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Admission Date: [2151-3-29] Discharge Date: [2151-4-3] Date of Birth: [2073-7-26] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1267] Chief Complaint: ACS, cardiogenic shock Major Surgical or Invasive Procedure: central line cardiac catheterization MVR possible CABG History of Present Illness: 77 year old female w/ a h/o [First Name3 (LF) ], hypercholesterolemia, DM, PMR on steroids who is transferred from [Hospital 2079] hospital w/ ACS in cardiogenic shock. She initially presented to [Hospital 2079] hospital w/ 2 days of CP and SOB. Family describes "chest congestion" starting at ~7 pm on the night of presentation to Southshore ([2151-3-28]) which was significantly worse than recently (had been complaing of chest congestion x 2 wks) now associate with SOB. Husband called 911 and she was brought to [Hospital 2079] hospital. In the Southshore ED, patient found to have ST depressions in V2-V6 and isolated STE in V1. She was also found to have pulmonary edema and was managed w/ BiPAP and diuresis. This am, patient was evaluated by Cardiology and was found to be hypotensive in cardiogenic shock. Cr rising w/ poor UOP despite diuresis. Cardiac enzymes were found to be elevated: CK 198->431->951-> 5403, MB 37->86->192->915, Trop 0.37->0.95->1.46->17.16. She was started on heparin gtt, integrillin, Plavix 300mg x1. She underwent cardiac cath showing TO LAD, 90% circ, tortuous RCA with L->L collaterals as well as R->L collaterals to septum. IABP placed and patient was intubated, Patient was briefly in asystole by report but converted with CPR and was placed on Levophed via a peripheral IV. 2 PIV's in place. Stat bedside ECHO showed moderate to severe MR and MR w/ apical and lateral HK. . Upon arrival to the CCU, patient is intubated and sedated but moving all extremities. She continues to have a high levophed requirement to maintain her pressures. She was taken emergently to the cardiac cath lab where her LAD TO was confirmed as well as her 90% circ w/ L->L collaterals and RCA w/ aneurysm vs. dissection and R->L collaterals. She received 2 BMS->Circ. The LAD was crossed but given likely chronicity of her TO, it was not opened. . Recent events discussed with patient's family. Family notes that since THR in [10/2150], patient has complained of increased fatigue. Has also had slow, slurred speech since that time. Family notes DOE w/ [2-4] of a mile over the last year. She must stop after a few steps on the stairs to rest. Patient also complained of "chest congestion" over the last few weeks which had recently improved. She also complained of "indigestion". Associated w/ recent chest congestion, patient also had orthopnea symptoms which improved w/ pillows. Past Medical History: # hypertension # hypercholesterolemia # diet controlled DM (family denies) # Polymyalgia Rheumatica # s/p R THR [10/2150] # s/p appendectomy in her 30s # s/p umbilical hernia repair Social History: Patient lives in [Location 77420] with husband. She has 3 daughters in the area as well as a son. She used to smoke [3-7] cigs/day x 20 yrs but quit 20 yrs ago. No EtOH use. Family History: No significant family h/o CAD or SCD Physical Exam: VS: T 100.3, BP 84/60, HR 74, RR 17, O2 99% on AC400x16,PEEP5, FiO2 100% Gen: pale, ill appearing female, intubated and sedated HEENT: NCAT. Sclera anicteric. PERRL. Neck: Supple with JVP of to angle of mandible. CV: RR, normal S1, S2. No S4, no S3. II/VI sys murmur at base Chest: Course breath sounds bilaterally w/ basilar crackles bilaterally. Abd: Decreased BS. Soft, NTND, No HSM or tenderness. No abdominal bruits. Groin: IABP in R groin. Arterial sheath and PA catheter in L groin. Ext: Cool extremities. Blue, cyanotic appearing L hand. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+; Femoral 2+; DP dopp Left: Carotid 2+; Femoral 2+; DP dopp Pertinent Results: COMMENTS: 1. Successful stenting of the LCX with two bare metal stents 3.0 X 18 mm and 2.5 X 12 mm Vision stents in a non-overlapping fashion with no residual stenosis (see PTCA comments for detail). 2. Engagement of the proximal cap of the chronic total LAD occlusion with Shinobi wire. 3. RCA angiography showing two proximal and mid vessel 60% lesion an a distal pseudoaneurysm with possible dissection. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Severe systolic and diastolic ventricular dysfunction. 3. Cardiogenic shock requiring IABP support. 4. Successful stenting of the LCA with two bare metal stents ------- TTE [3-30] The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with inferolateral akinesis, as well as inferior and lateral hypokinesis (LCx distribution). The remaining segments exhibit compensatory hyperkinesis (LVEF = 35-40%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. There is a partial rupture of the posterolateral papillary muscle with associated eccentric, anteriorly-directed jet of severe (4+) mitral regurgitation. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There is an anterior space which most likely represents a fat pad. IMPRESSION: Moderate regional left ventricular systolic dysfunction, c/w CAD. Partial papillary muscle rupture with severe mitral regurgitation. Moderate tricuspid regurgitation. Moderate pulmonary hypertension ---------------- TTE [3-31] after surgery Prebypass: moderate global LV hypokinesis (30-35%), severe mitral regurgitation with eccentric jet, partial rupture of posteromedial papillary muscle and chordae tendinae, moderate 2+ tricuspid regurgitation. Right ventricular free wall appears normal. There is evidence mildly calcified aortic leaflets but no evidence of aortic stenosis. Descending and ascending aorta within NL limits. Postbypass: overall LV function globally depressed (30-35%). Minimal improvement compared to prebypass. Prosthetic mitral valve leaflets well positioned and adequate movement of the leaflets. . No appreciable mitral regurgitation. Moderate tricuspid regurgitation as seen in the prebypass period.. RV free wall unchanged and normal. Descending and ascending aorta within normal limits and without evidence of dissection. [2151-4-3] 09:24PM BLOOD WBC-7.5# RBC-1.14# Hgb-3.5# Hct-10.9# MCV-96# MCH-30.7 MCHC-32.2 RDW-15.7 Plt Ct-29# [2151-4-3] 09:24PM BLOOD Neuts-73.2 Bands-0 Lymphs-16.3* Monos-9.5 Eos-0.2 Baso-0.8 [2151-4-3] 09:24PM BLOOD Plt Ct-29# [2151-4-3] 05:19AM BLOOD Glucose-142 UreaN-51* Creat-0.9 Na-146* K-3.9 Cl-113* HCO3-24 AnGap-13 [2151-4-2] 08:53AM BLOOD ALT-57* AST-53* LD(LDH)-714* AlkPhos-65 Amylase-264* TotBili-0.8 [2151-4-2] 08:53AM BLOOD Lipase-99* [2151-3-31] 03:30AM BLOOD CK-MB-76* MB Indx-13.9* cTropnT-8.97* [2151-4-3] 05:19AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.2 [2151-3-30] 03:02AM BLOOD %HbA1c-4.9 Brief Hospital Course: SUMMARY OSH AND CCU COURSE 77 y/o F with a history of type II diabetes, [Month/Day/Year ], dyslipidemia, PMR with increasing fatigue since undergoing THR in 9/[2150]. Patient had complaints of increasing DOE and orthopnea 2 weeks prior to admission. She was only able to climb a few steps on the stairs before stopping for rest. 2 days PTA patient also complained of "chest congestion" and "indigestion", on the day of admission patient c/o of worsening chest congestion and dyspnea. Husband called 911 and on [3-28] she presented to [Hospital 2079] hospital ED, in the Southshore ED patient??????s ECG showed ST depressions in V2-V6 and isolated STE in AVR. Cardiac enzymes revealed tropT 0.37, CK 198 and MB 37. She was started on heparin gtt, integrillin, Plavix 300mg x1. She was also found to have pulmonary edema and was managed w/ BiPAP and diuresis. Next morning patient was evaluated by Cardiology and found to be hypotensive, with rising creatinine, poor UOP despite dieresis. Cardiac enzymes rising CK 198->431->951-> 5403, MB 37->86->192->915, Trop 0.37->0.95->1.46->17.16. She underwent cardiac cath at [Hospital1 34] which showed a totally occluded LAD, 90% occluded left circ, tortuous RCA with evidence of L->L collaterals as well as R->L collaterals to septum. IABP placed and patient was intubated, Patient was briefly in asystole by report but converted with CPR . Levophed was started via a peripheral IV. Stat ECHO showed moderate to severe MR and MR w/ apical and lateral HK., EF 40-45%. Patient was then transferred to [Hospital1 18]. Upon arrival to the CCU, patient is intubated and sedated with a high levophed requirement to maintain her pressures, ECG showed ST depressions in V3-4, TWI V5-6. She was taken emergently to the cardiac cath lab which showed 2 sequential 90% left circ lesions which were stented with 2 non overlapping BMS, no residual stenosis with TIMI 3 flow afterwards, pressor requirements decreased with improvement in MAP. Her totally occluded LAD was probed, were able to break the cap but the wire was not easily advanced confirming the chronicity.RCA angiography showed two proximal and mid vessel 60% lesions with ? of aneurysm vs. dissection and multiple septal collaterals to LAD. On return from cath lab pressor requirements were decreased and patient was diuresed, PEEP increased to [Month (only) ]. preload( [Month (only) ] venous return from inc. thoracic pressures) and afterload. Next morning TTE showed EF 35-40% with inferolateral akinesis in LCx distribution, found to have a partial rupture of the posterolateral papillary muscle with severe (4+) mitral regurgitation. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Patient taken to surgery this morning. Cardiac enzymes trending down (tn 24 to 15, ck 4000 to 1500, mb 500 to 200) # CAD/Ischemia: ECG w/ evidence of anterolateral ischemia. ? whether due to collaterals from circ vs. RCA. Substantial infarct w/ CK-MB of 960. Now s/p BMS x 2 to LCx and no intervention on RCA. Decreased pressor requirements post PCI. - cont asa, plavix - cont heparin gtt - high dose statin - cycling cardiac enzymes - IABP - discuss adding beta blocker . # Pump: EF 40-45% w/ apical lateral HK at OSH. Now in cardiogenic shock. Suspect worsening of EF. Elevated filling pressures on RHC w/ PCW of 30. - off levophed - cont IABP 1:1. Will add ace inhibitor once weaning - going for surgery this morning, held off further diuresis overnight - add beta blocker once off vasopressors - TTE in am. If significant anteroapical AK or severely depressed EF will consider continuation of heparin beyond 48 hours w/ transition to coumadin . # Rhythm: - atrial tachycardia likely secondary to ischemia and severe MR causing left atrial stretch, held on further diuresis - MVR this morning - on heparin gtt . # Resp: significant A-a gradient on initial ABG w/ pO2 122 on 100% FiO2. Improved with PEEP to 10mg which decreases preload and afterload - repeat ABG - weaned oxygen overnight - cont vent support on AC for now - tx for possible aspiration pna as below - diuresis as tolerated . # ARF: unknown baseline but labs at OSH w/ Cr 0.9->1.8. Likely [3-6] poor forward flow in the setting of cardiogenic shock. - creatinine trending down - BUN elevated, component secondary to steroids - if continues to worsen can consider urine lytes/eos . # ID: leukocytosis on OSH labs. Potentially secondary to stress demargination in the setting of significant MI. Must also consider aspiration event in the setting of cardiac arrest at OSH. CXR w/ possible infiltrate in RUL and RLL. - check sputum and urine cx's - blood cultures if spikes, afebrile - empirically cover for aspiration w/ levo/flagyl x 7 days as WBC count and fever will be difficult to interpret in the setting of stress dose steroids and large MI . # [Month/Day (2) ]: hypotensive currently in cardiogenic shock. - holding home dose atenolol - stress dose steroids as below . # polymyalgia rheumatica: on prednisone daily at home but unknown dose. Cannot check [Last Name (un) 104] stim. - stress dose steroids with methylpred 40 mg IV Q8H, taper down - rapid taper w/ stabilization of BP . # DM: documented diet controlled DM although family denies. - HbA1C <5 - ISS . # FEN: NPO for now. Once stable will start TFs - [Hospital1 ] lytes once diuresis begun . # Prophylaxis: heparin gtt. PPI IV. bowel regimen . # Code: FULL. Confirmed w/ HCP Underwent MVR/cabg x1 with Dr.[Last Name (STitle) ] on [3-31]. Pt. already intubated and had IABP prior to OR. Transferred to the CVICU in fair condition on epinephrine, nitroglycerin, insulin and propofol drips. Abx continued for presumed pre-op PNA. ENT consulted for epistaxis. IABP removed and epinephrine drip weaned to off on POD #2. Amiodarone started for Afib. At 9PM on POD #3, she became acutely hypotensive and non-responsive. CPR started, and chest opened at the bedside. Moderate amount of blood around the heart noted.Open cardiac massage performed for asystole.Unable to pace the heart. No obvious sites of bleeding identified. Patient pronounced at 9:50 PM.Family notified. Permission for autopsy granted. Medications on Admission: atenolol 50 mg daily prednisone 5mg daily advil [Hospital1 ] prn fosamax Qwk Discharge Disposition: Expired Discharge Diagnosis: CAD s/p MVR/cabg x1 cardiogenic shock acute MI ruptured papillary muscle with severe 4+ MR [First Name (Titles) ] [Last Name (Titles) ] A fib elev. lipids polymyalgia rheumatica DM Discharge Condition: expired Completed by:[2151-6-24]	[ "41071", "5849", "9971", "41401", "4240", "4019", "2720", "25000", "496", "2875", "42731", "4280" ]
Admission Date: [2189-5-26] Discharge Date: [2189-5-27] Date of Birth: [2124-9-28] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / moxifloxacin / metronidazole / cefazolin / Iodine / morphine / piperacillin / trimethoprim / Avelox Attending:[First Name3 (LF) 3556] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Bronchoscopy with tracheal stent removal History of Present Illness: History of Present Illness: 64F with a hx of COPD, fibromyalgia, Factor V leiden c/b DVT and CVA, and tracheobronchomalacia s/p tracheal y-stent on [2188-3-27], stent removal [2188-10-27] for chronic infections and mesh tracheoplasty [11/2188] who presented with 1 day of dyspnea and hypoxia and admitted to the MICU for airway monitoring and bipap prior to bronchoscopy. . She states that the woke up and thereafter noticed SOB and checked her O2 sat using her husband's pulse ox and was at 85% at rest on RA. She then used some of her husband's O2 by nasal cannula (unclear dose) which brought her O2 to 99%. She ate breakfast and showered and began coughing junky grey and brown material. She then called her pulmonologist, who told her to come to the ED. She otherwise denies fevers, chills, nausea, vomiting, change in appetite, rashes, swelling, or any other symptoms. . Of note, patient recently underwent outpatient evaluation for dyspnea by IP who has been following including CT trachea which demonstrated malacic changes in the upper 3-4cm's of her trachea, PFT's which demonstrated low lung volumes (TLC 76% predicted, FEV1/FVC 104% predicted), and bronchoscopy ([5-21]) with dynamic maneuvers demonstrated severe cervical tracheomalacia, moderate bronchomalacia at the bronchus intermedius, but otherwise no malacia elsewhere. A 15-12-12 Y stent cut to a length of 4.5cm was deployed and pt was started on Mucinex, Albuterol, and Mucomyst nebs. Two days later she contact[Name (NI) ] the IP office with complaint of dyspnea but denied symptoms of plugging and described using the mucinex and nebs as prescribed but poor compliance of spiriva leading IP to believe her symptoms were more related to her COPD. She called the IP office again on the day of admission and felt her symptoms were related to plugging of her stent so she was advised to proceed to the ED for further evaluation. . ED Course: In the ED, initial VS were T 99.4, HR 110, BP 135/88, RR 16, 99% on RA. She was evaluated by the IP team in the ED, who expressed concern for possible mucous plugging and recommended taking to the patient to the OR for bronchoscopy. CXR wnl's. She received nebs with albuterol and racemic epinephrine as well as 80 mg IV solumedrol and zofran 4 mg IV for nausea. ICU admission was recommended as patient may require BIPAP as well as close monitoring post-bronchoscopy. Transfer vitals were T 98.4 ??????F, HR 89, RR 20, BP 121/67, O2 Sat 98% on RA. . On arrival to the MICU, patient's VS: 99.6, 101, 146/83, 14, 100%3LNC. She confirms the above history and denies significant symptoms other than some discomfort with breathing and a moderate headache which she often has. Past Medical History: - Tracheomalacia s/p tracheal y-stent on [2188-3-27], stent removal [2188-10-27] for chronic infections - s/p PFO closure [2183], [Hospital1 3278] - Factor V Leiden deficiency with h/o DVT and CVA - Migraine - Fibromyalgia - Asthma - COPD, bronchiectasis - Glaucoma - C. difficile ([2178]) Social History: Social History: Retired social worker. Married and lives with her husband. [Name (NI) ] a history of alcoholism but quit drinking almost 30 yaers ago. Former smoker, quit [2175]. No recreational drugs. Family History: Father (d) depression, COPD. Mother alcoholism. Physical Exam: Vitals: 99.6, 101, 146/83, 14, 100%3LNC General: Alert, oriented, no acute distress, not using accessory muscles HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD, soft submandibular fullness that seems to be adipose rather than edema CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding 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 Pertinent Results: [2189-5-26] 02:50PM BLOOD WBC-7.8# RBC-5.08# Hgb-13.4# Hct-44.9# MCV-89 MCH-26.3# MCHC-29.8 RDW-16.9* Plt Ct-316 [2189-5-26] 07:53PM BLOOD WBC-6.7 RBC-4.63 Hgb-12.1 Hct-40.5 MCV-88 MCH-26.1* MCHC-29.8* RDW-16.9* Plt Ct-239 [2189-5-26] 02:50PM BLOOD Neuts-75.7* Lymphs-18.0 Monos-3.2 Eos-2.6 Baso-0.4 [2189-5-26] 02:50PM BLOOD Plt Ct-316 [2189-5-26] 07:53PM BLOOD PT-11.1 PTT-31.0 INR(PT)-1.0 [2189-5-26] 07:53PM BLOOD Plt Ct-239 [2189-5-26] 07:53PM BLOOD Glucose-287* UreaN-21* Creat-0.6 Na-143 K-4.2 Cl-108 HCO3-23 AnGap-16 [2189-5-26] 07:53PM BLOOD Calcium-9.1 Phos-2.3# Mg-1.8 [2189-5-26] 02:50PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.014 [2189-5-26] 02:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM [2189-5-26] 02:50PM URINE RBC-1 WBC-8 Bacteri-NONE Yeast-NONE Epi-0 [2189-5-26] 02:50PM URINE Mucous-RARE Time Taken Not Noted Log-In Date/Time: [2189-5-26] 6:09 pm MRSA SCREEN Source: Nasal swab. MRSA SCREEN (Pending): CHEST (PORTABLE AP) Study Date of [2189-5-26] 2:14 PM IMPRESSION: No acute cardiopulmonary abnormality, and no significant interval change from prior. EKG: NSR @ 97, LAD which is old, NI, poor r-wave progression, otherwise similar to prior from [2188-12-9] Brief Hospital Course: Assessment and Plan: 64F with a hx of COPD, fibromyalgia, Factor V leiden c/b DVT and CVA, and tracheobronchomalacia s/p s/p mesh tracheoplasty [11/2188] and y-stent [5-21] who presented with 1 day of dyspnea and hypoxia and admitted to the MICU for airway monitoring and bipap prior to bronchoscopy. . # Hypoxia/Concern for Stent Plugging/Possible COPD Exacerbation: Pt with extensive tracheomalacia history on top of mild-moderate COPD without home O2 requirement presenting with repeated episodes of dyspnea following tracheal stent placement [5-21] concerning for mucous plugging. On exam, she is without significant stridor or upper airway sounds and without wheezes. While she does not currently have frank fevers, CXR infiltrates, or lung exam findings c/w pneumonia she does report history of productive cough that is different from her baselime sputum, temperatures are elevated, and she is somewhat diaphoretic raising possibility of COPD exacerbation. Unfortunately she has multiple antibiotic allergies which would make therapy selection more difficult. Interventional Pulmonology took the patient to the OR for bronchoscopy and removed the stent. They noted granulation tissue around the stent with mucous which was the likely cause of her dyspnea. They also removed some fo the granulation tissue. She was observed in the ICU for 4 hours after the procedure with O2 sat of 98 while ambulating on RA. Patient received methyl prednisolone while in the ICU and was discharged on 4 days of 40mg prednisone per IP recommendations. She will follow up with both IP and Thoracic surgery for eventual surgical repair of her tracheomalacia. . # COPD: Patient on no home O2, without wheezes on exams, only home med is spiriva. Patient's O2 saturation was monitored continously while in the ICU and was placed on PRN nebulized albuterol and ipratropium without issue. . # GERD: Stable. Perhaps a causative factor in her tracheomalacia. Patient was continued on ranitidine and omeprazole and tums. . # Fibromyalgia/Migraines: Stable. Patient was continued on her home gabapentin, citalopram, cyclobenzaprine. Medications on Admission: Medications: Confirmed with Rite-Aid pharmacy (237 [Location (un) ], [Location (un) 2498], MA; Phone: [Telephone/Fax (1) 77218]) - Sodium chloride 3% 3ml via nebulizer Q8H 20 minutes after albuterol nebs (this was in lieu of acetylcysteine nebs, which could not be obtained by pharmacy; script filled [2189-5-22]) - xBenzonatate 100 mg 2 capsule Q8H x 10 days PRN cough (script filled [2189-5-22]) - xClonazepam 1 mg PO TID PRN vertigo (script filled [2189-5-18]) - xLidoderm patch 5% 12 hours on/12 hours off (script filled [2189-5-16]) - Promethazine with codeine syrup, 240 ml, 1 tsp Q4H PRN cough (script filled [2189-5-16]) - xCyclobenzaprine 10 mg PO QHS x 30 days (script filled [2189-5-14]) - xVicodin 10-325 mg [2-9] tab PO TID PRN pain #50 (script filled [2189-5-14]) - xTramadol 50 mg [2-9] tab PO TID PRN pain #50 (script filled [2189-5-11]) - xRanitidine 300 mg PO QHS (script filled [2189-4-22]) - xPromethazine 25 mg PO QID PRN #50 (script filled [2189-4-7]) - Acetylcysteine nebs 20% 5ml Q8H to be used 20 minutes after albuterol nebs (prescribed [2189-5-22] but not filled as unavailable at pharmacy; saline nebs substituted) . Old scripts not filled in months: - Fiorcet 50 mg-325 mg-40 mg [2-9] Tablet(s) by mouth every six (6) hours as needed for headache (script last filled [10/2188]) - Gabapentin 200 mg PO BID (script last filled [1-/2189]) - Hydromorphone 2 mg [3-13] tab Q3H PRN pain #60 (script filled [1-/2189]) - Lorazepam 0.5 mg Q6H PRN (script last filled [12/2188]) - Nifedipine 10 mg PO Q8H (script last filled [1-/2189]) - Metformin 500 mg PO QHS (script last filled [8-/2188]) - Spiriva 18 mcg 1 cap inhaled daily (script last filled [2185]) - Citalopram 20 mg PO daily (script last filled [2183]) . Meds per OMR record, but no record at pharmacy: - Dozolamide-timolol eye drops, dose unknown - no record at Rite-Aid - Simvastatin 20 mg PO daily - no record at Rite-Aid - Omeprazole 40 mg PO, frequency unknown - no record at Rite-Aid (? OTC) - Colace 100 mg PO, frequency unknown - no record at Rite-Aid (? OTC) - Mucinex ER Multiphase 1,200 mg by mouth twice a day #60 (prescribed [2189-5-21], no record at Rite-Aid, ? OTC) . Discharge Medications: 1. prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for 4 days. Disp:8 Tablet(s) Refills:0 2. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for vertigo. 3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 4. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for spasm. 5. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO ONCE (Once) for 1 doses. 6. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 7. benzonatate 100 mg Capsule Sig: Two (2) Capsule PO every eight (8) hours as needed for cough for 5 days. 8. tramadol 50 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for pain for 7 days. 9. promethazine 25 mg Tablet Sig: One (1) Tablet PO four times a day for 10 days. 10. acetylcysteine Sig: 20% 5mL nebs Inhalation every eight (8) hours as needed for shortness of breath or wheezing for 7 days: use 20min after albuterol nebs. 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebs Inhalation Q6H (every 6 hours) as needed for SOB/Wheezes. Discharge Disposition: Home Discharge Diagnosis: tracheomalacia mucous plugging tracheal stent with granulation tissue causing airway narrowing Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [Known lastname 91270], You were admitted to [Hospital1 69] for shortness of breath. Our interventional pulmonologists removed your tracheal stent. You had formed some scar tissue around the stent and had mucous plugging which likely lead to your shortness of breath. We gave you steroids in the ICU to help with inflammation. Please take 4 more days of prednisone, a steroid, as prescribed. Followup Instructions: Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] ([Telephone/Fax (1) 3020]) and Dr. [Last Name (STitle) 11482] [Name (STitle) ] ([Telephone/Fax (1) 3020]) offices are making appointments for you. If they do not contact you by [Name (NI) 2974] [2189-5-29], please call their offices. The following appointments have already been scheduled: Provider: [Name10 (NameIs) 15040] [Last Name (NamePattern4) 15041], MD Phone:[Telephone/Fax (1) 41] Date/Time:[2189-5-28] 3:30 Provider: [First Name4 (NamePattern1) 1386] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2189-6-3] 9:00 Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 590] Date/Time:[2189-8-25] 8:30 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3559] MD, [MD Number(3) 3560] Completed by:[2189-5-27]	[ "53081", "25000", "V1582" ]
