insulin HTN CAD: CABG [2187], on asa, plavix; MIBI in [1-31] w/out rev [First Name (Titles) 110951] [Last Name (Titles) 110952] Social History: - no current etoh - no cigarette smoking, no illegal drug use - blood transfusion once before, at hospitalization at [Hospital1 18] in [1-/2193] Family History: non-contributory Physical Exam: PE: AFVSS NEURO: PERRL / EOMI MAE equally Answers simple commands Neg pronator drift Sensation intact to ST 2 plus DTR Neg Babinski HEENT: NCAT Neg lesions nares, oral pharnyx, auditory Supple / FAROM neg lyphandopathy, supra clavicular nodes LUNGS: CTA b/l CARDIAC: 2/6 SEM ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness EXT: rle - palp fem, [Doctor Last Name ], dop pt lle - palp fem, [Doctor Last Name ], dop pt, dp ulcer on the left heel, debrided bedside graft palp Pertinent Results: [2195-7-17] 07:10AM BLOOD WBC-11.7* RBC-3.39* Hgb-10.3* Hct-29.2* MCV-86 MCH-30.3 MCHC-35.1* RDW-14.2 Plt Ct-276 [2195-7-17] 07:10AM BLOOD Glucose-61* UreaN-32* Creat-2.4* Na-140 K-3.7 Cl-103 HCO3-25 AnGap-16 [2195-7-17] 07:10AM BLOOD Calcium-8.3* Phos-4.2 Mg-2.2 [2195-7-13] 06:00PM BLOOD Glucose-255* Lactate-2.2* Na-134* K-4.8 Cl-108 [Known lastname ],[Known firstname ] I [Medical Record Number 110955] M 60 [2134-9-18] Cardiology Report ECG Study Date of [2195-7-13] 7:33:08 PM Baseline artifact. Sinus rhythm. P-R interval prolongation. Left bundle-branch block. Compared to the previous tracing of [2195-7-8] there is no significant diagnostic change. Intervals Axes Rate PR QRS QT/QTc P QRS T 60 186 150 490/490 75 -26 -179 Brief Hospital Course: Patient is a 60 year old male with multiple medical problems including severe peripheral vascular disease and a non-healing left foot ulcer on which an angiogram was performed on previous admission [2195-7-7] without complication. Patient was scheduled for surgery [2195-7-13] and discharged home. Patient was found to have chronic renal insufficiency on previous admission and was discharged with stable Cr. On this admission patient underwent a Left superficial femoral artery to dorsalis pedis trunk bypass with reverse greater saphenous vein. The operation was uncomplicated. Patient returned to the floor. During his post-operative recovery patient experienced an episode of tachycardia for which he was followed by cardiology. ECG and cardiac enzymes were found to be negative and the patient was asymptomatic. Cardiology was consulted and it was determined no further workup was necessary. During his hospital admission patient's creatinine rose to 2.5. He was given IV bicarbonate and at discharge his creatinine has stabilized. Patient was discharged home on POD5 with visiting nurse to monitor his leg incision for signs of infection and with PT to help patient ambulate. Medications on Admission: xanax 1mg TID, Amlodipine 5 mg Tablet QD, Coreg 25 QD, Clonidine 0.2 mg Tablet TID, Plavix 75, Lasix 80mg [Hospital1 ], Hydralazine 25 mg Tablet TID, Vicodin prn, Lantus 55 units in a.m., 22 units at night, Lisinopril 2.5 mg Tablet QD, zocor Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 4. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Insulin Sliding Scale & Fixed Dose Fingerstick QACHS Insulin SC Fixed Dose Orders Breakfast Bedtime Glargine 55 Units Glargine 22 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Glucose Insulin Dose 0-50 mg/dL 4 oz. Juice 51-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 2 Units 2 Units 2 Units 2 Units 201-250 mg/dL 4 Units 4 Units 4 Units 4 Units 251-300 mg/dL 6 Units 6 Units 6 Units 6 Units 301-350 mg/dL 8 Units 8 Units 8 Units 8 Units 351-400 mg/dL 10 Units 10 Units 10 Units 10 Units > 400 mg/dL Notify M.D. 10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO four times a day for 10 days: prn. Disp:31 Tablet(s) Refills:0 11. [Last Name (un) 1724] xanax 1mg TID, Amlodipine 5 mg Tablet QD, Coreg 25 QD, Clonidine 0.2 mg Tablet TID, Plavix 75, Lasix 80mg [Hospital1 ], Hydralazine 25 mg Tablet TID, Vicodin prn, Lantus 55 units in a.m., 22 units at night, Lisinopril 2.5 mg Tablet QD, zocor 40mg QD 12. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day: On Hold check with PCP before taking. Discharge Disposition: Home With Service Facility: caritas home care Discharge Diagnosis: Peripheral Vascular Disease Gangrenous ulcer left heel CRI Low HCT post op requiring PRBC Bedside debridement of leftheel ulcer Diabetes mellitus type 2, HTN, coronary artery disease, CHF Discharge Condition: Stable Discharge Instructions: Incision Care: Keep clean and dry. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. -If you have staples, they will be removed during at your follow up appointment. . Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to ambulate several times per day. * No heavy ([10-8] lbs) until your follow up appointment. What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [1-27] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Followup with Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3469], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2195-8-6] 11:30 Follow-up with Podiatry: Dr. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name (STitle) ] for appt. Phone: ([Telephone/Fax (1) 19882]	[ "9971", "40390", "5859", "V4581", "4280" ]
Admission Date: [2166-9-9] Discharge Date: [2166-9-17] Service: MEDICINE Allergies: Lithium / Iodine; Iodine Containing Attending:[First Name3 (LF) 358] Chief Complaint: Malaise Major Surgical or Invasive Procedure: None History of Present Illness: This is an 84 yom with history of COPD, Prostate Ca, Schizoaffective disorder, Depression, Hypothyroidism, Gout, +PPD in [2140] s/p treatment who presents from his Nursing Home today for hypoxia and malaise. Per report from PCP, [Name10 (NameIs) ] has been found to be coughing with liquids and food at his nursing home. Patient was found to have increasing weakness and malaise at his nursing home yesterday, O2 sat noted to be 67% which rose to 90% on 3L NC. PCP was notified today and patient was referred to [Hospital1 18] ED. Per ED report, patient also complaining of left knee pain. . Per nursing home report: Patient found sitting on toilet, unable to get himself up. Patient complaining of left leg/left hip pain. V/S Temp 100.4, HR 94, RR 20, BP 103/74. 94% on RA. Patient then had O2 desaturation to 67% as above, with patient to ER> . In the ED: Temp 103.8, HR 128, RR 35 98% on NRB. CXR was done in the ED and was concerning for LLL PNA. Patient was started on Vanco/Zosyn. HR in 130s with Afib. He was given Diltiazem 10mg IV x 2, with HR 100s, also given 2L NS. Patient had increased work of breathing and was placed on BIPAP. Patient was transferred to MICU for further care. . On arrival to MICU, patient was on BIPAP and unable to answer questions. Past Medical History: Atrial fibrillation COPD Hypothyroidism S/P left hip bipolar hemiprosthesis Prostate Ca Schizoaffective disorder Depression Gout thoracic abdominal aortic aneuysm Social History: Lives at [Hospital ] Nursing home Family History: NC Physical Exam: Gen: NAD. HEENT: Anicteric. PERRL 3 to 2 mm bilaterally. Oral mucosa dry. Resp: Mildly increased respiratory effort. On shovel mask 50% O2. Clear at right apex. Slight inspiratory rales left apex. Decreased breath sounds at bases bilaterally. CV: JVP to angle of jaw. Irregular rhythm. S1, S2. No M/G/R. Abd: Bowel sounds present. Soft. Non-tender. Ext: 2+ to 3+ LE edema left, perhaps worsened from yesterday. 1+ LE edema right. Peripheral Vascular: (Right radial pulse: 2+), (Left radial pulse: 2+), (Right DP pulse: present by doppler), (Left PT pulse: present by doppler) Neurologic: Neurologic exam limited by mental status. Responds to simple commands. Keeps repeating ??????at 5:38??????. Speech limited to short phrases. Not oriented. PERRL 3 mm to 2 mm bilaterally. EOMI. Symmetric smile. Elevates palate in midline. Protrudes tongue min midline. Moves all 4 extremities. Brief Hospital Course: 84 yo M with COPD, Afib, prostate cancer, thoracic aortic aneurysm, s/p hip partial replacement, presented on [2166-9-9] with altered mental status, tachycardia, hypoxemia, LLE edema, and left hip/knee pain. Imaging studies revealed pneumonia, large thoracic aortic aneurysm, and multiple blastic bone lesions. The patient initially required non-invasive respiratory support but his respiratory status improved, and he has been off of respiratory support since last night [2166-9-10]. healt care acquired pneumonia/respiratory distress: The patient presented with desaturation and increased work of breathing, for which he was started on BIPAP in the ED. The patient continued to require non-invasive ventilatory support (CPAP with pressure support) until the evening of [2166-9-10], after which time, oxygenation was maintained with a face tent mask. Chest radiography was consistent with pneumonia, which was treated as healthcare associated pneumonia, given the patient's residence in a nursing home. The patient was treated with Zosyn, vancomycin, and azithromycin. At the time of transfer out of the MICU, the plan was to continue azithromycin for a 5-day course, which will be complete in the early morning of [2166-9-14], and to continue Zosyn and vancomycin for a 10-day course, which will be complete on [2166-9-17]. Legionella urinary antigen was negative. At the time of transfer out of the MICU, blood cultures x 2 were pending and were found to be negative. Altered mental status: Per nursing home, patient A&Ox3 without dementia at baseline. Mental status has fluctuated from hour to hour and tends to be better in the afternoon. At his best, the patient was able to respond to simple commands and answer simple questions. The patient's mental status changes were felt to be due todelirium in the setting of acute infection. However, CVA was considered in the differential diagnosis. The patient had a negative head CT. Neurology was consulted and felt that the patient's exam was non-focal and not consistent with CVA. The patients electrolytes remained stable during the duration of his hospital course. A repeat head CT showed no interval change. Atrial fibrillation with RVR: On presentation, the patient was tachycardic to 128. In the ED, he received diltiazem 10 mg IV x 2 and bolused with 2L NS, with improvement of the tachycardia. In the MICU, the tachycardia recurred and responded only transiently to diltiazam boluses. The patient was started on a diltiazem drip, on which he remained until the early morning of [2166-9-11]. At that time, digoxin was initiated to provide rate control while enhancing blood pressure, cardiac output, and renal perfusion. Rate control and BP were good on digoxin. The patient is not on anticoagulation. The MICU team contact[Name (NI) ] the patient's PCP, [Last Name (NamePattern4) ]. [First Name (STitle) ], who did not believe that anticoagulation was in the patient's interest given his fall risk. At the time of transfer out of the MICU, the plan was to continue digoxin for rate control, monitoring the patient's ECG and checking a digoxin level in the a.m. of [2166-9-13]. The patient's digoxin level remained therapeutic and he his EKG was unchanged. COPD ?????? Baseline COPD likely contributed to intiail poor respiratory status. Started on 60 mg q8 solumedrol bolus. Tapered methylprednisolone to 20 mg IV and then transitioned to PO, where he was tapered off. Blastic bone lesions ?????? Likely metastasis given history of prostate cancer and PSA 279.9. Consulted PCP regarding management of patient??????s prostate cancer, likely would not want medical interventions. AFter discussion with guardian, the conclusion was to not pursue aggressive intervention, including escalating the patients status to an ICU. She will consider a Do not hospitalize order during the upcoming days after discussion with Dr. [First Name (STitle) ], as well as referral to hospice. She preferred the patient be transported back to his nursing facility where he was comfortable, rather than spend additional time in the hospital. Externally rotated hip. LLE shortened and externally rotated. No evidence of fracture of dislocation on CT. External rotation likely chronic per ortho. MRI of spine ordered to rule out metastatic lesion. MRI positive for lesions in the thoracic and cervical spine, no lesions in lumbar spine or evidence of stenosis. LLE edema ?????? No clot. DDx includes venous insufficiency, CHF (although worse on left). Elevated CK ?????? [Month (only) 116] be due to traumatic muscle injury in the setting of a fall. Continuing to trend down. Schizoaffective disorder Home meds were held while NPO, then restarted Medications on Admission: Levothyroxine 100mcg daily Prilosec 20mg daily Diltiazem 120mg daily Acetaminophen 1000mg [Hospital1 ] Docusate 200mg [Hospital1 ] Depakote 750mg [Hospital1 ] Milk of Magnesia 30mg M/W/F Zyprexa 10mg qHS Doxazosin 2mg daily Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [Hospital1 ]: One (1) Injection TID (3 times a day). 2. Ipratropium Bromide 0.02 % Solution [Hospital1 ]: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 3. Acetaminophen 500 mg Tablet [Hospital1 ]: Two (2) Tablet PO Q 8H (Every 8 Hours). 4. Levothyroxine 100 mcg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [Hospital1 ]: [1-8] Drops Ophthalmic PRN (as needed). 6. Olanzapine 2.5 mg Tablet [Month/Day (2) ]: Two (2) Tablet PO HS (at bedtime). 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 8. Valproate Sodium 250 mg/5 mL Syrup [Last Name (STitle) ]: One (1) 750 mg syrup PO Q12H (every 12 hours). 9. Digoxin 125 mcg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 10. Aspirin 325 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO DAILY (Daily). 11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [Last Name (STitle) ]: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Last Name (STitle) ]: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [Location (un) 16662] - [Street Address(1) ] Discharge Diagnosis: 1. Pneumonia 2. Hypotension 3. Respiratory distress 4. Urinary retention s/p foley placement 5. Atrial fibrillation with rapid ventricular response 6. Weakness 7. L arm swelling Secondary 1. Schizoaffective disorder 2. Hypothyroidism 3. Metastatic prostate cancer 4. Thoracic aortic anneurysm Discharge Condition: Hemodynamically stable, tolerating PO intake Discharge Instructions: You have been diagnosed with altered mental status, respiratory distress and hypotension during your hospital stay. You should return to the hospital as needed for changes in mental status, difficulty breathing, fever, or other symptoms concerning to you, but during your hospital stay it was discussed with your guardian the possibility of do not hospitalize in the future. Followup Instructions: Please follow up with Dr. [First Name (STitle) ] in [1-8] weeks. You can call [Telephone/Fax (1) 608] to schedule an appointment. Completed by:[2166-9-17]	[ "5070", "51881", "496", "4280", "42731", "2449", "311" ]