Admission Date: [2177-7-24] Discharge Date: [2177-8-19] Date of Birth: [2147-8-13] Sex: F Service: MEDICINE Allergies: Demerol / Unasyn / Cephalosporins / Levaquin / Moexipril / Morphine / Cyclosporine Attending:[First Name3 (LF) 8367] Chief Complaint: ?infected hardware Major Surgical or Invasive Procedure: Left Obturator artery pseudoaneurysm embolization History of Present Illness: Ms. [Known lastname 14323] is a 29 year old woman with ESRD on HD s/p failed renal transplant (rejection [2174]) and s/p bilateral nephrectomy, now s/p right tibial IMN on [2177-6-24] who returns from rehab with worsening leg wound and possible infection. She also notes worsening right knee swelling and pain. . Her recent admission was complicated by possible cellulitis, which was treated with vancomycin/Zosyn to complete a 2 week course. She was discharged from [Hospital1 18] on [7-8] and was found hypotensive on [7-12] (blood cultures growing coag negative staph sensitive to vancomycin). She received one dose of gentamicin at that time. She responded well to IVF. The right knee was aspirated on [7-15] and showed gram positive cocci in pairs and clusters but nothing grew in cultures. She had a PICC line catheter tip culture on [7-12] which grew coag negative staph sensitive to vancomycin. She had another catheter tip sent for culture on [7-18] (unclear what line) which did not grow anything. She also underwent a debridement of the right lower extremity wound by vascular surgery. Coumadin and heparin were discontinued (started for DVT prophylaxis after tib/fib surgery) and she was anticoagulated with Lovenox. . She was transferred back to [Hospital1 18] for concern for hardware infection, and non-healing wound. The septic knee reportedly has improved significantly with surgery and antibiotics. . In the ED, vital signs were T99.1, HR 100, BP 99/50, RR 16, sat 95% on room air. She received dilaudid IV for pain, in addition to vancomycin IV x 1 (preceded by Benadryl) and clindamycin IV x 1. She was given 2 L NS for rehydration. . REVIEW OF SYSTEMS: She notes constipation, right lower extremity pain (both at the site of the wound and at the knee), and low grade temperature. She denies abdominal pain, nausea, vomiting, shortness of [Hospital1 1440], dizziness, and vomiting. She has mild numbness of the right lower extremity below the knee. Past Medical History: PAST MEDICAL HISTORY: - SLE diagnosed [2166] complicated by lupus nephritis, anemia, serositis and ascites - End stage renal disease secondary to lupus, HD T/Th/Sat - History of VSD s/p corrective surgery, age 13 - Hypertension - ITP - MSSA endocarditis - Sickle cell trait - S/p left oophorectomy related to IUD associated infection - Restrictive lung disease noted on PFTs [2166]. In [2173], chest CT with diffuse ground glass opacities. - GERD - S/p cadaveric renal transplant on [8-/2175] complicated by rejection and capsule rupture 11/[2174]. - Right pelvic abscess s/p TAH/RSO - B/L renal solid masses s/p resection pathology was negative for carcinoma - R tib/fib fx with ORIF [2177-6-24] Social History: No smoking, occasional alcohol, no drug use. Originally from [Country ], now lives in [Location 2268]. used to work at [Hospital1 18]. Family History: Non-contributory Physical Exam: Vitals: T 97.0, BP 92/70, HR 86, RR 18, Sat 100%2L Gen: Chronically ill appearing, no acute distress HEENT: EOMI, OP clear Neck: No lymphadenopathy Cardiac: RRR, normal S1/S2, 1/6 systolic murmur at apex Lungs: CTA bilaterally. No wheezes, rales, or rhonchi. Abd: Soft, but distended, mildly diffusely tender, normal active bowel sounds. No hepatosplenomegaly. Midline and bilateral oblique scars from previous abdominal surgeries. Ext: No clubbing, cyanosis, or edema. [12-10]+ DP pulses bilaterally. Right Knee: swollen and tender to palpation, no erythema, no warmth Right Leg: open wound with no purulence on anterior surface, approximately six inches long and 4 inches wide, 2cm deep, No swelling, no erythema. Skin: No rashes Neuro: A&O x 3 Pertinent Results: . [7-24] CT LLE with contrast: 1. Fluid collection due to an apparent skin defect in the anterolateral distal calf. It may represent seroma. Abscess less likely. 2. Distal calf intermuscular hypoattenuation which should be followed on further series but is likely to represent muscle edema. 3. Recent tibia and fibular fractures. 4. Subcutaneous edema in distal calf and foot. . 8/16 L tib/fib plain film: No definite radiographic evidence for osteomyelitis. Internally fixated tibial fracture and impacted nondisplaced nonangulated fibular fracture as previously described. Significant soft tissue ulceration at the level of the fracture site. . [7-24] R knee plain film: No definite radiographic evidence for osteomyelitis. Internally fixated tibial fracture and impacted nondisplaced nonangulated fibular fracture as previously described. Significant soft tissue ulceration at the level of the fracture site. . Shoulder Plain film 1. Demineralization of the bones associated with a reticular appearance, this may be seen in the setting of renal failure. 2. No erosions identified. 3. No fractures are seen. 4. Diffuse opacities within the visualized lungs, cannot exclude underlying pneumonia. . R LE U/S No evidence of DVT. . Bilateral arterial doppler u/s IMPRESSION: On the right normal arterial Doppler study _____ lower extremity at rest. On the left there appears to be mild tibial artery occlusive disease. . CXR 1. Stable bibasilar opacities may reflect underlying pneumonia with possible associated atelectasis. 2. Findings consistent with pulmonary artery hypertension. 3. Interval removal of left-sided PICC line. . [7-30] CTA Chest with and without contrast 1. Slightly limited study due to patient motion and insufficient contrast -bolus, but no evidence of pulmonary emboli. 2. Stable extensive airspace opacities in both lungs with ground glass opacities with interlobular thickening. Findings are likely related to a combination of left ventricular heart failure superimposed on an underlying chronic process such as COP or lupus pneumonitis. 3. Stable mediastinal and hilar lymphadenopathy. 4. Enlarged pulmonary artery consistent with underlying pulmonary arterial hypertension. . [8-1] Echocardiogram with bubble study. IMPRESSION: No ASD/PFO seen. No evidence of endocarditis. Possible shunting through the pulmonary vasculature. Symmetric LVH with preserved global and regional systolic function. Mildly dilated right ventricle with preserved systolic function. Moderate tricuspid regurgitation. Mild pulmonary hypertension. . Compared with the prior study (images unavailable for review) of [2177-2-10], right ventricular systolic function may have slightly improved. Severity of mitral regurgitation appears less. Discrete mitral valve echodensity is not appreciated on the current study. The other findings are similar. . [8-7] CT abd/ pelvis: IMPRESSION: 1. Interval decrease in size of bilateral renal fossa fluid collections. 2. Interval development of the presumed hematoma in the left obturator internus muscle. 3. There is significant interval change in bibasilar ground-glass opacities, with redemonstration of a right middle lobe pulmonary nodule now measuring 5 mm in size. 4. Stable pelvic lymphadenopathy. . [8-13] CT abd/ pelvis: IMPRESSION: 1. Slightly worsened left lower lobe peribronchial opacity and airspace consolidation. This nonstanding. 2. Interval expansion of the obturator internus presumed hematoma. There is also an avidly enhancing focus here. The findings are highly concerning for pseudoaneurysm. 3. Stable nephrectomy bed postoperative collections. . [8-14] IR embolization: IMPRESSION: Angiographically successful embolization of left obturator artery pseudoaneurysm with microcoils and thrombin. . [2177-7-24] 04:25PM BLOOD WBC-8.6 RBC-2.82* Hgb-8.5* Hct-26.5* MCV-94 MCH-30.2 MCHC-32.1 RDW-20.5* Plt Ct-114# [2177-7-29] 04:32AM BLOOD WBC-6.6 RBC-2.62 Hgb-8.0* Hct-25.0* MCV-95 MCH-30.5 MCHC-31.9 RDW-19.8* Plt Ct-147* [2177-7-31] 12:38PM BLOOD WBC-7.5 RBC-2.81* Hgb-8.4* Hct-26.2* MCV-93 MCH-29.9 MCHC-32.0 RDW-19.5* Plt Ct-100* [2177-8-2] 08:00AM BLOOD WBC-7.0 RBC-3.15* Hgb-9.3* Hct-28.8* MCV-91 MCH-29.6 MCHC-32.4 RDW-19.5* Plt Ct-147* [2177-7-24] 04:25PM BLOOD PT-12.8 PTT-31.3 INR(PT)-1.1 [2177-8-1] 05:00AM BLOOD PT-12.9 PTT-32.3 INR(PT)-1.1 [2177-7-24] 04:25PM BLOOD ESR-115* [2177-7-25] 04:42AM BLOOD Ret Aut-4.3* [2177-7-24] 04:25PM BLOOD Glucose-98 UreaN-23* Creat-7.0# Na-136 K-4.8 Cl-101 HCO3-24 AnGap-16 [2177-8-2] 08:00AM BLOOD Glucose-83 UreaN-24 Creat-7.4* Na-137 K-4.5 Cl-101 HCO3-27 AnGap-14 [2177-7-25] 04:42AM BLOOD ALT-12 AST-19 LD(LDH)-204 AlkPhos-193* TotBili-0.2 DirBili-0.1 IndBili-0.1 [2177-7-25] 04:42AM BLOOD Albumin-2.5* Calcium-8.8 Phos-3.1 Mg-2.3 Iron-59 [2177-7-31] 12:38PM BLOOD Albumin-2.8* Calcium-9.1 Phos-2.6* Mg-2.7* [2177-7-25] 04:42AM BLOOD calTIBC-130* Hapto-77 Ferritn-1223* TRF-100* [2177-7-26] 05:20AM BLOOD PTH-144* [2177-7-29] 08:06AM BLOOD PTH-80* [2177-8-2] 08:30AM BLOOD PTH-153* [2177-7-25] 04:42AM BLOOD CRP-33.6* [2177-7-26] 05:20AM BLOOD PEP-POLYCLONAL IgG-3236* IgA-289 IgM-155 IFE-NO MONOCLO [2177-7-26] 05:20AM BLOOD Vanco-40.4* [2177-7-27] 05:59AM BLOOD Vanco-27.6* [2177-7-28] 04:56AM BLOOD Vanco-26.4* [2177-7-29] 04:32AM BLOOD Vanco-25.3* . Blood cx [7-24] (venipuncture): ENTEROCOCCUS FAECIUM \| AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S PENICILLIN------------ =>64 R VANCOMYCIN------------ =>32 R All subsequent blood cultures are thus far negative. . Swab wound cultures: no growth (final) Brief Hospital Course: A/P: Ms. [Known lastname 14323] is a 29yo female s/p failed renal transplant (rejection [2174]) and s/p bilateral nephrectomy, now s/p right tibial IMN on [2177-6-24] who was transferred from [Hospital ] rehab with bacteremia, worsening RLE, and concern for hardware infection. . #) Bacteremia: The patient was transferred from rehab with positive BCx growing coag negative staph sensitive to vancomycin on [7-12], and grew VRE sensitive to Linezolid in BCx on [7-24]. There was no clear source for the bacteremia ?????? CXR and CT of the chest was not suggestive of PNA. Surgery and orthopedics were not concerned for wound infection or hardware infection as a possible septic source. CT of the abdomen/ pelvis was without evidence of abscess or any other infectious source. Surgery was not concerned for the L obturator hematoma (see below) as potential source for sepsis. The ID service was consulted, and the patient was treated with Linezolid for VRE bacteremia and vancomycin for coag. negative staph. Vancomycin will be dosed at dialysis. It will be continued for an unspecified course, to be determined during outpatient follow-up with Dr. [Last Name (STitle) 4020]. Surveillance cultures remained negative for the remainder of the patient??????s hospital course and the patient was clinically well (afebrile, without leukocytosis, negative blood cultures) upon discharge. . #) Hypotension: On [8-8] while on the floor, the patient was found to be lethargic with desaturation to 85% and SBPs~70's. She had received Dilaudid >10mg IV over the course of the day and had a rapid yet brief improvement in her mental status and BP in response to Narcan. BP was unresponsive to IVF boluses and she was transferred to the MICU for closer management, where she briefly required pressors in addition to multiple fluid boluses. She was started on Linezolid, Aztreonam, and Flagyl for presumed sepsis, with sources likely either hardware or abdomen. She was started on stress dose steroids, which was quickly tapered. Hypotension stabilized while in the MICU and the patient was transferred to the floor in stable condition. As above, subsequent cultures have been negative to date. . #) RLE Ulcer: Upon presentation there was no clear purulent drainage but the wound was exquisitely painful to touch. There was no fever or leukocytosis, and no clear osteomyelitis on right leg films. CT, however, demonstrated small abscess in the anterior subcutaneous tissues near the fixation but no deep abscess. She was started on clindamycin and vancomycin, and plastic surgery and orthopedics were consulted for wound care. She was continued on dry sterile dressing changes during her hospital course. Both services monitored the wound regularly and felt that the wound was healing well by discharge. The patient will see orthopedics as an outpatient to follow-up re: IMR placement and plastic surgery to follow-up progression of wound healing. . #) Abdominal pain: The patient has complained of significant diffuse abdominal pain during admission, up to [9-17]. CT scan of abdomen/pelvis was unremarkable except for an incidental finding of a L obturator hematoma (spontaneous in nature - no history of manipulation or trauma). General surgery did not suspect any acute process that could account for her symptoms. Pain subsequently resolved; however, the patient began experiencing significant LUQ pain different than prior on [8-9]. A repeat CT of the abd/ pelvis showed slight interval expansion of the hematoma, and there was a concern for a pseudoaneurysm. The patient was taken for angiography with placement of 13 coils and thrombin into the pseudoaneurysm with a rapid improvement in pain. LUQ pain was thought by GI and general surgery services to be referred pain from this pseudoaneurysm. The patient was able to tolerate po well subsequently and had much improved pain managed by a fentanyl patch (uptitrated to 200mcg) and oral dilaudid by discharge. . #) S/p nephrectomy: The patient was continued on a Tues, Thurs, Sat schedule for dialysis without any complication. She is to continue as an outpatient on this schedule. . The patient was discharged in stable condition to home. She was afebrile, VSS, tolerating po well, and ambulating with crutches (secondary to RLE wound). She was discharged to home with PT follow-up and VNA for dressing changes. Medications on Admission: Vitamin C 500mg [Hospital1 ] Aspirin 81mg daily Amitryptyline 100mg QHS Calcium Acetate 1334mg TID with meals Senna [Hospital1 ] PRN Dulcolax 10mg daily Lovenox 30mg QPM-->Contraindicated in HD patients? Gabapentin 200mg PO QHS Prednisone 5mg daily Colace 100mg [Hospital1 ] Lactulose 30mg Q8H Acetaminophen 650mg PO Q6H Sevelamer 1600mg TID Silver Sulfadiazine 1% cream applied [Hospital1 ] . ALLERGIES: Demerol / Unasyn / Cephalosporins / Levaquin / Moexipril Discharge Medications: 1. Home Oxygen Patient needs oxygen at home 2-3L NC as she has ambulatory desaturations to 88% 2. Comode Please give patient high comode 3. Shower Chair Please give patient shower chair 4. Amitriptyline 50 mg Tablet [Hospital1 ]: Two (2) Tablet PO HS (at bedtime). Disp:60 Tablet(s) Refills:2 5. Ascorbic Acid 500 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 6. Aspirin 81 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO DAILY (Daily). 7. Calcium Acetate 667 mg Capsule [Hospital1 ]: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:180 Capsule(s) Refills:2 8. Docusate Sodium 100 mg Capsule [Hospital1 ]: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 9. Senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:1 10. Sevelamer 800 mg Tablet [Hospital1 ]: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:90 Tablet(s) Refills:2 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 12. Linezolid 600 mg Tablet [Hospital1 ]: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:20 Tablet(s) Refills:0 13. Prednisone 5 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 14. Gabapentin 100 mg Capsule [Hospital1 ]: Two (2) Capsule PO HS (at bedtime). Disp:60 Capsule(s) Refills:2 15. Silver Sulfadiazine 1 % Cream [Hospital1 ]: One (1) Appl Topical [Hospital1 ] (2 times a day). Disp:1 tube Refills:2 16. Hydromorphone 2 mg Tablet [Hospital1 ]: 1-3 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:90 Tablet(s) Refills:0 17. Lactulose 10 g/15 mL Syrup [Hospital1 ]: Thirty (30) ML PO DAILY (Daily) as needed for constipation. Disp:30 units Refills:1 18. Medication during dialysis Vancomycin IV (to be given at hemodialysis per HD protocol) 19. Outpatient Lab Work Please draw 2 sets of blood cultures after patient finishes linezolid on [2177-8-14] Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: Right lower extremity cellulitis/wound infection Right tibia/fibula fracture Septic right knee bacteremia hypoxia . Secondary: End-stage renal disease on hemodialysis Discharge Condition: Good, pain well-controlled, BP stable 100-130s Discharge Instructions: You were admitted for an infection of your right leg and bloodstream. This was treated with antibiotics, and with evaluation by orthopedics, plastic surgery, and vascular surgery, who felt that the wound had good blood flow and would heal over time. Because of the type of organism and the fact that you have orthopedic hardware in your leg, you need to take 2 antibiotics: the first, linezolid, is an oral medication you should take for 10 more days; the second, vancomycin is an intravenous antibiotic which you should get during dialysis. You will need this for several months. We have arranged followup with Dr. [First Name8 (NamePattern2) ] [Name (STitle) 4020] of infectious disease, please see below for details. You were seen by the pulmonary doctors because [Name5 (PTitle) ] have needed extra oxygen to avoid feeling short of [Name5 (PTitle) 1440]. You should follow-up with them as an outpatient (details below - Dr. [Name (NI) 18849] office will call you with an appointment, but you should have a repeat CT scan of the chest before that. You should also have pulmonary function tests before or on the day of that appointment, Dr.[Name (NI) 18850] office can arrange this). You have been started on several new medications: linezolid, vancomycin, and lactulose. Please return to the emergency room if you experience worsening knee pain, fevers, shortness of [Name (NI) 1440], chest pain, or any other new or concerning symptoms. Followup Instructions: Provider: [First Name8 (NamePattern2) 4021] [Name11 (NameIs) ] (infectious disease specialist), MD Phone:[Telephone/Fax (1) 457] Date/Time:[2177-8-28] 11:30 . [2177-9-30] 10:15am Follow-up CT Scan of the chest. Please do not eat anything from 3 hours before study in [Hospital Ward Name 23] clinical center on [Hospital Ward Name ]. Provider: [Name10 (NameIs) ] SCAN Phone:[Telephone/Fax (1) 327] Date/Time:[2177-9-30] 10:15. . Dr. [First Name8 (NamePattern2) 4944] [Last Name (NamePattern1) ] of pulmonology and would like to see you as an outpatient in [1-11] months. Her office will call you with an appointment. If you do not hear from them in a few weeks, call ([Telephone/Fax (1) 513] to make an appointment. . Orthopedic followup: Provider: [Name10 (NameIs) ] XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2177-8-14] 10:10 Provider: [Name10 (NameIs) ] [Name8 (MD) 18851], MD Phone:[Telephone/Fax (1) 1228] Date/Time:[2177-8-14] 10:30 . Followup with the [8-21] at 1pm with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], NP in [Hospital Ward Name 23] [Location (un) ] central suite. (she is a nurse practitioner who works with Dr. [Last Name (STitle) ] Followup with Dr. [Last Name (STitle) ] on [10-3] at 10:40am. If she wants to see you sooner, someone from her office will call you.	[ "40391", "2875" ]
Admission Date: [2136-8-14] Discharge Date: [2136-9-16] Date of Birth: [2058-10-11] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1835] Chief Complaint: Cognitive decline Major Surgical or Invasive Procedure: bifrontal craniotomy peg placement tracheostomy History of Present Illness: The patient is a 73-year-old female who recently presented to my outpatient clinic. She had been followed for decreasing cognitive decline. The patient was worked up including imaging. A bifrontal large olfactory groove meningioma measuring 7 x 6 cm was found. The patient was extensively counseled. Given the family history and the large extent of the lesion, the decision was made by the brain tumor conference to resect the lesion for a better prognosis. The patient was extensively counseled. The patient was consented. The patient was taken electively to the OR. Preoperative films had been obtained. The patient was taken to the operating room on [2136-8-16]. Past Medical History: 1. macular degeneration 2. HTN 3. Hypercholesterolemia 4. meningioma Social History: Retired dental hygienist. She is married. She lives with her spouse and her daughter. She does not smoke, She drinks wine with dinner. Denies any recreational drugs. Family History: Mother died at age [Age over 90 ] of old age. Father died at age [Age over 90 ] with heart disease. Her sister is 71 in good health. She has two children both in good health. Physical Exam: Exam [2136-9-16]: Patient opens eyes to voice. She does not speak but attempts to stick out her tongue to command. PERRL. 3-2 mm bilaterally. The left one is larger initially but when rechecked is equal to the left. Motor: Moves left arm spontaneously and squeezes to command. Moves right arm with noxious stimuli. Withdraws both legs to noxious stimuli. Toes upgoing bilaterally. Her incision has healed well. Pertinent Results: RADIOLOGY Final Report [Numeric Identifier 82379] EXT CAROTID BILAT [2136-8-14] 7:55 AM Reason: angio w/embolization for bifrontal planum sphenoidale mening Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 77 year old woman with bifrontal planum sphenoidale meningioma. REASON FOR THIS EXAMINATION: angio w/embolization for bifrontal planum sphenoidale meningioma. TYPE OF STUDY: Cerebral angiogram. CLINICAL HISTORY: A 77-year-old female with bifrontal planum sphenoidale meningioma presents for evaluation with angiogram with possible embolization. Comparison is made with CT angiogram of the head performed [2136-7-3] and MRI of the brain performed [2136-7-2]. TECHNIQUE: Informed consent was obtained from the patient and the patient's family after explaining the risks, indications, and alternative management. Risks explained included bleeding, hemorrhage, stroke, loss of vision and/or speech, injury to blood vessels and/or nerves, allergic reaction to contrast material, renal failure, and death. Additionally possible use of embolization coils if needed was discussed. The patient was brought to the interventional neuroradiology suite and placed on the biplane table in the supine position. Prior to the start of the procedure, a timeout was performed to verify the patient's identity using two patient identifiers and the procedure to be performed. Both groins were prepped and draped in the usual sterile fashion. General anesthesia was provided by the anesthesiology service. Access to the right common femoral artery was obtained using a 19-gauge single-wall needle, under local anesthesia using 1% lidocaine mixed with sodium bicarbonate with aseptic precautions. Through the needle, a 0.35 [Last Name (un) 7648] wire was introduced and the needle was taken out. Over the wire, a 5-French vascular sheath was placed and connected to a saline infusion (mixed with heparin 500 units and 500 cc of saline) with a continuous drip. Through the sheath, a 4 French Berenstein catheter was introduced and connected to the continuous saline infusion (with heparin mixture: 1000 units of heparin and 1000 cc saline). The following vessels were selectively catheterized and arteriograms were performed from these locations. After review of the study, the catheter and the sheath were withdrawn and pressure was applied on the groin until hemostasis was achieved. The procedure was uneventful and the patient tolerated the procedure well without immediate post-procedure related complications. The patient was sent to the floor with post-procedure orders. The following blood vessels were selectively catheterized and arteriograms were obtained in the AP and lateral projections: 1. Right external carotid artery. 2. Right internal carotid artery. 3. Right common carotid artery. 4. Left external carotid artery. 5. Left internal carotid artery. 6. Left common carotid artery. FINDINGS: Evaluation of the above blood vessels demonstrates no evidence of aneurysm or vascular malformation. Upon injection of the right internal carotid artery there is a large hypervascular mass with a large tumoral blush identified in the bifrontal region which is largely supplied by the right anterior ethmoidal and right ophthalmic arteries. Additionally, upon injection of the left internal carotid artery, there is identification of this large hypervascular mass to be supplied by a branch arising from the left paricallosal branch on the anterior cerebral artery. Additionally, upon injection of the bilateral external carotid arteries there is minimal tumor-related blush seen to supply from branches of the bilateral middle meningeal arteries. Also, additionally upon injection of the left external carotid artery there is a hypervascular mass with a prominent tumor-related blush seen overlying the left frontal lobe. This hypervascular mass appears to be largely supplied by branches from the left middle meningeal artery. IMPRESSION: 1. Large bifrontal hypervascular mass is consistent with meningioma as reported on prior cross-sectional images which is larger beings supplied by the right anterior ethmoidal and ophthalmic arteries and a left branch arising from the left callosal artery. 2. Large hypervascular mass overlying the left frontal lobe consistent with a meningioma as correlated with prior cross-sectional images largely being supplied by branches from the left middle meningeal artery. These findings were discussed with Dr. [Last Name (STitle) ] at the time of the examination. Dr. [Last Name (STitle) ], attending interventional neuroradiologist, was present and performed the procedure. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) 815] DR. [First Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Approved: TUE [2136-8-21] 3:13 PM RADIOLOGY Final Report [Numeric Identifier 7649] CAROTID/CERVICAL BILAT [2136-8-14] 7:55 AM Reason: angio w/embolization for bifrontal planum sphenoidale mening Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 77 year old woman with bifrontal planum sphenoidale meningioma. REASON FOR THIS EXAMINATION: angio w/embolization for bifrontal planum sphenoidale meningioma. TYPE OF STUDY: Cerebral angiogram. CLINICAL HISTORY: A 77-year-old female with bifrontal planum sphenoidale meningioma presents for evaluation with angiogram with possible embolization. Comparison is made with CT angiogram of the head performed [2136-7-3] and MRI of the brain performed [2136-7-2]. TECHNIQUE: Informed consent was obtained from the patient and the patient's family after explaining the risks, indications, and alternative management. Risks explained included bleeding, hemorrhage, stroke, loss of vision and/or speech, injury to blood vessels and/or nerves, allergic reaction to contrast material, renal failure, and death. Additionally possible use of embolization coils if needed was discussed. The patient was brought to the interventional neuroradiology suite and placed on the biplane table in the supine position. Prior to the start of the procedure, a timeout was performed to verify the patient's identity using two patient identifiers and the procedure to be performed. Both groins were prepped and draped in the usual sterile fashion. General anesthesia was provided by the anesthesiology service. Access to the right common femoral artery was obtained using a 19-gauge single-wall needle, under local anesthesia using 1% lidocaine mixed with sodium bicarbonate with aseptic precautions. Through the needle, a 0.35 [Last Name (un) 7648] wire was introduced and the needle was taken out. Over the wire, a 5-French vascular sheath was placed and connected to a saline infusion (mixed with heparin 500 units and 500 cc of saline) with a continuous drip. Through the sheath, a 4 French Berenstein catheter was introduced and connected to the continuous saline infusion (with heparin mixture: 1000 units of heparin and 1000 cc saline). The following vessels were selectively catheterized and arteriograms were performed from these locations. After review of the study, the catheter and the sheath were withdrawn and pressure was applied on the groin until hemostasis was achieved. The procedure was uneventful and the patient tolerated the procedure well without immediate post-procedure related complications. The patient was sent to the floor with post-procedure orders. The following blood vessels were selectively catheterized and arteriograms were obtained in the AP and lateral projections: 1. Right external carotid artery. 2. Right internal carotid artery. 3. Right common carotid artery. 4. Left external carotid artery. 5. Left internal carotid artery. 6. Left common carotid artery. FINDINGS: Evaluation of the above blood vessels demonstrates no evidence of aneurysm or vascular malformation. Upon injection of the right internal carotid artery there is a large hypervascular mass with a large tumoral blush identified in the bifrontal region which is largely supplied by the right anterior ethmoidal and right ophthalmic arteries. Additionally, upon injection of the left internal carotid artery, there is identification of this large hypervascular mass to be supplied by a branch arising from the left paricallosal branch on the anterior cerebral artery. Additionally, upon injection of the bilateral external carotid arteries there is minimal tumor-related blush seen to supply from branches of the bilateral middle meningeal arteries. Also, additionally upon injection of the left external carotid artery there is a hypervascular mass with a prominent tumor-related blush seen overlying the left frontal lobe. This hypervascular mass appears to be largely supplied by branches from the left middle meningeal artery. IMPRESSION: 1. Large bifrontal hypervascular mass is consistent with meningioma as reported on prior cross-sectional images which is larger beings supplied by the right anterior ethmoidal and ophthalmic arteries and a left branch arising from the left callosal artery. 2. Large hypervascular mass overlying the left frontal lobe consistent with a meningioma as correlated with prior cross-sectional images largely being supplied by branches from the left middle meningeal artery. These findings were discussed with Dr. [Last Name (STitle) ] at the time of the examination. Dr. [Last Name (STitle) ], attending interventional neuroradiologist, was present and performed the procedure. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) 815] DR. [First Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Approved: TUE [2136-8-21] 3:13 PM RADIOLOGY Final Report MR HEAD W/ CONTRAST [2136-8-15] 5:23 AM MR HEAD W/ CONTRAST Reason: Please do at 6 am for pre-op Contrast: MAGNEVIST [Hospital 93] MEDICAL CONDITION: 77 year old woman with bifrontal meningioma who will have surgery [8-15] REASON FOR THIS EXAMINATION: Please do at 6 am for pre-op CONTRAINDICATIONS for IV CONTRAST: None. MRI HEAD HISTORY: 77-year-old woman with meningiomas, here for pre-op evaluation. TECHNIQUE: Triplanar post-gado T1-weighted images of the head as well as post-gado MP-RAGE of the head were obtained with fiduciary markers in place. FINDINGS: Comparison is made to a prior head MR from [2136-7-2] as well as a CTA from [2136-7-3] and a cerebral angiogram from [2136-8-14]. Again seen is a large extra-axial enhancing mass consistent with a planum sphenoidale meningioma which is compressing and distorting the frontal lobes bilaterally. There is surrounding vasogenic edema of the frontal lobes extending into the right side of the corpus callosum with marked compression of the frontal horns of the lateral ventricles. There is also a approximately 3.4 x 2.8 cm extra-axial mass with underlying hyperostosis overlying the left frontal parietal lobe consistent with a second meningioma. This meningioma shows new internal necrosis which is new compared to the prior study. No new lesions are identified. IMPRESSION: Two large meningiomas as described above with a smaller meningioma over the left frontoparietal lobe showing some internal necrosis which is new. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Approved: [Doctor First Name ] [2136-8-16] 8:53 AM RADIOLOGY Final Report CT HEAD W/O CONTRAST [2136-8-15] 9:01 PM CT HEAD W/O CONTRAST Reason: Follow up blood products [Hospital 93] MEDICAL CONDITION: 77 year old woman with meningioma resection REASON FOR THIS EXAMINATION: Follow up blood products CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Status post meningioma resection. COMPARISON: [2136-7-3]. TECHNIQUE: Non-contrast head CT scan. FINDINGS: Patient is status post resection of previously seen large bifrontal extra-axial mass. Large amount of expected post-surgical pneumocephalus seen in the bifrontal region. Heterogeneous appearance in the resection bed is seen, with high-density material consistent with acute blood in the resection bed. Scattered foci of gas also seen in the resection bed. Hypodensity again seen in this region consistent with edema. Configuration of the ventricles appears relatively unchanged. No new hydrocephalus. Second calcified extra-axial mass along the lateral aspect of the left frontal lobe appears unchanged from prior. High-density material now also seen within the nasopharynx. Bone windows demonstrate frontal craniotomy defects and post-surgical hardware. Subcutaneous emphysema noted with multiple staples in the frontal scalp. Minimal mucosal thickening seen within the ethmoid, maxillary and sphenoid sinuses. IMPRESSION: 1. Status post resection of previously seen large bifrontal extra-axial mass, with expected pneumocephalus. Heterogeneous appearance of the resection bed, with multiple pockets of gas and high density material consistent with blood in the resection bed. 2. Unchanged appearance of calcified left meningioma. 3. High-density material is seen within the nasopharynx consistent with blood. Clinical correlation recommended. Findings were discussed with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at 10:45 p.m., [2136-8-15]. The study and the report were reviewed by the staff radiologist. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) 7415] Approved: [Doctor First Name ] [2136-8-16] 10:18 AM RADIOLOGY Final Report PORTABLE ABDOMEN [2136-8-25] 12:07 PM PORTABLE ABDOMEN Reason: eval for dilated loops [Hospital 93] MEDICAL CONDITION: 77 year old woman s/p craniotomy s/p dobhoff pneumonia, now w/ b/l rhonci, distended abdomen REASON FOR THIS EXAMINATION: eval for dilated loops HISTORY: Abdominal distention. Single supine radiograph of the abdomen demonstrates air and stool projecting over a normal caliber rectum. Small amount of air and stool are seen along the descending colon as well. Multiple loops of normal caliber air-distended small bowel are seen to collect in the middle of the abdomen. There is a featureless collection of air within a viscus projecting over the epigastrium. Given the presence of the patient's Dobbhoff tube on chest radiographs both prior and subsequent to this study the finding does not represent the stomach. IMPRESSION: Nonspecific bowel gas pattern. A single collection of air within a viscus projecting over the upper mid abdomen is unlikely to represent the stomach. Close clinical followup is requested. DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 6892] Approved: SAT [2136-9-1] 12:24 AM RADIOLOGY Final Report CT HEAD W/O CONTRAST [2136-8-25] 7:43 AM CT HEAD W/O CONTRAST Reason: assess for herniation, progression of lesion [Hospital 93] MEDICAL CONDITION: 77 year old woman with large meningioma, now more somnolent, with dilated left pupil REASON FOR THIS EXAMINATION: assess for herniation, progression of lesion CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 77-year-old female with large meningioma with dilated left pupil, assess for herniation. COMPARISON: [2136-8-20]. TECHNIQUE: Non-contrast head CT scan. FINDINGS: Again seen is a large calcified left frontal parietal mass previously described as a meningioma. Hyperdensity at the anterior medial aspects is consistent with hemorrhage and is unchanged. Vasogenic edema has increased resulting in increased rightward subfalcine herniation, now 6 mm and compression of the left lateral ventricle. Suprasellar cistern is effaced and there is mild compression on the brainstem indicating transtentorial herniation. Fourth ventricle is largely similar in appearance. Patient is status post bifrontal craniotomy with small amount of expected pneumocephalus and extraaxial fluid, which represents hemorrhage. Evolving intraparenchymal hemorrhage with associated edema and local sulcal effacement is seen in the bifrontal lobes anteriorly. IMPRESSION: 1. Increased mass effect from vasogenic edema and hemorrhage surrounding calcified left frontal parietal meningioma has resulted in an increased rightward subfalcine herniation and compression on the left lateral ventricle and near complete effacement of the suprasellar cistern resulting in new transtentorial herniation. There may be mild compression of the brainstem. These findings were discussed with Dr. [Last Name (STitle) 877] on [2136-8-25], at 9:35 a.m. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) ] [Doctor Last Name ] DR. [First Name (STitle) 3905] [Initials (NamePattern4) ] [Last Name (NamePattern4) 3906] Approved: SAT [2136-8-25] 12:16 PM Neurophysiology Report EEG Study Date of [2136-9-1] OBJECT: HX OF MENINGIOMA WITH ALTERED MENTAL STATUS. EVALUATE FOR SEIZURES. REFERRING DOCTOR: DR. [First Name (STitle) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ] FINDINGS: ABNORMALITY #1: Throughout the recording there is persistent mixed frequency theta and delta frequency slowing seen over the right frontal and central regions. ABNORMALITY #2: There is some voltage asymmetry between the two hemispheres with decreased voltage noted over the left anterior quadrant. ABNORMALITY #3: Throughout the recording the background rhythm is slow typically in the 6 Hz frequency range slightly disorganized and poorly reactive. ABNORMALITY #4: Intermixed with the already slow and disorganized background are brief intermittent bursts of moderate amplitude mixed frequency slowing. BACKGROUND: As above. HYPERVENTILATION: Could not be performed as this was a portable study. INTERMITTENT PHOTIC STIMULATION: Could not be performed as this was a portable study. SLEEP: There were no clear transitions or change in state noted. CARDIAC MONITOR: Showed a generally regular rhythm with an average rate of 78 bpm. IMPRESSION: This is an abnormal portable EEG due to persistent focal slowing in the right fronto-central region suggestive of an area of underlying subcortical dysfunction. In addition, there was a voltage asymmetry of decreased amplitudes noted over the left anterior quadrant suggestive of a structural or destructive process in that region. The background rhythm was also slow, disorganized, and poorly reactive with admixed bursts of generalized mixed frequency slowing suggestive of a mild global diffuse encephalopathy. This suggests ongoing bilateral subcortical or deeper midline dysfunction. Medications, metabolic disturbances, infection, and anoxia are among the most common causes of encephalopathy but there are others. There were no clearly epileptiform discharges and no electrographic seizures were seen. INTERPRETED BY: [Last Name (LF) ],[First Name3 (LF) ] L. ([5-/3059]B) RADIOLOGY Final Report CT HEAD W/O CONTRAST [2136-9-5] 12:37 PM CT HEAD W/O CONTRAST Reason: eval interval change [Hospital 93] MEDICAL CONDITION: 77F with large bifrontal meningioma, now s/p bifrontal crani, partial resection of tumor; returned to ICU for s/s of herniation, ameliorated w/ mannitol and decadron, persistent hyponatremia s/p tx w/ hypertonic saline REASON FOR THIS EXAMINATION: eval interval change CONTRAINDICATIONS for IV CONTRAST: None. CT SCAN OF THE BRAIN WITHOUT INTRAVENOUS CONTRAST HISTORY: Large bifrontal meningioma. Status post bifrontal craniotomy and partial resection of tumor, returned into the ICU for signs and symptoms herniation ameliorated with mannitol and Decadron. Persistent hyponatremia, status post treatment with hypertonic saline. Evaluate for interval change. TECHNIQUE: Non-contrast head CT scan. COMPARISON STUDY: [2136-8-30] non-contrast head CT scan interpreted by Dr. [Last Name (STitle) ] as revealing "evolution of blood products in the left frontal lobe adjacent to the meningioma. The edema and midline shift associated with this lesion are unchanged." FINDINGS: The large heavily calcified lesion within the left frontal region as well as the marked surrounding edema unaltered in extent. There is little change in the mass effect exerted upon the frontal [Doctor Last Name 534] and body of the left lateral ventricle. There is approximately 5 mm rightward subfalcine herniation seen. The subfrontal lesion, as before, is quite difficult to discern, but there does appear to be residual edema, which persists after the extensive resection. A small bifrontal extraaxial fluid filled compartment, which appears contiguous to and subjacent to the large frontal craniotomy flap appears unaltered in size. No other new extracranial abnormalities are discerned. CONCLUSION: Relatively little change in the appearance of the postoperative CT scan, as noted above. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9987] Approved: WED [2136-9-5] 3:17 PM RADIOLOGY Final Report CHEST (PORTABLE AP) [2136-9-5] 5:31 AM CHEST (PORTABLE AP) Reason: Fever, question PNA [Hospital 93] MEDICAL CONDITION: 77 year old woman s/p craniotomy s/p dobhoff HIT+, awaiting trach and PEG REASON FOR THIS EXAMINATION: Fever, question PNA INDICATION: 77-year-old woman status post craniotomy status post Dobbhoff; fever; evaluate for pneumonia. COMPARISONS: Chest radiograph dated [2136-8-30]. FINDINGS: A single AP portable upright view of the chest was obtained. An endotracheal tube terminates 4 cm above the carina. The nasogastric tube terminates in the pyloric region. A left internal jugular catheter terminates at the confluence of the brachiocephalic veins, as before. There is increased left basilar opacity, without pneumothorax or pulmonary vascular congestion. The cardiac silhouette is stable. IMPRESSION: 1. Increased left basilar opacity, compatible with a pleural effusion and adjacent atelectasis or pneumonia. The study and the report were reviewed by the staff radiologist. DR. [First Name (STitle) 7805] [Name (STitle) ] DR. [First Name (STitle) 3901] [Initials (NamePattern4) ] [Last Name (NamePattern4) 3902] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3891] Approved: [Doctor First Name ] [2136-9-6] 7:40 AM Cardiology Report ECG Study Date of [2136-8-15] 1:32:28 AM Normal sinus rhythm, rate 61. Left ventricular hypertrophy. Non-specific lateral repolarization changes consistent with left ventricular hypertrophy and/or ischemia. Compared to the previous tracing of [2136-7-24] probably no significant change. Read by: [Last Name (LF) ],[First Name3 (LF) ] S. Intervals Axes Rate PR QRS QT/QTc P QRS T 61 128 90 458/459 23 -12 115 [Hospital1 69] [Location (un) 86], [Telephone/Fax (1) 15701] Pathology Examination Name Birthdate Age Sex Pathology # [Hospital1 18] [Known lastname 106730],[Known firstname ] [2058-10-11] 77 Female [-5/3667] [Numeric Identifier 107533] Report to: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ] Gross Description by: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ], DR. [Last Name (STitle) ]. ROBENS/cofc SPECIMEN SUBMITTED: FS FRONTAL TUMOR, FRONTAL TUMOR (2). Procedure date Tissue received Report Date Diagnosed by [2136-8-15] [2136-8-15] [2136-8-20] DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/cma?????? Previous biopsies: [Numeric Identifier 107534] BACK/st. DIAGNOSIS: Specimen #1: "Frontal tumor, ? meningioma", craniotomy (A, B-C): Meningioma meningothelial subtype (WHO grade I) (see note). Note: The tumor lacks any atypical features including necrosis, sheeting and prominent nucleoli. Mitotic rate is less than 1 per 10 hpf. Specimen #2: "Frontal tumor, ? meningioma", craniotomy (D-H): Meningioma, meningothelial subtype (WHO grade 1). Clinical: ? Meningioma. Gross: This specimen has been received in two parts. Specimen 1, is received fresh for intraoperative consult labeled with the patient's name "[Known lastname ], [Known firstname ]", and the [Hospital 228] medical record number. The specimen consists of an aggregate of soft tan tissue measuring 3.5 x 2 x 0.6 cm. 20% of the tissue is consumed for intraoperative frozen section (FS1) smear, (SM1 and touch preps), (PP1). The frozen section diagnosis by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4223] is: "Meningioma with no atypical features". The specimen is entirely submitted as follows: A=frozen section remnant, B-C = Nonfrozen portion of specimen. Specimen 2, is received fresh labeled with "[Known firstname ] [Known lastname ]", the medical record number and "frontal tumor ?meningioma", and consists of multiple tan pink soft tissue fragments measuring approximately 9.0 x 4.6 x 1.8 cm in aggregate. Representative sections are submitted in D-H. Brief Hospital Course: Pt was admitted through SDA for Bifrontal craniotomy for mengioma resection / elective. [8-17] pt was extubated and was noted to be abulic. [8-20] Pt noted with Right facial droop and right pronator drift with R hemiparesis. CT revealed that second known meningioma in left parietal region with spontaneous hemorrhage. The bleed was considered to be non surgical. [8-23] CXR revealed CHF and PNA, lasix and abx started. [8-25] pt with unilateral pupillary enlargement / mannitol and decadron given emergently / re-intubated /exam followed closely. Hyponatremia treated with 23% (twenty three) normal saline which was then converted to 3% NS. [8-30] pt with thrombocytopenia - HIT antibodies sent and were inconclusive. All heparin products held. Trach and peg placed on hold until plts recovered. hematology consult obtained. [9-1] exam continues to fluctuate / eeg ordered / no sz activity noted / CT scans followed. Keppra decreased [12-30] possible cause of [Month (only) ]. mental status. [9-5] repeat CT stable. Decadron wean complete. Vanco started for GNR, GPC, GPR in sputum. [9-8] trach and peg complete/ off ventilator [9-9] neuro exam improving / following commands / eyes open [9-12] transferred to step down unit. PT and OT have evaluated the patient and both recommended rehab. She was accepted at [Hospital 100] Rehab and was supposed to go on [9-14] but the bed was unavailable. On [9-16] the bed was available and she was transferred to [Hospital 100] Rehab. Her exam prior to discharge was stable. See physical exam section above. Medications on Admission: [Last Name (un) 1724]: 1. Toprol 25 mg 2. Lipitro 20 mg 3. Prozac 20 mg Discharge Medications: 1. Fluoxetine 10 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Colace 50 mg/5 mL Liquid Sig: Two (2) PO twice a day. 5. Keppra 100 mg/mL Solution Sig: 10 ml PO twice a day. 6. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 7. heparin Sig: 5,000 units Subcutaneous three times a day. 8. Ketoconazole 2 % Cream Sig: One (1) Topical Q 12 hours PRN: Please apply under breasts. 9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) PO QID PRN. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Intracranial meningioma s/p resection Discharge Condition: Neurologically stable Discharge Instructions: ?????? Have your incision checked for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? 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. ?????? You have been prescribed an anti-seizure medicine, take it as prescribed. 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 WEEKS. YOU WILL NEED AN MRI OF THE BRAIN WITH AND WITHOUT GADOLINIUM PRIOR TO YOUR VISIT. Completed by:[2136-9-16]	[ "2761", "2859", "4019" ]
Admission Date: [2168-10-17] Discharge Date: [2168-10-26] Date of Birth: [2124-11-30] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: sternal incision pain, purulent drainage Major Surgical or Invasive Procedure: sternal debridement([10-18]) closure with bilat pectoral flaps and sternal plates. ([10-20]) History of Present Illness: This 43 year old woman is s/p mitral valve replacement and PFO closure on [2168-9-19]. She presented to an outside hospital with eight hours of sternal incision pain and purulent drainage. Blood cultures demonstrated 3/4 bottles positive for Methicillin Sensitive Staph Aureus. Symptoms worsen with deep inspiration. The patient was febrile and found to have WBC 19,000.m She was transferred to [Hospital1 18] for evaluation. Past Medical History: Mitral regurgitation Psoriasis Psoriatic arthritis Endometriosis Obesity Social History: Lives with spouse ETOH rare Tobacco 20 year pack history - currently smoking Not currently working Family History: Mother deceased at 62 from cardiomyopathy Physical Exam: Gen: NAD Neuro: alert and oriented, non-focal Pulm: lungs CTAB Cardiac: RRR, frequent PVCs Sternal Incision: no erythema. Wound clean. 2 JPs remain in place. Abd: soft, non-tender, non-distended. Ext: warm, 1+edema Pertinent Results: [2168-10-25] 05:23AM BLOOD WBC-8.4 RBC-3.22* Hgb-9.6* Hct-29.6* MCV-92 MCH-30.0 MCHC-32.5 RDW-16.6* Plt Ct-280 [2168-10-25] 05:23AM BLOOD Glucose-114* UreaN-18 Creat-0.8 Na-138 K-3.9 Cl-106 HCO3-24 AnGap-12 [2168-10-23] 04:47AM BLOOD ALT-10 AST-18 LD(LDH)-216 AlkPhos-83 Amylase-36 TotBili-0.2 [2168-10-23] 04:47AM BLOOD Lipase-79* [Known lastname ],[Known firstname 8031] M [Medical Record Number 79500] F 43 [2124-11-30] Date: [2168-10-26] Signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD on [2168-10-26] Affiliation: [Hospital1 18] NEEDS COSIGN Initial Intake Infectious Disease Clinic Outpatient Antimicrobial Management Program Surgeon: [Last Name (LF) ],[Name8 (MD) 177] MD Infectious Disease Fellow: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 111], MD Infectious Disease Preceptor: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 724], MD Infusion Company: [Location (un) 511] Home Therapies Phone: 1.[Telephone/Fax (1) ] Fax: [Telephone/Fax (1) 79503] VNA: Home Health and Hospice of [Location (un) ], NH Phone: [Telephone/Fax (1) 79504] Type of Intravenous Access Where placed: RUE [10-23] PICC ( X ) Length ( 52cm ) Discharge diagnosis: MSSA sternal wound infection Brief Summary of Patient History: Ms [Known lastname ] is a 43-year old woman with a history of uncomplicated MVR (bioprosthetic) and closure of PFO in [2168-9-19] presenting to [Hospital 5279] Hospital on [10-14] and transferred to [Hospital1 18] on [10-17] with sternal wound pain and drainage. She presented to [Hospital 5279] Hospital on [10-14] with a progressive, 2-day history chest wall pain associated with nausea, shortness of breath, and worsened with movement. In the ER at [Doctor First Name 5279], she had a temperature of 100.4, BP 80s/40s, WBC 19K (87% PMN). A TTE demonstrated LVEF 35%, small posterior pericardial effusion, well-seated MV prosthesis. Blood cultures demonstrated ([3-15]) demonstrated MSSA, a CT of chest w/ and without contrast demonstrated a "tiny" fluid collection at the midline incision site. Wound cultures demonstrated WBC w/o organisms, although at time of transfer culture was pending. Empiric antibiotics with vancomycin and ceftazidime ([10-14]) were continued. During the admission, she remained afebrile, hemodynamically stable, and was transferred for further evaluation. She was taken to OR [10-18] for debridement and returned [10-20] for sternal plating. Blood cultures at [Hospital1 18] [Date range (1) 60609] remain negative at time of discharge. Although a swab culture from the wound on [10-17] was negative, all 4 intra-operative swab and tissue cultures from [10-18] demonstrated MSSA; no swab was taken on [10-20] (some necrotic tissue was debrided). A TEE was negative for endocarditis. For the remainder of the admission, she remained afebrile and generally improved. Two anterior chest drains remained intact and in place at the time of discharge (to be removed approx 1 week post-discharge). She had [1-14] loose stools daily for several days toward the end of the admission, briefly started empirically on metronidazole, but was C. diff toxin negative x1. She was continued on Nafcillin starting [10-18], and should be continued for 6 weeks minimum starting [10-20]. In clinic follow-up, duration of antibiotics will be determined, including possible long-term suppression with ciprofloxacin and rifampin, as well as a further discussion with surgery re: plate removal if indicated. PAST MEDICAL HISTORY: ++ Cardiomyopathy with mitral regurgitation ++ Mitral valve replacement, bioprosthetic, [2168-9-19] ++ patent foramen ovale closure, [2168-9-19] ++ Hypertension ++ Hypercholesterolemia ++ Psoriatic arthritis ++ Endometriosis - R Salpingo-oophorectomy ++ Obesity ++ Depression ++ Panic disorder ++ Narcolepsy [Hospital 5279] Hosp (micro [Telephone/Fax (1) 79505]): Wound culture ([10-16]): light presumptive Staph Blood culture ([10-15]) x2: NGTD Blood culture ([10-14]): 2/2 bottles MSSA (pan-[Last Name (un) 36]) Urine culture ([10-14]): NEG Nares culture, MRSA screen ([10-14]): NEG [Hospital1 18]: Sternal wound swab [10-17]: negative (stain w/o PMN/orgs) Intra-op ([10-18]) Sternal wound swab x2: MSSA Sternal wound tissue x2: MSSA BCx [10-17] x2, [10-20], [10-21] x2: NEG/NGTD UCx [10-17], [10-21] NGTD Cath tip Cx [10-17] NGTD Cdiff toxin [10-18], [10-23], [10-25]: NEG TEE [10-18] LVEF 35-40% no veg MV well-seated LABORATORY REVIEW DATE WBC ESR CRP Cr ALT/AST/tbili [10-14] 19 1.8 [10-15] 121 [10-16] 12 37.4 1.2 [10-17] 8.4 125 >300 1.0 14/17/0.5 [10-18] 7.8 1.1 11/15/0.3 [10-19] 6.2 0.8 [10-20] 9.5 0.8 [10-21] 11.4 0.9 [10-23] 10/18/0.2 [10-24] 6.9 0.9 Patient Allergies: NKDA Prescribed Antibiotic Information: Nafcillin 2g IV q4hr x6 weeks minimum, starting [2168-10-20] laboratory monitoring required CBC/diff, Chem 12, ESR/CRP qweek All laboratory results should be faxed to Infectious disease R.Ns. at ([Telephone/Fax (1) 6313] All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([Telephone/Fax (1) 14199] FOLLOW-UP: [2168-11-18] 10:00a ID,[Location (un) ] [Location (un) ] LM [Hospital Ward Name ] BLDG ([Doctor First Name ]), BASEMENT ID WEST (SB) Brief Hospital Course: The patient was admitted for further management of her sternal wound infection. On [2168-10-18] she was brought to the operating room where she underwent sternal debridement and wound VAC placement with the assistance of the plastic surgery team. The patient returned to the operating room on [10-20] for chest closure with pectoralis muscle flaps and plating. Please see operative notes for details. Overall the patient tolerated the procedures well and post-operatively was transferred to the CVICU for observation and recovery. By POD 1 (from chest closure) she was hemodynamically stable, extubated, alert and oriented and breathing comfortably. ID was consulted for assistance in antibiotic administration. Nafcillin therapy was initiated per ID recommendations. The patient was transferred to the step down unit on [2168-10-22]. She developed diarrhea and was started on Flagyl empirically. Two c-diff toxins were negative. Imodium therapy was initiated. A third c-diff toxin was sent. Her stool frequency decreased to twice a day and began to firm. Only 2 doses of Imodium were taken and Flagyl was stopped. The patient remained in sinus rhythm,however, she continued to have frequent PVCs with non-sustained ventricular tachycardia. Electrolytes were repleted and beta-blocker titrated accordingly. Her ectopy improved dramatically with these treatments. Two JPs remain in place and she is afebrile. ID and Plastic Surgery continued to follow her and she was ready for discharge on [10-26]. Arrangements were made for home infusion therapy for Nafcillin and lab draws and follow-up with both infectious disease and plastic surgery. Medications, instructions and restrictions were discussed with the patient before discharge. . Medications on Admission: aspirin 81 mg daily klonopin 1mg [Hospital1 ] folic acid 1mg daily lasix 10mg tid lopressor 25mg q8h remeron 15mg daily ativan 0.5mg q6h prn anxiety duoneb inh q4h prn lovenox 40mg sq zofran 4mg q6h prn protonix 40mg daily vancomycin 1gIVdaily ceftazidime 2g q12h dilaudid 0.5-1mg IV q1h prn morphine 2mg IV prn Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 4 weeks. Disp:56 Tablet(s)* Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a day). Disp:1 15gm Refills:0 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). Disp:30 Tab Sust.Rel. Particle/Crystal(s) Refills:2 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO every four (4) hours as needed for loose stool for 2 weeks: after loose stool. No more than 6 a day. Disp:30 Capsule(s) Refills:0 13. Ibuprofen 200 mg Tablet Sig: Four (4) Tablet PO three times a day for 3 weeks: take with food. Disp:252 Tablet(s) Refills:0 14. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. Disp:60 Tablet(s) Refills:2 15. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. Disp:90 Tablet(s) Refills:2 16. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams Intravenous Q4H (every 4 hours) for 6 weeks: as direscted. Disp:504 grams Refills:0 17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush for 6 weeks. Disp:QS ML(s) Refills:2 18. Heparin Flush (10 units/ml) 1 mL IV PRN line flush Temporary Central Access-Floor: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN. 19. saline flush Sig: 1-2 mg Intravenous every 4-6 hours for 6 weeks. Disp:50 Refills:2 20. Compazine 10 mg Tablet Sig: One (1) Tablet PO every [4-17] hours as needed for nausea for 2 weeks. Disp:50 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: homehealth vna of [Location (un) ] Discharge Diagnosis: sternal wound infection s/p sternal debridement s/p closure with bilat pectoral flaps and sternal plates s/p MVR(tissue) & closure of PFOPsoriasis arthritis endometriosis obesity Discharge Condition: good Discharge Instructions: Take all medications as prescribed. Call for any fever greater than 100.5 report any redness or drainage from wounds no lifting more than 10 pounds for 10 weeks no driving until cleared by plastic surgery Followup Instructions: ) Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2168-11-18] 10:00 Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ](plastic surgery) next week Dr [Last Name (STitle) 914] in 4 weeks from original surgery ([Telephone/Fax (1) 170]) Completed by:[2168-10-26]	[ "496", "4240", "4019", "3051", "2724", "311", "32723" ]