Admission Date: [2106-8-27] Discharge Date: [2106-8-31] Date of Birth: [2023-2-21] Sex: F Service: MEDICINE Allergies: Ace Inhibitors Attending:[First Name3 (LF) 1253] Chief Complaint: Hypoglycemia Major Surgical or Invasive Procedure: none History of Present Illness: 83 yo W with PMH of Type II DM, HTN presents with hypoglycemia. Patient woke this morning and fell out of bed. She was unable to get up. She had no head trauma or loss of consciousness. Son found her and called EMS. In the field, her FS was in the 20's associated with altered mental status. She received oral glucose + juice and both mental status and FS's improved. She also reports epigastric/ substernal CP, nonradiating that lasted for several hours and improved on arrival to the ED without intervention. . On arrival to the ED, VS: T97.5 HR 76 BP 148/103 RR 17 100%RA. FS was 29. She received 1 amp of D50, 50 ucg of octreotide and was started on D5 infusion. There was a question of new infiltrate in R base and received Levaquin x 1. Labs notable for elevated CE's. Per notes, patient was seen by cards, but was refusing heparin or ASA at this time Pt was refusing treatment with heparin and ASA. Past Medical History: DM type II Mild-moderate diabetic retinopathy HTN Arthritis Cataracts Social History: Patient was born in [Country ]. Moved to the United States in [2075]. Currently living with her daughter. Previously worked as a housekeeper at [Hospital 13128]. Denies tobacco/EtOH. Family History: Son in good health. Physical Exam: Vitals Stable. GEN: elderly female, pleasant, NAD. HEENT: eomi, mmm. RESP: CTA B. No wrr. CV: RRR. No mrg. Abd: benign. Ext: No cee. Pertinent Results: [2106-8-27] 09:00PM BLOOD cTropnT-0.10* [2106-8-28] 10:15AM BLOOD CK-MB-10 MB Indx-7.0* cTropnT-0.22* [2106-8-29] 09:05AM BLOOD CK-MB-4 cTropnT-0.21* [2106-8-30] 02:00PM BLOOD cTropnT-0.21* . [2106-8-30] 02:00PM BLOOD WBC-6.3 RBC-3.54* Hgb-10.6* Hct-31.4* MCV-89 MCH-29.9 MCHC-33.8 RDW-15.0 Plt Ct-263 . [2106-8-30] 02:00PM BLOOD Glucose-175* UreaN-37* Creat-1.3* Na-139 K-4.2 Cl-109* HCO3-20* AnGap-14 . [2106-8-27] 09:00PM BLOOD ALT-15 AST-24 LD(LDH)-217 CK(CPK)-135 AlkPhos-87 TotBili-0.2 . [2106-8-28] 10:15AM BLOOD CK(CPK)-143* [2106-8-29] 09:05AM BLOOD CK(CPK)-73 . [2106-8-28] 10:15AM BLOOD Triglyc-33 HDL-65 CHOL/HD-2.2 LDLcalc-70 . [8-27] EKG: Sinus rhythm. Poor R wave progression, probably a normal variant. Compared to the previous tracing of [2103-7-24] there is no significant diagnostic change. . CXR: IMPRESSION: No acute cardiopulmonary abnormality . Cardiac Echo: IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Diastolic dysfunction. Mildly thickened aortic valve leaflets without stenosis and mild aortic regurgitation. Brief Hospital Course: 83 yo W with PMH of Type II DM, HTN presents with hypoglycemia. Patient woke and fell out of bed at home. She was unable to get up. She had no head trauma or loss of consciousness. Son found her and called EMS. In the field, her FS was in the 20's associated with altered mental status. She received oral glucose + juice and both mental status and FS's improved. She also reports epigastric/ substernal CP, nonradiating that lasted for several hours and improved on arrival to the ED without intervention. . On arrival to the ED, VS: T97.5 HR 76 BP 148/103 RR 17 100%RA. FS was 29. She received 1 amp of D50, 50 ucg of octreotide and was started on D5 infusion. There was a question of new infiltrate in R base and received Levaquin x 1. Labs notable for elevated CE's. Per notes, patient was seen by cards, but was refusing heparin or ASA at this time Pt was refusing treatment with heparin and ASA. In the ICU she was found to have an NSTEMI with her troponin peaking at 0.22 the am prior to transfer to the floor. Her care in the ICU was complicated by her refusing labs and medications. Thus they were not able to continue to cycle her enzymes. Started on lovenox 60 mg SQ x 3 doses first one given at 1600 on [2106-8-28] while asleep. She was initially on an insulin gtt and this was changed to SQ insulin. Family is aware of her refusing many interventions. She remains full code with full treatment. . Pt completed treatment with 3 days of SQ Lovenox, without recurrance of chest pains. Pt remained off of her glyburide, however metformin was restarted. Geriatrics consulted, and recommended pt have VNA after discharge to assist with medications at home, and recommended Geriatrics follow up as an outpt for formal eval and treatment (if needed) of dementia, with formal memory assessment. Appointments scheduled. . Pt also c/o some constipation which was relieved during hospitalization. Pt discharged on standing colace and prn senna. . Pt discharged to home with VNA, feeling well. Medications on Admission: Acetaminophen Amitryptiline 10mg PO qHS Cozaar 100 mg q daily glipizide 10mg PO bid metformin 500 mg [Hospital1 ] pravastatin 40mg qHS Colace Discharge Medications: 1. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 5. Apraclonidine 0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 6. Brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic [Hospital1 ] (). 7. Scopolamine HBr 0.25 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 8. Bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic [Hospital1 ] (2 times a day). 9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 10. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic QID (4 times a day). 11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 13. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime). 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 15. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: # NSTEMI # Hypoglycemia . Secondary diagnoses: Type II Diabetes Hypertension Discharge Condition: stable Discharge Instructions: Take all of your medications as prescribed. Keep your follow up appointments as scheduled. Please return to the Emergency Department if you develop new chest pain, shortness of breath; otherwise contact your primary care provider with concerns. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 10134], MD Phone:[Telephone/Fax (1) 7976] Date/Time:[2106-9-7] 8:30 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 12898], DPM Phone:[Telephone/Fax (1) 7976] Date/Time:[2106-9-14] 12:00 Provider: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2983] Phone:[Telephone/Fax (1) 719] Date/Time:[2106-11-11] 9:00	[ "41071", "4019" ]
Admission Date: [2150-10-29] Discharge Date: [2150-11-6] Date of Birth: [2114-1-27] Sex: F Service: MED HISTORY OF PRESENT ILLNESS: This is a 36-year-old female with a past medical history of alcohol abuse, cocaine use, with hepatitis C cirrhosis who presented to .......... for detox. She was transferred to [Hospital1 18] on [2150-10-29] for mental status changes, hallucinations, auditory and visual. She was admitted to the Medical Intensive Care Unit for further evaluation. In her MICU course she had a lumbar puncture which was negative, right upper quadrant ultrasound which was negative. She had a temperature spike to 103. She was found to have pyelonephritis. During her hospital course she had a questionable history of coffee ground emesis and nasogastric lavage cleared after 100 cc. The patient was transferred to the Medicine floor after her mental status improved. She had been started on Levofloxacin, Ampicillin and Flagyl. PAST MEDICAL HISTORY: 1. Alcohol abuse. 2. Cocaine abuse. 3. Heroin abuse. 4. History of hepatitis C. 5. Anemia. MEDICATIONS: 1. Trazodone. 2. Celexa. 3. Serax. It is unclear if she is actually taking them or not. ALLERGIES: Percocet; do not know what reaction is causes. SOCIAL HISTORY: Abuses alcohol, cocaine, and tobacco. PHYSICAL EXAMINATION ON ADMISSION TO THE MEDICAL INTENSIVE CARE UNIT: Her temperature is 101.3, blood pressure is 108/54, heart rate is 96, satting 99% on room air. In general, she is somnolent but speaking nonsensibly. She can follow commands. Her pupils are 2 mm, minimally reactive. Sclerae are anicteric. Oral mucosa is dry. Neck is supple; there is no jugular venous distention. Cardiovascular: Regular rate and rhythm; normal S1, S2; no murmurs. Lungs are clear. Abdomen is soft. Extremities: There is no edema. Neuro: Unable to assess because of her inability to cooperate. LABORATORY DATA ON ADMISSION: Her hematocrit was 29.3, white blood cell count was 6.3, platelets were -2, Chem-7 was significant for creatinine of 2.0. Her ABG was 7.45, 29, 67 on room air. Liver function tests: Her ALT was 57, AST was 85, alkaline phosphatase was 89, total bilirubin was 1.8, albumin was 3.2, amylase was 66, lipase was 58. Her urine toxicity screen was positive for benzodiazepines. Her urinalysis had positive leukocyte esterase, positive blood, 30 protein, 20 to 50 white blood cells, moderate bacteria. CT of the abdomen showed some perinephric stranding, no stones. CT of the head was negative. Micro: Blood culture, urine culture, and cerebrospinal fluid cultures were pending. EKG: Sinus tachycardia; normal axis; 1 to [Street Address(2) 1766] depression in V4 through V6. The patient was admitted to the Medical Intensive Care Unit. REVIEW OF HOSPITAL COURSE BY SYSTEMS: 1. Mental status changes: Likely secondary to withdrawal versus from the pyelonephritis. She was continued on intravenous antibiotics. CIWA Scores were followed. Four to five days into her hospital course her mental status improved. Feel like it was secondary to her infection. 2. Pyelonephritis: She was continued on intravenous antibiotics in the Intensive Care Unit, Levaquin and Flagyl. When she was transferred to the floor she was continued only on the Levaquin if it was apparent that they were only treating pyelonephritis. 3. Acute renal failure and hypernatremia: The acute renal failure was likely secondary to hypovolemia. The patient was fluid resuscitated and her creatinine improved to 0.8 on the day of discharge. 4. Hypernatremia: The patient's free water deficit was corrected daily. The patient's sodium was 145 on the day of discharge. 5. Gastrointestinal: Pancreatitis. The patient was kept NPO and was given intravenous fluids until her abdominal pain improved. Her diet was advanced as tolerated. 6. Anemia: Likely secondary to chronic disease and her alcohol use. The patient did not receive any blood transfusions. Her hematocrit was 24.6 on discharge. She was asymptomatic. 7. Hepatitis C cirrhosis: She will follow up with Gastroenterology. 8. Diarrhea: The patient developed diarrhea during her hospital course. Clostridium difficile was sent; it was negative for Clostridium difficile. The patient was not interested in taking Imodium for symptomatic relief. 9. Psych: The patient was followed on CIWA Scale for alcohol withdrawal throughout her hospital course, getting p.r.n. Valium as needed and had a one-to-one sitter. On discharge, it was recommended to the patient that she return to ........... for further outpatient treatment, but the patient refused to go to ........... and went home with her mother instead and promised to go to A.A. for further support. DISCHARGE CONDITION: Stable. DISPOSITION: Home. DISCHARGE INSTRUCTIONS: 1. You should not drink any alcohol or use drugs once you are discharged from the hospital. That was emphasized. 2. Take all medications as prescribed. Take all of the remaining antibiotic pills. 3. Return to ............ for detox or another outpatient detoxification facility of your choice. 4. Follow up with Dr. [First Name4 (NamePattern1) 12589] [Last Name (NamePattern1) 12590], Gastroenterology, within three weeks. 5. Follow up with your primary care physician within the next week. FINAL DIAGNOSES: 1. Alcoholic hepatitis. 2. Alcohol withdrawal. 3. Acute pyelonephritis. 4. Metabolic-respiratory disorder, acid-based acidosis. 5. Toxic metabolic encephalopathy. DISCHARGE MEDICATIONS: 1. Levaquin 500 mg p.o. q.d. times seven more days. 2. Protonix 40 mg p.o. q.d. 3. Trazodone 25 mg p.o. q. h.s. p.r.n. insomnia. 4. Folic acid 1 mg p.o. q.d. 5. Multivitamins 1 mg p.o. q.d. 6. Thiamine 1 mg p.o. q.d. 7. Loperamide 2 mg p.o. q.i.d. p.r.n. diarrhea. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 2506] Dictated By:[Name8 (MD) 8736] MEDQUIST36 D: [2151-3-1] 15:32 T: [2151-3-3] 21:21 JOB#: [Job Number 12591]	[ "5849", "2761", "2875" ]
[ ] Date: [2171-2-16] Discharge Date: [2171-2-21] Date of Birth: [2093-5-31] Sex: F Service: MEDICINE Allergies: Oxycodone / Codeine / morphine / OxyContin Attending:[First Name3 (LF) 613] Chief Complaint: Hypotensive, concern for cholangitis Major Surgical or Invasive Procedure: ERCP History of Present Illness: 77F history of CAD, hypertension, atrial fibrillation on coumadin, IBS, epilepsy, diabetes, and dementia presents with ? cholangitis. She is being transferred from [Location (un) 620] with fever, elevated LFTs/bili. Her nursing home was concerned about increased abdominal pain, increased LFTs, and hypoxemia. There was also a concern about ? CHF. Labs signifcant for AST 195, ALP 293, ALT 223, Tbili 3.1 (mostly direct - 2.5). She was sent to the ER at [Location (un) 620]. VS on transfer were BP 180/80, HR 81, RR 20, T 97.2. At [Location (un) 620], initial VS in ER were 100.8 HR: 89 BP: 133/67 Resp: 22 Sat: 98 Normal. Her chief compliant was chest pain intermittent for weeks. She was noted to be lethargic appearing and unable to given an adequate history. Patient also would desat to 85 % depending on position. Exam was significant for skin mottling of lower extremity, cyanotic finger tips, and significant swelling of left leg. Labs performed showed WBC 8.2, Hgb 11.2 (unknown baseline), Hct 34.9, Plt 125 with Diff N 93.6. Lactate was 2.2. Coags significant for INR was 7.6. Chemistry panel showed Na 138 K 4.1 Cl 101 Glu 319 BUN 39 Cr 1.6 (unknown baseline, last Cr 1.1 in [2167] and 1.3 in [2168]), Ca [69].2 (H). LFTs were albumin 3.4, Tbili 3.79, ALP 369, ALT 236, ALT 177. Lipase was wnl. Initial troponin T was < 0.01. ECG showing atrial fibrillation at rate of 96, NA, NI (except QTc 463 ms). No ST/T changes. Compared to prior dated [2164-1-10], atrial fibrillation is new. UA showed many bacteria, 0 epi, negative LE/nitrate. Blood cultures were drawn and per prelim report are [4-24] for GNR. CXR, Abdominal US, CT Abd and pelvis without contrast were performed. CXR showed minimal opacity in left lung base likely representing atelectasis/scar as there is no obscuration of the hemidiaphgragm. There are low lung volumes, which may represent COPD. Cardiomegaly persists. RUQ US was "negative" per reports. CT abdomen/pelvis showed "no acute abnormality." Patient appeared ill with fever. Impression was sepsis. She was covered with flagyl/levaquin/vancomycin for ? cholangitis. She had gradual worsening of hemodynamics with BP trending down from 130s to 90s for which she received 4 L NS. She was transferred to [Hospital1 18] for ICU [Hospital1 ] and ERCP. In the main [Hospital1 18] ED inital vitals were, 0 99.0 80 110/58 22 94% 2L Upon arrival to [Hospital1 18] ER, she was complaining of lower abdominal pain and nausea. She was alert and oriented x 2. ERCP was consulted and recommended [Hospital1 ] to [Hospital Unit Name 153] with ? ERCP. She had no further episodes of hypotension in the [Hospital1 18] ER. Labs in [Hospital1 18] ER were performed. Chemistry panel was within normal limits except BUN 33, Cr 1.4, glucose 227 with no anion gap. LFTs were abnormal with ALT 167, AST 86, AP 257, Tbili 3.2. CBC showed WBC 5.9, Hgb 10, plt 118 with neutrophilia. Coags were significant for INR 8.7, PTT 55.5. She was given zofran and morphine for the aforementioned symptoms. She was also given flagyl 500 mg IV x 1. VS on transfer: HR 83 BP 127/58 RR 22 pOx 100 on 2L . On arrival to the ICU, patient was AAOx3 (unable to name year exactly). She was able to say the days of the weeks backwards. She complained primarily of RUQ abdominal pain. She denied any history of chest pain. Past Medical History: - DM2 (last A1c 7.2 on [2170-3-2]) - CAD - atrial fibrillation on coumadin - IBS - epilepsy - meningioma - urinary retention with prior history of UTI - gait abnormality - osteoarthritis - GERD - hypertension - hyperlipidemia - hypercalcemia - bronchitis - Hyperparathyroidism - History of stroke - glaucoma - Depression/personality disorder - Cerebral aneurysm - Pancreatitis mass (?cyst) - ? Recent left lower extremity DVT SURGICAL HISTORY: 1. Total abdominal hysterectomy, [2119]. 2. Colectomy for colon cancer, [2148]. 