Admission Date: [2168-2-2] Discharge Date: [2168-2-4] Service: MEDICINE Allergies: Penicillins / Erythromycin Base Attending:[First Name3 (LF) 99] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Arterial line History of Present Illness: [Age over 90 ]F with COPD, CAD, CHF sent in from [Hospital ] rehab, russian speaking only. History from daughter and [Hospital 100] rehab notes. Per the daughter she was called by [Hospital 100] rehab with concerns about her mother. [Name (NI) ] mother's urine output had decreased she had a new oxygen requirement, low blood pressures and poor oral intake. The note from [Hospital 100] rehab is confusing as to what exactly was going on in terms of blood pressure however it does state that her lisinopril was stopped and she was started on IVF. A CXR was checked which revealed a new right sided pleural effusion. Labs at [Hospital 100] rehab were notable for a potassium of 6 without peaked T-waves, an increase in her creatinine from 2.2 on [1-27] to 4.0 on [2-2] with an associated drop in her bicarb to 18. She received a kayexalate enema for her hyperkalemia. . She was also started on imipenem for a presumed ESBL UTI. The patients daughter initially wanted to keep her out of the hospital, however she asked the patient . In the ED, initial vs were 96.6 58 97/67 16 94% 4L. She received vancomycin, levaquin and flagyl for initial presumption of sepsis NOS. She received 2L of NS with no improvement in her lactate. She was intermittently hypotensive to the 80's and responded to a second 2L of NS. An EKG revealed AFIB without significant changes. She had a non-contrast adbdominal CT to look for a source of infection which was unrevealing. CXR revealed the aformentioned new right pleural effusion. Of note her UE BPs were unreliable in the ED, and the ED resident attempted to check them via doppler, he was unable to find them and bedside ultrasound revealed no radial pulses despite warm well perfused hands. Several attempts were made at placing a right femoral a-line which failed and finally a left femoral a-line was placed. Two 18 gauge peripherals were placed as the patients daughter was refusing central line. Peripheral levophed was started prior to leaving the ED. . On the floor, she remained unresponsive to a 250cc NS bolus with MAPs in the low 60's. . Past Medical History: Recurrent ESBL UTIs Dementia with hallucinations, delerium with delusions Hypertension Chronic renal insufficiency Osteoarthritis Back Pain Clavicle Fracture Peripheral Artery Disease History of an aneurysmal neck vein A. Fib Social History: Lives at [Hospital 100] Rehab, HCP is daughter [Name (NI) 2951]. Family History: Non-contributory Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: On admission: [2168-2-2] 06:00PM BLOOD WBC-16.8# RBC-4.25# Hgb-13.6# Hct-42.3# MCV-99 MCH-32.0 MCHC-32.2 RDW-18.0* Plt Ct-97# [2168-2-2] 09:05PM BLOOD PT-17.5 PTT-38.3* INR(PT)-1.6* [2168-2-2] 06:00PM BLOOD Glucose-116* UreaN-87* Creat-4.0# Na-139 K-5.8 Cl-103 HCO3-20* AnGap-22* [2168-2-2] 06:00PM BLOOD ALT-15 AST-48* CK(CPK)-98 AlkPhos-94 [2168-2-2] 06:00PM BLOOD CK-MB-8 cTropnT-0.12* [2168-2-3] 02:42AM BLOOD Calcium-8.1* Phos-6.0# Mg-2.2 [2168-2-2] 11:05PM BLOOD Type-ART Temp-37.3 FiO2-92 O2 Flow-15 pO2-204 pCO2-38 pH-7.22* calTCO2-16* Base XS--11 AADO2-431 REQ O2-73 Intubat-NOT INTUBA Vent-SPONTANEOU [2168-2-2] 06:22PM BLOOD Lactate-3.3* . IMPRESSION: 1. Partially imaged moderate right and small left pleural effusions with overlying atelectasis. Cardiomegaly, in conjunction with diffuse subcutaneous edema and mesenteric haziness suggests volume overload. Small amount of perihepatic fluid. Presacral edema. 2. 2 to 3 small fluid density rounded structures along the inferior medial border of the right lobe of the liver, of unclear etiology. Recommend clinical correlation with history of malignancy, superinfection cannot be excluded. 3. Extensive colonic diverticulosis, without evidence of acute diverticulitis. 4. Cholelithiasis. . [2-2] CXR: IMPRESSION: 1. Interval development of moderate-to-large right pleural effusion with overlying atelectasis, underlying consolidation cannot be excluded. 2. Persistent cardiomegaly. No overt pulmonary edema. Brief Hospital Course: In brief, this is a [Age over 90 ] year old female who was transferred from [Hospital 100] Rehab to the MICU at [Hospital1 18] for further evaluation of hypotension, hypoxia, and acute on chronic kidney injury secondary to urosepsis. She was admitted to the MICU and despite pressor support, fluid resuscitation, and appropriate antibiotics, it soon became clear that the patient's clinical status would not recover as evidenced by increasing lactate and worsening acidemia. The patient's daughter, [Name (NI) 2951], was informed of the patient's worsening clinical status and given her poor prognosis, it was decided to change her code status from DNR/DNI to CMO. The patient passed away shortly after institution of a morphine drip and withdrawal of pressors. The patient's daughter, [Name (NI) 2951], was present at bedside and refused autopsy. Time of death was 4:45AM. The following summarizes her hospital course: . #. Urosepsis: The patient presented with a floridly positive U/A in the setting of gross pyuria, hypotension, hypothermia, leukocytosis, and increased respiratory rate all c/w infectious etiology. UTI with sepsis is the most likely source. Lactate was initially 3.3 and the patient was fluid resuscitated. Blood and urine cultures were drawn and pending at time of death. CT scan was unremarkable. She was started on pressors. Meropenem/Vancomycin were started out of concern for ESBL UTI given history of same. Levophed was changed to phenylephrine out of concern for tachycardia. CVP was 20 in setting of 4+ TR. On HD #2, lactate began trending up and phenylephrine was again changed to Levophed in addition to vasopressin. She was administered additional fluid boluses, but her lactate trended up to 7.5 and she was acidemic with a pH of 7.05. Her daughter, [Name (NI) 2951], was informed of her worsening clinical prognosis and it was decided to change to patient's code status to CMO. . #. Acute on Chronic Renal Faillure: Cr was initially 4, up from baseline of 1. Thought to be [3-10] ischemic ATN in the setting of septic shock. On HD #2, Cr improved to 3.5 with IVFs. . #. Lactic acidosis: 3.3 on transfer to ICU. Likely [3-10] to septic shock. Initially, lactate improved with IVF but on HD#2 it began rising and peaked at 7.5. Pressors were administered as described above. Medications on Admission: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO HS (at bedtime). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day: Do not take if your systolic blood pressure is less than 105. 6. Ipratropium Bromide 0.03 % Spray, Non-Aerosol Sig: Two (2) sprays Nasal twice a day: in each nostril. 7. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day. 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation twice a day as needed for SOB. 9. Glyburide 5 mg Tablet Sig: 0.5 Tablet PO twice a day. 10. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 12. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Fluocinonide 0.05 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). Disp:qs Refills:2 Discharge Medications: Patient expired Discharge Disposition: Expired Discharge Diagnosis: Patient expired Discharge Condition: Patient expired Discharge Instructions: Patient expired Followup Instructions: Patient expired	[ "0389", "51881", "78552", "5845", "99592", "40390", "5859", "496", "2875", "25000" ]
Admission Date: [2152-6-28] Discharge Date: [2152-7-7] Date of Birth: [2152-6-28] Sex: M Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: [Known lastname 2795] [Known lastname 42741] was born at 35 and 2/7 weeks gestation to a 32 year-old gravida 3 para 1 now 2 woman. Her prenatal screens are blood type A positive, antibody negative, Rubella immune, RPR nonreactive, hepatitis surface antigen negative and group B strep unknown. This twenty years and elevated blood pressures during the pregnancy prompting a repeat cesarean section. The infant emerged vigorous. Apgars were 8 at one minute and 9 at minutes. There was rupture of membranes at the time of delivery. No intrapartum fever and no other sepsis risk factors. The infant's birth weight was 1175 grams, birth ADMISSION PHYSICAL EXAMINATION: Premature nondysmorphic infant large for gestational age. His anterior fontanel open and flat. Positive bilateral red reflex. Intact palette. Positive sternal and intercostal retractions, grunting and retracting, minimal air entry, grade [2-2] low pitch systolic murmur at the left sternal border, femoral pulses +2, three vessel umbilical cord, no hepatosplenomegaly. Testes descended bilaterally. Patent anus. Normal sacrum. Stable hip examination and symmetric tone and reflexes. HOSPITAL COURSE: 1. Respiratory status: The infant was intubated for respiratory distress soon after admission to the Neonatal Intensive Care Unit. He received one dose of Surfactant and extubated to room air on day of life number one where he has remained. He had one episode of apnea, bradycardia, and desaturation on day of life number four. He was monitored for five days subsequent to this without further episodes. 2. Cardiovascular status: He required a normal saline bolus for blood pressure support on admission. The initial murmur resolved. He has had a grade [1-2] soft intermittent murmur without any hemodynamic consequences. He has remained normotensive since day of life number one. 3. Fluid, electrolyte and nutrition status: Enteral feeds were begun on day of life number one and advanced without difficulty to full volume feedings. At the time of discharge he is taking Enfamil 20 calories per ounce or breast milk on an ad lib schedule. At the time of discharge his weight is 2105 grams. His length is 47.5 cm and his head circumference is 32 cm. The infant initially had some hypoglycemia requiring boluses of IV dextrose, but with adequate volume intake of formula, that has resolved. 4. Gastrointestinal status: He was treated with phototherapy for hyperbilirubinemia of prematurity from day of two until day of life three. His peak bilirubin on day of life two was total 9.4, direct 0.3. 5. Hematological status: His hematocrit at admission was 42.3. He has received no blood transfusions. 6. Infectious disease status: [Known lastname 2795] was started on ampicillin and gentamicin at the time of admission for sepsis risk factors. The antibiotics were discontinued after 48 hours and the blood cultures were negative and the infant was clinically well. 7. Sensory status: Hearing screen was performed with automated auditory brain stem responses, and the infant passed in both ears. 8. Psycho/social: The parents have been very active in the infant's care throughout his Neonatal Intensive Care Unit stay. CONDITION ON DISCHARGE: Good. DISPOSITION: The infant is being discharged home with his parents. PEDIATRIC PROVIDER: [Name10 (NameIs) ] pediatric care will be provided by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 38807]. Telephone number [Telephone/Fax (1) 37949]. SCREENING: He passed a car seat position screening test on [2152-7-7]. State newborn screen was sent on [2152-7-1]. IMMUNIZATIONS: The infant received his first hepatitis C vaccine on [2152-7-2]. FOLLOW UP: 1. Primary pediatric care provider. 2. [Hospital6 407] of Greater [Location (un) 5871]. Telephone number 1-[Telephone/Fax (1) 42742]. DISCHARGE DIAGNOSES: 1. Prematurity 35 and 2/7 weeks. 2. Status post hyaline membrane disease. 3. Sepsis ruled out. 4. Status post apnea of prematurity. 5. Infant of diabetic mother- status post hypoglycemia. 6. Status post hyperbilirubinemia. [First Name11 (Name Pattern1) 37693] [Last Name (NamePattern4) 37927], M.D. [MD Number(1) 37928] Dictated By:[Last Name (NamePattern1) 36864] MEDQUIST36 D: [2152-7-7] 06:41 T: [2152-7-7] 06:52 JOB#: [Job Number 42743]	[ "V290", "V053" ]
Admission Date: [2153-6-11] Discharge Date: [2153-6-12] Date of Birth: [2094-12-22] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 1436] Chief Complaint: elective cardiac cath Major Surgical or Invasive Procedure: left and right heart cath History of Present Illness: 58 y/o male with hx borderline hyperlipidemia, remote smoking, who presents for scheduled PCI after postitive stress test. Taken to cath lab and found to have 90% p-LAD, 80% m-LAD involving D1 takeoff. Normal filling pressures. LVgram 63%. Pt had 2 overlapping stents with transient jail of D1. Pt developed hypotension in the cath lab requiring dop gtt to 18, now in the CCU for weaning of dopamine. Etiology of hypotension presumably [3-14] medication affect. Past Medical History: hyperlipidemia htn Social History: remote smoking Family History: non-contrib Physical Exam: AF 120's/70's 70's 15 Gen: NAD, A&O X 3 Heent: Diffuse rash over face and trunk (chronic) Neck: No JVD Heart: RRR no mrg Lungs: CTAB Abd: Soft, nt/nd. NABS Ext: No c/c/e Pertinent Results: [2153-6-12] 04:15AM BLOOD WBC-9.1 RBC-4.34* Hgb-12.9* Hct-36.6* MCV-84 MCH-29.6 MCHC-35.2* RDW-13.1 Plt Ct-204 [2153-6-11] 12:44PM BLOOD Neuts-83.2* Bands-0 Lymphs-11.5* Monos-3.1 Eos-1.8 Baso-0.4 [2153-6-11] 12:44PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [2153-6-12] 04:15AM BLOOD PT-12.0 PTT-26.6 INR(PT)-0.9 [2153-6-12] 04:15AM BLOOD Glucose-87 UreaN-23* Creat-1.0 Na-140 K-4.0 Cl-106 HCO3-29 AnGap-9 [2153-6-12] 04:15AM BLOOD CK(CPK)-91 [2153-6-12] 04:15AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1 Prox and mid LAD stented (90% and 80% resp). Brief Hospital Course: 1. Hypotension: Liklely [3-14] drug effect in setting of hypovolemia (low PCWP). Preserved CO and normal SVR, so unlikely cardiogenic or distributive shockDop easily weaned. Restarted BB. 2. CAD: S/P overlapping LAD stents to 90% and 80% prox and mid LAD lesions. Cont asa/plavix/statin. Hold ACE for now. Outpt stress in future. 3. Pump: Preserved EF and CO. Normal valves. Hypo-euvolemic. 3. Rhythm: Cont tele. 4. Rash: Pt has hx skin cancer. He has been seeing dermatology who has prescribed him topical lotions with to help heal the sun-damaged areas. This is a chronic problem. 5. Polyuria: Pt has a long history of polyuria. He has been followed by urology and this problem is being worked on as an outpt. He is c/o severe pain [3-14] catheter insertion, which he has been started on pyridium for. Medications on Admission: lipitor asa atenolol plavix Discharge Medications: 1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual Q5MIN () as needed for chest pain. Disp:30 Tablet, Sublingual(s) Refills:3 4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Elective heart cath Discharge Condition: good Discharge Instructions: If you have these symptoms, call your doctor: - fevers/chills - chest pain - shortness of breath - dizziness - visual changes Followup Instructions: f/u with your PCP [Last Name (NamePattern4) ] 2 weeks Completed by:[2153-6-12]	[ "41401", "4019", "2724" ]
Admission Date: [2153-2-6] Discharge Date: [2153-3-19] Date of Birth: [2094-3-1] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: 1. Pseudoaneurysm of ascending aorta and arch 2. 2+ Aortic insufficiency 3. Respiratory failure Major Surgical or Invasive Procedure: [2153-2-7] 1. Ascending aorta hemiarch replacement with 26mm Gelweave graft 2. Aortic valve repair with 21mm pericardial tissue valve [2153-2-19] 1. Tracheostomy History of Present Illness: 58 year-old woman with hypertension, former tobacco use, and Type B aortic dissection [9-13] with surgical repair. At that time an ascending aortic hematoma was also noted. After several missed appointments, she now presents with chest pain and shortness of breath and a blood pressure of 200/100. She was found to have an enlarging ascending aortic pseudoaneurysm on CTA. Past Medical History: s/p type B aortic dissection repair [9-13] Poorly controlled hypertension Asthma Obesity COPD s/p L frontal and R parietal lobe CVA a fib s/p retraoperitoneal hematoma s/p repiratory failure with trach [10-14] Social History: Smoked 15 pk years until aortic dissection. No Etoh, No Drugs. Family History: Negative for aortic dissection; negative for CAD. Physical Exam: VS: P 60, BP 96/60 R-20 100% PS 0.4 GEN: [Last Name (LF) 3584], [First Name3 (LF) 2995] HEENT: PERRLA EOMI Neck: No Carotid Bruits Heart: Distant, RRR w/o M Chest: Bilateral Rhonchi, wheezes l>r ABD: SNTND, no rebound Vasc: Radial Femoral DP PT R A-Line 2+ 2+ 2+ L 2+ 2+ 2+ 1+ Pertinent Results: [2153-2-23] 04:17AM BLOOD WBC-10.4 RBC-3.22* Hgb-9.8* Hct-28.2* MCV-88 MCH-30.4 MCHC-34.7 RDW-14.8 Plt Ct-185 [2153-2-23] 04:17AM BLOOD Plt Ct-185 [2153-2-23] 04:17AM BLOOD Glucose-94 UreaN-21* Creat-0.4 Na-142 K-4.0 Cl-106 HCO3-30* AnGap-10 [2153-2-23] 04:17AM BLOOD Mg-2.0 Cardiac catheter [2154-2-6] FINAL DIAGNOSIS: 1. Coronary arteries are normal. 2. Moderate aortic regurgitation. 3. Mild systolic ventricular dysfunction. 4. Mild diastolic ventricular dysfunction. 5. Large aneurysmal dilation of the ascending aorta. Brief Hospital Course: After admission, Mrs. [Known lastname 58041] underwent a cardiac catheter. Supravalvular aortography revealed a large aneurysmal (>7cm) dilation arising from 2-3 cm above the aortic valve and encroaching on the true lumen of the aorta. 2+ aortic regurgitation was noted. On [2-7], she was taken to the operating room for ascending aortic and hemiarch relacement as well as aortic valve replacement with a tissue valve. Postoperatively, she was admitted to the cardiac ICU. Her postoperative course was complicated (again) by repiratory failure. She weaned slowly off the vent but failed extubation after successfully passing several breathing trials. She had to be reintubated and underwent an open trachestomy by the thoracic surgery team on [2153-2-19]. Her blood pressure was controlled on a nipride drip initially. Later she could be controlled below 110 systolically on oral Antihypertensives. She was fed via a Dobhoff tube and tube feedings. During the days she tolerated several hours on trach mask in the chair but spend the night on the ventilator on minimal settings. She was diuresed appropriately until she reached preoperative weights. She was ultimately weanod off the ventilator, and placed on trach collar. On [2-23], she was started on IV Vancomycin for MRSA on a central line, and 1 positive blood culture. She should complete a 6 week course. Her trough levels have been approx. 17 (goal trough per ID service is 15-20), on 1250 mg IV BID. She has passed swallow studies, oral feedings have been advanced, and her feeding tube was removed, as she is now eating a regular diet without difficulty. Her trach was downsized from a 6 to a 4, then subsequently removed (on [2153-3-16]). At discharge, she was in a good condition. Her wound was without signs of wound infection. Of note, during her hospitalization, she had a possible exposure to a TB+ person. Since she had a previous +PPD, we can not use this as a screening test to monitor sero-conversion. Ms. [Known lastname 58041] therefore must be monitored for the next year for symptoms of tuberculosis and worked up if these symptoms are found. Medications on Admission: Albuterol Lopressor 50mg po bid Amiodarone 200mg po qd Norvasc 10mg qd Lasix 40mg [Hospital1 ] Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 2. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 3. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 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. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 6. Vancomycin HCl 10 g Recon Soln Sig: 1250 mg Intravenous twice a day for until [4-6] doses. Disp:17 doses Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 672] Hospital Discharge Diagnosis: 1. Pseudoaneurysm of ascending aorta and arch 2. 2+ Aortic insufficiency 3. Respiratory failure Discharge Condition: Good Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 3 months. You should shower, let water flow over wounds, pat dry with a towel. Followup Instructions: Of note, during her hospitalization, she had a possible exposure to a TB+ person. Since she had a previous +PPD, we can not use this as a screening test to monitor sero-conversion. Ms. [Known lastname 58041] therefore must be monitored for the next year for symptoms of tuberculosis and worked up if these symptoms are found. Make an appointment with Dr. [Last Name (STitle) 1290] for 4 weeks. [Telephone/Fax (1) ] Follow-up with PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 1300] in [2-11] weeks Completed by:[2153-3-19]	[ "51881", "4241", "42731", "2875", "4019" ]
Admission Date: [2178-10-1] Discharge Date: [2178-10-12] Date of Birth: [2126-10-22] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 338] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Mechanical ventilation PICC line placement Left Femoral Central line, placed and removed Right Arterial line History of Present Illness: Mr. [Known lastname ] is a 51 year-old man with a history of chronic hypercapneic respiratory failure s/p trach, COPD, and morbid obesity who presented from [Hospital 100] Rehab with hypotension and is admitted to the MICU for further management. He was trached on [2178-8-13] and last discharged on [2178-9-18] for hypercapneic respiratory failure which was thought to be secondary to a cuff leak, though he was also treated for resistant psuedomonas VAP during this admission. He went to [Hospital 100] rehab and completed a course of tobramycin (last dose ?[2178-9-19]). He also had blood cx that grew coag negative staph and was started on vanc on [9-27]. He had a leukocytosis, with a WBC count of 16 that trended down to 6 on the day of admission. A urine cx grew ESBL klebsiella on [9-30] but he was not started on antibiotics for this for unclear reasons. During this time, his metoprolol was also increased from 12.5 mg po tid to 25 mg po tid on [9-27] for improved a. fib heart rate control. On the day of admission, he was found to have a BP of 85/65 -> 60/palp from a baseline in the low 100s systolic after debridement of a right flank wound. He was thought to be bacteremic and given approximately 1L IVF bolus with no response. He was then transferred to [Hospital1 18] for further management. On arrival, VS were 97.8 84 80/47 24 100% on unknown vent settings. He was thought to be septic vs having beta blocker toxicity (last metoprolol given at 2 p.m.) and was given zosyn, 1.5 L IVF, and glucagon, with improvement in SBP to 120 transiently after the glucagon. Toxicology was consulted and felt that beta blocker toxicity was unlikely given absence of bradycardia. A right radial a-line and left femoral line were placed for access. A CXR was performed and demonstrated infiltrate vs overload. IVFs were held after the CXR, and he was started on levophed. Per report, a bedside ECHO was also performed to eval for tamponade but was limited secondary to body habitus. On the floor, he was minimally responsive to verbal stimuli and began having rhythmic, tooth clattering motions at the chin. He was given 1 mg IV ativan x 2 with resolution. Past Medical History: COPD on oxygen Obstructive Sleep Apnea and obesity hypoventilation Anxiety on klonopin Morbid Obesity Chronic LLE DVT ARF [3-9] AIN, recent baseline Cr low-mid 2's Pseudomonas VAP [First Name5 (NamePattern1) 564] [Last Name (NamePattern1) 104697] UTI treated with fluc Sacral decubitus ulcer right flank Chronic pain of unclear etiology-trach site ulceration Constipation AF Anemia Social History: Was living at home with mother but was recently discharged to [Hospital 100] rehab. He denies any history of tobacco, etoh, or drug use. He was using a motorized chair for most of his mobility. Family History: Noncontributory Physical Exam: Vitals: 97.8 84 80/47 24 100% FIO2 50% General: morbidly obese, trached and vented, responds to verbal stimuli, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, gazing to the left Neck: supple, JVP unable to assess, no LAD Lungs: bilateral rhonchi, no rales or wheezes CV: distant heart sounds, regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, distended, bowel sounds present, no organomegaly GU: purulent discharge around foley. Ext: warm, well perfused, 2+ pulses, 1+ LE edema, erythematous patches scattered across chest, arms, and legs. Pertinent Results: Admission Notes; [2178-10-1] 05:59PM HGB-9.7* calcHCT-29 O2 SAT-89 CARBOXYHB-1 MET HGB-0.1 [2178-10-1] 05:59PM GLUCOSE-104 LACTATE-1.0 NA+-140 K+-5.1 CL--99* [2178-10-1] 05:59PM TYPE-ART RATES-/30 TIDAL VOL-500 O2-50 PO2-50* PCO2-81* PH-7.27* TOTAL CO2-39* BASE XS-6 -ASSIST/CON INTUBATED-INTUBATED [2178-10-1] 06:10PM URINE RBC-0-2 WBC-[4-9] BACTERIA-MOD YEAST-NONE EPI-0-2 [2178-10-1] 06:10PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [2178-10-1] 06:10PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.008 [2178-10-1] 06:10PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [2178-10-1] 06:10PM URINE HOURS-RANDOM [2178-10-1] 06:40PM FIBRINOGE-593* [2178-10-1] 06:40PM PLT SMR-NORMAL PLT COUNT-229 [2178-10-1] 06:40PM PT-13.7* PTT-35.1* INR(PT)-1.2* [2178-10-1] 06:40PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL STIPPLED-OCCASIONAL [2178-10-1] 06:40PM NEUTS-69 BANDS-2 LYMPHS-10* MONOS-10 EOS-0 BASOS-0 ATYPS-0 METAS-4* MYELOS-5* NUC RBCS-2* [2178-10-1] 06:40PM WBC-10.5 RBC-3.25* HGB-8.4* HCT-29.7* MCV-91 MCH-26.0* MCHC-28.5* RDW-19.0* [2178-10-1] 06:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2178-10-1] 06:40PM proBNP-[Numeric Identifier 21797]* [2178-10-1] 06:40PM LIPASE-17 [2178-10-7] LE Dopplers: FINDINGS: Grayscale, color and Doppler son[Name (NI) 1417] of bilateral common femoral, superficial femoral, popliteal and tibial veins were performed. Note is made that the study is limited by the patient's body habitus. There is normal low, compression, and augmentation seen in all of the vessels. IMPRESSION: No evidence of deep vein thrombosis in either leg. [2178-10-7] ECHO: The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. [2178-10-2] CT Head FINDINGS: There is no intracranial hemorrhage, edema, mass effect, or vascular territorial infarction. The ventricles and sulci are normal in size and in configuration. Included osseous structures are unremarkable, and the visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: No acute intracranial process. [2178-10-2] CT CHEST: Findings: There has seen no interval change in diffuse paraseptal and centrilobular emphysematous changes of the lungs which predominantly affect the apices. Diffuse fibrotic interstitial abnormality evidenced by bronchiectasis, bronchiolectasis, ground-glass opacities and honeycombing appears unchanged. There is new focus of consolidation within the left lower lobe. Elevated left hemidiaphragm is unchanged. No central pathologically enlarged nodes are visualized. No pleural or pericardial effusion is seen. The visualized part of the upper abdomen including adrenal glands, superior pole of the kidneys, liver, and spleen appear unremarkable. Gastrostomy tube is in place. Ultrasound LEs CONCLUSION: No evidence of deep vein thrombosis. KUB FINDINGS: A gastric tube is visualized. There is a paucity of gas is seen in the abdomen. Supine films only were obtained and therefore I cannot assess for any air-fluid levels. Micro- [2178-10-5] 10:28 am SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. FINAL REPORT [2178-10-12] GRAM STAIN (Final [2178-10-5]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [2178-10-12]): OROPHARYNGEAL FLORA ABSENT. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. PSEUDOMONAS AERUGINOSA. 3RD TYPE. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA \| PSEUDOMONAS AERUGINOSA \| \| CEFEPIME-------------- 16 I 16 I CEFTAZIDIME----------- 16 I 16 I CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ 2 S 2 S MEROPENEM------------- =>16 R =>16 R PIPERACILLIN---------- =>128 R =>128 R PIPERACILLIN/TAZO----- =>128 R =>128 R TOBRAMYCIN------------ <=1 S <=1 S Brief Hospital Course: Mr. [Known lastname ] is a 51 year-old man with a history of chronic hypercapnic respiratory failure s/p trach, COPD and Cor Pulmonale, and morbid obesity who presented from [Hospital 100] Rehab with hypotension and was admitted to the MICU for further management # Hypotension/Sepsis: Acute hypotension was likely related to sepsis given coag neg staph in blood cultures and ESBL klebsiella in urine culture, which was not yet treated at Rehab. Pneumonia was also thought to be a source of infection. There was some initial concern for beta blocker toxicity but this seemed unlikely considering that patient was stable regimen for three days and was not bradycardic on presentation. Chest CT showed extensive interstitial lung disease with end stage emphysema change. Pt was cultured and sputum showed growth first of proteus and later MDR pseudomonas. Also, pt had a large flank ulcer on the right side with drainage, with GNRs. Surgery evaluated wound, but pt did not appear to have any pockets of infection and was to unstable for more exploration. IVF were given initially. Later pressors were needed to sustain SBP>110. Echo showed worsening cor pulmonale. Pt was started on vanco and meropenum. Later change to [Female First Name (un) ] and vancomycin level was supratherapeutics after the third dose throughout his hospitalization. He required increasing amounts of vasopressors- Levophed, vasopressin, and then on day of expiation was also on Neo-Synephrine and tried briefly on dobutamine without improvement in BP. # Hypoxic/Hypercapnic respiratory failure: Multifactorial respiratory failure secondary to obstructive COPD and restrictive lung disease and obesity hypoventilation, s/p tracheostomy on [2178-8-13]. Also had worsening cor pulmonary from lund disease. As stated about was treated for sepsis including pneumonia. Became difficult to ventilate and PCO2 continued to rise despite increased ventilator settings. PCO2 rose to >100 and pt was paralyzed. Pt was continued on albuterol and ipratropium bronchodilators. Diuresis was attempted later in his course without significant improvement. Esophageal balloon was placed to optimized his PEEP. As stated above he was treated with tobramycin for his PNA. For his acidosis, as his pH fell below 7.2, he was treated with bicarb gtt and boluses. # Altered mental status: Was gazing to the right and had rhythmic movements of chin/teeth clattering concerning for seizure versus clattering from hypothermia vs electrolyte abnormality on admission. This appeared to respond to Ativan. Per [Hospital 100] rehab, usually responsive to name and does occasionally have right [Hospital1 ] gaze. Before paralysis pt was responsive to simple questions with nodding/shaking of the head. EEG was ordered to evaluate for seizure activity. # Rash with erythematous patches: concerning for urticaria though had received beta-lactams before without reaction. Improved with Benadryl. Did not reoccur # Chronic kidney injury: Cr of 1.3 was improved from creatinine at last discharge of 2 and has had elevated Cr during recent hospitalizations. Cr baseline was 0.6 in [2178-8-5]. History of AIN. Renally dosed his medications. # Atrial fibrillation: Was on metoprolol at rehab for rate control, not on warfarin secondary to history of RP bleed. Held his metoprolol due to hypotension. On the morning of [2178-10-12], pt became steadily more hypoxic with sats in the 70s despite maximizing vent settings. BP dropped lower and pt required 3 pressors. ABG showed increasing acidosis. Bicarb x 5 amps was given. Atropine and Epi were given as pt became more bradycardic and then asystolic. CPR was started and was not success in regaining a cardiac rhythm. Time of death was 11:47. Attending called the family as these events occurred, family arrived at bedside after pt had expired. No autopsy was requested. Medications on Admission: Vancomycin - renally dosed ([9-27]) Lactulose 30 mL NG Q8H:PRN bm Fentanyl Patch 100 mcg/hr TP Q72H Clonazepam 1 mg NG [Hospital1 ] Fluticasone Propionate 110mcg 1 PUFF IH [Hospital1 ] Lidocaine 5% Patch 1 PTCH TD DAILY 12 hrs on, 12 hrs off Magnesium Oxide 400 mg DAILY THROUGH GTUBE Omeprazole 40 mg NG DAILY Lorazepam 1 mg IV Q4H:PRN anxiety Polyethylene Glycol 17 g PO DAILY:PRN Albuterol Inhaler [3-11] PUFF IH Q4H:PRN dyspnea Ipratropium Bromide MDI [3-13] PUFF IH QID Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [Hospital1 ] Insulin SC (per Insulin Flowsheet) Sliding Scale Heparin 5000u sc tid Metoprolol tartrate 25 mg tid Hydromorphone 5 mg q6h prn per gtube Lorazepam 1 mg q2h IV prn Morphine 4 mg q4h SL prn Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[2178-10-12]	[ "5990", "2762", "2760", "99592", "42731", "32723", "5859" ]
Admission Date: [2137-11-24] Discharge Date: [2137-12-19] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3233] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: Thoracentesis Paracentesis History of Present Illness: 81yo man with h/o CLL c/b malignant pleural effusion, primary resected melanoma, type II diabetes mellitus, and Gout presented to [Hospital1 18] ED after mechanical fall and found to have subdural hematoma. . The patient reports he tripped and fell on his oxygen cord at home. He was started on supplemental oxygen after his last d/c from NEBH on [2137-11-22]. On initial presentation to ED T 98.8 HR 96 BP 99/43 RR 19 92% 2.5L. He was admitted to the MICU for further evaluation and treatment, and neurosurgery was consulted. Head CT showed multiple high density nodules concerning for metastatic disease. He was loaded with dilantin and monitored overnight without any detioration in neurologic status. Repeat head CT showed stable appearance of the SDH. Hematology/Oncology was consulted. He was transfused 6units platelets in the ED, and underwent leukopheresis in the MICU. Of note, patient was recently hospitalized [Date range (1) 25864]/05 on Oncology service for leukopheresis and chemo for his CLL after presenting with dyspnea and WBC 678K. . On presentation now his is oriented x3 and complains only of pain in his right shoulder. He denies headache, dizziness, confusion, vision changes, nausea. On ROS he denies fever, chills, sweats, palpitations, chest pain, SOB, abdominal pain, nausea, vomiting, diarrhea, constipation, bloody stools, dysuria, hematuria. He notes some skin changes in his arms c/w small bruises. Past Medical History: 1. T cell CLL/PLL; previously treated with pentostatin, cyclophosphamide, fludarabine, cytoxan. currently getting regular leukopharesis and Campath. c/b left malignant pleural effusion requiring thoracentesis 2. h/o left chest wall melanoma s/p resection, no nodal dissection 3. type II diabetes mellitus 4. Gout 5. Hypertension 6. H/o right knee arthritis 7. H/o small bowel obstruction Social History: married, lives with his wife retired construction worker, originally from [Country 2559] Tob: previously smoked 2ppd, quit 21yrs ago EtOH: avg 1/week illicits: none Family History: Mother died at 86 of [Name (NI) 2481] Father died at 52 of an accident Brother died at 67 of lung cancer Physical Exam: T 99.3 HR 90 BP 101/55 RR 20 95%5Lnc Gen: comfortable, alert, NAD HEENT: anicteric, PERRL, EOMI, OP with petechia posteriorly, MMM Neck: supple, no LAD, R SC pheresis catheter in place, JVP nondistended CV: RRR, II/VI SEM, PMI nondisplaced Resp: decreased BS B bases with mild crackles Abd: +BS, soft, NT, ND, liver palp 2cm below costal margin, spleen not palpable Ext: [1-2]+ pitting edema BLE, nontender Skin: petechiae arms, abdomen, legs Neuro: A&Ox3, answers questions appropriately and follows commands, CN II-XII intact, strength 5/5 biceps/triceps/grip/quads/dorsi&plantar flexion, sensation intact to fine touch BUE and BLE, coordination intact FTN, no plantar deviation. gait and romberg not assessed Pertinent Results: [11-24] Head CT: 1. High density nodules and multiple ill-defined hypodensities scattered throughout the brain, suggestive of a metastatic process. 2. Very small (approximately 1 mm) right extra-axial fluid collection, with associated mild edema of the right hemisphere, but without midline shift. An MRI of the brain is recommended for further evaluation of these findings. . [11-24] CXR: New moderate-sized right pleural effusion, with underlying collapse and/or consolidation. Atelectasis at left base. Prominent right hium -- . [11-25] Head CT: No interval change in the appearance of the brain. Stable tiny right subdural hemorrhage. Unchanged appearance of multiple high attenuation lesions scattered within the brain concerning for metastasis. . [12-1] CXR: There is a right-sided IJ central venous catheter, with the distal tip in the SVC, unchanged. There is again seen a large right-sided pleural effusion likely layering and a left-sided pleural effusion which is moderated sized. These are unchanged from previous. There is no evidence for overt pulmonary edema. There is a left retrocardiac opacity. This finding is unchanged. Underlying pneumonia would be difficult to exclude given the retrocardiac opacity and the large pleural effusions. . ECHO: [12-6]: Conclusions: There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. Trivial mitral regurgitation is seen. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. . CT Head [2137-12-5]: FINDINGS: There is a new moderate sized mixed density subdural fluid collection on the right. The lateral ventricle is completely compressed indicating mass effect from the subdural fluid collection as well as a 3 mm shift of the normally midline structures. The mixed intensity of the collection likely consists of blood and other fluid given the mixed densities. The previously identified high-density lesions are subsiding indicating that these were most likely hemorrhages rather than amyloid angiopathy. . CT Head [2137-12-6]: There is no change in the size or configuration of the right-sided subdural hemorrhage. Denser blood products are layering posteriorly. The hematoma extends under the right temporal lobe, which is slightly elevated and medially displaced. However, the basal cisternal spaces retain their normal configuration. There is mild shift of midline structures to the left, unchanged since the previous day's examination. Brain parenchymal attenuation is also stable. . CT Head [2137-12-9]: IMPRESSION: Stable right subdural hematoma with slight progression of mass effect and shift of midline structures. . CT Head: [2137-12-18]: IMPRESSION: Slightly improved right subdural hematoma and associated mass effect, with lessened contralateral shift of normally midline structures. . [2137-11-24] 08:17PM GLUCOSE-144* UREA N-56* CREAT-2.2* SODIUM-137 POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-27 ANION GAP-11 [2137-11-24] 08:17PM CALCIUM-7.9* PHOSPHATE-2.0* MAGNESIUM-2.1 [2137-11-24] 08:17PM WBC-665.6* HCT-22.5# [2137-11-24] 08:17PM PLT COUNT-51# [2137-11-24] 08:17PM PT-14.4* INR(PT)-1.4 [2137-11-24] 12:00PM GLUCOSE-171* UREA N-54* CREAT-2.2# SODIUM-136 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-27 ANION GAP-12 [2137-11-24] 12:00PM CK(CPK)-63 [2137-11-24] 12:00PM CK-MB-NotDone cTropnT-0.07 [2137-11-24] 12:00PM CALCIUM-8.1* PHOSPHATE-1.4* MAGNESIUM-2.2 [2137-11-24] 12:00PM WBC-846.7# HCT-35.0# [2137-11-24] 12:00PM NEUTS-0* BANDS-0 LYMPHS-19 MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 OTHER-81* [2137-11-24] 12:00PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL [2137-11-24] 12:00PM PLT SMR-RARE PLT COUNT-15# [2137-11-24] 12:00PM PT-13.9 PTT-21.2* INR(PT)-1.3 Brief Hospital Course: 81yo man with h/o CLL c/b malignant pleural effusion, primary resected melanoma, type II diabetes mellitus, and gout presented to [Hospital1 18] ED after mechanical fall and found to have subdural hematoma. During his hospitalization the following issues were addressed: . #. Subdural hematoma: Hemorrhage occurred in the setting of mechanical fall. He was seen by neurosurgery who recommended keeping SBP <140 and loading with Dilantin. He was admitted to the MICU for frequent neuro checks, and remained there for one day. On day two, his Dilantin level was subtherapeutic, and he was reloaded. On day three he developed neurologic changes of increased lethargy and dysarthria. Findings were consistent with Dilantin toxicity. His AM dose was held on day four, and symptoms resolved. He was continued on Dilantin 100mg po TID. His head CT showed multiple lesions concerning for mets disease. It was unclear whether these lesions could be due to his CLL/PLL or due to his remote history of nonmetastic resected melanoma. He had a brain MR that showed a single parietal lesion concerning for mets. The other lesions were read as consistent with amyloid angiopathy. Neuro-oncology was consulted, and did recommend LP for staging, and that patient may benefit from XRT. . A repeat head CT on [2137-12-5] showed new midline shift and rebleed (unclear of duration) without herniation. Hence, an LP was held. Neurosurgery was consulted and patient was not a surgical candidate because of his comorbidities and the size of the lesion. In addition, his thrombocytopenia introduced a substantial bleeding risk if any drains were placed in his head. On [2137-12-9], another head CT showed no interval changes in the midline shift, but worsening mass effect. Follow up CT on [12-18] showed stable midline shift. . Throughout the hospitalization, he was transfused platelet products for counts <50 to minimize worsening of his intracranial hemorrhage. . #. CLL: The patient is followed by oncology attending Dr. [Last Name (STitle) ] at NEBH; but has been admitted to the BMT service at [Hospital1 18] previously. He underwent leukopharesis three times prior to transfer to BMT for hyperleukocytosis. His last dose of Campath was at NEBH [2137-11-22]. He was transfused both PRBC and platelets without much increase. In the MICU, he was followed by the BMT fellow and BMT attending with the OMED resident/intern team following. He underwent leukophoresis several times here with reductions in his WBC to usually < 300K. . Because of his previously failed chemotherapy experiences, he was offered to be treated with the anti-CD52 antibody, Campath. While the family was advised about the significant risks (inlcuding worsening of his ascites and the mass effect in his brain) regarding the administration of this drug in the face of his multiple medical comorbidities, they still requested that this drug be given. . 4 doses of Campath were given from [Date range (1) 25865] (with an initial test dose of 3mg).He experienced small WBC count decrements, but soon started to rebound. At this time, his WBC count consisted predominantly of prolymphocytes. A short wait period was done to assess his response to the campath. And in the face of continuing rises in his WBC count, the family requested to have another trial of campath. Hence, he continued to receive campath on [2-15] and [12-16] and [12-18]. . # ID issues: - Bacteroides and Citrobacter in 2 different blood cultures - on Vanco and ceftaz/flagyl and caspo, ganciclovir - [12-10]: switched [Last Name (un) 2830] to ceftaz - CMV VL [Numeric Identifier 961] on [2137-12-4]: started on Ganciclovir -> [12-7]: VL 7670 - CMV VL on [12-14]->2050 - patient was cultured significant temperature spikes. . # Bilateral malignant pleural effusions. - Thoracentesis [2137-12-3]: 1.5L by IP service - CXR: [2137-12-9]: A moderate right and small left pleural effusion are stable. - CXR: [12-12]: b/l layering pleural effusions and perihilar edema . # DIC: as per previous labs, pt. in chronic DIC. On [11-16] pt developed persistent bleeding at site of phereis catheter. Transfused 3 u platelets, 2 u FFP, 2 u cryoprecipitate c improvement in clinical symptoms and improvement in DIC labs. Plat cnt up to 60 from 20 s/p transfusions. This likely accounts for his petechial rash. Throughout his hospitalization, patient was transfused to keep his fibrinogen >100 for suspected chronic DIC. . #. ARF: baseline creat 1.0; elevated on admission 2.1. allopurinol and [Last Name (un) ] held. creatinine improved daily. FeNA calculated < 1%; appeared dry on exam. Likely prerenal in etiology. Renal ultrasound obtained to r/o post renal etiology. baseline creatinine of 1. Unclear cause - possibly secondary to leukemic infiltration vs. previous TLS. Dry on physical exam; may represent some component of pre-renal azotemia. . - U Na - 28, U Cr - 124, FeNA = .21%; c/w prerenal azotemia - renal u/s showing no obstruction - Cr 2.9 on [2137-12-7]: decreased ganciclovir on [12-6]; decreased spironolactone on [2137-12-7] -> Cr 2.7 on [12-16] . #. HTN: Dyazide and Cozaar held given relative hypotension. goal SBP <140 per neurosurgery recc's. . #. Skin: patient has rash [1-2] lymphoma per oncology; also with diffuse petechiae. . #. TIIDM: maintained on sliding scale insulin with good control. . # End of life issues: The hematology team had several discussions with the [Known lastname ] family regarding the state of health of the patient. It was reiterated multiple times that he had multiorgan failure and that there was only a small chance that he could recover from his illness. It was reiterated that campath could worsen his condition and they accepted this risk. He continued to be a DNR/DNI during the last days of his life. In the AM of [12-19], the patient passed after worsening respiratory status for the last few days of his life. He had become more and more unresponsive and was increasing his O2 requirements over the last few days of his life. The daughter (proxy) was offered an autopsy, but refused. Medications on Admission: Meds on Admission: Allopurinol 60mg daily Dyazide 37.5/25 daily Cozaar 50mg daily Campath supplemental O2 previously on metformin; stopped during last hospitalization Discharge Medications: Patient passed away in hospital Discharge Disposition: Expired Discharge Diagnosis: CLL/PLL Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A Completed by:[2138-1-5]	[ "5119", "5849", "4280", "25000", "4019", "V1582" ]
Admission Date: [2132-12-11] Discharge Date: [2132-12-17] Date of Birth: [2095-6-17] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 949] Chief Complaint: abdominal pain, acute liver failure Major Surgical or Invasive Procedure: none History of Present Illness: 37 YOF nurse who presents with nausea/vomiting and RUQ pain x 3 days. Presented initially to OSH where she was found to have ALT 8856 AST 7932 TB 5.9 and INR 3.4. Creat and bicarb normal. She then revealed that she has been taking upwards of 6G APAP/day since [Month (only) 958] for back pain. Isn't sure exactly how many tablets she takes, but estimates 10 extra-strength Tylenol tabs and [2-28] Tylenol PM, as well as occasional Vicodin. Denies poor PO in the days preceeding onset of sx but since then hasn't been eating well as oral intake has exacerbated her sx. Denies other toxic habits/ingestions. Feels sleepy now since she has been up all night but denies changes in mental status or excessive sleepiness preceeding presentation. Drinks socially (about [5-3] beers in one sitting, once per week or every 2 weeks) including the night prior to the onset of her sx. Denies any suicidal intent. . Reports that she lives at home w husband and 5 kids. She was fired from her nursing job becuase of her back/neck pain, she reports. She feels happy and safe at home and reports a close family support system. She does admit to a suicide attempt at age 14 but doesn't remember the details. . In speaking with her huband he reports that she also takes Fioricet and Nyquil occasionally in addition to the other meds, and agrees that this was not a deliberate attempt to hurt herself. He corroborates that she does not use street drugs. Past Medical History: Body Dysmorphic Disorder Anxiety chronic neck/back pain [1-29] work-related injury remote hx of OD suicide attempt as teen GERD IBS Bilateral breast augmentation 00' and 04' Social History: Lives w/ husband and 5 kids (age [4-8]). Married 4 years. Last worked as RN but injured back at work and was then laid off. Parents live on [Hospital3 ]. -Reports up to 4 drinks 3x a week (2 drinks 4 days a week) per husband. + blackouts. [12-31] CAGE. No previous detoxes. -Denies IV drugs, tobacco, cocaine Family History: No liver dz, AI disease, IBD or cancer Physical Exam: PHYSICAL EXAMINATION: VS - Temp afebrile, BP 91/46, HR 86, R 18, O2-sat 98% RA GENERAL - well-appearing woman in NAD, comfortable, appropriate HEENT - PERRL, EOMI, sclerae mildly icteric with B/L lateral conjunctival hemorrhages, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft, TTP in RUQ & epigastrium, ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [4-30] throughout, sensation grossly intact throughout, gait not observed, no asterixis Pertinent Results: [2132-12-10] EKG: Sinus tachycardia. Modest diffuse ST-T wave changes are non-specific. No previous tracing available for comparison. . [2132-12-11] ECHO: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF 80%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is no aortic valve stenosis. 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. . [2132-12-11] CXR: The lungs are well expanded and clear without focal consolidation, pleural effusion or pneumothorax. The cardiac and mediastinal silhouette and hilar contours are normal. . [2132-12-11] RUQ U/S: Ultrasound of the right upper quadrant demonstrates no focal liver lesions. The gallbladder is contracted, accentuating wall thickness. The portal vein is patent with hepatopetal flow. No ascites is seen. No intra- or extra-hepatic biliary dilation is seen. The CBD measures 3 mm. No evidence of cholelithiasis is seen. IMPRESSION: 1. Patent portal vein with hepatopetal flow. 2. Contracted gallbladder without specific signs to suggest cholecystitis. . Labs: Brief Hospital Course: 37 yo W with acute hepatitis and liver injury secondary to chronic acetaminophen use . #. Acute hepatitis/liver failure: Determined to be secondary to chronic, unintentional, overuse of tylenol for control of a work-related back injury. On presentation the patient had grade I encephalopathy and a transplant evaluation was initiated. She was started on the NAC protocol. Her liver function tests improved obviating the need for urgent transplant. She remained on the NAC gtt for a total of 5 days, then was monitored for an additional day, and discharged after it was ensured that her labs were all improving. We instructed her to abstain from all alcohol and acetaminophen until she follows up with Dr. [Last Name (STitle) 497] in the Liver Clinic. At that time she will have her ceruloplasm levels re-checked, as this was found to be low during her transplant work-up. . #. Chronic back pain: secondary to a work-related injury, and the reason she was taking large amounts of tylenol daily. The patient has been seeing an Orthopedic Pain Specialist for steroid injections and plans to continue this treatment. Her pain was controlled on Tramadol, which we provided a prescription for at discharge. She will need to follow up with her Primary Care Physician and [Name9 (PRE) 1194] Specialist to develop a plan to manage her chronic pain. She was instructed to stop all medications with acetaminophen. . #. Adjustment Disorder with Anxious and Depressed Mood: The patient was evaluated by Psychiatry and Social Work upon admission. It was determined that her chronic acetaminophen ingestion was not intentional. She was not currently on an antidepressant, but has tried some in the past and discontinued use secondary to bothersome side effects. She would likely benefit from a SSRI or SNRI, which can be determined by the patient and her Primary Care Physician on an outpatient basis. . #. RUQ abdominal pain and nausea: likely secondary to her liver injury. The patient remained afebrile, without leukocytosis. She was started on a daily PPI. . #. Urinary Tract Infection: The patient was treated with three days of Ampicillin for an Enterococcal UTI. Her dysuria resolved. . #. Herpes labialis: The patient was started on Valtrex for recurrent HSV cold sores. . #. Pancytopenia: Unclear etiology, possibly secondary to acetaminophen or NAC. Also, may have had an element of hemodilution from the large amount of fluids received during the admission. She had no evidence of bleeding and remained hemodynamically stable throughout the admission. Medications on Admission: Tylenol Percocet Klonopin 5mg PRN Discharge Medications: 1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain for 1 weeks. Disp:42 Tablet(s) Refills:0 2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for breakthrough abdominal pain for 1 weeks. Disp:28 Tablet(s) Refills:0 3. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 4 days. Disp:14 Tablet(s) Refills:0 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 5. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO as instructed as needed for anxiety. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a day. Disp:30 Capsule(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: acute hepatitis secondary to chronic acetaminophen overuse abdominal pain urinary tract infection adjustment disorder pancytopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mrs. [Known lastname 19499], . You were recently admitted to the [Hospital1 1170] for continued evaluation and management of your abdominal pain secondary to acute liver failure from chronic overuse of tylenol. You were initially admitted to the Intensive Care Unit, and then transferred to the floor. We provided you with medications and you improved. We also found evidence of a urinary tract infection and started you on antibiotics. We also provided you with treatment for herpes labialis (cold sores). Please continue to see your outpatient therapist, and consider seeing a Psychiatrist in the future for your anxiety. Also, it is important that you keep all of your follow up appointments after discharge. . We are also giving you a short course of pain medications that are safe to take during your liver injury. You will need to follow up with your Primary Care Physician and [Name9 (PRE) 1194] Specialist to figure out the best regimen for yout to continu on to treat your chronic neck pain. . We are making the following changes to your outpatient medication regimen: -Please STOP all products containing acetaminophen (tylenol, eccedrin, percocet) until you follow up with Dr. [Last Name (STitle) 497]. Please read all of the labels of your over the counter medications to ensure they do not contain acetaminophen. -Please START Famotidine twice daily -Please START Valtrex twice daily until [2132-12-20] -Please take Tramadol every 4 hours as needed for pain -Please take Oxycodone 5 mg every 6 hours as needed for pain (please note that this medication can be sedating as well as cause constipation) - You may also take colace (a stool softener to prevent constipation) . It was a pleasure taking care of you during this hospitalization. Followup Instructions: Name: [Name6 (MD) 19500] [Name8 (MD) ],MD Specialty: Internal Medicine When: Thursday [12-18] at 10:30am Location: [Hospital1 ] HEALTHCARE - [Location (un) ] Address: [Location (un) ], [Location (un) ],[Numeric Identifier 6698] Phone: [Telephone/Fax (1) 6699] Please note that this appointment is in the [Location (un) ] office . Department: LIVER CENTER When: FRIDAY [2133-1-9] at 2:40 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 8507], MD [Telephone/Fax (1) 2422] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "5990" ]
Admission Date: [2136-7-25] Discharge Date: [2136-8-9] Date of Birth: [2081-10-26] Sex: F Service: MEDICINE Allergies: Codeine Attending:[First Name3 (LF) 943] Chief Complaint: hemetemsis and respiratory failure Major Surgical or Invasive Procedure: intubation, bronchoscopy, EGD History of Present Illness: 54 yo f with h/o Hep C cirrohsis on inferon presents after 2 days days of vomiting blood. The patient's husband reports that she has been feeling unwell and having a lot of epigastric abdominal pain and has had several episodes of hemetemsis over the past few days. He noted she had a fever to [Age over 90 ] yesterday and some chills. He also noted that her skin became more yellow in the past few days. The patient adamantly refused to come to the hospital. She has been feeling SOB with a chronic cough that has not change; her family also reports chronic diarrhea. She does not have a history of previous varices or UGIB. . In the ED, initial vs were: T 99 P 110 BP 138/78 R 16 O2 sat 100% ra. On exam in the ED, she was found to have coffee ground material in her oropharaynx, jaundice and + asterisix. Consulted liver and surgery. She then developed 2 more episodes of coffee ground emesis in ICU. cleared slightly with NG lavage. She became more confused and she was intubated for airway protection; however, the intubation was quite difficult, she was noted to aspirate blood. In the ED, she was given Vancomycin, octreotide drip and PPI drip. She recieved one unit of FFP but no other blood products at the time of transfer. Her vital signs prior to transfer were as follows: T 101.9 HR 137 BP 174/74, A/C TV 450 RR 14 PEEP 5 FIO2 100%. . On the floor, urgent EGD was performed which showed diffuse duodenal ulcers and portal hypertensive gastropathy. Also fundic erosions were noted. One large erosion on the lesser curvature had a clot over it suggesting it as a site of bleed. The site was clipped. No varices were noted. Review of systems: unable to obtain [12-26] sedation/intubation Past Medical History: # chronic hepatitis C infection dx'ed [2128], started interferon/ribavirin approx 6 months ago. # Cirrohsis # anxiety/ depression. # h/o viral meningitis in [2110]. # back pain r/t herniated disc # likely COPD based on medications - family denies lung disease. Social History: Married with 2 children. Current smoker [11-25] PPD. EtOH rare since starting Hep C tx, but previous heavy use. Previous h/o cocaine use - none recently. Not currently employed. Family History: Mother with cardiac disease died of gastric cancer. Dad with DM/CAD. Physical Exam: Upon admission to the MICU: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: rhonchorous breath sounds R>L CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Labs on admission: [2136-7-25] 09:15PM GLUCOSE-138* UREA N-23* CREAT-0.7 SODIUM-137 POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-17* ANION GAP-13 [2136-7-25] 09:15PM CALCIUM-6.6* PHOSPHATE-2.0* MAGNESIUM-1.7 [2136-7-25] 09:15PM WBC-8.5 RBC-2.69* HGB-7.9# HCT-25.9# MCV-96# MCH-29.5 MCHC-30.7* RDW-19.4* [2136-7-25] 09:15PM PLT COUNT-76# [2136-7-25] 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2136-7-25] 04:00PM URINE RBC-0 WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-0-2 [2136-7-25] 01:45PM ALT(SGPT)-51 AST(SGOT)-107* CK(CPK)-437* ALK PHOS-102 TOT BILI-2.7* [2136-7-25] 01:45PM LIPASE-19 [2136-7-25] 01:45PM cTropnT-0.02* [2136-7-25] 01:45PM CK-MB-7 Micro: [2136-8-1] URINE URINE CULTURE-FINAL {YEAST} INPATIENT [2136-7-31] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2136-7-31] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2136-7-31] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST, YEAST} INPATIENT [2136-7-31] URINE URINE CULTURE-FINAL {YEAST} INPATIENT [2136-7-31] MRSA SCREEN MRSA SCREEN-negative FINAL INPATIENT [2136-7-30] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-negative PRELIMINARY; BLOOD/AFB CULTURE-negative PRELIMINARY INPATIENT [2136-7-30] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST, YEAST}; LEGIONELLA CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY {YEAST}; ACID FAST SMEAR-FINAL; ACID FAST CULTURE-PRELIMINARY INPATIENT [2136-7-30] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2136-7-30] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Anaerobic Bottle Gram Stain-negative FINAL INPATIENT [2136-7-29] URINE Legionella Urinary Antigen -negative FINAL INPATIENT [2136-7-29] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [2136-7-29] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST, YEAST} INPATIENT [2136-7-29] URINE URINE CULTURE-negative FINAL INPATIENT [2136-7-26] BLOOD CULTURE Blood Culture, Routine-negative FINAL INPATIENT [2136-7-26] BRONCHOALVEOLAR LAVAGE GRAM STAIN-negative FINAL; RESPIRATORY CULTURE-FINAL INPATIENT [2136-7-26] SEROLOGY/BLOOD HELICOBACTER PYLORI ANTIBODY TEST-negative FINAL INPATIENT [2136-7-26] SPUTUM GRAM STAIN-negative FINAL; RESPIRATORY CULTURE-FINAL {YEAST} INPATIENT [2136-7-26] URINE URINE CULTURE-negative FINAL INPATIENT [2136-7-26] BLOOD CULTURE Blood Culture, Routine-negative FINAL INPATIENT [2136-7-25] MRSA SCREEN MRSA SCREEN-negative FINAL INPATIENT Imaging: CXR ([2136-7-25]): An endotracheal tube has been placed, the tip projects 5 cm above the carina. Also new is a nasogastric tube, the side port projects over the gastroesophageal junction, the tube should be advanced by several centimeters. There is no evidence of complications, notably no pneumothorax. In both lungs, on the right substantially more severe than on the left, are aveolar densities. These create multiple air bronchograms, in the right upper lobe, these changes create a large area of subtotal parenchymal consolidation. Although the changes are less severe in the left lung, ill- defined opacities are predominant in the perihilar lung regions. There is no evidence of lymphadenopathy and no evidence of pleural effusions. No cardiomegaly. Overall the image could be suggestive of parenchymal bleeding or diffuse alveolar damage. For ARDS, the assymetry of changes and the distribution of the right lung pathologies would be atypical. Another consideration would be severe aspiration with the patient positioned in the right body position. CT chest ([2136-7-27]): IMPRESSION: Almost complete consolidation of the right upper lobe withe widespread multilobar ground glass opacities and more confluent consolidations. A component is likely from pulmonary hemorrhage given the history, however superimosed edema is also likely and possibly pneumoia. Cirrhosis. Splenomegaly likely reflects portal hypertension. U/S abdomen with dopplers ([2136-7-30]): IMPRESSION: 1. Coarsened hepatic echotexture with a nodular contour, compatible with provided history of cirrhosis. No focal lesions identified. 2. Patent portal venous system, with directionally appropriate flow. 3. No evidence of ascites. Echo ([2136-7-31]): The left ventricular cavity size is normal. There may be mild left ventricular hypertrophy. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. A mid-cavitary gradient is identified. Outflow and midcavitary gradients appear to be due to the patient's hyperdynamic state. 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. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. CXR [8-4]: The patient was extubated in the meantime interval. The right internal jugular line tip is at the level of low SVC. Cardiomediastinal silhouette is stable. There is significant interval improvement of the appearance of the chest radiograph consistent with resolution of pulmonary edema. The right upper lobe and lower lobe consolidations are still present but also improved most likely due to resolution of underlying pulmonary edema. There is no appreciable pleural effusion or pneumothorax. Brief Hospital Course: This is a 54 yo f with h/o Hepatitis C infection and cirrohsis presenting with UGIB. # UGIB - s/p EGD which showed no varices, but multiple ulcers and s/p clipping of ulceration with clot in lesser curvature of fundus. Findings more consistent with NSAID-induced vs H Pylori PUD. Pt with recent history of motrin use per family though dosage uncertain. H Pylori was negative. Patient was maintained on IV PPI and tranfused as necessary with PRBC and FFP. IVF and pressors were used to keep MAP>65. Patient was transitioned to oral PPI once out of the ICU and diet was advanced as tolerated. Patient was noted to be orthostatic on day prior to discharge, however hematocrit was stable. This was likely [12-26] poor PO intake and patient responded positively to 1L bolus of NS. Hematocrit was stable until discharge with no sign of repeat bleed or active bleeding. . # Respiratory failure - Patient intubated for airway protection in the setting of hemetemsis and AMS. Pt with large aspiration of blood during intubation. No CXR prior to intubation so unclear if infiltrates r/t to observed aspiration vs previous aspiration/evolving PNA. Bronch showed bright red blood throughout right lung, no growth on BAL. CT chest showed 'almost complete consolidation of the right upper lobe. Widespread patchy opacities throughout both lungs, right worse than left, is consistent with pulmonary hemorrhage given history.' Serial CXR showed gradual improvement in alveolar infiltrates. Patient was extubated on [2136-8-3]. She also was having fevers, and since infection could not be excluded on imaging, she was empirically started on cipro/vanco/cefipime/flagyl. Antibiotics stopped on [2136-8-3] because afebrile, no white count, clinically stable, no positive cultures other than [11-27] blood cx bottles with GPC (likely contaminant). Patient was transferred to the floor on 2L oxygen by nasal canula and was weaned to room air overnight. Mrs. [Known lastname 54205] had no oxygen requirement x48 hours, with good O2 saturation and no complaints of shortness of breath on discharge. . # Fevers - Patient with fevers over much of her MICU stay, last fever on [7-31]. Only positive culture was 1/4 bottles on blood culture growing GPC, likely contaminant. Was on empiric antibiotics for HAP/aspiration pneumonia, all d/c'ed prior to transfer from MICU. Beta glucan and galactomannan both negative. Also d/c'ed ribavirin for possible medication effect. Concern for vasculitis; [Doctor First Name ] positive at 1:640. ANCA neg. [Last Name (un) 15412] wnl, IgG elevated. Anti-GBM negative. C3, C4 not significantly depressed. Cryoglobulins negative x 2, HCV VL <43 (undetectable). Patient was afebrile once antibiotics and ribavirin were discontinued and remained so until discharge. . # Hemoptysis - Patient had bright red blood on suctioning and BAL while intubated. See respiratory failure section for further details. She was placed on pulse steroids x 5 days for empiric treatment of possible vasculitis. Vasculitis work-up, including possible cryoglobulinemia was negatvie except for [Doctor First Name ] 1:640. She had no hemoptysis after extubation and was stable from a respiratory standpoint on transfer to the floor and at discharge. Patient is to follow-up in the pulmonary clinic as an outpatient. . # Hepatitis C treatment - IFN discontinued prior to admission, Ribavirin discontined during admission due to possible medication effect causing possible fever. HCV VL negative. Patient to follow-up with hepatologist for further management as an outpatient. Medications on Admission: Advair 500-50 2 puffs [Hospital1 ] flonase 50 mg nasal daily Combivent 2 pufss [Hospital1 ] lorazepam 1 mg PO TID motrin 400mg PO daily PRN omeprazole 40 mg PO daily percocet 10-325mg 1-2 tabs q4-6 hrs PRN pain PegIntron inject 120 mcg/0.5 ml SQ q week. Compazine 10mg PO q 6hrs PRN nausea Ribavirin 600mg PO QAM and 400mg PO QPM Trazodone 50 mg PO QHS Zoloft 100mg PO qday Discharge Medications: 1. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:0 4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for anxiety. Disp:12 Tablet(s) Refills:0 5. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 6. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1) Nasal once a day. 7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:12 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary Diagnosis: 1. Gastric Ulcer s/p clip [Clip Number (Radiology) ]. Duodenal Ulcer 3. Respiratory Failure 4. Encephalopathy 5. Hepatitis C Discharge Condition: Hemodynamically Stable. Tolerating PO. Ambulating independently. Discharge Instructions: You were admitted to the hospital due to vomitting blood. You were given blood products to replace the blood you lost. Additionally, you were given medicine to artificially elevate your blood pressure for a short period. There was concern that you would not be able to breath on your own so you had a tube placed in your throat so a machine could breath for you. During this time, there was blood noticed in your right lung. This was monitored and improved. You were given antibiotics due to concern for infection. Your Ribavirin (treatment for your Hepatitis C) was discontinued. Please follow-up with your PCP, [Name Initial (NameIs) ] lung doctor (pulmonologist) and your liver doctor (hepatologist) as instructed below. The following changes were made to your Medications: 1. Pegintron (discontinued), discuss with Dr. [Last Name (STitle) ] before restarting. 2. Ribavirin (discontinued), discuss with Dr. [Last Name (STitle) ] before restarting. 3. Compazine (discontinued) 4. Protonix 40mg twice daily (to replace omeprazole) 5. Omeprazole discontinued. 6. Motrin discontinued. 7. Ativan discontinued. 8. Clonazepam 0.5mg three times per day as needed for anxiety (to replace ativan). 9. Oxycodone 5 mg by mouth every 6 hours as needed for pain 10. Stop Percocet . If you experience fever > 100.4, shortness of breath, chest pain, blood in your vomit or sputum, blood in your stool, sleepiness, light-headedness or any other symptom that concerns you, please contact your PCP or go to the nearest emergency room for evaluation. Followup Instructions: Please follow up with your PCP within one week of discharge. An appointment has been made with you with the lung and liver doctors as listed below. 1. Please arrange an appointment with your PCP and Counselor in the next 2 weeks for follow-up 2. Liver Doctor (Hepatology): [Name6 (MD) ] [Last Name (NamePattern4) 2424], MD Phone:[Telephone/Fax (1) 2422] Date/Time:[2136-8-30] 11:00 3. Lung Doctor (Pulmonology): [Hospital1 18] [Hospital Ward Name 516], [Hospital Ward Name 23] [Location (un) ] -Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2136-9-7] 8:40 -Provider: [Name10 (NameIs) 1570],INTERPRET W/LAB NO CHECK-IN [Name10 (NameIs) 1570] INTEPRETATION BILLING Date/Time:[2136-9-7] 9:00	[ "5070", "51881", "2851", "2760", "2875", "496", "3051" ]
Admission Date: [2134-10-20] Discharge Date: [2134-10-23] Date of Birth: [2078-11-11] Sex: M Service: [Doctor First Name 147] Allergies: Penicillins / Iodine; Iodine Containing / Carbamazepine Attending:[First Name3 (LF) 668] Chief Complaint: Bleeding R brachiocephalic AV fistula Major Surgical or Invasive Procedure: repair bleeding AV fistula aneurysm History of Present Illness: 55yo male who presents wth bleeding from R brachiocephalic fistula. Pt is s/p repair of AV fistula aneurysm on [10-8]. Pt with acute blood loss and Hct drop secondary to bleeding Past Medical History: ESRD secondary to glomerulonephritis HTN Hep C PVD Hypoparathyroidism CHF Restless Leg Syndrome Social History: N/C Family History: N/C Physical Exam: AAO times 3 RRR S1+S2 CTA Bilat Soft NT/ND BS+ R AV Fistula pulsating, tender R Ulnar/Radial pulses 2+ Pertinent Results: [2134-10-19] 11:55PM BLOOD WBC-4.5 RBC-2.49# Hgb-7.1# Hct-21.8# MCV-88 MCH-28.6 MCHC-32.5 RDW-18.6 Plt Ct-253 [2134-10-20] 04:09AM BLOOD WBC-5.9 RBC-3.18# Hgb-9.2# Hct-26.8* MCV-84 MCH-28.8 MCHC-34.2 RDW-16.5* Plt Ct-189 [2134-10-20] 02:57PM BLOOD Hct-32.7* [2134-10-21] 05:00AM BLOOD WBC-11.4# RBC-2.54 Hgb-7.7* Hct-21.5# MCV-85 MCH-30.4 MCHC-36.0 RDW-18.4* Plt Ct-229 [2134-10-21] 08:08AM BLOOD Hct-21.1* [2134-10-21] 07:30PM BLOOD Hct-24.7* [2134-10-22] 05:55AM BLOOD WBC-6.4 RBC-3.13* Hgb-9.1* Hct-26.4* MCV-85 MCH-29.2 MCHC-34.5 RDW-17.8* Plt Ct-189 [2134-10-23] 05:10AM BLOOD WBC-4.4 RBC-3.54* Hgb-10.7* Hct-30.4* MCV-86 MCH-30.2 MCHC-35.2* RDW-17.0* Plt Ct-190 [2134-10-20] 2:10 am SWAB Site: FISTULA R A-V. GRAM STAIN (Final [2134-10-20]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [2134-10-22]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. Brief Hospital Course: Pt admitted on [2134-10-20] with bleeding AV fistula, taken to the OR. Aneursym of fistula ligated and resected. Pt given 3U PRBC during the operation. Pt on GET secondary to SOB at the onset of MAC. Pt unable to be extubated after the case, transferred to the MICU intubated. Pt then extubated overnight, tolerated well. Pt transferred to the floor. Pt with tunneled dialysis cath placed on [10-22]. Pt continued to improve. Pt tolerated diet well, pain controlled. Pt D/C'd with VNA for dressing changes on [10-23]. Discharge Medications: 1. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO QD (once a day). 2. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QD (once a day). 3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Prednisone 5 mg Tablet Sig: 0.5 Tablet PO QD (once a day). 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO QD (once a day). 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: ESRD with repaired AV fistula, tunneled dialysis catheter Discharge Condition: stable Discharge Instructions: Please keep all follow-up appointments Take all medications as prescribed Reuturn for dialysis as scheduled Return to the ER if any increased pain, fevers, redness or swelling, drainage from wound, significant weight gain or weight loss, shortness of breath, chest pain, or nausea and vomitting Followup Instructions: Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] (TRANSPLANT) TRANSPLANT CENTER (NHB) Where: LM [Hospital 5628] CLINIC Phone:[Telephone/Fax (1) 673] Date/Time:[2134-10-25] 1:10 Provider: [Name Initial (NameIs) ]/ [Doctor Last Name 1201] Where: [Hospital6 29] NEUROLOGY Phone:[Telephone/Fax (1) 8302] Date/Time:[2135-1-5] 4:00 Provider: [Name10 (NameIs) 1918] [Name11 (NameIs) ], MD Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 902] Date/Time:[2135-3-24] 1:00 Completed by:[2134-10-23]	[ "40391", "4280", "2851" ]
Admission Date: [2145-8-2] Discharge Date: [2145-8-10] Date of Birth: [2086-1-19] Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: This is a 58-year-old female with type 2 diabetes and extensive history of alcohol abuse, who is admitted to an outside hospital for alcohol withdrawal after she was found on the floor. She was discharged to a skilled-nursing facility for rehab and she was taken to the outside hospital ED on [2145-8-1] for increased fatigue, abdominal girth, and leg swelling. The patient, however, reports that she only drinks socially until [Holiday 1451] [2143], when she started to drink heavily as she drinks heavily during the holiday and continues to drink about three Manhattans per day until [Month (only) 216] when she did some binge drinking before her first admission. She denies any previous episodes of ascites or jaundice. She had decreased appetite since the first admission, and also some nausea and vomiting, but no fevers, chills, diarrhea, dysuria, cough, no history of upper GI or lower GI bleed. PAST MEDICAL HISTORY: 1. Type 2 diabetes. 2. Alcohol abuse. MEDICATIONS ON ADMISSION: 1. Lasix. 2. Remeron. 3. Insulin. 4. Multivitamin. 5. Spironolactone. ALLERGIES: 1. Penicillin. 2. Sulfa. SOCIAL HISTORY: Lives in [State 622], but vacations in [Hospital3 ] over the summer. She is a high school teacher, who lives with her husband, who also is an alcohol abuser, but no history of tobacco use and only one sexual partner, and she has only had one blood transfusion which was in [Month (only) 216] of this year at this hospital and she denies any other IV drug use. VITALS ON ADMISSION: Temperature 97.6, pulse 90, blood pressure 110/50, respiratory rate 22, and O2 98% on 2 liters. PHYSICAL EXAM: In general: She is icteric. Looking older than her stated age, but comfortable. HEENT is icteric sclerae. Extraocular muscles are intact. Moist mucous membranes. Oropharynx clear. Neck: There is no lymphadenopathy. Cardiovascular: Tachycardic, though with regular rhythm. Lungs: Left lung base without breath sounds and left mid lung with crackles, no rhonchi or wheezes. Abdomen is markedly distended, positive shifting dullness and no caput medusa. Extremities: There is 2+ edema up to the knee bilaterally. Positive Dupuytren's contractures and no pallor or erythema. Neurologic: Is awake, alert, and oriented times three with mild asterixis. Skin with scattered petechiae over the abdomen, no spider angioma. LABORATORIES ON ADMISSION: White count 14.3, hematocrit 39, platelets 545 with 77% neutrophils, 3% lymphocytes, 14% monocytes. Sodium is 126, potassium 4.9, chloride is 88, bicarb 27, BUN 17, creatinine 0.4, glucose 341. INR of 1.4. Calcium 8.5, magnesium 2.2, phosphorus 3.6. Lactate was 2.5. Urinalysis with negative leukocyte esterase, trace blood, nitrite negative, no white blood cells, no red blood cells, occasional bacteria, and moderate yeast. ALT is 41, AST 162, alkaline phosphatase 268, LDH 470, amylase 58, lipase 56, T bilirubin 18.1, albumin 2.5, and total protein 5.5. Diagnostic tap in the ED was 68 white blood cells and [Pager number ] protein, glucose 1.0. CT of the abdomen with no intrahepatic focal cholelithiasis, pancreas, spleen, kidney all normal. Pelvis normal. Only large ascites. Chest x-ray was bilateral pleural effusions left greater than right bibasilar atelectasis. Liver ultrasound: No biliary tract dilatation, gallbladder wall edema, no evidence of acute cholecystitis. EKG: Normal sinus rhythm at 100, normal axis, normal intervals, low voltage, no ST changes. HOSPITAL COURSE: The patient was admitted for liver failure, which was felt to be acute alcoholic hepatitis. Her bilirubin decreased over the course of her stay from 18.1 to 12. Her LFTs also remained within normal range. Patient had therapeutic paracentesis on the 5th with removal of four liters of fluid. Patient had started to require oxygen to maintain sats in the 90s. After the tap, the patient's O2 saturations remained normal without oxygen. Patient was also followed by the Hepatology service, who performed an EGD on the 2nd secondary to some coffee-ground emesis in the morning. The EGD showed no evidence of varices, but did show some esophagitis and some candidiasis, and recommended proton-pump inhibitor, and antifungal. Patient also had multiple serologies sent. Her hepatology serologies were all negative. Her iron studies were all normal except for slightly elevated ferritin, which was considered consistent with her acute inflammatory state and her lipid profile was also within normal limits. Her [Doctor First Name ] and other rheumatologics were also within normal. Patient was continued on her Lasix and aldactone, and a stable level with blood pressure remaining in the 110s. Patient had a diagnostic paracentesis in the Emergency Room, which ruled out SBP and patient was not started on antibiotics. Otherwise patient was also started on pentoxifylline 400 mg t.i.d. for a total course of four weeks, which per studies had shown to improve short-term survival in severe alcoholic hepatitis. Patient had mild evidence of asterixis on admission, and was started on lactulose initially, but as she had no other encephalopathic signs, was discontinued upon further course. Patient was transferred to the Intensive Care Unit for the EGD secondary to concerns of varices and risk for bleeding during her EGD. The patient tolerated the stay well and although did become slightly hypotensive during her stay with some oliguria, which resolved on its own. Patient's hematocrits remained stable after her upper GI bleed, and scope, and did not require blood transfusion. However, patient was also fluid restricted secondary to her hyponatremia and her ascites to 1 liter q.d. Patient tolerated it well and he sodium remains stable around 131. Patient had some oliguria during her ICU stay with a FENa of 0.2%, which is consistent with prerenal in the setting of her hypotension and decreased effective volume. Her urine output improved and she was stable for discharge back to the floor. She was continued on fluid restriction, but remains stable otherwise. She was tolerating p.o. diet well, and tolerating her Lasix and spironolactone well. For her insulin dependent-diabetes mellitus, originally the patient had been on oral glycemic agents, but because of her liver disease, was started on insulin. Initially, she was started on sliding scale with poor control and then was switched to NPH 70/30 fixed scale with sliding scale inbetween and her fingersticks remained in the 100 range and were fairly stable. For patient's alcohol abuse, the patient was evaluated by Additions and Social Work. Social Work tried to recommend and discussed with patient about followup. Patient states that she had been to AA meetings while at rehab and admitted that she would like to continue working to decrease her alcohol intake. Patient seems to be compliant and had no evidence of withdrawals during her stay. Patient is to be followed by PT and OT throughout her course. Physical Therapy initially recommended patient to getting out of bed with assistance and to ambulate with assistance as tolerated and increasing strength. Otherwise, she would require some endurance training prior to discharge. The patient was evaluated and seen by Nutrition, who recommended a regular low sodium diet with the addition of supplements secondary to decreased p.o. intake. For patient's depression, the patient was continued on her Remeron 15 mg daily and seems stable through the course of her stay. For nutrition, the patient was on a house diet with low salt with nutritional supplements t.i.d. For prophylaxis and for her GI esophagitis, patient was continued on her Protonix twice a day. Patient's electrolytes remained normal on fluid restriction and was repleted as needed, but was not necessary. DISCHARGE CONDITION: Good. DISCHARGE STATUS: Discharged to acute skilled-nursing facility. DISCHARGE DIAGNOSES: 1. Alcoholic hepatitis. 2. Ascites. 3. Alcohol abuse. 4. Type 2 diabetes. 5. Depression. DISCHARGE MEDICATIONS: 1. Ursodiol 1600 mg p.o. b.i.d. 2. Lasix 40 mg p.o. q.d. 3. Protonix 40 mg q.12. 4. Spironolactone 25 mg p.o. q.d. 5. Multivitamins one p.o. q.d. 6. Miconazole topical t.i.d. as needed. 7. Remeron 15 mg p.o. q.h.s. 8. Pentoxifylline 400 mg p.o. t.i.d. 9. At breakfast, patient is on 7 units of NPH and 3 units of regular insulin. At dinnertime, patient gets 3 units of NPH and 2 units of regular, and sliding scale as needed inbetween. FOLLOW-UP INSTRUCTIONS: The patient is to followup with her primary care physician in [Name9 (PRE) 622] in [12-3] weeks, and also setup with a hepatologist in [State 622]. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 4446] Dictated By:[Name8 (MD) 264] MEDQUIST36 D: [2145-8-9] 11:28 T: [2145-8-9] 11:30 JOB#: [Job Number 51713]	[ "5119", "25000", "311" ]