3. Meningioma of the right frontal lobe, [2152] Social History: Patient denies current alcohol, tobacco, or illicit drug usage Family History: Patient denies family history of hepatic disease Physical Exam: [Year (4 digits) ] Exam: General Appearance: No acute distress, Overweight / Obese Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic, Poor dentition Lymphatic: Cervical WNL, Right EJ Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : , Diminished: bases) Abdominal: Soft, Bowel sounds present, Tender: RUQ, - [Doctor Last Name ] sign Extremities: Right lower extremity edema: Absent, Left lower extremity edema: 3+, ? lymphedema with some patches of erythema with ? cellulitis vs. stasis changes Skin: Warm Neurologic: Attentive, Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed, right sided UE and LE weakness, [4-25] Pertinent Results: [Month/Day (1) ] Labs: [2171-2-16] 05:46AM BLOOD WBC-5.9 RBC-3.33* Hgb-10.0* Hct-30.2* MCV-91 MCH-29.9 MCHC-33.0 RDW-13.2 Plt Ct-118# [2171-2-16] 05:46AM BLOOD Neuts-89.3 Lymphs-6.0* Monos-3.9 Eos-0.5 Baso-0.3 [2171-2-16] 05:46AM BLOOD PT-85.1* PTT-55.5* INR(PT)-8.7* [2171-2-16] 05:46AM BLOOD Fibrino-742* [2171-2-16] 05:46AM BLOOD Glucose-227* UreaN-33* Creat-1.4* Na-138 K-3.7 Cl-108 HCO3-23 AnGap-11 [2171-2-16] 05:46AM BLOOD ALT-167* AST-86* CK(CPK)-23* AlkPhos-257* TotBili-3.2* DirBili-2.7* IndBili-0.5 [2171-2-16] 05:46AM BLOOD Lipase-12 [2171-2-16] 05:46AM BLOOD CK-MB-1 cTropnT-<0.01 [2171-2-16] 05:46AM BLOOD Albumin-3.5 [2171-2-16] 09:59AM BLOOD Lactate-1.4 Brief Hospital Course: 77F history of CAD, hypertension, atrial fibrillation on coumadin, prior stroke, epilepsy, diabetes mellitus type II, and dementia presents with cholangitis, sepsis, GNR bacteremia. # Sepsis/cholangitis: Patient meets sepsis criteria on presentation with fever, tachpynea with blood cultures suggestive of high grade bacteremia from GNR (in OSH cultures). Patient was placed on vancomycin and zosyn initially. UA with bacteria, but negative nitrate/LE. CXR not suggestive of pulmonic process initially. Her sacral decubitus ulcer, present on [Month/Day/Year ], does not appear infected. Hypotension responded to 4 L fluid resuscitation. Intra-abdominal imaging and US at OSH not suggestive of gallstone or other acute intraabdominal process however given RUQ pain, elevated LFTs/Tbili, and fever, ERCP was performed with sphincterotomy, decompression with extraction of pus and stone. Patient remained hemodynamically stable with LFTs improving, on broad spectrum antibiotics, ultimately tailored to ceftriaxone for bacteremia and with flagyl given ? of aspiration pneumonia (see below). # Hypoxemia: Per nursing home notes, there was some concern about a heart failure exacerbation (although do not have formal documentation of such history) with home medications including lasix and spironolactone. She was given lasix for ? tachypnea at nursing home. CXR was without pulmonary edema or other pulmonic process but did have cardiomegaly. Per nursing home notes, concern about CHF given weight increased 9 lbs from [2170-12-5]. She has been on lasix 80 mg PO qD since [Month (only) 359] in addition to spironolactone. Patient has also been on systemic anticoagulation making PE less likely. Respiratory thought to be secondary to sepsis. Patient given several doses of lasix IV (80mg) after FFP administration, with moderate UOP and stable oxygenation saturation in the mid90s. Trop neg x1. Echo showed preserved function. Patient is at aspiration risk, and though she's been given nectar thick liquids, she may have aspirated contributing to her oxygen sats in the low 90s at times, and repeat chest xray suggested possible aspiration pneumonia in the mid left and lower lung zones. Treated with ceftriaxone and with flagyl (latter for 8 day course total). # Supratherapeutic INR: Reversed for ERCP. Heparin bridge to therapeutic warfarin initiated. Heparin d/c'd once INR over two. At time of discharge INR was 2.8. # ARF: Patient appears to have CKD III-IV at baseline. Baseline Cr around 1.3, but was up to 1.5 during [Month (only) ]. Likely pre-renal etiology on [Month (only) ] given insensible losses with fevers with Cr trending down with fluid resuscitation. # Left leg swelling: Patient has reported history of both LLE DVT and ? lymphedema. Per nursing home staff, her leg has been swollen for some time - but unclear history overall. No evidence of DVT on LENI U/S performed at [Hospital1 18] this [Hospital1 ]. # Skin impairments: Stage 3 decubitus ulcer and multiple skin breakdowns on left lower extremities was managed by wound care, and with frequent turnings. # Atrial fibrillation: Patient with atrial fibrillation on [Hospital1 ], high CHADS2 score given ?CHF, HTN, age, diabetes mellitus type II, prior stroke. High risk for cardioembolic issues. INR was temporarily reversed for ERCP and warfarin was restarted within 36hrs of procedure. Beta blocker was held in the setting of sepsis, but restarted soon after. # Hypertension: Held atenolol given sepsis, discharged on metoprolol given eGFR. # Epilepsy: continued keppra. # Diabetes mellitus type II: Managed on HISS and lantus. # Dementia: Patient appeared to be AAOx3 on [Hospital1 ]. Per nursing home documents, she cannot make medical decisions due to underlying dementia # Aspiration risk: Patient with known aspiration risk per nursing home records. Patient was given thickened nectar liquids. # QTc prolongation: QTc was 463 ms [First Name (Titles) ] [Last Name (Titles) ]. Qtc prolonging drugs were avoided. Repeat EKG showed QTc of 422. # Mood disorder: continued home psychiatric medications. Medications on [Last Name (Titles) ]: - acetaminophen 650 mg PO q 4 hr prn pain, fever - hydrocodone/APAP 5-500 mg PO q 4 hr prn pain - nitrostat 0.4 mg SL prn - coumadin 4.5 mg PO every Tues, Thurs, Sat - coumadin 5 mg PO every Monday, Wed, [Last Name (LF) 2974], [First Name3 (LF) ] - SSI - lantus 17 units qhS - abilify 5 mg PO qD - atenolol 50 mg PO qD - cranberry 425 mg PO BID - vitamin B12 1000 mcg INH qmonth - docusate/senna - furosemide 80 mg PO qD - [First Name9 (NamePattern2) 32469] [Male First Name (un) ] 0.005 % 1 drop each eye qHS - levetiracetam 1000 mg PO qAM - levetiracetam 500 mg PO qHS - melatonin 6 mg PO qHS - omeprazole 20 mg PO qD - spironolactone 25 mg PO qD - vitamin C tab 500 mg PO qD - vitamin D 1000 units PO qD - sertraline 200 mg PO qD - tylenol 650 mg PO qD Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever > 100.5. 2. aripiprazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 4. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 5. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 6. sertraline 50 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 7. petrolatum Ointment Sig: One (1) Appl Topical DAILY (Daily). 8. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: inr goal is 2.5-3.5. 9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours) for 10 days. 16. metronidazole 500 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days. Tablet(s) 17. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units, insulin Subcutaneous at bedtime. 18. insulin lispro 100 unit/mL Solution Sig: per sliding scale units, insulin Subcutaneous QIDACHS: see attached sliding scale. Discharge Disposition: Extended Care Facility: [Location (un) 582] at [Location (un) 620] Discharge Diagnosis: 1. choledocholithiasis s/p ercp and sphincterotomy with stone extraction 2. probable aspiration pneumonia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: see below Followup Instructions: [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617] Completed by:[2171-2-21]	[ "0389", "5070", "5849", "41401", "4019", "42731", "53081", "2724", "25000", "V5861", "V5867" ]
Admission Date: [2195-5-13] Discharge Date: [2195-5-22] Date of Birth: [2173-5-29] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 5831] Chief Complaint: ? GBS/[Doctor First Name 1557] [Doctor Last Name 957] syndrome Major Surgical or Invasive Procedure: intubation and extubation History of Present Illness: 21 year-old right-handed M who presents with numbness of hands and feet, progressive weakness, and diplopia. The patient has had URI symptoms for 2 weeks, including sore throat, cough and congestion. He received Z-pack on [5-8] for possible sinus infection. On [5-10], his R hand felt numb and tingling (whole hand, all digits, to wrist), which he thought might be a side effect of antibiotic. That day, he also felt subjective R thigh/quad weakness, though he could still walk normally and do stairs. On [5-11], his L hand also became numb and tingly. He developed a strange numb feeling on his anterior abdomen, it was not around his entire torso, not like a band or constriction, and it did not affect his respirations. Both legs felt weaker as well, and he went to [Hospital1 2436] ED, sent home. On [5-12] (yesterday), patient was weaker in his legs, and his walking was "wobbly." He was not dragging one leg or catching his toes. His feet were now tingling, up to the ankles bilaterally. He also noticed that speaking and swallowing was difficult and tiring. Per his parents, his voice is more nasal, as well as slurred and much softer. He has not been eating or drinking much since swallowing is tiring, he had some nasal regurgitation once, but no choking or frank aspiration. Today, the patient was worse in terms of weakness and ability to ambulate. He nearly fell walking down stairs, but parent was there to support him and avoided fall. He has trouble sitting up from lying position and getting out of bed. The patient also noticed diplopia today. He noticed something strange with his vision x 2 days, but could not define it before. Today, he has noticed horizontal diplopia that is constant. He has been able to urinate and move bowels normally, but has loss of sensation in the groin and rectal areas. The patient had a similar presentation 6 years ago at age 15. He was treated at CHB, and father thinks the diagnosis was [Name (NI) 1557] [Doctor Last Name 957] syndrome. At that time, he developed weakness and loss of balance. His mother notes that his gait looked strange in a similar way as it does now, and his voice sounded similar. His mother thinks he was actually weaker then vs. now. His respiratory status remained stable. He did not have sensory symptoms at that time, nor diplopia. He received IVIG and improved quickly within a few days. He was out of school for 2 weeks. After some PT to build up strength in the legs after disuse, he was back to baseline without residual symptoms or deficits. Past Medical History: none other than episode [Doctor First Name 1557] [Doctor Last Name 957] syndrome 6 yrs ago Social History: works in construction. No tobacco. EtOH- 4-5 drinks most weekends. No illicits. No recent travel, sick contacts, toxic or environmental exposures. Family History: negative for neurologic disease, no seizures, no MS. Physical Exam: At admission: Vitals: T: 98.5 P:86 R: 16 BP:114/76 SaO2:98/RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [Doctor Last Name 1841] backward without difficulty. Speech is possibly mildly dysarthric (based on parents' assesment), becomes increasingly quiet and effortful after a long conversation. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall [3-28] at 5 minutes. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 2mm and brisk. VFF to confrontation with red pin. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: Impaired abduction of L eye, otherwise EOMI, no nystagmus. Smooth saccades. There is diplopia in all extremes of gaze, worst on far right gaze, worse far than near. Images are horizontal side by side, farthest apart on R gaze. Resolves with covering either eye. V: Facial sensation intact to light touch, cold and pinprick. VII: No facial droop, upper and lower facial musculature full strength and symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate does not elevate well on either side, weak gag reflex. [Doctor First Name 81]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline with normal strenght on lateral movements. -Motor: Normal bulk, tone throughout. No pronator drift but bilateral arms titubate up and down, cannot hold them out steadily. No pseudoathetosis. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [First Name9 (NamePattern2) 2339] [Last Name (un) 938] EDB L 5-* 5 5 5 5 5 5 3 5 4 5 5 5 5 R 5 5 5 5 5 5 5 3 5 4+ 5 5 5 5 * limited by L shoulder pain, giveway L ADM 4+, finger flexors 5 hip abduction [4-30] bilaterally, adduction [5-30] neck flexion [4-30], extension [5-30] -Sensory: No deficits to light touch. Decreased pinprick at L medial forearm only (80%). Decreased cold sensation L toes, intact on foot. Decreased vibratory sense (nearly absent L great toe and present L medial malleolus, 2-3 seconds at R great toe). Intact proprioception at bilateral great toes. No extinction to DSS. -DTRs: absent throughout Plantar response was flexor bilaterally. -Coordination: slow and clumsy on finger to crease tapping bilaterally. On FNF there is severe ataxia bilaterally, with no intention tremor. All limbs movements are wobbly and unsteady. On mirroring task there is overshoot and rebound with bilateral upper extremities. Unable to perform HKS due to weakness. -Gait: unable to ambulate At transfer out of NeuroICU: horizontal diplopia in upward extremes of gaze only, conjugate EOMI, palate rises in midline, [5-30] full strength throughout, including neck flex/ext. Dysmetric in all 4 ext (greatest in LUE. Areflexic, toes down. Gait (with supervision) is slightly unsteady but independent. NIF [5-13]: -65 --> -50 ------> [5-20] -70 V cap [5-13]: 2.7 --> 1.9 -----> [5-20] 3.5-4L PHYSICAL EXAM AT DISCHARGE: VS - 97.8, 120/80's, 70's, 18, 99 on RA GEN: young man lying in bed in NAD HEENT: OP clear CV: RRR PULM: CTAB ABD: soft, NT, ND EXT: no edema . NEURO EXAM: MS - AAOx3 CN - EOMI, PERRL 4-->2mm, face symmetrical, facial sensation intact, tongue midline MOTOR - [5-30] throughout REFLEXES - absent throughout (per pt this is chronic since his first GBS episode) SENSORY - intact to light touch throughout GAIT - narrow based, good arm swing, good initiation Pertinent Results: ADMISSION LABS: [2195-5-13] 08:05PM BLOOD WBC-11.5* RBC-5.43 Hgb-16.3 Hct-47.2 MCV-87 MCH-29.9 MCHC-34.4 RDW-12.2 Plt Ct-252 [2195-5-16] 02:09AM BLOOD WBC-19.1* RBC-4.61 Hgb-13.7* Hct-40.4 MCV-88 MCH-29.8 MCHC-34.0 RDW-12.4 Plt Ct-214 [2195-5-21] 03:15AM BLOOD WBC-8.2 RBC-4.78 Hgb-14.0 Hct-42.5 MCV-89 MCH-29.2 MCHC-32.8 RDW-12.3 Plt Ct-297 [2195-5-13] 08:05PM BLOOD Neuts-77.9* Lymphs-17.2* Monos-4.1 Eos-0.4 Baso-0.5 [2195-5-13] 08:05PM BLOOD Plt Ct-252 [2195-5-16] 02:09AM BLOOD PT-14.2* PTT-30.6 INR(PT)-1.3* [2195-5-13] 08:05PM BLOOD Glucose-87 UreaN-16 Creat-1.0 Na-139 K-3.9 Cl-103 HCO3-24 AnGap-16 [2195-5-21] 03:15AM BLOOD Glucose-111* UreaN-13 Creat-0.7 Na-138 K-3.9 Cl-101 HCO3-26 AnGap-15 [2195-5-15] 02:29AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.0 [2195-5-18] 01:42AM BLOOD Triglyc-211* [2195-5-15] 04:03PM BLOOD TSH-0.72 [2195-5-13] 08:05PM BLOOD IgA-241 [2195-5-18] 05:33AM BLOOD Vanco-1.9* [2195-5-14] 09:43AM BLOOD Type-ART pO2-104 pCO2-43 pH-7.38 calTCO2-26 Base XS-0 [2195-5-14] 09:43AM BLOOD Glucose-88 Lactate-1.4 [2195-5-15] 04:03PM BLOOD GQ1B IGG ANTIBODIES-PND [2195-5-14] 11:51PM URINE Color-YELLOW Appear-Cloudy Sp [Last Name (un) ]-1.027 [2195-5-14] 11:51PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [2195-5-14] 11:51PM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 DISCHARGE LABS: [2195-5-22] 05:17AM BLOOD WBC-7.2 RBC-4.85 Hgb-14.6 Hct-42.4 MCV-88 MCH-30.1 MCHC-34.3 RDW-12.4 Plt Ct-303 [2195-5-22] 05:17AM BLOOD Glucose-90 UreaN-15 Creat-0.6 Na-135 K-4.3 Cl-101 HCO3-25 AnGap-13 [2195-5-22] 05:17AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2 MICROBIOLOGY: [2195-5-13] 09:55PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-0 Lymphs-82 Monos-18 [2195-5-13] 09:55PM CEREBROSPINAL FLUID (CSF) TotProt-64* Glucose-54 [2195-5-13] 9:55 pm CSF;SPINAL FLUID #3. FINAL REPORT [2195-5-17] GRAM STAIN (Final [2195-5-14]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [2195-5-17]): NO GROWTH. [2195-5-16] 1:03 am SPUTUM FINAL REPORT [2195-5-18] GRAM STAIN (Final [2195-5-16]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2195-5-18]): SPARSE GROWTH Commensal Respiratory Flora. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. MODERATE GROWTH. Beta-lactamse negative: presumptively sensitive to ampicillin. Confirmation should be requested in cases of treatment failure in life-threatening infections.. [2195-5-16] 6:19 am URINE Source: Catheter. FINAL REPORT [2195-5-17] Legionella Urinary Antigen (Final [2195-5-17]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. [2195-5-16] 10:00 pm BRONCHOALVEOLAR LAVAGE Site: LUNG LEFT LUNG. FINAL REPORT [2195-5-18] GRAM STAIN (Final [2195-5-17]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [2195-5-18]): NO GROWTH, <1000 CFU/ml. [2195-5-14] CXR: FINDINGS: A single portable view of the chest is provided. The lungs are essentially clear. The cardiomediastinal silhouette and hilar contours are unremarkable. There are no pneumothoraces or pleural effusions. The bones are intact. IMPRESSION: No evidence of acute intrathoracic process. [2195-5-16] CXR: CHEST, SINGLE AP PORTABLE VIEW. An ET tube is present, tip approximately 7.3 cm above the carina. The tip lies relatively high, approximately 14 mm above the upper edge of the medial clavicle. Slight asymmetry of the clavicles is present, unchanged, with the right medial clavicular head more angulated and inferior compared to the left. An NG-type tube is present -- the tip is not well delineated and cannot be traced beyond the lower mediastinum. There is increased retrocardiac density, worse compared with [2195-5-14], and bibasilar atelectasis. Possible slight clearing at the right base. Doubt gross effusion. No CHF. IMPRESSION: 1. ET tube as described, relatively high. Clinical correlation requested. 2. Left lower lobe collapse and/or consolidation, slightly worse. Atelectasis at right base, slightly better. 3. Asymmetric positioning of the right and left clavicular heads. Is there a history of trauma to account for this? [2195-5-17] Abd XR: ABDOMEN, TWO VIEWS. Gas and stool are seen throughout the colon down to level of the rectum. No air-filled dilated loops of large or small bowel to suggest ileus are identified. No free air is seen beneath the diaphragm. An NG tube is present, tip overlying stomach. [5-18] ECG: Baseline artifact. Probable sinus rhythm with right axis deviation and early precordial R wave progression. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 100 146 94 [Telephone/Fax (3) 110477] 106 179 [5-20] CXR: FINDINGS: In comparison with the study of [5-19], the endotracheal tube and nasogastric tubes have been removed. Right subclavian catheter remains in satisfactory position. There is persistent opacification in the region of the costophrenic angle on the left. However, the more medial portion of the right hemidiaphragm is quite well seen, suggesting some decrease in the left lower lobe volume loss, possibly related to clearing of a mucus plug. Asymmetry is again seen in the left infrahilar region, consistent with the previous suggestion of consolidation. The right lung is clear with the heart border and hemidiaphragm sharply seen. [5-21] CXR: IMPRESSION: AP chest compared to [5-17] through 23: Left lower lobe collapse developed over preceding 24 hours. Aeration in the left lower lobe has improved but there is still a large infrahilar region of what could be pneumonia, and now there is new consolidation at the right lung base, also suspicious for infection due to aspiration. Endotracheal tube ends above the thoracic inlet, no less than 6.5 cm from the carina and should be advanced 3 cm for more secured seating. Enteric tube passes as far as the upper stomach and out of view. Heart size is normal. There is no appreciable pleural effusion. Right PIC line ends in the low SVC. No pneumothorax. Brief Hospital Course: 21 year-old right-handed M with history of [Doctor First Name 1557] [Doctor Last Name 957] syndrome s/p IVIG 6 years ago who presented with numbness of hands and feet, progressive weakness, dysphagia, saddle anesthesia with bowel/bladder changes, and diplopia. Neuro exam at admission was remarkable for binocular horizontal diplopia on extremes of gaze, with impaired L eye abduction c/w CNVI palsy, weak gag/palate elevation. Motor exam revealed weak neck flexion and proximal LE weakness (IP, hip abductors, hamstring). Sensory deficits were minimal except for decreased vibratory sensation at great toes. There was limb ataxia, rebound and overshoot with bilateral UEs. He is areflexic, although this is his baseline since his prior episode of GBS. His presentation on this admission was consistent with [Doctor First Name 1557] [Doctor Last Name 957] variant of GBS. CSF protein was mildly elevated, with normal cell count and diff, which was consistent as well. Similarly to his past presentation, there was a preceeding viral URI. He was initially admitted the the general neurology step down unit on [2195-5-13], however, due to increased difficulties with swallowing oral secertions and worsening respiratory status, he was transferred the to NeuroICU early [5-14]. He was electively intubated a few hours later for airway protection and started on IVIG. Of note, his hospital course was complicated by pneumonia, for which he was started on empiric abx on [2195-5-16] to cover VAP, which were later narrowed when Haemo influenza was identified. He was extubated [5-19] without complication. NEURO: s/p intubation [5-14] for inability to swallow secretions and increasing resp distress. Completed 5 days IVIG [2106-5-13]. Neurological exam was then significant for dysmetria in all extremities, LUE greatest, as well as mild diplopia on upward gaze. Prior to intubation he had NIFs that were -65 --> -50 --> -48; VC 2.7--> 1.9 --> 1.58; [5-18] NIF -35. [5-20] NIF -70 and VC 4L. While at admission the patient was having bladder/bowel retention and saddle anesthesia these symptoms subsequently improved and he was no longer having bowel/bladder retention. At discharge he had an essentially normal neurological exam. CARDS: patient was temporarily on metoprolol for tachycardia, which was weaned prior to discharge. GI: patient was NPO with TF's while intubated in the ICU. Afterwards, his diet was advanced until he was tolerated regular foods. When he initially began taking solid foods he had lots of nausea and vomiting, which require reglan for improvement. He was subsequently able to be weaned off of reglan and eat solid foods with no nause or other ill effects. ID: Pt diagnosied here with Haemo influenza pneumonia, likely acquired in the ICU during intubation. Patient had copious secretions, with CXR [5-16] showing RLL infiltrate. He was tarted on vanc/cefepime d1= [5-16] for VAP. Narrowed to CTX [5-20]. He completed 7 days total treatment (end date [5-22]) PENDING RESULTS: G1QB Antibody TRANSITIONAL CARE RESULTS: Patient told to return to the hospital if he develops any further similar sx. He understands that if his sx recur again he may need to be on prophylactic immunosuppressant medication as he more likely would have CIDP. He agreed to be vigilant if he had any further sx and always seek out medical care. Medications on Admission: Recently finished azithromycin course for URI. Otherwise no daily meds Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: [Last Name (un) 4584] [Location (un) ] Syndrome Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [Known lastname ], You were seen in the hospital for weakness and were diagnosed with [Last Name (un) ] [Location (un) ] syndrome. We made no changes to your medications. If you experience the below listed Danger Signs, please contact your doctor or go to the nearest emergency room. It was a pleasure taking care of you on this hospitalization. Followup Instructions: Department: NEUROLOGY When: MONDAY [2195-9-7] at 4:00 PM With: DRS. [Name5 (PTitle) 43] & [Doctor Last Name 2336] [Telephone/Fax (1) 44] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "51881" ]
Admission Date: [2135-7-14] Discharge Date: [2135-7-19] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 898] Chief Complaint: GIB Major Surgical or Invasive Procedure: intubation (electively for EGD only; otherwise DNR/DNI) colonoscopy EGD History of Present Illness: 86M with h/o recent NSTEMI [1-17], and recent admission to OSH for GIB of unclear source (plavix stopped x5d, then restarted), presenting to [Hospital1 18]-N this morning for altered mental status, lethargy, and black stools. VS there 97.7 118 16 78/48 90%RA. Exam notable for guaic positive stool and lethargy. Labs revealed HCT 22, K 6.0 (hemolyzed), CRE 2.9. NG lavage revealed green gastric contents, no blood, no coffee grounds. He received 2 PIVs, nexium gtt, CTX 1 gm, azithromycin, and 2U PRBC, with BP improvement to 101/42 HR 89 at time of transfer to [Hospital1 18]. Of note, he was admitted to [Hospital ] Hospital [Date range (1) 30614] in the setting of weakenss and [Doctor Last Name ] large dark bowel movement, found to be anemic (HCT 21.3 on admission, up to 34.1 at discharge after total 5U PRBCs), and was admitted for evaluation of GIB with EGD, with course c/b respiratory failure requiring intubation (per family x3d) felt [3-14] CHF vs PNA. EGD at that time revealed esophagitis and duodenitis per discharge summary. In ED VS = 97.8 93 128/58 20 100%. Labs upon arrival notable for K 5.8, CRE 2.4 (baseline 1.3 at time of discharge [6-30]), HCT 25.6 (after 2U PRBC from OSH), WBC 20.1, INR 1.2. SBP dropped to 77/42 with HR 103, so CVL was placed and he was started on levophed, and received an additional . SBP improved to 120s after 1L NS and an additional 1U PRBC, which is still hanging. GI consult obtained, cardiology made aware. Past Medical History: - CAD s/p 2 vessel CABG in [2126], bioprosthetic AVR, NSTEMI [1-17] with DES to RCA (>90% stenosis), and PL, otherwise open SV grafts x 2 (LAD, DIAG), native 90% LCx dx. - CHF (EF= 30-44%), mod TR, LAE on TTE [6-18] at OSH. - PVD - known R SFA occlusion @ cath [1-17]. - HTN - DM2 - on oral meds. - Hyperlipidemia - h/o CVA in [5-19] with slurred speech, found to have (atrophy, small vessel ischemic changes, subtle chronic left pontine infarct) on CT HEAD at OSH [6-18]. Social History: Lives alone, 7 children. No tobacco, drinks [2-11] glasses of wine a week, denies IVDU. Family History: HTN, CAD, DM. Physical Exam: Vitals: 97.4 95 150/55 27 99%2L General: lethargic, oriented x1, no acute distress HEENT: MM dry, oropharynx clear, poor dentition Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation anteriorly, no wheezes, rales, ronchi CV: Regular rate, normal S1 + S2, 2/6 SEM @ RSB, no rubs, gallops Abdomen: soft, non-tender, non-distended, hypoactive bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2135-7-14] 08:35PM WBC-18.7* RBC-2.82* HGB-8.5* HCT-25.0* MCV-89 MCH-30.2 MCHC-34.1 RDW-18.7* [2135-7-14] 08:35PM PLT COUNT-214 [2135-7-14] 08:28PM GLUCOSE-232* UREA N-111* CREAT-2.0* SODIUM-142 POTASSIUM-5.5* CHLORIDE-112* TOTAL CO2-20* ANION GAP-16 [2135-7-14] 08:28PM CK(CPK)-152 [2135-7-14] 08:28PM CK-MB-23* MB INDX-15.1* cTropnT-0.63* [2135-7-14] 04:51PM TYPE-ART PO2-475* PCO2-40 PH-7.32* TOTAL CO2-22 BASE XS--5 [2135-7-14] 04:51PM LACTATE-0.8 [2135-7-14] 03:37PM WBC-17.6* RBC-2.66* HGB-8.3* HCT-23.5* MCV-88 MCH-31.1 MCHC-35.2* RDW-18.7* [2135-7-14] 03:37PM PLT COUNT-215 [2135-7-14] 01:03PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [2135-7-14] 10:36AM LACTATE-1.4 [2135-7-14] 09:47AM HGB-9.0* calcHCT-27 [2135-7-14] 09:45AM GLUCOSE-231* UREA N-123* CREAT-2.4# SODIUM-136 POTASSIUM-5.8 CHLORIDE-104 TOTAL CO2-19* ANION GAP-19 [2135-7-14] 09:45AM ALT(SGPT)-21 AST(SGOT)-25 ALK PHOS-43 TOT BILI-1.0 [2135-7-14] 09:45AM LD(LDH)-163 CK(CPK)-95 [2135-7-14] 09:45AM LIPASE-85* [2135-7-14] 09:45AM cTropnT-0.42* [2135-7-14] 09:45AM calTIBC-291 HAPTOGLOB-163 FERRITIN-94 TRF-224 [2135-7-14] 09:45AM WBC-20.1* RBC-2.83* HGB-8.6* HCT-25.6* MCV-90# MCH-30.4# MCHC-33.7 RDW-17.9* [2135-7-14] 09:45AM NEUTS-92.3* LYMPHS-5.7* MONOS-1.9* EOS-0.1 BASOS-0.1 [2135-7-14] 09:45AM PLT COUNT-245 [2135-7-14] 09:45AM PT-14.1* PTT-24.6 INR(PT)-1.2* STUDIES: [2135-7-14] ECG: LBBB (old), nl axis, no STE per sgarbossa criteria, STD and TWI in 1, avl, V4-6 c/w LVH. [2135-7-14] CXR: no obvious infiltrate, pulmonary edema. ?free air under right diaphragm. prior cabg and avr seen. [2135-7-15]: Colonoscopy: There was a very tight bend at the sigmoid colon which could represent previous anastomosis if patient has had prior surgery. There were a few areas of a few red drops of blood seen in the ascending colon which were washed without underlying lesion seen. Mucosa appeared very friable and occasional contact bleeding was seen. However, this was minimal and does not account for transfusion requirement. Polyp in the sigmoid colon Bile was seen in the terminal ileum and cecum without evidence of blood. Ileum was normal up to 25 cm. Otherwise normal colonoscopy to terminal ileum to 20 cm. [2135-7-15]: EGD: Impression: Mild gastritis. Otherwise normal EGD to second part of the duodenum [2135-7-15]: CT ABD/PELVIS 1. No retroperitoneal bleed. Right femoral venous catheter in expected position. 2. Two rim calcified infrarenal abdominal aortic aneurysms measuring up to 3 cm in diameter are chronic, without adjacent paraaortic abnormality. These may be the sequelae of prior penetrating ulcer or focal dissection. Dense calcification at the origin of the renal arteries and SMA; significant stenosis cannot be excluded. 3. Cholelithiasis without evidence for cholecystitis on this limited non-contrast exam. [2135-7-16] Echo The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with inferior and infero-lateral akinesis with septal hypokinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild functional mitral stenosis (mean gradient 5 mmHg) due to mitral annular calcification. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: # GIB - Patient having melanotic stools with hemodynamic instability requiring total of (6units, last transfusion on [2135-7-15]) of pRBCs at [Hospital1 18]. GI was consulted. EGD was negative for acute bleed. Colonoscopy was negative for acute bleed. CT scan was negative for RP bleed. Hemolysis labs were negative. Hct remained stable since last transfusion on [2135-7-15] # hypotension - Initially concerning for GIB given guaic positive stool, decreased HCT, and recent similar admission. ddx also included sepsis, so evaluated for possible sources with CXR, Bcx, and UCx. CXR was negative. Bcx and Ucx were negative Patient was given aggressive IVF and blood as above. After the colonoscopy he did require levophed briefly, but then was able to maintain BPs without pressor-support. # confusion - per family, confusion was typical of pt's hospitalizations, and likely multifactorial with contribution from poor neurologic reserve (h/o CVA, chronic vascular changes), hypotension, and possible septic picture. No evidence to suggest primary CNS infection (no meningismus, headache, kernig, brudzinki negative), no focal neurologic deficits on exam. Seroquel was held, then restarted at home dose. Pt returned alert and oriented x 3 once transferred out of ICU. # hyperkalemia - likely [3-14] ARF. no ECG changes c/w hyperkalemia. Resolved. . # ARF - likely [3-14] volume depletion. lactate negative. Resolved with IVF. . # CAD - s/p NSTEMI. denies chest pain or dyspnea, and EKG without frank evidence of ischemia though has old LBBB, and worsening TWI and STD in V4-6 in setting of sinus tach and anemia (likely reflects both LVH and some demand ischemia). feels ACS is unlikely, but given +troponin and recent NSTEMI, will proceed as follows: - held ASA and plaivx initially, then restarted when EGD revealed no active bleeding. - held metoprolol, lisinopril given initial hypotension, then restarted when pt actually became hypertensive on the floor - transfuse to maintain HCT > 27. - Echo done, result as above . # CHF - EF 40% at OSH in [6-18], on lasix at home. Held lisinopril and lasix initially, then restarted prior to discharge. # DM2 - on orals at home; covered with ISS during hospital stay. . # hyperlipidemia - held statin initially, then restarted prior to discharge. . # Code: DNR/DNI Medications on Admission: - metformin 500mg po bid - plavix 75mg po qdaily (stopped x5d during [6-18] admission) - glipizide 10mg po bid - metorolol 50mg po bid - isosorbide mononitrate 30mg po qdaily - lisinopril 20mg po qdaily - digoxin 125mg po qdaily - hydralazine 25 mg po tid - lipitor 20mg po qdaily - senna - colace - aspirin 81mg po qdaily - mvi - seroquel 25mg po bid (started [6-18]) - lasix 40mg po qdaily - prilosec 40mg po bid Discharge Medications: 1. Equipment 3-in-1 commode (diagnosis of CVA) 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO twice a day. 7. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 10. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. Disp:30 Tablet Sustained Release(s) Refills:2 11. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 13. Lipitor 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day. 15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 17. Multivitamins Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 18. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for yeast infection on buttocks. Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary: GI bleed Acute renal failure . Secondary: Coronary artery disease Hypertension Chronic systolic heart failure Discharge Condition: Improved Discharge Instructions: You were admitted to the hospital for bleeding in the gastrointestinal tract. Upper and lower endoscopy was done however we could not find the source of the bleeding because it had stopped bleeding by then. . A capsule study has been scheduled for you. You will receive instructions by mail, but you should also call [Location (un) 13544] at [Telephone/Fax (1) 30615] to confirm the appointment and learn more about the procedure. . Some changes were made to your medications: - Stopped hydralazine (blood pressure medication) - Stopped Prilosec and instead started Ranitidine - Changed Seroquel from 25 mg twice a day to 25 mg once at bedtime - Added Nystatin cream as needed for fungal infection of the buttocks . CT scan of your abdomen and pelvis done during this hospitalization showed some changes that should be followed up with a repeat scan in 3 months ([Month (only) 216]-[2135-10-11]). Your primary care doctor [First Name (Titles) ] [Last Name (Titles) ] this. . Please weigh yourself every morning and call your doctor if weight > 3 lbs. Please adhere to 2 gm sodium diet. . If you experience dizziness, palpitations, black tarry stools, red blood with stools, or any other symptoms concerning to you, please call your doctor or return to the emergency room. Followup Instructions: Please go to the following appointments as scheduled: Capsule study: [2135-7-26] 8:00 AM with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1982] Phone:[Telephone/Fax (1) 463] Follow up appointment with gastroenterology: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8718], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2135-8-2] 1:30 PM . Please call Dr.[Name (NI) 30616] office at [Telephone/Fax (1) 29110] to follow up in [4-13] weeks (sometime after your appointment with Dr. [Last Name (STitle) 4539]. Please mention that you were asked to get a repeat imaging of your abdomen for the findings seen on CT scan during your hospital stay. A summary of your hospitalization will be faxed to her office. Completed by:[2135-8-3]	[ "5849", "4280", "2859", "2767", "41401", "V4582", "4019", "25000", "V5867", "2724", "412" ]