Admission Date: [2115-11-5] Discharge Date: [2115-11-27] Date of Birth: [2049-7-29] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2297] Chief Complaint: Cardio-pulmonary Failure Major Surgical or Invasive Procedure: Endotracheal Intubation History of Present Illness: 66 yo man with PMH HTN and recent admission for pna in [Month (only) ] who presents to ED after syncopal episode. Pt intubated and sedated w/o family memeber in ICU so HPI by report and records which is missing ED resident note. Pt presented after syncopal episode with 5-6 minute of LOC with head trauma after he got up from dinner to get to the bathroom. No other Sx compliant but noted to be diaphoretic; no CP or SOB. ON arrival pale and diaphoretic. HDS during EMS travel but tachycaric with tarnsient RBBB. ECG w/ ? STE. Given ASA/BB/NTG and started on hep gtt. Pt became more pale, diaphoretic and less responsive. Pt intubated for airway protection as MS changed and Pt became hypotensive. Post intubateion SBP 50's -> levophed. CVL placed. Bedside echo obtained which showed evidence of right sided ventricular dilation and hypokinesis. CTA demonstrated massive b/l PE While in ED, became hypotensive with respiratory distress. Intubated. Bedside echo showed evidence of right sided dilation and hypok. CTA demonstrated massive b/l PE -> heparin restarted and then administered TPA (15 mg IVP, 42mg/hr). Unable to place foley prior to TPA. Pt transfered to MICU. Past Medical History: HTN Social History: Lives in [Location 86] with his wife. Retired quality engineer. Does not smoke or drink. Family History: noncontributory Physical Exam: General - intubated and sedated HEENT - blood around ETT neck - supple, oozing from left SC sight and soft tissue swelling CVS - tachycardic but RR, s1/s2 possible s4. no M Lungs - CTAB b/l - ant Abd - soft ND, + BS Ext - cool/moist, no edema Neuro- moves all extremities Pertinent Results: Admit Labs [2115-11-5] 07:22PM BLOOD WBC-11.6* RBC-5.49 Hgb-17.4 Hct-49.3 MCV-90 MCH-31.6 MCHC-35.3* RDW-13.5 Plt Ct-227 [2115-11-5] 07:22PM BLOOD Neuts-56.5 Lymphs-35.8 Monos-4.0 Eos-1.7 Baso-2.0 [2115-11-5] 07:22PM BLOOD Glucose-157* UreaN-16 Creat-1.1 Na-140 K-4.4 Cl-106 HCO3-23 AnGap-15 [2115-11-6] 03:30AM BLOOD Calcium-7.6* Phos-3.7 Mg-2.2 [2115-11-6] 05:21AM BLOOD Type-ART Temp-36.8 Rates-18/ Tidal V-650 FiO2-40 pO2-84* pCO2-44 pH-7.31* calTCO2-23 Base XS--4 -ASSIST/CON Intubat-INTUBATED [2115-11-5] 07:22PM BLOOD PT-12.7 PTT-23.7 INR(PT)-1.1 . . Significant Diagnostic Imaging Studies . [2115-11-5] ECHO: Conclusions: There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). The right ventricular cavity is moderately dilated. Right ventricular systolic function appears depressed. The number of aortic valve leaflets cannot be determined. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. . [2115-11-5] CXR: PORTABLE CHEST: Cardiac and mediastinal contours appear stable. Pulmonary vasculature appears within normal limits. Small nodular densities are seen over the right mid lung. No evidence of focal consolidation or pleural effusions. Likely bibasilar atelectasis is seen. . [2115-11-5] CTA Chest: IMPRESSION: 1. Massive burden of pulmonary embolism bilaterally extending from the mid to distal right and left main pulmonary arteries outward into nearly all branches of the pulmonary arterial vasculature. 2. Multiple pleural-based calcified plaques consistent with prior asbestos exposure. . [2115-11-5] Head CT: IMPRESSION: 1. No acute intracranial hemorrhage or mass effect. No fractures. 2. Soft tissue lesion on vertex of scalp. Please correlate with physical examination to confirm sebaceous cyst versus neoplasm. . [11-6] U/S Bil LE: Nonocclusive thrombus identified within the right popliteal vein. . [11-8] CXR: Mild edema has developed in the lower lungs. Upper lungs are clear, with persistent vascular congestion on the left and diminished vascularity peripherally. . [11-8] f/u CXR: Worsening patchy areas of opacity in both lower lobes. This could be due to aspiration, hemorrhage, or pneumonia. . [11-9] CXR: Slight interval improvement in bilateral pulmonary infiltrates. . [11-10] CXR: Persistent bibasilar pulmonary infiltrates. No significant internal change. . [11-11] CXR: Lung volumes are low, and mild cardiomegaly with mediastinal vascular engorgement are stable. Atelectasis at the left lung base is more pronounced. There is no pulmonary edema or pneumonia. Lateral aspect of the left lower chest is excluded from the examination. Pleural effusion, if any, is on the left and small; the other pleural surfaces are unremarkable. No pneumothorax. . [11-12] CXR: Left lower lobe collapse has worsened, accompanied by increasing small left pleural effusion. Major interval change has been significant increase in caliber of mediastinal vessels suggesting marked elevation in central venous pressure, which could be a reflection of either volume overload, cardiac decompensation or right heart failure due to increase in pulmonary vascular resistance from worsening pulmonary embolism. Left subclavian line tip projects over the left brachiocephalic vein. No pneumothorax. . [11-13] CXR: Lung volumes are lower, mild-to-moderate pulmonary edema has developed. Severe mediastinal widening suggests persistence of marked increase in central venous pressure, exaggerated by lower lung volumes. Tip of the left subclavian line projects over the left brachiocephalic vein. Small left pleural effusion has increased. No pneumothorax. . [11-13] f/u CXR: Portable AP chest radiograph compared to [2115-11-13]. The enlarged heart size is unchanged as well. There is increased width of the mediastinum, most likely was known to be due to fat deposition. The bilateral pleural effusions and left lung consolidation are again noted. Noted, right more than left. The ET tube tip is 7.8 cm above the carina. The left subclavian line tip is in the mid portion of the left brachiocephalic vein. . [11-13] Echo: Preserved global and regional biventricular systolic function. Moderate pulmonary artery systolic hypertension. Mild mitral regurgitation. Compared with the prior study (images reviewed) of [2115-11-5], the right venticular cavity is smaller and free wall motion is normal. Pulmonary artery systolic hypertension is now identified. . [11-14] CT-PA: 1. Reduction in bulk of bilateral pulmonary embolus. The largest amount centrally is seen about the right upper lobe pulmonary artery origin with minimal opacification of right upper lobe pulmonary arteries. No infarcts. 2. Bilateral pleural effusions and atelectasis/consolidations. . [11-14] CT Head w/o Contrast: No acute intracranial hemorrhage. Increasing sinus opacification, likely related to intubation. . [11-14] CXR: The ET tube tip is too high, 6.7 cm above the carina. The mediastinal width has been decreased with the decrease of pulmonary edema. The left lower lobe atelectasis is unchanged. . [11-15] U/S RUQ: 1. Extremely limited study. No gallstones or biliary dilatation. 2. Right-sided pleural effusion. . [11-18] U/S Bil LE: Persistent nonocclusive thrombus identified within the right popliteal vein. No evidence of DVT within the left lower extremity. . [11-20] CT Head w/ Sinus Views Study significantly degraded by patient motion artifact, demonstrating resolution of the hyperdense air/fluid level in the right maxillary sinus, partial clearing of the left sphenoid sinus air cell, and relatively stable, virtually complete opacification of the right sphenoid sinus. ENT consultation suggested, and particularly if drainage is contemplated, a repeat study is advised. . [11-22] CXR: Stable left lower lobe atelectasis versus airspace consolidation. Small left-sided pleural effusion. . . Micro . BCX - negative from [11-6], [11-8], [11-14], [11-17]. . UCX - negative from [11-17] . C-Diff - negative from [11-15] and [11-18]. . Sputum - [11-7] & [11-9] STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN-------------<=0.25 S . Sputum - [11-14] RARE GROWTH OROPHARYNGEAL FLORA. . Sputum - [11-17] SPARSE GROWTH OROPHARYNGEAL FLORA. . Central Venous Cath Tip [11-15] - No significant growth. Brief Hospital Course: Given massive bilateral PEs with associated respiratory failure and shock, pt was stabilized in the ED, treated with TPA, and admitted to the MICU for further management. During pt's course in the MICU, the following issues were addressed: . 1. Respiratory failure: Pt was intubated in the ED for airway protection and cardiopulmonary failure [2-14] massive PE. Pt was maintained on the ventilator from [11-5] to [11-9], extubated on [11-9], reintubated on [11-13] due to further respiratory distress, and extubated on [11-22]. Throughout course, pt received oral care, HOB > 30%, serial CXRs, and daily attempts to wean O2 and ventilator control of respiration. During intubation, pt was sedated with propofol, midazolam, and fentanyl. Pt's respiratory failure was complicated by resolving PEs, VAP (which was treated with abx specific to sputum culture growth), and some level of pulmonary edema (secondary to resuscitation efforts which was treated with diuresis). Pt's initial trial of extubation (beginning [11-9]) was successful until an acute spontaneous decompensation of respiration on [11-13] during bathing; because several nurses were with pt (bathing), he was immediately bag-mask ventilated following desaturation; pt progressed to hypotension with ALOC, and anesthesia was called to bedside w/in 5 minutes of decompensation; anesthesia was able to reintubate pt via fiberoptic ETT placement. F/u CT-PA failed to reveal new or worsening clot burden, and CXR failed to reveal signs of acute CHF or PTX; pt's decompensation was likely secondary to transient mucus plugging. Pt was maintained on the ventilator with daily efforts to wean O2 and to decrease PS; discussion with pt's wife and family regarding trach and trial of reextubation occurred daily, and the decision was made to pursue trial of extubation and to defer trach unless absolutely necessary. Following significant improvement in RSBI and overall clinical appearance, pt was extubated on [11-22] w/o issue. Pt's f/u CXR was encouraging, and pt was verbal and AAOx3 following weaning of sedation. . 2. Bilateral PE with hypotension - Diagnosed with [Name (NI) ], pt's hemodynamic shock showed significant improvement s/p TPA. Pt was placed on heparin gtt per [Hospital1 18] weight-based nomogram. Pt was supported on levophed for < 24 hours with subsequent return of normotension. Serial HCTs and f/u CT head failed to reveal signs of hemorrage secondary to TPA and anticoagulation. U/S Bil LE revealed residual RLE popliteal DVT. Initial TTE revealed that the right ventricular cavity was moderately dilated with right ventricular systolic function appearing depressed. F/u TTE revealed pulmonary hypertension but improved right heart dilatation. F/u CT-PA following [11-13] resp distress showed improvement w/o further clot burden. Given that this was pt's initial episode of DVT/PE, he will need further hypercoagulability workup following step-down from ICU setting. . 3. Ventilator Associated PNA - Pt's difficulty weaning from the ventilator, worsening CXRs, fever spikes, and continued copious sputum production prompted empiric broad-spectrum abx which were subsequently narrowed to nafcillin due to sputum samples which grew MSSA. Pt continued to produce copious secretions and experienced reintubation on [11-13] and subsequent fever spikes, prompting switch back to broad spectrum abx. Pt's CXRs and respiratory status continued to improve subsequenty, sputum from [11-18] was negative, and the cause of his fevers became better explained by sinusitis; pt was then switched to Unasyn to cover sinusitis w/o further issue from VAP. . 4. Sinusitis - pt began to spike fevers following reintubation on [11-13], and he was treated with broad spectrum abx until CT of the head identified significant maxillary and sphenoid sinusitis. Unasyn was started to cover typical pathogens, and ENT was consulted for advice regarding the need for drainage. Dedicated sinus CT revealed interval improvment on Unasyn, and surgical drainage was deferred given improving fever and leukocytosis. Plan is to continue unasyn (or transition to augmentin) for total of 14 day course. . 5. Cardiovascular (a) Rhythm - no history of rhythm abnormalities; pt developed atrial flutter and fibrillation following his PE, which were muted via vagal maneuvers (such as passage of stool) but returned subsequently. Pt was managed with beta blockade and started on amio per cardiology recommendations. Subsequently, pt regained sinus rhythm w/o further issue. (b) [Name (NI) ] - pt's EF and ventricular function remained intact as evidenced by two encouraging TTEs. Fluid overload was managed by diuresis. (c) Vessels = epigastric pain was worked-up for possible ACS, and was negative on several occassions via markers and EKGs. Pt was maintained on daily ASA. . 5. Epigastric Pain - r/o MI with negative markers and EKGs; occurred on several occassions when pt was intubated and NPO, so unable to provide GI cocktail for relief; seemed to worsen with pt was sitting up; treated with IV PPI (GERD) and IV morphine for pain. . 6. HTN - initially held home meds due to hypotension, metoprolol was started as patient had tachycardia. . 7. Right Popliteal DVT - on heparin gtt for PE, stable per f/u U/S. Patient will need labs to eval for hypercoaguability status. Medications on Admission: HCTZ 25mg PO QD Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Bilateral Pulmonary Emboli Discharge Condition: Stable Discharge Instructions: Please return to the hospital if you have sudden shortness of breath, chest pain, dizziness or fevers. . Please take all medications as directed. You have been started on a new medication, Coumadin, which is a blood thinner. It is very important that you take this medication as directed and have your blood checked weekly. Followup Instructions: Please follow up with your primary care physician [Name Initial (PRE) 176] 2 weeks of discharge to rehab.	[ "51881", "42731", "5070", "2760", "5849", "4280", "4019", "2859" ]
Admission Date: [2123-12-11] Discharge Date: [2123-12-13] Date of Birth: [2078-1-8] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern4) 290] Chief Complaint: Alcohol and opioid withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: 45 M w/ pmh of alcoholism went to detox on [12-9] (from EtOH and opiates) and was receiving ativan and methadone. Got increasing tachycardic and hypertensive at detox so was sent to the ED w/ concern for withdrawal. . In the ED, initial vs were: T 97.7 P 116 BP 161/102 R 28 O2 sat 99% on RA. He was aggitated w/ visual hallucinations on arrival to the ED. Patient was given valium 10 mg po then 10 mg IV q 10 minutes and had some witnessed apneic scales but then tachy and hypertensive again and given another 10 mg IV valium. Also given 1.5 L NS. . On the floor, he is c/o full body pain. Denies CP/SOB/N/V. Endorses goosepimples on his skin, diarrhea, abdominal pain. His last drink was on Monday at 8am. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. No dysuria. Past Medical History: GERD Hiatal hernia Hemorroids IVDA Alcoholism Social History: 1-1.5 ppd of tob since age 23. Uses [1-11] g of heroin per day and a 5th of burbon daily. Lives w/ his partner. Is on SSI. Family History: N/C Physical Exam: Vitals: T: 99.6 BP: 179/96 P: 91 R: 30 18 O2: 93% on RA General: Alert initially, able to tell an adequate medical history, then somnolent after getting diazepam HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Distant heart sounds, regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [2123-12-11] 01:35PM BLOOD WBC-9.2 RBC-4.61 Hgb-13.2* Hct-37.4* MCV-81* MCH-28.6 MCHC-35.3* RDW-14.2 Plt Ct-280 [2123-12-13] 05:22AM BLOOD WBC-8.8 RBC-5.13 Hgb-15.6 Hct-41.4 MCV-81* MCH-30.4 MCHC-37.6* RDW-13.6 Plt Ct-263 [2123-12-11] 01:35PM BLOOD Neuts-77.9* Lymphs-14.5* Monos-6.7 Eos-0.4 Baso-0.5 [2123-12-13] 05:22AM BLOOD PT-12.5 PTT-22.6 INR(PT)-1.1 [2123-12-11] 01:35PM BLOOD Glucose-104 UreaN-15 Creat-0.9 Na-133 K-3.5 Cl-100 HCO3-19* AnGap-18 [2123-12-13] 05:22AM BLOOD Glucose-120* UreaN-16 Creat-1.0 Na-130* K-3.6 Cl-100 HCO3-20* AnGap-14 [2123-12-11] 01:35PM BLOOD ALT-18 AST-33 AlkPhos-100 TotBili-0.5 [2123-12-11] 01:35PM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.6 Mg-1.9 [2123-12-13] 05:22AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.2 [2123-12-13] 05:22AM BLOOD VitB12-459 Folate-17.1 [2123-12-11] 01:35PM BLOOD TSH-1.2 [2123-12-11] 01:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2123-12-11] 01:44PM BLOOD Lactate-1.2 . CXR: PORTABLE AP CHEST: Examination is limited by low lung volumes. The heart is probably normal in size. Increased pulmonary vascularity is likely related to vascular crowding secondary to low lung volumes. The lungs are grossly clear. There is no pneumothorax or definite pleural effusion. IMPRESSION: Limited study. No definite consolidation. Recommend repeat examination once the patient is able to have better inspiratory effort. . EKG: Sinus tach, nl axis, no LVH, sm q-wave in III, no additional ST/TW changes Brief Hospital Course: This is a 45 M w/ pmh of alcohol and heroin abuse transferred from detox w/ hypertension and tachycardia concerning for EtOH and opioid withdrawal. He is no longer tachycardic and his blood pressure is now stable. He is medically stable to go back to detox. . # EtOH withdrawal: Had symptoms consistent with delirium tremens w/ tachycardia (to the 120s), hypertension (up to systolic of 200) and mild fever (99.2 F -- never had an higher temperature). Also had mild alcoholic hallucinosis per ED. He was also aggitated, and was ripping out his IVs, urinating and stooling in bed. By [12-13], he was much more coherent and asking to go back to Bournwood to be able to continue his treatment program. He was seen by psychiatry who also feel that he should go back to Bournwood when medically stable. - treated w/ diazepam per CIWA scale and received 230 mg diazepam during the first 24 hours - received thiamine, folate, MVI - has required only 40 mg of diazepam since midnight and is safe to be on a CIWA q 4-6 hours . # Opioid withdrawal: On arrival, was endorsing symptoms of opioid withdrawal, with abdominal pain diarrhea, goosepimples. He was noted to be s/p a fast methadone taper at Bournwood (20 mg on [12-9] mg on [12-10] and 10 mg on [12-11]). - he was given 20 mg of methadone on [12-12] and [12-13] with a plan to taper by 5 mg q day - started on clonidine 0.1 mg tid in the setting of opioid withdrawal - given Methocarbamol 750 mg PO Q6H:PRN muscle cramps - given HydrOXYzine 25 mg PO Q6H:PRN anxiety - DiCYCLOmine 20 mg PO Q4H:PRN abdominal pain - Loperamide 2 mg PO QID:PRN diarrhea . # Low back pain: given Ibuprofen 600 mg PO Q6H:PRN pain . # Gerd: PPI was continued . # Apnea: by report, had witnessed apneic episodes per ED. Also intermittently desats during sleep. Given build and weight, likely has OSA. - outpatient work-up . # Tobacco abuse: nicotine patch . # FEN: 1L IVF, replete electrolytes, regular diet . # Prophylaxis: Subcutaneous heparin . # Access: peripherals . # Code: presumed full . # Communication: Patient, [Name (NI) ] ([Telephone/Fax (1) 42338] . # Disposition: to Bournwood when bed available . Medications on Admission: Medications: Home: Pantoprazole . At [Hospital 42339] Hospital: Methadone 20 mg on [12-9] mg on [12-10] and 10 mg on [12-11] Ativan taper Thiamine Folate MVI Ativan prn Loperimide prn Dicyclomine prn Quinine Sulfate prn Ibuprofen prn Trazadone 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. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 6. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 8. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 9. Dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours) as needed for abdominal pain. 10. Loperamide 2 mg Capsule Sig: One (1) Capsule PO q6 hrs prn as needed for diarrhea. 11. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): taper once SBP < 130 and no longer withdrawing from opioids; would not use for long-term treatment of hypertension. 12. Methadone 5 mg Tablet Sig: 15 mg on [12-14] mg on [12-15] mg on [12-16] Tablets PO once a day for 3 days. 13. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO q6 hrs prn as needed for muscle cramps. 14. Diazepam 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for CIWA > 10. Discharge Disposition: Extended Care Facility: [Hospital3 8063] - [Location (un) ] Discharge Diagnosis: Opioid withdrawal Alcohol withdrawal . Secondary: Likely obstructive sleep apnea Discharge Condition: Hemodynamically stable. Ambulatory. Discharge Instructions: You were admitted from [Hospital 42339] hospital in acute alcohol and opioid withdrawal. You were treated for this and are now stable to continue your detox treatment at [Hospital 42339] hospital. Followup Instructions: Please make an appointment to see your primary care doctor once you are finished with your detox treatment: [Last Name (LF) ],[First Name3 (LF) ] S. [Telephone/Fax (1) 250]. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "53081", "32723", "3051" ]
Admission Date: [2197-5-10] Discharge Date: [2197-5-19] Date of Birth: [2135-5-14] Sex: F Service: MED CHIEF COMPLAINT: Respiratory distress. HISTORY OF PRESENT ILLNESS: The patient is a 61 year old female with a history of small cell lung cancer diagnosed in [2188], status post chemotherapy, radiation therapy including prophylactic whole brain irradiation and stem cell rescue, also with a history of chronic obstructive pulmonary disease on home oxygen and recurrent right sided pleural effusion who presented to the clinic on the day of admission with increasing shortness of breath. The patient was sent to the emergency department from the clinic where she was found to be saturating in the 90s on 100 percent nonrebreathing. A right sided thoracentesis was done with removal of 600 cc of serous fluid which initially improved the patient's oxygen saturation. However, the patient subsequently desaturated again on the nonrebreather requiring intubation. The patient's daughter reported that she has had increased agitation and somnolence as well as green/[Doctor Last Name 352] sputum over the past seven days. She had been started on levofloxacin without significant improvement in the sputum production. On the day prior to admission she developed increased somnolence and lethargy prompting her visit to clinic. She received ceftriaxone and azithromycin. PAST MEDICAL HISTORY: Small cell lung cancer diagnosed in [2188], status post radiation, chemotherapy, stem cell rescue, prophylactic brain radiation. Chronic obstructive pulmonary disease. Hypothyroidism. Atypical pneumonia. Recurrent right pleural effusion. Mental status changes. SOCIAL HISTORY: The patient has been married for 38 years. Her daughter is a nurse [First Name (Titles) ] [Hospital1 188]. She is a former smoker and quit 70 pack years. She quit in [2188]. She denies any alcohol or drug use. FAMILY HISTORY: Is significant for mother diabetes and father with hypertension. MEDICATIONS ON ADMISSION: Synthroid 100 mcg q.d., Celebrex, Serevent, Atrovent, albuterol, home oxygen, levofloxacin 500 mg q.d. No known drug allergies. PHYSICAL EXAMINATION: On admission temperature 98, blood pressure 127/63, heart rate 126, respiratory rate 22, saturating 90 percent on 100 percent non-rebreather. In general this is an ill appearing woman in respiratory distress. Head, eyes, ears, nose and throat examination: Mucous membranes slightly dry, extraocular movements intact. Jugular venous distension was 6 cm. Cardiac examination: Tachycardic with a regular rhythm, no murmurs, rubs or gallops. Lung examination: Coarse breath sounds throughout with decreased breath sounds on the right. Abdomen was soft, nontender, nondistended with normoactive bowel sounds. Extremities revealed 1+ lower extremity edema bilaterally. Neurologically alert and responsive. LABORATORY DATA: On admission: CBC revealed a white count of 15.6 with 81 percent neutrophils, hematocrit was 39.1, platelet count 321. Chem-7 revealed a sodium of 137 with potassium of 5.9, chloride of 93, bicarbonate of 38, BUN of 18, creatinine of 0.4 and glucose of 106. Pleural fluid showed 1335 white blood cells and [Pager number 6326] red blood cells. Total protein was 4.1, glucose was 111 and albumin was 1.1. Electrocardiogram showed sinus tachycardia at 132 with normal axis and normal [Doctor Last Name 1754]. There were no ST or T wave changes. There were Q waves in 3 and AVF. Chest x-ray showed a large right pleural effusion with right lower lobe collapse. Her endotracheal tube was in place. HOSPITAL COURSE BY PROBLEMS: 1. Respiratory failure: Patient was intubated in the emergency department. Her respiratory failure was felt to be multifactorial with the pleural effusion and sizable lobar collapse playing a large role. She was also treated for possible pneumonia and had bronchoscopy with BAL done on both [5-10] and [5-11]. BAL grew pansensitive pseudomonas and she was treated for this initially with ceftriaxone and azithromycin and then subsequently with ceftazidime to complete a 14 day course. Given her underlying lung disease including bronchiectasis and severe chronic obstructive pulmonary disease, it was felt that she would likely have a long wean off the ventilator. She therefore underwent tracheostomy on [5-15]. She was initially maintained on pressure controlled ventilation and was eventually able to be weaned from pressure support mode. She is currently tolerating 10 of pressure support with 5 of PEEP and an FIO2 of 0.4. On those settings she is pulling tidal volumes in the 300s and saturating 96 to 98 percent. We did consider chest tube placement to treat her effusion. However, the patient was oxygenating and ventilating well and this was therefore deferred. 1. Pneumonia: As stated above patient was felt to likely have an underlying pneumonia as the source of her acute decompensation. She was treated with ceftazidine for pseudomonas pneumonia and will complete a 14 day course. She also received chest physical therapy and suctioning p.r.n. 1. Small cell lung cancer: Cytology from both her BAL and from her pleural fluid were negative for malignant cells. At this time there is no evidence of disease recurrence. 1. Hypothyroidism: The patient was continued on her home dose of Synthroid. Given her persistent tachycardia a TSH and free T4 were checked and are pending at the time of this dictation. 1. Tachycardia: The patient was persistently tachycardic throughout her admission. This was initially felt to be secondary to volume depletion. However, this did not resolve with intravenous fluids. She underwent an echocardiogram which showed depressed left ventricular ejection fraction and was started on an ACE inhibitor for afterload reduction. As mentioned above thyroid function tests were also checked given her history of hypothyroidism and are currently pending. 1. Fluids, electrolytes and nutrition: The patient had a Dobhoff tube placed and has been on tube feeds since admission. A speech and swallow evaluation is pending. 1. Metabolic alkalosis: This is felt to be compensatory for the patient's primary respiratory acidosis from her chronic obstructive pulmonary disease. A urine chloride was checked and was 112 suggesting that her metabolic alkalosis was not chloride responsive. 1. Access: Patient had a right subclavian vein and right radial arterial line which were both discontinued prior to discharge. A PICC line was placed by Interventional Radiology. 1. Prophylaxis: The patient was maintained on subcutaneous heparin, Venodynes and proton pump inhibitor. 1. Hyperglycemia: The patient was on an insulin sliding scale with good glycemic control throughout her admission. DISCHARGE DIAGNOSES: 1. Respiratory failure. 2. History of small cell lung cancer. 3. Recurrent pneumonia, now pseudomonas. 4. Recurrent right pleural effusion. 5. Chronic obstructive pulmonary disease. 6. Hypothyroidism. DISCHARGE MEDICATIONS: Ceftazidime 2 grams intravenous q 8 hours times four days, Vibrazole 30 mg q.d., Flovent 110 mcg 4 puffs B.I.D, Atrovent 2 puffs q.i.d., albuterol 2 puffs q 2 hours, heparin subcutaneously 5,000 units B.I.D, Levoxyl 125 mcg P.O. q.d., Tylenol 325 mg 1 to 2 tablets P.O. q 4 to 6 ours p.r.n., Colace 100 mg P.O., B.I.D, senna 1 tablet P.O. q.h.s., Captopril 25 mg P.O. t.i.d., Humalog insulin sliding scale. DISCHARGE PLAN: Patient will follow up with her primary care doctor, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1022], and was instructed to follow up with her pulmonologist, Dr. [Name (NI) ] in one to two weeks. She is being discharged to rehabilitation where her ventilator will be weaned as tolerated. [First Name8 (NamePattern2) ] [Name8 (MD) ], [MD Number(1) 6327] Dictated By:[Doctor Last Name 6328] MEDQUIST36 D: [2197-5-18] 20:20:02 T: [2197-5-18] 21:22:44 Job#: [Job Number 6329]	[ "5180", "5119", "2762", "2449" ]