Admission Date: [2125-1-8] Discharge Date: [2125-1-23] Date of Birth: [2052-3-19] Sex: M Service: CARDIOTHORACIC Allergies: Vasotec / Codeine / Ismo / Hytrin / Procardia / Erythromycin Ethylsuccinate / Inderal / Amoxicillin / Indocin / Lotensin / Ceftin / Iodine; Iodine Containing Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pressure Major Surgical or Invasive Procedure: [1-8] Cardiac catheterization [1-16] Coronary artery bypass graft (left internal mammary artery > left anterior descending, Saphenous vein graft > obtuse marginal) History of Present Illness: 72 year old male presented to emergency department at [Hospital3 17021] with chest pain. After dinner [2125-1-5] he started having 8/10 chest pain unrelieved with sublingual nitroglycerin which he took twice. He was brought in by ambulance. He ruled in for Non ST elevation myocardial infarction with troponin 0.94 and CK MB 11.7. He was stabilized and was transferred a few days later for cardiac evaluation. Past Medical History: cerebral vascular incident [2107] Diabetes mellitus type 2 Right bundle branch block Obesity Gastroesophageal reflux disease H/o nephrolithiasis S/p hernia repair S/p cataract surgery S/p appendectomy Social History: Quit smoking 40 years ago. Rare alcohol Lives with spouse Retired auto mechanic Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: Admission: VS: T 98.7, HR 75, BP 120/73, RR 18, POx 95% on RA Gen: Obese male in NAD. Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Unable to assess [12-18] body habitus CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 2/6 systolic mm loudest at base. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Obese, Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. R groin - non-tender, no hematoma. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 17022], [Known firstname ] [Hospital1 18] [Numeric Identifier 17023]TTE (Complete) Done [2125-1-9] at 3:43:23 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) 2052], [First Name11 (Name Pattern1) 2053] [Initial (NamePattern1) ] [Last Name (NamePattern4) 18] - Interventional Cardiolo [Street Address(2) 8667], [Hospital Ward Name ] 4 [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2052-3-19] Age (years): 72 M Hgt (in): 69 BP (mm Hg): 132/60 Wgt (lb): 208 HR (bpm): 67 BSA (m2): 2.10 m2 Indication: Left ventricular function. Right ventricular function. Valvular heart disease. ICD-9 Codes: 424.1, 424.0 Test Information Date/Time: [2125-1-9] at 15:43 Interpret MD: [First Name8 (NamePattern2) ] [Name8 (MD) ], MD Test Type: TTE (Complete) Son[Name (NI) 930]: [Name2 (NI) 16812] [Last Name (un) 16813], RDCS Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Adequate Tape #: 2009W005-0:56 Machine: Vivid [5-22] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 4.0 cm <= 4.0 cm Left Atrium - Four Chamber Length: 6.0 cm <= 5.2 cm Right Atrium - Four Chamber Length: 5.1 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.4 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.2 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.1 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.3 cm Left Ventricle - Fractional Shortening: 0.35 >= 0.29 Left Ventricle - Ejection Fraction: 60% to 65% >= 55% Left Ventricle - Lateral Peak E': 0.08 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.06 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 11 < 15 Aorta - Sinus Level: 3.1 cm <= 3.6 cm Aorta - Ascending: 4.0 cm <= 3.4 cm Aorta - Arch: 3.2 cm <= 3.0 cm Aortic Valve - Peak Velocity: 2.5 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 25 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 14 mm Hg Aortic Valve - LVOT VTI: 22 Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.8 m/sec Mitral Valve - E/A ratio: 1.00 Mitral Valve - E Wave deceleration time: 297 ms 140-250 ms Findings LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global systolic function (LVEF>55%). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Moderately dilated ascending aorta. Mildly dilated aortic arch. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Minimally increased gradient c/w minimal AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral annular calcification. Mild thickening of mitral valve chordae. No MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Thickened pulmonic valve leaflets. No PS. Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - body habitus. Conclusions The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. The pulmonic valve leaflets are thickened. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved regional and global biventricular systolic function. Dilated thoracic aorta. Minimal aortic stenosis. Electronically signed by [First Name8 (NamePattern2) ] [Name8 (MD) ], MD, Interpreting physician [Last Name (NamePattern4) ] [2125-1-9] 16:39 [2125-1-8] CARDIAC CATH: 1. Coronary angiography of this right dominant system revealed three vessel coronary artery disease. The LMCA had a distal hazy 30% ulcer extending into the LAD and LCx. The LAD had mild diffuse disease with a long 85%-90% lesion in the mid vessel. The LCx had an ostial 60% lesion. The RCA was diffusely diseased and occluded in the mid vessel. 2. Limited resting hemodynamics demonstrated severe systemic arterial hypertension (SBP 184 mm Hg). 3. Left ventriculography was deferred. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 17022], [Known firstname ] [Hospital1 18] [Numeric Identifier 17024] (Complete) Done [2125-1-16] at 1:53:32 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) ] R. [Hospital1 18], Division of Cardiothorac [Hospital Unit Name 4081] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2052-3-19] Age (years): 72 M Hgt (in): 69 BP (mm Hg): 126/70 Wgt (lb): 208 HR (bpm): 57 BSA (m2): 2.10 m2 Indication: Intraoperative TEE for CABG procedure. Aortic valve disease. Cerebrovascular event/TIA. Chest pain. Hypertension. Left ventricular function. Mitral valve disease. Myocardial infarction. Preoperative assessment. Right ventricular function. ICD-9 Codes: 402.90, 786.51, 440.0, 424.1, 424.0 Test Information Date/Time: [2125-1-16] at 13:53 Interpret MD: [Name6 (MD) 1509] [Name8 (MD) 1510], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 1510], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW5-: Machine: AW5 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 50% >= 55% Aorta - Annulus: 2.2 cm <= 3.0 cm Aorta - Ascending: 3.6 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.4 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 8 mm Hg < 20 mm Hg Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 0.3 m/sec Mitral Valve - E/A ratio: 2.33 Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild symmetric LVH. Mild regional LV systolic dysfunction. Mildly depressed LVEF. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. Simple atheroma in ascending aorta. Simple atheroma in aortic arch. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions Prebypass No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. There is mild regional left ventricular systolic dysfunction with hypokinesia of the apex, apical and mid portions of the anterior and anteroseptal walls.. Overall left ventricular systolic function is mildly depressed (LVEF= 50 %). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results on [2125-1-16] at 1330. Post bypass: The patient is on no infusions, AV paced. Preserved biventricular systolic fxn. Trace - mild MR [First Name (Titles) ] [Last Name (Titles) ]. Aorta intact post decannulation. Post bypass study performed and read by Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3318]. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [Name6 (MD) 1509] [Name8 (MD) 1510], MD, Interpreting physician [Last Name (NamePattern4) ] [2125-1-17] 14:48 . [2125-1-8] EKG: Sinus rhythm. Left atrial abnormality. Right bundle-branch block. Borderline left axis deviation. Possible left anterior fascicular block. Borderline left ventricular hypertrophy with ventricular premature depolarizations and diffuse non-diagnostic repolarization abnormalities. Compared to the previous tracing of [2118-2-15] right bundle-branch block is now present. . . [2125-1-9] CAROTID U/S: Less than 40% stenosis of the internal carotid arteries bilaterally. Brief Hospital Course: Transferred from outside hospital for cardiac catherization that revealed moderate diffuse disease. He was referred for surgical evaluation and underwent preoperative workup and plavix was discontinued. He continued to have intermittent episodes of chest pain relieved with nitroglycerin and no EKG changes. On [1-16] he was brought to the operating room and underwent coronary artery bypass graft surgery, see operative report for further details. He received vancomycin for perioperative antibiotics because he was in the hospital preoperatively. He was transferred to the intensive care unit for hemodynamic monitoring. In the first twenty four hours he was weaned from sedation, awoke neurologically intact, and was extubated without complications. He was started on beta blockers and diuresis. He had hyperkalemia and was treated with insulin and dextrose with resolution. He remained in the intensive care unit for monitoring and was transfered to the floor post operative day 2. He was started on flomax due to failure to void, foley reinserted, after two days it was removed with no further difficulty. His nasal swab was positive for methicillin resistant staph aureus and started on bactroban. He continued to progress and was ready for discharge to rehab postoperative day 7. Medications on Admission: On transfer: Heparin at 400u/hr Ecotrin 325mg Plavix 75mg (rec'd today, s/p loading dose of 300mg on [1-6] - separate doses of 75 and 225 given) Nexium 40mg NTG paste (0.5" at 8am) . At home: Aspirin 325mg daily Nexium 40mg daily Diovan 160mg daily Imdur 60mg daily Niacin 500mg daily Folic acid 1mg daily Zinc Lecithin Natoff L-carnitine CoQ10 Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 5. Niacin 250 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for moderate to severe pain. 13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for mild-moderate pain. 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Discharge Disposition: Extended Care Facility: [Location (un) 582] at Silver [Doctor Last Name ] Discharge Diagnosis: Coronary artery disease s/p coronary artery bypass graft Methicillin resistant staph aureus from nasal swab Non ST elevation myocardial infarction Gastroesophageal reflux disease Diabetes mellitus type 2 nephrolithiasis cerebral vascular accident in [2107] Discharge Condition: deconditioned Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: Please call and schedule the following appointments Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 17025] after discharge from rehab [Telephone/Fax (1) 17026] Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 17027] after discharge from rehab Completed by:[2125-1-23*]	[ "41071", "5849", "41401", "25000", "2767", "53081" ]
Admission Date: [2131-5-10] Discharge Date: [2131-5-12] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: Fever Major Surgical or Invasive Procedure: Central Venous Line History of Present Illness: 85 y/o female with a h/o CAD, CVA, AF/sick sinus syndrome s/p pacer placement, T2DM, hyperlipidemia, and COPD who presented to the ED with fever. Pt was transferred from [Hospital 100] Rehab where she is a resident when she spiked a temp to 101 and subsequently sent to [Hospital1 18] ED for further evaluation. Of note, she is s/p recent left BKA c/b MRSA wound infection treated with vancomycin, ceftriaxone, and Flagyl. In the ED, she was given cefepime and clindamycin for broader coverage. Past Medical History: CAD s/p stenting of MI [2124] history of left CVA1/[2129] manafested with left hemiparesis history of cardiac arrythmia, sick sinus syndrome, AF ,s/p paacemaker history of DM2, diet controlled hsitory of GI bleed while on anticoagulation for renal thrombus history of hyperllpdemia history of COPD history of aortic valve stenosis history of Left ventricular diastolic dysfunction history of asscending aortic aneurysem history of pulmonary hypertension history of urosepsis [2128] history of dysphasia history of hyperlipdemia postoperative hypovolemia with low urinary output-fluid resustated postoperative blood loss anemia-transfused posopterative electrolyte imbalance-corrected Social History: nursing home resident since [2129] post CVA Family History: NC Physical Exam: Vitals - T 102.4, BP 108/57, HR 85, RR 17, O2 sat 94% 7L FM General - elderly female, no acute distress HEENT - mild anisocoria; R>L pupil, both reactive; OP clr, MMM, no LAD CV - RRR; [3-20] crescendo-decrescendo murmur @ LUSB Chest - coarse crackles with expiratory wheezes throughout Abdomen - NABS, soft, NT/ND Extremities - L lower extremity surgically absent; AKA stump with ~3-5 mm skin defect with minimal surrounding erythema, minimal whitish drainage Pertinent Results: [2131-5-10] 07:52PM GLUCOSE-189* UREA N-13 CREAT-0.6 SODIUM-142 POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-24 ANION GAP-12 [2131-5-10] 07:52PM CK(CPK)-34 [2131-5-10] 07:52PM CK-MB-NotDone cTropnT-0.07* [2131-5-10] 07:52PM CALCIUM-8.5 PHOSPHATE-3.8 MAGNESIUM-1.8 [2131-5-10] 07:52PM WBC-7.7 RBC-3.16* HGB-10.6* HCT-31.8* MCV-101* MCH-33.6* MCHC-33.4 RDW-15.7* [2131-5-10] 07:52PM PLT COUNT-157 [2131-5-10] 04:20PM PO2-89 PCO2-43 PH-7.37 TOTAL CO2-26 BASE XS-0 [2131-5-10] 03:47PM TYPE-ART PO2-46* PCO2-46* PH-7.37 TOTAL CO2-28 BASE XS-0 INTUBATED-NOT INTUBA [2131-5-10] 01:00PM URINE COLOR-Amber APPEAR-Hazy SP [Last Name (un) 155]-1.030 [2131-5-10] 01:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [2131-5-10] 01:00PM URINE RBC-0-2 WBC-[12-4]* BACTERIA-MOD YEAST-NONE EPI-[3-19] [2131-5-10] 11:52AM TYPE-[Last Name (un) ] COMMENTS-NOT SPECIF [2131-5-10] 11:52AM GLUCOSE-108* LACTATE-1.2 NA+-143 K+-5.1 CL--109 [2131-5-10] 11:48AM GLUCOSE-113* UREA N-10 CREAT-0.7 SODIUM-145 POTASSIUM-4.7 CHLORIDE-111* TOTAL CO2-29 ANION GAP-10 [2131-5-10] 11:48AM estGFR-Using this [2131-5-10] 11:48AM CALCIUM-8.7 PHOSPHATE-3.7# MAGNESIUM-2.0 [2131-5-10] 11:48AM WBC-6.9 RBC-3.51* HGB-11.7* HCT-35.8# MCV-102# MCH-33.4* MCHC-32.8 RDW-15.9* [2131-5-10] 11:48AM PLT COUNT-176 [2131-5-10] 11:48AM PT-12.5 PTT-25.5 INR(PT)-1.1 Echo [2131-5-11]: EF 70-75%, 3+TR 2+MR, 2+AR, mod AS, mod pulm HTN. CXR [2131-5-10]: 1. Left internal jugular central venous catheter likely terminating within the brachiocephalic confluence. No definite pneumothorax identified; however, left apex was not included on current radiograph. 2. Grossly unchanged appearance to bilateral pleural effusions and basilar atelectasis. More dense opacity within the retrocardiac region also likely represents atelectasis; however, underlying consolidation cannot be excluded. Brief Hospital Course: 85 F s/p recent left AKA on [2131-3-23], transferred from [Hospital 100] Rehab with fever and hypotension. Felt to be related to possibly multiple sources including AKA stump (cellulitis vs abscess vs osteo), C Diff colitis, UTI; also possible early pneumonia with retrocardiac opacity on CXR). Pt initially covered broadly with vanco/cefepime/metronidazole without good effect. Hemodynamics continued to decline as well as respiratory status with increasing CO2 retention despite non-invasive positive pressure ventilation. Pressors initially started with moderate effect, however, pt's mental status began to decline despite improved mean arterial pressures. Family meeting was held given continued decline, and pt was made comfort measures only by son. Pt expired at 19:49 [2131-5-12] and family was informed. Autopsy was declined. Medications on Admission: Acetaminophen 650 TID Aspirin 325 Ceftriaxone 1 gm QD Iron 325 QD Gabapentin 300 QHS Heparin 5000 SQ TID Lactobacillus [Hospital1 ] Toprol XL 37.5 QD Flagyl 500 PO Q8h Mirtazapine 30 PO QHS Protonix 40 PO QD Senna 2 QHS Simvastatin 40 QHS Vancomycin 750 IV QD Discharge Medications: na Discharge Disposition: Expired Discharge Diagnosis: Sepsis Hypotension Probable C diff colitis Probable nosocomial pneumonia Probable stump cellulitis Congestive heart failure Atrial fibrillation with sick sinus syndrome Hypoxic respiratory distress Hypercarbic respiratory failure Discharge Condition: expired	[ "41401", "2720", "0389", "496", "4241", "42731", "486", "4280", "51881" ]
Admission Date: [2193-4-8] Discharge Date: [2193-4-9] Date of Birth: [2131-11-10] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Last Name (NamePattern1) 1838] Chief Complaint: IPH Major Surgical or Invasive Procedure: n/a History of Present Illness: [Doctor Last Name 5656] ([Known firstname ]) [Known lastname 1022] is a 60 year old man with a history of hemorrhagic strokes who presents this evening after being found unresponsive. His wife reports that he was doing well today, his typical routine of exercises and such. He was watching TV as they normally do in the evening when she went to prepare dinner. A few minutes later, she came to feed him his dinner (she often helped to feed him) when he suddenly said to her "I'm sick, I'm in pain". His head then deviated to the right. She was unable to get his head back to midline. His son was home at the time in another room and he realized that something was very wrong, as his father was unresponsive; 911 was called. When EMS arrived, there was concern for possible seizure activity given the head deviation and so he was given 5 of Valium without effec. Fingerstick 120. On arrival to the ED, he was felt to have decerebrate posturing in arms. He had son[Name (NI) 7884] respirations and a clenched jaw and he was rapidly intubated. CT of the head demonstrated a large ICH and neurology was initially consulted, but this hemorrhage was felt to be not compatible with life. Neurology was then consulted. The patient's wife reports that he was recently started on coumadin (unknown reason) and there may have been some changes to blood pressure medications. There was otherwise no recent illness and the patient had no complaints. Further ROS could not be obtained. Past Medical History: - Hypertension - Hemorrhagic Stroke x 2: 1 in [2181] treated at [Location (un) ] [Hospital ] hospital, one in [2187] treated here (left BG hemorrhage). Wears an AFO on the right leg; can walk with a cane and leg brace - ASD on Echo [2187] Social History: SH: Married, 2 sons, owns Chinese restaurant. Family History: unknown Physical Exam: < ON ADMISSION > 180/100, HR 77, Intubated O2 sat 100% GEN: Intubated, sedated. CV: RRR PULM: symmetric mechanical breaths ABD: Soft EXT: well perfused NEURO: Off of sedation. Initially right pupil 6mm and minimally reactive, left 3mm and ovoid, then bilateral 6mm and unreactive. + corneals bilaterally, + cough, unable to elicit OCR. Right arm with hand flexion. Increased tone on the right arm and leg compared to left. + reflexes in the arms, 3+ patella. Unable to elicit AJ. Toes up bilaterally. Pertinent Results: [2193-4-8] 09:03PM URINE HOURS-RANDOM [2193-4-8] 09:03PM URINE HOURS-RANDOM [2193-4-8] 09:03PM URINE GR HOLD-HOLD [2193-4-8] 09:03PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2193-4-8] 09:03PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.014 [2193-4-8] 09:03PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-600 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2193-4-8] 09:03PM URINE RBC-13* WBC-9* BACTERIA-NONE YEAST-NONE EPI-0 [2193-4-8] 09:03PM URINE HYALINE-1* [2193-4-8] 09:03PM URINE MUCOUS-RARE [2193-4-8] 08:54PM PH-7.27* COMMENTS-GREEN TOP [2193-4-8] 08:54PM GLUCOSE-123* LACTATE-6.8* NA+-144 K+-5.4* CL--105 TCO2-24 [2193-4-8] 08:54PM HGB-16.7 calcHCT-50 O2 SAT-83 CARBOXYHB-3 MET HGB-0 [2193-4-8] 08:54PM freeCa-1.14 [2193-4-8] 08:51PM UREA N-26* CREAT-1.3* [2193-4-8] 08:51PM estGFR-Using this [2193-4-8] 08:51PM LIPASE-109* [2193-4-8] 08:51PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2193-4-8] 08:51PM WBC-8.5 RBC-5.13 HGB-16.3 HCT-46.6 MCV-91 MCH-31.8 MCHC-35.1* RDW-13.5 [2193-4-8] 08:51PM PT-111.1* PTT-46.4* INR(PT)-13.5* [2193-4-8] 08:51PM PLT COUNT-183 [2193-4-8] 08:51PM FIBRINOGE-350 NCHCT: large amount of acute intraventricular hemorrhage involving bilat lateral ventricles R>>L, third and 4th ventricles and inferior. evolving hydrocephalus. perivent hypodensity could = transependymal spread of CSF. acute hemorrhage extends intraparenchymal into right temporoparietal region and right thalamus. focus of left frontal hemorrhage appears to involve corpus collosum. ~ 8mm leftward midline shift at level of third ventricle. concern for impending right uncal herniation. Brief Hospital Course: Mr. [Known lastname 1022] was admitted to the SICU as described above. He shortly thereafter became hypertensive to the 230s SBP (nicardipine gtt was briefly started for this) and then hypotensive to the 40s SBP (pressors were started for this), a presumed herniation event given that all cranial nerve reflexes were lost at that point overnight. In the morning, pupils remained fixed and dilated (as described above, with ovoid Left pupil 5mm and round Left pupil 7mm) and fundoscopic examination was notable for bilateral irregular and blurred optic disc margins. There were no eye movements on either side to cold calorics testing, no VOR, no corneal reflexes, no spontaneous breaths on the ventilator, no cough, no gag. A cerebral nuclear perfusion study confirmed the complete absence of cerebral blood flow, which is diagnostic of brain death (time of study = 1:40pm = time of death). The family were informed, and after a son arrived from out of town in the evening, the Mr. [Known lastname 1022] was extubated. They were contact[Name (NI) ] by the NE organ transplantation bank. The family was not interested in organ donation. His family (wife and son) declined autopsy. The medical examiner office asked our thoughts re: the INR of 13, which Dr. [Last Name (STitle) 54849] told them was unexplained; the ME office waived the case and Dr. [Last Name (STitle) ] completed and submitted the Death Report [4-9] in the evening around 9pm. Medications on Admission: - Coumdain 5mg daily - Unknown antihypertensives Discharge Medications: n/a (died) Discharge Disposition: Expired Discharge Diagnosis: Intraparenchymal Hemorrhage Discharge Condition: n/a (died) Discharge Instructions: n/a (died) Followup Instructions: n/a (died) Completed by:[2193-4-10]	[ "4019", "V5861" ]
Admission Date: [2104-7-14] Discharge Date: [2104-7-17] Date of Birth: [2039-1-16] Sex: M Service: CT Surgery ADMISSION DIAGNOSES: 1. Esophageal mass. 2. Upper gastrointestinal bleed, questionably secondary to esophageal mass. 3. Hypertension. 4. History of chronic renal insufficiency. 5. Claudication. 6. Hyperlipidemia. 7. History of alcohol abuse. 8. Depression. DISCHARGE DIAGNOSES: 1. Esophageal mass-pathology pending. 2. Upper gastrointestinal bleed 3. Hypertension. 4. History of chronic renal insufficiency. 5. Claudication. 6. Hyperlipidemia. 7. History of alcohol abuse. 8. Depression. HISTORY OF PRESENT ILLNESS: The patient is a 65 year old male who had had multiple episodes of hematemesis along with associated nausea but without abdominal pain most recently, about two days prior to admission, on [2104-7-14], but noted that this had been going on for about two weeks. The hematemesis was definitely bright red and bloody. According to the patient, he initially presented to an outside hospital and underwent an esophagogastroduodenoscopy which observed distal esophageal bleeding at 28 to 30 cm and was injected with epinephrine. It was subsequently re-evaluated with an EGD which showed no bleed. Initially, his hematocrit at that time was 21 and he had been transfused with four units of packed red blood cells. Notably on EGD, there was a significant tumor which was described as "large, ulcerating, bulky, extending 28 to 35 cm from the incisor". This was thought to be the origin of the bleeding. The patient was transferred to [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ] for definitive evaluation of this tumor with a possibility of operative intervention. LABORATORY DATA: On admission to [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ], the patient's white blood cell count was 14.1 with a hematocrit of 34.8 and platelet count of 171,000 with a prothrombin time of 13, partial thromboplastin time 22.5 and INR of 1.1. His admission potassium was 3 (which was subsequently repleted) with a BUN and creatinine of 31 and 0.7. Liver function tests were within normal limits with an ALT of 12, AST 17, alkaline phosphatase 47, and total bilirubin 0.5. PHYSICAL EXAMINATION: On admission, the patient had a temperature of 97.8 with a pulse of 69 which was regular, with a blood pressure of 130/60, respiratory rate 20 and oxygen saturation 99% in room air. He appeared to be in no acute distress. Head, eyes, ears, nose and throat: Unremarkable, no lymphadenopathy, no jugular venous distention. Chest: Clear to auscultation bilaterally and symmetric. Cardiovascular: Regular rate and rhythm without rub. Abdomen: Soft, nontender, nondistended, no hepatosplenomegaly, no ascites noted. Extremities: Warm and well perfused with 2+ dorsalis pedis and posterior tibialis pulses, no notable clubbing or edema. HOSPITAL COURSE: The patient was admitted and initially underwent a CT scan of the chest, abdomen and pelvis in order to assess for the extent of the lesion and also possible metastatic disease if this was, in fact, a cancer. Notably, the CT scan showed thickening of the mid-esophagus which likely corresponded to the known esophageal mass. There was an enlarged subcarinal node but this could have also been a direct extension of the mass. Right sided pulmonary nodules were seen and an 8 mm gastrohepatic ligament node and soft tissue nodules posterior to the liver were seen, which may have represented metastatic disease. There was a right greater than left septal thickening and ground-glass opacity in the lungs, which were consistent with congestive heart failure, but there is a possibility of these being lymphangitic carcinomatosis. Incidentally, there were renal cysts and diverticula present. Subsequent to this evaluation by cardiothoracic surgery, the patient underwent a bronchoscopy and esophagoscopy to evaluate the extent of disease and also to determine what treatment options the patient could undergo. He was taken to the Operating Room on [2104-7-16] and underwent the procedure without notable complication. There were no definitive intraoperative findings aside from the likelihood that there was not any notable esophageal perforation. On postprocedure day one, the patient was scheduled to have a clinic visit for further evaluation of this and we will schedule him for an outpatient PET CT scan for evaluation for metastatic disease. Otherwise, at the time of discharge, the patient is doing quite well. He has been ambulating and maintaining good oxygen saturations in the 90% range. His discharge hematocrit is 36.6 with a white blood cell count of 11.4 and platelet count 203,000. Otherwise, the patient is to follow up with Dr. [Last Name (STitle) 51205] in one week. He is to have his PET scan prior to that and he is also to follow up with his primary care physician. [Name10 (NameIs) ] patient has been instructed to maintain a mechanical soft diet as tolerated. He has also been asked to follow up with his primary care physician this week in order to discuss the events of the week. DISCHARGE MEDICATIONS: The patient will not be discharged with any new medications. The patient takes atenolol, Paxil, trazodone, Lipitor and Maxzide but is currently unaware of the dosages of these medications. He has been instructed to resume these at their current doses when he is discharged. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3351], M.D. [MD Number(1) 3352] Dictated By:[Last Name (NamePattern1) 26688] MEDQUIST36 D: [2104-7-17] 01:20 T: [2104-7-25] 19:11 JOB#: [Job Number 51206]	[ "2724", "4019", "311" ]
Admission Date: [2169-5-25] Discharge Date: [2169-5-31] Date of Birth: [2136-9-18] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 32 year-old woman with a recurrent demyelinating illness brought to the Emergency Room by her parents on the recommendation of her neurologist for evaluation of behavior changes including increased sexual promiscuity, increased spending and report that she is compulsively wanting to have sexual activity and unable to control it to the degree that she is placing herself and her parents at risk. She has contact[Name (NI) ] many men by computer and phone. Several nights prior to admission her father heard noises in the middle of the night and found a strange man in the patient's bedroom. The father called the police and the police knew him to be a dangerous the patient left the house unbeknown to the parents and was waiting outside for a cab to take her to a motel where she had arranged a liaison with the same man. The father stated he had also escorted other strange men out of the house and is very worried about the patient and the families safety. She also has had increased spending and has had a progressive decline in her ability to care for herself including decreased ambulation. The other stresses beside her declining physical abilities was that her fiance who was bipolar committed suicide by jumping in front of a train in [2169-1-20]. On [2169-5-11] she was seen by a neurologist and an MRI was ordered. The patient was then referred for evaluation for psychiatric admission for behavioral control. PAST PSYCHIATRIC HISTORY: Admission to [Hospital1 190] in [2164-2-18] for a psychotic disorder with hallucinations secondary to prescribed steroids. In [2158] she was seen by a psychiatrist when her neurological illness was first diagnosed and she started to exhibit disinhibited behavior and impulsiveness with late night phone calls. Her neuropsychologist is Dr. [Last Name (STitle) 3085]. PAST MEDICAL HISTORY: She was diagnosed with a demyelinating illness in [2158], which has involved frontal lobe dysfunction and neurogenic bladder as well as difficulty with the ambulation. She has chronic sinusitis. Her primary care physician is [Last Name (NamePattern4) ]. [Last Name (STitle) 3086]. Her neurologist is Dr. [Last Name (STitle) 3087] and her consulting neurologist at [Hospital1 190] is Dr. [Last Name (STitle) 3088]. ALLERGIES: Flu shots. MEDICATIONS ON ADMISSION: Baclofen 820 mg tablets q.d., Ditropan XL 20 mg q.d., Beconase nasal spray two times a day, ferrous sulfate 325 mg a day, Solu-Medrol q.m. intravenous last dose [2169-5-4] next dose scheduled for [2169-6-1] and Celexa 20 mg q.d. SUBSTANCE ABUSE HISTORY: The patient denies. SOCIAL HISTORY: Both the patient and her 28 year-old brother were adopted and live with their parents in [Location (un) 38] [State 350]. She was six weeks old when she was adopted. She was an average student with no academic difficulties. Question of history of sexual assault in [2159-7-21]. She graduated from [Last Name (Prefixes) 3089] College where she studied early childhood development. She is single. Never married. FAMILY PSYCHIATRIC HISTORY: Not available. LABORATORY DATA ON ADMISSION: CBC and SMA were within normal limits. RPR was negative. HCG was negative. TSH was within normal limits. Tox screen was negative. MENTAL STATUS EXAMINATION ON ADMISSION: The patient was pleasant, well groomed and appropriately dressed sitting on a stretcher. Her attitude was cooperative. Her speech was articulate. Very matter of fact with little affect. Mood was depressed. Affect minimally reactive. Thought form was linear and coherent. She denied any preoccupations, obsessions and delusions except for her thoughts about sex. She did not appear to have any delusions. She denied suicidal or homicidal ideation. Her insight and judgment were impaired. Her cognitive examination was abnormal in her inability to do serial sevens. She was able to do serial threes. She remembered 2 out of 3 in five minutes. Calculations and fund of knowledge were within normal limits. HOSPITAL COURSE: The patient was admitted to [Hospital1 ] Four. A trial of Depakote ER was begun to help with her impulsive behaviors. Her family and her outpatient physicians were contact[Name (NI) ]. The patient was pleasant and involved in MILU activities. She did have a fall on the unit with no acute injuries noted and fall precautions were put into place. Her family met with the inpatient team as well as Dr. [Last Name (STitle) 3088] who reviewed her recent MRI and said that it showed worsening of her demyelinating disorder, which could be consistent with her current change in behavior. He would continue to follow her. The patient had no further urges or attempts to engage anyone sexually and was in very good control on the unit. She did have another fall using her walker and began to use her wheel chair more frequently. She denies side effects from the Depakote. On [5-30] she complained of an upset stomach, diarrhea and a productive cough for three days with some blood in her sputum. She denied any shortness of breath. Lungs were clear on examination. The patient had an extensive physical therapy consult and evaluation and further physical therapy was recommended. Discharge planning proceeded with the patient agreeing to go to a brief rehab stay for continued physical therapy before returning home. On [2169-5-31] the patient was being assisted in transfer from bed to her wheel chair and had a sudden cardiac and respiratory arrest. CPR was initiated and she was transferred to the Intensive Care Unit. In the MICU, the patient was in pulseless electrical activity (PEA) and was felt to have suffered a massive pulmonary embolism. She was given thrombolysis with restoration of pulse and blood pressure while being maintained on vasopressors and mechanical ventilation. However, despite maximum supportive measures, hypotension became refractory and the patient died within 24 hours of transfer to the ICU. The patient's family was notified of the events and was with the patient in her final hours. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3090], M.D. [MD Number(1) 3091] Dictated By:[Last Name (NamePattern1) 3092] MEDQUIST36 D: [2169-7-24] 17:18 T: [2169-8-1] 07:09 JOB#: [Job Number 3093]	[ "5845", "2762" ]
Admission Date: [2185-1-29] Discharge Date: [2185-2-22] Date of Birth: [2163-1-27] Sex: M Service: Trauma Surgery CHIEF COMPLAINT: Status post motor vehicle collision. HISTORY OF PRESENT ILLNESS: The patient is a 23-year-old male, unrestrained driver, high-speed motor vehicle collision, with significant front end damage to the automobile and shattered windshield. The patient presented hemodynamically stable with [Initials (NamePattern4) ] [Last Name (NamePattern4) 2611] Coma Scale of 14. The patient's left lower extremity was splinted by Emergency Medical Service. The patient was complaining of lower extremity pain. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. MEDICATIONS AT HOME: None. ALLERGIES: He has no known drug allergies. SOCIAL HISTORY: The patient is an occasional ethanol drinker. He denies tobacco. Denies recreational drugs. PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 99.4, his blood pressure was 108/palp, his heart rate was 86, his respiratory rate was 20, and his oxygen saturation was 100%. On examination, his pupils were equal and reactive to light. The extraocular muscles were intact. The tympanic membranes were clear. The oropharynx was clear. The patient had a left-sided facial laceration. Chest was regular in rate and rhythm. Clear to auscultation bilaterally. The abdomen was soft, nontender, and nondistended. The pelvis was stable. No costovertebral angle tenderness bilaterally. Cervical spine and thoracolumbosacral had no deformities, stepoff, or tenderness. Guaiac-negative with good rectal tone. The patient had bruises, ecchymosis, and abrasions of the right shoulder and ecchymosis and tenderness at the middle humerus, and the right lower extremity revealed full range of motion with no deformities. The left lower extremity was positive for a deformity of the middle shaft of the femur. The patient had 2+ radial pulses bilaterally, 2+ femoral pulses bilaterally, 2+ dorsalis pedis pulses bilaterally, and 2+ posterior tibialis pulses bilaterally. The patient had an ankle-brachial index of 1.2 on the right and 0.98 on the left. The patient had a Foley catheter inserted at the scene. PERTINENT RADIOLOGY/IMAGING: The patient had a head computed tomography on admission and on the 17th which were both negative. He also had a computed tomography of the cervical spine which was negative and a computed tomography of the chest which was normal. The patient's abdominal computerized axial tomography showed a tiny focus, decreased attenuation of the posterior spleen, question of a very small laceration but no hematoma or extravasation was seen. Films of the right humerus and left shoulder were negative. Plain films of the left femur showed a fracture at the middle shaft. PERTINENT LABORATORY VALUES ON PRESENTATION: Complete blood count, chemistries, and coagulations were all within normal limits. Urine and serum toxicology screens were negative. His lactate was 1.7. BRIEF SUMMARY OF HOSPITAL COURSE: The patient was taken to the operating room by Orthopaedics on [2-1] and is status post intramedullary nail of the left femur on [2185-2-1]. Upon admission to the Intensive Care Unit, the patient developed respiratory distress with oxygen saturations in the 77th percentile. An arterial blood gas was performed and showed a very low PAO2. The patient was subsequently intubated and sedated on propofol for hypertension and increased heart rates. Prior to this time, the patient was brought to the operating room by Orthopaedics, and the left femur was placed in traction. The patient had a right chest tube placed on [2185-1-29] and a computed tomography angiogram was obtained. This showed multiple peripheral pulmonary emboli bilaterally, but no large central pulmonary embolus. It also showed multifocal areas of consolidation, which were new from prior examination. The patient also had the presence of secretions in the airway which suggested multifocal pneumonia as well. As mentioned, bilateral chest tubes was placed for the respiratory distress a right pneumothorax. During the Intensive Care Unit course, the patient was treated with antibiotics for pneumonia (as per culture data). The patient also developed transient thrombocytopenia. For this, Pepcid was discontinued, Protonix was started, and a heparin-induced thrombocytopenia antibody was sent which was negative. The patient was also transfused as needed for low hematocrits. The patient had a repeat head computed tomography on [2-1] which showed no change, and no intracranial bleed. The patient's heparin drip was started postoperatively secondary to the pulmonary emboli. Throughout the Intensive Care Unit course, the patient was also diuresed as needed. A feeding tube was placed, and tube feeds were started and were tolerated well. The patient also had periodic temperature spikes which were cultured and adequately treated. On [2185-2-8] the patient's bilateral chest tubes were discontinued, and the patient tolerated this procedure well. A chest x-ray was obtained and showed no pneumothorax. The patient was also started on Coumadin during the Intensive Care Unit stay, and the heparin drip was continued until a therapeutic INR was obtained. On [2185-2-11] the patient was extubated and tolerated this well with an arterial blood gas within normal limits. The Speech and Swallow therapists were consulted throughout the hospital stay, performing multiple swallow studies. As the patient became more alert, the patient improved with the swallowing studies and was able to tolerate good oral intake by discharge. After extubation, it was noted that the patient had a decreased level of alertness. The Neurology Service was consulted to comment whether this was pharmacological, metabolic, infectious, or an intracranial hemorrhage. They recommended a repeat head contrast to rule out bleed given the patient was being anticoagulated at this time. Neurology recommended obtaining a magnetic resonance imaging of the brain to evaluate for axonal injury. The magnetic resonance imaging showed a nonspecific increased T2 signals in the white matter of the left frontal lobe and linear areas of restricted diffusion at the bilateral parietal white matter which could represent areas of diffuse axonal injury consistent with a motor vehicle collision. A magnetic resonance imaging of the spine also showed right-sided disc herniation at L5-S1 with no evidence of fracture in the lumbar region. Neurosurgery was consulted regarding these findings and recommended an elective repair in the future and to follow up as an outpatient. The patient was transferred to the floor on [2185-2-16] in a stable condition. The [Hospital 228] hospital course on the floor was remarkable for an increased alertness and orientation. Prior to discharge, the patient was alert and oriented times three. He was able to follow commands and without any neurologic deficits. The hospital course on the floor was unremarkable. The patient passed a swallowing study and video swallow and was able to tolerate a ground diet with thin liquids by discharge. The patient's INR was therapeutic upon discharge, and the heparin drip was discontinued. The patient was afebrile and finished a course of antibiotics with a decreased white count and no signs of infection. As the patient increased oral intake, tube feeds were weaned, and the feeding tube was discontinued. Physical Therapy worked with the patient and deemed him safe to receive physical therapy as an outpatient and recommended disposition to be home. DISCHARGE DISPOSITION: The patient's disposition was to home. CONDITION AT DISCHARGE: Stable. DISCHARGE DIAGNOSES: 1. Status post motor vehicle collision. 2. Left femur fracture. 3. Multiple pulmonary emboli. 4. Diffuse axonal injury. 5. Right pneumothorax. 6. Bilateral diffuse pulmonary opacities. 7. Acute respiratory distress. 8. Adult respiratory distress syndrome. 9. L5-S1 disc bulge. 10. Pneumonia. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was set up with a primary care physician to follow Coumadin dosage and INR levels. An appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] was made for [2-25] at 1:30. The patient was to have an INR check two times per week and have followup that Friday of discharge. 2. The patient was to follow up at the [Hospital 9696] Clinic regarding left femur fracture. 3. The patient was to follow up at the [Hospital 4695] Clinic if the patient desired an elective repair of disc herniation. MAJOR SURGICAL/INVASIVE PROCEDURES PERFORMED: 1. Status post bilateral chest tube placement. 2. Status post PA catheter placement. 3. Status post tracheal intubation secondary to respiratory distress. 4. Status post open reduction/internal fixation of left femur on [2185-2-1]. MEDICATIONS ON DISCHARGE: 1. Albuterol 1 to 2 puffs inhaled q.6h. as needed. 2. Methadone 5 mg by mouth twice per day. 3. Levofloxacin 500 mg once per day (times seven days - to finish a 14-day course). 4. Coumadin 10 mg five times per week and 12.5 mg two times per week. The patient was to have an INR draw on Friday, [2-25], prior to his appointment with his primary care physician regarding Coumadin dosing. The rest of follow-up appointments were to be made by the patient. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 11889] Dictated By:[Last Name (NamePattern1) 27744] MEDQUIST36 D: [2185-3-2] 16:14 T: [2185-3-3] 07:53 JOB#: [Job Number 52648]	[ "486", "5070", "2875", "2760" ]
Admission Date: [2118-10-3] Discharge Date: [2118-10-6] Service: TSURG Allergies: Codeine Attending:[Last Name (NamePattern1) 1561] Chief Complaint: Dyspnea secondary to right sided obstructing small cell lung cancer. Major Surgical or Invasive Procedure: Rigid bronchoscopy and stent placement. History of Present Illness: Patient is 85 yo female transferred from [Hospital 1562] Hospital where she was hospitalized for several weeks of dyspnea. CXR and CT chest at the outside hospital revealed complete right hemithorax white-out and large right lung mass. Pleural effusion was aspirated at that time, later to reveal small cell lung cancer. Patient was then transferred to [Hospital1 18] for further evaluation and treatment. Past Medical History: 1. Diabetes mellitus 2. Hypertension 3. Hypothyroidism 4. Osteopenia Social History: Unremarkable. Family History: Unremarkable. Physical Exam: Gen: intubated, sedated HEENT: no scleral icterus, atraumatic Neck: no masses CV: regular rate rhythm Pulm: diminished breath sounds on right Abd: soft, NT, ND, + BS Ext: no C/C/E Neuro: MAE, PERRLA Pertinent Results: [2118-10-3] 09:02PM TYPE-ART TEMP-37.6 RATES-/10 TIDAL VOL-400 PEEP-5 O2-100 PO2-198* PCO2-42 PH-7.29* TOTAL CO2-21 BASE XS--5 AADO2-489 REQ O2-81 INTUBATED-INTUBATED Brief Hospital Course: Patient is an 85 yo female transferred from outside hospital with obstructing right sided lung malignancy with extension to the trachea and mediastinum. She arrived intubated. Dr. [Name (NI) ] took patient for rigid bronchoscopy and stent placement on [2118-10-4]. Post-procedure, patient returned to the ICU where she did not progress. Poor oxygenation on maximal ventilator settings and poor urine output ensued. After discussion with the family regarding bleak long term prognosis, the decision was made to make the patient DNR/DNI and later comfort measures only. Patient was place on morphine drip at 10 PM [2118-10-5]. Pt. expired at 8:00 AM, [2118-10-6]. Daughters were at the bedside and decline a post-mortem. Medications on Admission: 1. Humalog insulin 2. Lantus insulin 3. Altace 4. Synthroid 5. Trental 6. Fosamax 7. Lipitor Discharge Medications: N/A Discharge Disposition: Extended Care Discharge Diagnosis: 1. Small cell lung cancer 2. Diabetes mellitus 3. Hypertension 4. Hypothyroidism Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A	[ "2449", "25000", "4019" ]
Admission Date: [2119-5-26] Discharge Date: [2119-5-27] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: CC:[CC Contact Info 15218] Major Surgical or Invasive Procedure: None. History of Present Illness: HPI: 81M w/recent subdural hematoma s/p evacuation in [3-30], CHF, Afib, aortic aneurysm, recently ([4-29]) admission to [Hospital Unit Name 153] for altered mental status and hypoxia ([2039-5-11]) found to have RML MRSA PNA plus CHF with intubation. Sent to ED for evaluation for somnolence, and apnea from [Hospital1 599] at [Location (un) 55]. This am pt's RR fluctuated from 24/min to periods of 30-40 sec apneic episodes with O2 sats ranging from 88-94% on RA. In the ED, found to be somnolent but arouseable and able to eat and answer questions. Weight is stable at 126 lbs on lasix 40 mg PO daily. His Vancomycin course is due to end [5-27]. Dose is 500 mg IV q24h due to high troughs. In ED afebrile, BP 110/70 P 80 O2 97% RA. . Also in his hospitalization in [3-30] at [Hospital1 18] he was found to have an Enterobacter UTI and a LLL pneumonia (treated with Levoflox). . Pt denies any complaints at this time. Endorses feeling confused this morning and reports that sometimes he "loses days" and that bothers him. . ROS: Denies CP, SOB, orthop, PND, palpitations, cough, fevers, new weaknesses, changes in sensation or vision, nausea, vomiting, diarrhea, abdominal pain, hematuria, dysuria, blood in the stools. Past Medical History: 1. CHF: [2-27] echo: mild symm LVH, EF 55% but likely overestimation with degree of MR 2. 3+ mitral regurgitation 3. Atrial fibrillation 4. Ascending aortic aneurysm- [11-27] CTA: 5.7 x 5.4 cm stable (pt. currently not interested in surgery) 5. DM2 6. Gout 7. Inflammatory Colitis (?)on chronic sulfasalazine. No prior surgeries or recent flares. 8. Hypertension 9. GERD 10. h/o Asbestosis 11. Recent B12 and Fe def. anemia 12. ?progressive dementia Social History: Married, lives with wife, no prior [Name (NI) ]/ETOH. Worked as a salesman. h/o asbestosis exposure when in the service (?shipyards). Family History: no Alzhemer's or Parkinson's Physical Exam: VS: T 96.9 HR 109/41 HR 71 R 19 98% 3L Gen: NAD, A&O X 2 Skin: no rash HEENT: EOMI, PERRL, O/P clear Neck: supple, no LAD CV: RRR nl s1 s2 2/6 sem at llsb Pulm: CTAB Abd: soft, NT, ND +BS Ext: cachetic, no edema Neuro: A&O X [1-27], moves all 4, sensation intact to LT, 2+ DTR at [Name2 (NI) 15219] b/l, [Last Name (un) ] down b/l Pertinent Results: Studies: [5-26]: CT Head: no intracranial hemorrhage, unchanged hypodense fluid collection subdural R frontal lobe. [5-26]: CXR: no new infiltrate Brief Hospital Course: A/P: 81M w/recent subdural hematoma s/p evacuation in [3-30], CHF, Afib, aortic aneurysm, recent MRSA PNA and CHF flare now admitted with somnolence and periods of apnea. . # Somnolence: Now seems to be resolved. Pt's family noted him to be unresponsive, or minimally responsive this morning. DDx includes infection, hypercarbia, extension of subdural hematoma. UA, CXR clear, ABG without hypercarbia, CT head OK. ?Worsening of baseline dementia vs. post-ictal from seizure? Likely secondary to severe sleep apnea and daytime sleepiness. . # Apnea: Unclear if this is new, or newly recognized. Pt has characteristic findings of [Last Name (un) 6055]-[Doctor Last Name ] breathing. Will need outpt sleep study for titration of CPAP if necessary. Pt reports that he would not want CPAP, can be discussed with PCP. . # hx CHF: Currently euvolemic, no evidence of CHF flare. last echo ([2119-4-3]) w/EF >55%, 2+ MR, mod AR. -- Continue home doses of lasix, BB, ACE-I . # PNA: Hx MRSA PNA during last admission. - CXR shows resolving infiltrate. - No leukocytosis or febrile episodes. Last thoracocentesis in [4-29] showed transudative fluid c/w CHF exacerbation - Recent sputum grew MRSA ([5-12] & [5-14]), sensitive to vanco. 10 day course to end [5-27]. . # Subdural hematoma: - No change on today's head CT - On Keppra for seizure prophylaxis post-craniotomy (to be continued until out-pt neurology or neurosurgical follow-up). . # AAA: ascending; measured >5cm in [11-27] & pt refused surgical intervention at that time. . # CRI: (baseline creatinine 1.2-1.6) Today 1.1. . # Paroxysmal Afib: -- continue metoprolol for rate control -- No anticoagulation with warfarin given recent subdural hematoma and h/o frequent falls. . # DM2: -- RISS -- Diabetic diet. . # Anemia: iron studies most c/w chronic dz (ferritin 86). Hct stable. Cont ferrous sulfate. Guaiac all stools. . # Hypothyroidism: clinically euthyroid. Continue synthroid. . # Depression: remained stable. Continue celexa. . # FEN: PO diet, monitor lytes, replete prn. # Prophylaxis: protonix and pneumoboots. bowel regimen. # Communication: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] (daughter) [Telephone/Fax (5) ] 248 2146 # Code: DNR/I, confirmed with pt and last d/c summary # Dispo: back to rehab. Medications on Admission: 1. Ferrous Sulfate 325 PO DAILY 2. Docusate Sodium 100 mg PO BID 3. Furosemide 40 mg PO DAILY 4. Levetiracetam 250 mg PO QAM 5. Levetiracetam 250 mg PO HS 6. Citalopram 10 mg PO DAILY 7. Ascorbic Acid 250 mg PO DAILY 8. Vancomycin 500 mg IV q24h 9. Levothyroxine 25 mcg PO DAILY 10. Metoprolol Tartrate 50 mg PO BID 11. Lisinopril 5 mg PO once a day. Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 6. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 7. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Ascorbic Acid 250 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 1 doses: pt has one dose left in his course for [5-27] evening. Discharge Disposition: Extended Care Discharge Diagnosis: [Last Name (un) 6055]-[Doctor Last Name ] breathing pattern Sleep Apnea CHF Resolving MRSA PNA. Discharge Condition: Stable. Discharge Instructions: Call your primary care physician or return to the emergency room if you have shortness of breath, chest pain, or any other symptom that bothers you. Followup Instructions: Please call [Hospital1 18] Sleep Lab for a sleep study [Telephone/Fax (1) 15220]. Please call your primary care physician for an appointment at [Telephone/Fax (1) 3070].	[ "4280", "5859", "42731", "25000" ]
Admission Date: [2126-11-16] Discharge Date: [2126-12-3] Date of Birth: [2063-10-30] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 1267] Chief Complaint: Shortness of breath, transfer for new finding of flail mitral valve Major Surgical or Invasive Procedure: [2126-11-18] - Cardiac Catheterization [2126-11-20] - CABGx2, MVR (26mm Mechanical St. [Male First Name (un) 923]). History of Present Illness: This is a 63 year-old gentleman with hypercholesterolemia admitted to the [Hospital3 13313] on [2126-11-16] after he developed dyspnea on exertion on [2126-11-12]. He also noted having a cough that was exacerbated by lying flat and productive of pinkish phlegm. He noted no chest pain, palpitations or diaphoresis. No dizziness, or loss of consciousness. He did not note any swelling of his extremities. In addition, he did report that had had a mild fever and nausea over the past few days. Also of note, the patient had a minor dental procedure on the 18th; he had been started on amoxicillin on [11-14] by his PCP. [Name10 (NameIs) ] presentation to the OSH, the patient was afebrile, tachycardic (P 110-120) with a BP of 108/70 R of 20 and O2 sat. of 93 on RA. He was given a one time dose of lopressor, 5 mg with bought his rate to the 100's. Pt had rales on lung exam. Chest x-ray revealed RUL infiltrate and pulmonary edema. EKG revealed some ST depressions in V4 to V6, troponin I level 0.19 (0.5 or higher is consistent with MI) BNP found to be 538. WBC mildly elevated Echo was performed revealing prolapse of the posterior leaflet of the mitral valve with 4+ MR. Systolic function reportedly normal. Pt was started empirically on ceftriaxone and azithromycin for presumed community acquired pneumonia. Also given one time dose of Lasix for CHF exacerbation. Pt also received 1x dose of 90 mg subcutaneous lovenox at 1700 today. No recent sick contacts. [Name (NI) ] had been nauseous but not vomiting or diarrhea. No changes in urine or bowel movements. He has not had any prolonged travel recently. Past Medical History: Hypercholesterolemia HTN Right DVT in past Pneumonia s/p right TKR Social History: Married, former athletic director at local high school. Occasional alcohol use, no smoking. No heroin or other IV drug use. No cocaine use. Family History: Non-contributory. Physical Exam: T 98.6 P 115-120 BP 118/72 RR 20-22 O2 81-85 on RA 95 on 2L FM Gen: WD/WN male Caucasian in no acute distress, speaking in full sentences. [Name (NI) ], friendly, and cooperative. Head: NCAT Eyes: PERRL, sclerae anicteric Mouth: MMM, no lesions Neck: JVD to 8 cm, no HJR. No bruits Chest: Decreased breath sounds at bases, no rales, rhonchi, or wheezes. Heart: Tachycardic, RR, S1 difficult to hear S2 loud holosytolic murmur most prominent at apex and radiating to axilla, occasional extra sound which may be S3 gallop. PMI not displaced Abd: Obese, nl bowel sounds, no bruit, no HSM Ext: No edema Pulses: Carotid pulses, b/l 2+ with no bruit Radial pulses b/l 2+ Inguinal pulses b/l 2+ DP pulses b/l 2+ Pertinent Results: EKG: Sinus tachycardia, nl intervals, axis 60, isolated q wave in III ST depressions in V4 to v6. No changes from EKG at OSH. Echo from OSH: LV function preserved, MV prolapse with flail posterior leaflet of mitral valve, 4+ MR [First Name (Titles) 151] [Last Name (Titles) 34486] jet directed medially. [2126-11-16] 09:13PM WBC-12.9* RBC-4.67 HGB-15.6 HCT-42.9 MCV-92 MCH-33.3* MCHC-36.2* RDW-12.9 [2126-11-16] 09:13PM ALT(SGPT)-10 AST(SGOT)-11 CK(CPK)-51 ALK PHOS-53 TOT BILI-1.1 [2126-11-16] 09:13PM GLUCOSE-148* UREA N-35* CREAT-1.0 SODIUM-141 POTASSIUM-3.4 CHLORIDE-101 TOTAL CO2-23 ANION GAP-20 [2126-11-28] 06:20AM BLOOD Hct-27.6* [2126-11-28] 06:20AM BLOOD PT-14.9* INR(PT)-1.5 [2126-11-28] 06:20AM BLOOD UreaN-12 Creat-1.1 K-5.0 [2126-11-18] 05:15PM BLOOD %HbA1c-5.3 [Hgb]-DONE [A1c]-DONE [12-3] Hct 31.2 [2126-11-18] CT Chest 1. No pulmonary embolus. 2. There are diffuse ground-glass opacities within both lungs, with associated left atrial enlargement and bilateral pleural effusions, findings consistent with congestive heart failure. 3. There is a focal confluent opacity within the right upper lobe, and to a lesser degree in the left upper lobe. This is associated with multiple mediastinal lymph nodes. These findings are consistent with an infectious process or pneumonia superimposed upon underlying CHF. [2126-11-18] ECHO The left atrium is dilated. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is partial mitral leaflet flail. Moderate to severe (3+) mitral regurgitation is seen. The mitral regurgitation jet is [Month/Day/Year 34486]. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. No vegetation seen (cannot exclude). [2126-11-18] Cardiac Catheterization 1. Selective coronary arteriography revealed a right dominant system with severe three vessel CAD. The LMCA had 60-70% stenoses both at its ostium and distally. The LAD had a 70% ostial stenosis and had 60% distal stenosis. The remainder of the vessel had mild diffuse disease with apparently good touch-down targets. The LCX had a 60% proximal stenosis. The OM branches had mild luminal irregularities. The RCA was diffusely disease proximally and 100% occluded in its mid section. The distal vessel filled via left to right collaterals. 2. Hemodynamics revealed markedly elevated wedge pressures with significantly depressed cardiac output/index. There was mild pulmonary hypertension. 3. Left ventricuolography was not performed. 4. Because of the patient's low blood pressure and low cardiac index, the decision was made to place a 40cc IABP via the right femoral artery. The patient was transferred to the CCU. [2126-11-26] CXR 1. Cardiomegaly without acute pulmonary edema. 2. Bibasilar patchy opacities most likely represent atelectasis. 3. Bilateral small to moderate pleural effusions [2126-11-26] EKG Sinus rhythm with first degree A-V delay and a brief pause which is probably second degree AV block (Wenckebach). Modest nonspecific ST-T wave changes. Since previous tracing of [2126-11-23], A-V dissociation with junctional rhythm now absent. Brief Hospital Course: Mr. [Known lastname ] was admitted to the [Hospital1 18] on [2126-11-16] for further management. A CT scan was obtained which ruled out a pulmonary embolism. As he had 4+ mitral valve regurgitation by echo at an outside hospital, the cardiac surgical service was consulted for evaluation. Blood cultures were obtained to assess for endocarditis which were negative. A repeat echo revealed a normal ejection fraction, 3+ mitral regurgitation with a partial flail leaflet. A cardiac catheterization was performed which revealed severe mitral valve regurgitation, a 70% stenosed left main, a 70% stenosed left anterior descending artery, a 60% stenosed circumflex artery and a chronically occluded right coronary artery. A intra-aortic ballon was placed for a low cardiac index and coronary perfusion. Heparin was started for brief runs of atrial fibrillation. He was taken to the cardiac care unit for further management. Mr. [Known lastname ] was worked-up in the usual preoperative manner including a carotid duplex ultrasound which revealed no significant internal carotid artery stenosis. On [2126-11-20], Mr. [Known lastname ] was taken to the operating room where he underwent coronary artery bypass grafting to two vessels and a mitral valve replacement with a 26mm St. [Male First Name (un) 923] mechanical valve. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Mr. [Known lastname ] [Last Name (Titles) ]e neurologically intact and was extubated. His intra-aortic balloon was slowly weaned off and removed without difficulty. Coumadin was started for anticoagulation. On postoperative day two, Mr. [Known lastname ] was transferred to the cardiac surgical step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. He developed atrial flutter followed by a high grade heart block. The electrophysiology service was consulted for a possible pacemaker. All nodal agents were held and it was decided that if his AV conduction system did not return, that a pacemaker would be placed. Coumadin was subsequently held and heparin was started. As his conduction system began to recover, the pacemaker was put on hold and telemetry was continued. Coumadin was resumed for anticoagulation. Mr. [Known lastname ] continued to make steady progress and was discharged home on postoperative day #13. He will follow-up with Dr. [Last Name (STitle) ], the electrophysiology service, his cardiologist and his primary care physician as an outpatient. His coumadin will be managed by Dr. [Last Name (STitle) 36897] for a target INR of 2.5-3.5. He will have his blood draw on [12-4] at [Hospital3 13313]. Coumadin 5 mg dose tonight and further dosing by Dr. [Last Name (STitle) 36897]. HR88 107/67 RR 18 96% RA sat T 97.3 Medications on Admission: Medications at home: Amoxicillin since [11-14] No regular medications Medications on transfer Zithromax 500 PO daily Ceftriaxone 1 g IV daily ASA 162 mg PO daily Lopressor 50 (?) mg IV Lovenox 90 mg SC Robitussin/Codeine cough medication Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:5 Tablet(s) Refills:0 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 5 days. Disp:10 Capsule, Sustained Release(s) Refills:0 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day for 1 days: take 5mg (1 tablet) today ([12-1]), then VNA to draw INR, call to Dr.[Name (NI) 62995] office for continued dosing.(Discharge dose on [12-3]) Disp:60 Tablet(s) Refills:0 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Hyperlipidemia Hypertension Right deep vein thrombosis Third degree heart block Atrial Fibrillation Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of more then 2 pounds in 24 hours. 4) No lotions, creams or powders to wound until it has healed. 5) No lifting more then 10 pounds for 4 weeks. 6) you will take coumadin for a St. [Male First Name (un) 923] Mechanical valve. Your goal INR is 3.0-3.5. You will need to have your blood (PT/INR) checked on Wednesday ([12-4]) with Dr. [Last Name (STitle) 36897]. Your discharged dose will be 5mg. Please note that your dose may change based on your blood levels. Only take as directed by Dr. [Last Name (STitle) 36897]. Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] in 4 weeks. Follow-up with Dr. [Last Name (STitle) ] in 2 weeks ([Telephone/Fax (1) 8793]. Follow-up with your primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 36897] in [3-1] weeks. ([Telephone/Fax (1) 62996] Blood draw (PT/INR) for coumadin dosing on [2126-12-4] at [Hospital3 13313]. Have lab call Dr. [Last Name (STitle) 36897] with results, ([Telephone/Fax (1) 62996] Completed by:[2126-12-4]	[ "41401", "4280", "4240", "42731", "2720", "4019" ]

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