Admission Date: [2150-7-24] Discharge Date: [2150-8-4] Date of Birth: [2094-12-15] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5790] Chief Complaint: Right lower lobe lung nodule Major Surgical or Invasive Procedure: Flexible bronchoscopy, VATS right lower lobe wedge, followed by VATS right lower lobectomy, mediastinal lymph node dissection. History of Present Illness: Mr. [Known lastname 37080] is a 55-year-old gentleman who is referred to the Thoracic [Hospital 32535] Clinic by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1968]. Mr. [Known lastname 37080] had had a cerebellar tumor resected in [2140]. The pathology on this was adenocarcinoma, which appeared to be metastatic from an unknown primary. During recent workup for his shoulder pain, he underwent films which revealed a new pulmonary nodule on the right side. This was followed with a chest CT, which confirmed the presence of two new nodules (in comparison with CT scan done in [2143]), in the right lower lobe (FDG avid) as well as a stable nodule in the right upper lobe. Mr. [Known lastname 37080] [Last Name (Titles) ] any shortness of breath, cough, purulent sputum production or hemoptysis. He [Last Name (Titles) ] any recent pulmonary infection or travel to the southwest United States. He notes that he exercises regularly without any shortness of breath or chest pain. He [Last Name (Titles) ] any fevers, chills, or sweats. He [Last Name (Titles) ] any weight loss. He [Last Name (Titles) ] any new body pain or neurological symptoms. Past Medical History: Hypertension Coronary artery disease s/p Myocardial infarction CABG ([2139]) Heart Failure (EF 20-30%) Hypercholexterolemia Cerebellar tumor (adenocarcinoma) s/p resection ([2140]) Tremor Anxiety Avascular necrosis of right humerus S/P Cholecystectomy S/P Right shoulder surgery x 2 Hypothyroidism Bilateral cataract surgery Erectile dysfunction Social History: He is married. He has 3 children between the ages of 20-30. He works for NSTAR and does have a history of asbestos exposure. He smoked 2-1/2 packs per day for 20 years, but quit 10 years ago. He does not drink alcohol. Family History: There is no family history of breast, ovarian, uterine, colon, or lung cancer. His brother did have pancreatic cancer at the age of 70. His mother died at age 83. He does not know of any specific medical problems that she had. His father died at age 52 of a myocardial infarction. He also had a sister who died of an aneurysm. Physical Exam: VITAL SIGNS: Temperature 98.8, pulse 72, blood pressure 98/65, respiratory rate 16, oxygen saturation 95% on room air, height 68 inches, and weight 193.8 Lbs. GENERAL: Well-nourished, well-developed gentleman in no apparent distress, alert and oriented x3 with an obvious tremor. HEENT: Surgical scar on the cranium. EOMI. PERRL. Sclerae are anicteric. Oropharynx and nasopharynx free of mucosal abnormality. Tongue midline. Palate elevates symmetrically. Trachea is midline. NECK: Supple and nontender without mass. Thyroid is of normal size. LUNGS: Clear to auscultation and percussion. Chest excursion is symmetric and good. There is no tactile fremitus or gapping. There is no spine or CVA tenderness. BACK: There is a healed median sternotomy scar. HEART: Regular rate and rhythm without murmur, rub, or gallop. There is no JVD, PMI is normal position. GI: Soft, nontender, nondistended, without mass or hepatosplenomegaly. There is a well-healed scar from his cholecystectomy. NEUROLOGIC: Strength is symmetric and intact. Sensation is symmetric and intact. There is a obvious tremor. Gait is slow but symmetric. LYMPH NODES: No supraclavicular, cervical or axillary lymphadenopathy. EXTREMITIES: No clubbing, cyanosis, or edema. There is some facial erythema. Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2150-7-30] 10:45AM 36.1* BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [2150-7-29] 10:26AM 311 MISCELLANEOUS HEMATOLOGY ESR [2150-7-29] 06:10AM 113* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2150-8-2] 04:43AM 3.9 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [2150-7-31] 07:00AM 143* OTHER ENZYMES & BILIRUBINS Lipase [2150-7-31] 07:00AM 165* CPK ISOENZYMES CK-MB MB Indx cTropnT [2150-7-24] 10:50PM 15* 1.3 <0.011 ART 1 <0.01 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI [2150-7-24] 02:40PM 5 <0.011 ADDED TNT,CK,CPIS [2150-7-24] 5:08PM 1 <0.01 [Month/Day/Year 706] Final Report CHEST (PA & LAT) [2150-7-31] 10:36 AM Reason: eval for interval change [Hospital 93] MEDICAL CONDITION: 55 year old man with s/p vats RLL REASON FOR THIS EXAMINATION: eval for interval change INDICATION: Evaluation for interval change. FINDINGS: There is mild improving apical right pneumothorax. There has been interval increase in right lower lobe atelectasis. However, the subpulmonic effusion is stable. Left lung is clear. Heart, mediastinum and hilar contours are normal. The patient is status post sternotomy. IMPRESSION: Improving small right apical pneumothorax.Worsening right basilar atelectasis CT HEAD W/ & W/O CONTRAST [2150-7-28] 10:21 AM Reason: please eval for etiology Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 55 year old man with aggitation altern w/ episode sedation; s/p cerebellar tumor resection '[40] REASON FOR THIS EXAMINATION: please eval for etiology CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 55-year-old man with agitation alternating with sedation. Status post cerebellar tumor resection in [2140]. Please evaluate for etiology. TECHNIQUE: CT scan of the head prior to and following administration of IV contrast. COMPARISON: MR of the head with and without contrast from [2150-6-20]. FINDINGS: There is no evidence of acute intracranial hemorrhage or major vascular territorial infarcts. [Doctor Last Name ]-white matter differentiation is preserved. There is hypoattenuation of the periventricular white matter consistent with chronic microvascular disease. The ventricles are mildly enlarged and the sulci are prominent for the patient's age, consistent with atrophy. The fourth ventricle is enlarged from patient's previous cerebellar resection. The superior vermis appears to be resected. The visualized paranasal sinuses are clear. There are no soft tissue or bony abnormalities. IMPRESSION: 1. No acute intracranial abnormality. 2. Evidence of prior cerebellar resection of the superior vermis resulting in enlargement of the fourth ventricle. 3. Periventricular white matter disease. Cardiology Report ECG Study Date of [2150-7-28] 8:40:14 AM Sinus rhythm First degree A-V delay Left atrial abnormality Intraventricular conduction delay Inferior infarct, age indeterminate Diffuse ST-T wave abnormalities - cannot exclude ischemia - clinical correlation is suggested Since previous tracing of the same date, no significant change Read by: [Last Name (LF) ],[First Name3 (LF) 177] W. Intervals Axes Rate PR QRS QT/QTc P QRS T 69 [Telephone/Fax (2) 97846] 23 -7 Brief Hospital Course: Mr. [Known lastname 37080] was taken to the operating room where he underwent flexible bronchoscopy, VATS right lower lobe wedge resection, followed by a VATS right lower lobectomy and mediastinal lymph node dissection. He was initially extubated, however in the PACU, he developed hypotension requiring pressors, and progressive respiratory acidosis requiring reintubation for airway protection and repeat flexible bronchoscopy. He was transferred in stable condition to the thoracic intensive care unit. He recovered quickly with improving respiratory status and was weaned off of pressors. He was weaned from the ventilator and extubated without complication on the morning of post-operative day #1 ([2150-7-25]). Despite being awake and alert he developed agitation and confusion requiring a 1:1 sitter, but he continued to improve clinically, and was transferred to the floor on [2150-7-27]. His chest tubes were pulled later that afternoon without incident. He experienced several short burst of ventricular tachycardia on post-operative day #4 which were asymptomatic and not hemodynamically significant. He was evaluated by the cardiology service for possible AICD placement, however these episodes did not recur, and it was decided to revisit the issue once his mental status cleared. In addition, he was evaluated by the neurology service for his confusion and agitation. CT of the head did not demonstrate any acute abnormality. Mr. [Known lastname 37080] continued to improve both clinically and mentally. He began to get out of bed and ambulate with the assistance of physical therapy, and his mental status gradually cleared to the point where he no longer required a sitter or other supervision. He is currently doing well and ready for discharge to the rehabilitation facility. He will require cardiac follow up for his dysrrhytmia with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] electrophysiology at [Hospital1 18]. Medications on Admission: AMIODARONE 200 MG--One by mouth qd; brand name ASPIRIN 81MG--One by mouth every day ATENOLOL 25MG--Half a tablet by mouth every day FLEXERIL 10 mg--1 tablet(s) by mouth at bedtime GEMFIBROZIL 600 MG--One tablet by mouth twice a day IMDUR 30MG--Every day KLONOPIN 0.5 mg--1 tablet(s) by mouth twice a day as needed for anxiety LEVOXYL 75MCG--One by mouth every day PAXIL 40MG--One by mouth qd; brand name ZESTRIL 10MG--One by mouth every day ZOCOR 40MG--One by mouth every day Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache. 2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 12. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 13. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [Hospital1 ] (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Hypertension, Coronary artery disease s/p MI & CABG '[39], CHF (EF20-30%), Cerebellar tumor s/p resection '[40], tremor, anxiety, ^cholesterol, avascular necrosis R humerus s/p Right shoulder surgery x2, s/p cholecystectomy. T1/N1/Mx Lung Adenocarcinoma Discharge Condition: deconditioned- requires pulmonary hygeiene and physical rehab. Discharge Instructions: Call Dr.[Name (NI) 2347]/Thoracic Surgery office [Telephone/Fax (1) 170] for any post- surgical issues including: fever, shortness of breath, chest pain, productive cough. Followup Instructions: Please call the Thoracic Oncology Office at [Telephone/Fax (1) 170] to arrange a follow-up appointment with Dr. [Last Name (STitle) ]. Provider: [Name10 (NameIs) 706] MRI Phone:[Telephone/Fax (1) 327] Date/Time:[2151-4-15] 7:30 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 6781], [Name12 (NameIs) 280] Phone:[Telephone/Fax (1) 1844] Date/Time:[2151-4-15] 9:00 please f/u with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] (cardiology) for possible AICD placement [Telephone/Fax (1) 2934] Completed by:[2150-8-6]	[ "4280", "4019", "V4581" ]
Admission Date: [2104-2-13] Discharge Date: [2104-2-18] Date of Birth: [2030-7-16] Sex: F Service: MEDICINE Allergies: Ketek Pak / Augmentin / Lisinopril / Cozaar / Norpace Attending:[First Name3 (LF) 4327] Chief Complaint: Palpitations/fatigue Major Surgical or Invasive Procedure: Atrial Flutter Ablation [2104-2-13] History of Present Illness: Mrs. [Known lastname 95052] is a 73 year old woman with a history of ASD repair in [2065], hypertension, hyperlipidemia, atrial flutter (on coumadin) who was admitted for an atrial flutter ablation and developed complications of an RP bleed with hypotension, now improved. She had been diagnosed with atrial flutter since [2095] and since then has had intermittent palpitations. Lately she developed worsening fatigue secondary to the a flutter as well as the medications for a flutter and therefore elected to undergo an ablation. . In the EP lab, she underwent a successful ablation and seemed to tolerate the procedure well. After the procedure, the patient developed acute hypotension. EKG revealed inferior ST elevations and so she went to the cath lab which revealed an incidental 80% D1 lesion as well as a total obstruction of a very small distal LCx - no intervention was done. Her ST elevations resolved on their own, however, a HCT showed a drop to 24 from 37 preprocedure. CT abdomen/pelvis revealed a retroperitoneal bleed, so she was urgently admitted to the CCU. The massive transfusion protocol was activated and she received 4 units of PRBCs, and 4 units of FFP. Her HCT corrected to 32.8 and INR to 1.8. She was also given lasix 20mg IV for mild CHF, which responded well. Vascular was consulted who recommended correcting the coagulopathy, and holding pressure until INR was 1.5 or less. . On the floor, she noted some recurrent wheezing, dry mouth, and groin pain where we are holding pressure. . 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, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: - Hypertriglyceridemia - Hypertension 2. CARDIAC HISTORY: - Atrial flutter/fibrillation s/p DCCV ([2-/2101]) 3. OTHER PAST MEDICAL HISTORY: - Subclinical hypothyroidism - Allergic rhinitis - Osteopenia - s/p ASD repair ([2065]) Social History: Born and raised in [Location (un) 1468]. Married with 2 kids. No grandchildren. Retired secretary. Smoked 2 packs per day from age 20-40. No EtOH. Goes to the gym and does yoga, spinning, muscle conditioning, and aerobics. Family History: Mother and father both with some type of CA when elderly. No significant cardiac history. Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: VS: 97 82/50 73 21 99%RA GENERAL: Agitated elderly woman in moderate distress HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with normal JVP CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Cool extremities. No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 1+ Left: DP 1+ Pertinent Results: LABS ON ADMISSION: [2104-2-13] 07:35AM BLOOD WBC-6.4 RBC-4.35 Hgb-13.9 Hct-40.9 MCV-94 MCH-32.0 MCHC-34.0 RDW-12.6 Plt Ct-178 [2104-2-13] 07:35AM BLOOD Neuts-69.5 Lymphs-22.2 Monos-5.8 Eos-1.7 Baso-0.7 [2104-2-13] 07:35AM BLOOD PT-28.0* INR(PT)-2.7* [2104-2-13] 07:35AM BLOOD Plt Ct-178 [2104-2-13] 07:35AM BLOOD Glucose-102* UreaN-10 Creat-0.6 Na-141 K-4.5 Cl-105 HCO3-28 AnGap-13 [2104-2-13] 06:30PM BLOOD Calcium-7.4* Phos-5.3# Mg-1.6 CARDIAC ENZYMES: [2104-2-13] 02:45PM BLOOD CK-MB-3 cTropnT-0.51 [2104-2-13] 06:30PM BLOOD CK-MB-6 cTropnT-0.86* [2104-2-14] 02:24AM BLOOD CK-MB-30* MB Indx-9.6* cTropnT-1.17* [2104-2-14] 10:54AM BLOOD CK-MB-47* MB Indx-8.8* cTropnT-1.69* [2104-2-14] 03:59PM BLOOD CK-MB-37* MB Indx-7.0* cTropnT-1.60* Micro: [2104-2-15] 4:52 pm URINE Source: CVS. FINAL REPORT [2104-2-16] URINE CULTURE (Final [2104-2-16]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Imaging: [2-13] TTE: No atrial septal defect is seen by 2D or color Doppler. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. IMPRESSION: Low-normal LV systolic function. The inferior wall motion is probably normal. The right ventricle appears mildly dilated/hypokinetic. No ASD/PFO seen but cannot exclude on basis of this study. [2-13] CT Abd/Pelvis: MPRESSION: 1. Large hematoma extending along the left pelvic sidewall into the preperitoneal and subperitoneal space surrounding the bladder 2. Small amount of ascites 3. Cholelithiasis without cholecystitis. [2-14] TTE: The left atrium is elongated. The right atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the apical inferior and apical lateral segments. 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 are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Mild focal LV systolic dysfunction (consistent with known PDA occlusion). Normal size and function of right ventricle. No significant valvular abnormality seen. [2-14] CXR: IMPRESSION: 1) Increase in vascular congestion with lower lung volumes and new right basilar atelectasis. No pleural effusion is seen. 2) No pulmonary edema. [2-14] Renal US: RENAL ULTRASOUND: The right kidney measures 10.4 cm and the left kidney measures 10.9 cm. There is no hydronephrosis, mass or stone. The parenchymal echogenicity is symmetric bilaterally. In the upper pole of the right kidney, there is a 9 x 8 x 7 mm anechoic avascular cyst. This study was performed with a decompressed urinary bladder. In the suprapubic region at the midline, there is a 10 cm fluid collection with some solid components presumed to be the retroperitoneal hemorrhage. IMPRESSION: No evidence of hydronephrosis. Brief Hospital Course: 73 year old woman with a history of ASD repair in [2065], hypertension, hyperlipidemia, atrial flutter (on coumadin) who was admitted for an atrial flutter ablation and developed complications of an RP bleed with hypotension and STEMI secondary to PDA ablation. . ACTIVE DIAGNOSES: . # ST elevation MI: Patient was found to have posterior STE on EKG. At cath, she was found to have tight distal PDA lesion likely secondary to ablation. Patient was asymptomatic despite persistent ST elevations. TTE showed mild focal LV systolic dysfunction (consistent with known PDA occlusion), normal size and function of right ventricle, and no significant valvular abnormality. Patient was eventually restarted metoprolol succinate 50mg daily, Atorvastatin 80, ASA 81 mg PO daily, Coumadin 2mg daily. She was not started on an ACEi or [Last Name (un) ] as patient is allergic. # Atrial flutter: Now resolved s/p ablation. She was restarted on metoprolol when her blood pressure could tolerate it, and was started on Amiodarone 200mg PO BID x2 weeks, then 200mg PO daily x1-2 months. # RP bleed: The patient was found to be hypotensive after her aflutter ablation, secondary to acute blood loss from retroperitoneal bleed as confirmed by CT abdomen/pelvis. This bleeding resolved with aggressive blood transfusions and FFP. Hct stabilized 12 hours after bleed at a hct of 30, and there was no evidence of persistent bleeding. Patient did experience abd and back pain, likely secondary to irritation from bleeding. Pain from irritation from bleeding was controlled with oxycodone as needed and a lidocaine patch. Her anticoagulation was reversed at the time of RP bleed, but Coumadin was eventually restarted, initially at half home dose (2mg) and then titrated to meet INR goal [2-1]. # Dyspnea/wheezing: After the multiple transfusions, the patient developed wheezing on exam and dyspnea that worsened on lying flat. Most likely etiology of dyspnea is secondary to pulmonary edema due to aggressive volume resuscitation during RP bleed. Patient was diuresed a total of ~2L during length of hospital stay. Upon discharge, she was breathing comfortably and her oxygen saturation was well-maintained on room air. # Leukocytosis: Mild up to 12, has been up to 13 before, most likely secondary to stress. Differential showed no bandemia. Patient remained afebrile, with no cough, dysuria or other focal symptoms. Urine and blood cultures showed no growth. Leukocytosis eventually resolved. . CHRONIC DIAGNOSES: . # HLD: Patient was continued on Atorvastatin 80. # Subclinical hypothyroidism: Last T4 was normal and pt without sx of hypothyroidism. Medications on Admission: METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 100 mg Tablet Extended Release 24 hr - 2.5 (two and a half) Tablet(s) by mouth once a day WARFARIN - (Prescribed by Other Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) 73] - 2 mg Tablet - 2 (Two) Tablet(s) by mouth once a day/afternoon Medications - OTC CALCIUM CARBONATE [TUMS] - (Prescribed by Other Provider; OTC) - Dosage uncertain CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) - 1,000 unit Capsule - 1 (One) Capsule(s) by mouth once a day MULTIVITAMIN - (Prescribed by Other Provider; OTC) - Tablet - 1 Tablet(s) by mouth daily Discharge Medications: 1. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: Two (2) Tablet, Chewable PO once a day. 3. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 4. warfarin 2 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM. 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 10. 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 11. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:30 Adhesive Patch, Medicated(s) Refills:0 12. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for Pain. Disp:30 Tablet(s) Refills:0 13. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: PRIMARY: 1. atrial flutter ablation 2. retroperitoneal bleed 3. myocardial infarction secondary to RF catheter ablation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname 95052], You were admitted to the hospital for a procedure called atrial flutter ablation. You developed a complication, and had bleeding into the back (retroperitoneal bleed). During this event, you had a small heart attack. This was managed with maximal medical therapy. You received blood products for your bleeding, and stabilized. MEDICATION CHANGES: - START amiodarone to control your heart rate - Decrease warfarin to 3mg daily - Decrease metoprolol succinate to 100 mg daily - START lipitor (Atorvastatin) to help prevent heart attacks and help the current heart attack heal - START amiodarone to help prevent further episodes of unstable rhythm - START aspirin to help prevent heart attacks and help the current heart attack heal - START lidocaine patches for pain control - START oxycodone as needed for pain control - START senna as needed for constipation - START colace for bowel control - START tylenol as needed for pain Please seek medical attention for worsening symptoms. Followup Instructions: Unfortunately we were unable to make a post-discharge appointment for you with your primary care provider. [Name10 (NameIs) 357] call Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 10813] to follow up, we would ideally like you seen within 1 week. If you encounter problems making a quick appointment call [Telephone/Fax (1) 72722]. Department: CARDIAC SERVICES When: THURSDAY [2104-3-13] at 1:40 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 11899], 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: CARDIAC SERVICES When: MONDAY [2104-4-7] at 10:40 AM With: [Doctor First Name 900] [Name8 (MD) 901], M.D. [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: THURSDAY [2104-4-24] at 2:20 PM With: [Doctor First Name 900] [Name8 (MD) 901], M.D. [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "9971", "4019", "2720", "V5861" ]
Admission Date: [2194-11-17] Discharge Date: [2194-11-20] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1481] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a [Age over 90 ]-year-old gentleman who is s/p a right colectomy for cecal adenocarcinoma on [2194-10-28] with Dr. [Last Name (STitle) ]. He was discharged to rehab on [2194-11-5]. Per daughter he was having low blood pressures and constipation at rehab. He returns now with difficulty breathing and coughing. In the ED he is requiring 15L NRB. Past Medical History: # Right colecomy [2194-11-5] # Hemophilia C: diagnosed in [2194-4-24] # hypertension # valvular CHF: TEE [2194-6-24]: Severe, possibly flail TR, moderate AS, severe MR, EF 65-75%, PAP of 35 # question of prior rheumatic fever # glaucoma # BPH, s/p TURP. # bacteremia of unknown source c/b C.diff colitis ([2194-5-24], [Hospital1 112]) # hernia repair x 3 # Hip and Shoulder Surgery 3yrs ago Social History: - Tobacco: past history of 3ppd (stopped 50-60yrs ago) - Alcohol: rare and small amounts per family (pt says not at all) - Ambulates with walker. Supportive and involved children. Family History: non-contributory Physical Exam: Vitals - not collected, pt 98 at 0400 Gen - A&O x 3, NAD Pulm - crackles bilat CV - atrial fibrillation with rate 120-150 Abd - soft, NTND, incision healing well, clean, dry, intact extrem - bilat lower extremity edema Pertinent Results: none Brief Hospital Course: The patient was admitted to the general surgery service on [2194-11-17] for treatment of a pneumonia. He was intubated on HD1 and started on broad spectrum antibiotics, which he tolerated well. Neuro: The patient received tylenol PO with good effect and adequate pain control. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. During HD 1 he was placed brifly on an esmolol drip and after a brief episode of bradycardia he converted to sinus rhythm. On HD 3 he declined further care and was made CMO, his atrial fibrillation returned and at the time of discharge his heart rate was 120-150. Pulmonary: The patient was intubated on HD 1 but the ventillatoor was weaned and he remained on 4LNC throughout the remainder of his hospital stay. GI/GU: Fluids were kept to a minimum throughout this hospital stay because of his history of CHF. On HD 3 he was given a 10mg dose of lasix, which caused the patient to diurese nicely. he took minimal PO through this hospital stay. Foley was kept in place and the patient will be discharged to home with it for comfort. ID: The patient was started on IV vanc, cipro, cefapime, and flagyl upon admission. this was continued through HD 3, when the patient refused any further care. After HD 3 th epatient's temperature was watched closely and treated with tylenol PRN to provide comfort. Prophylaxis: The patient received subcutaneous heparin until HD 3. At the time of discharge on HD 4, the patient was afebrile abd his pain was well controlled. Given his decision to become CMO and to expire at his home among his family, a palliative care consult was obtained to maximize patient comfort while inhouse and hospice was set up for the patient. He will be discharged to [Last Name (un) ] on oxygen and suction, as well as pain medication to be administered by hospice via their protocol. Medications on Admission: finasteride 5mg q/day, gabapentin 300mg q/day, tramadol 50mg QHS, MVI, Fe, timolol gtt 0.5%, xalatan gtt 0.005% Discharge Medications: 1. Home Oxygen Please provide home oxygen, titrate for comfort per company protocol. 2. Suction Please provide suction device for patient per company protocol. 3. hyoscyamine sulfate 0.125 mg/mL Drops Sig: [1-25] PO every four (4) hours as needed for shortness of breath or wheezing. Disp:30 ml Refills:0 4. morphine concentrate 20 mg/mL Solution Sig: One (1) ml PO q1H as needed for pain. Disp:30 ml Refills:0 5. Lorazepam Intensol 2 mg/mL Concentrate Sig: One (1) ml PO every four (4) hours as needed: Please administer for agitation. Disp:30 ml Refills:0 Discharge Disposition: Home With Service Facility: Old [Hospital ] Hospice Discharge Diagnosis: Pneumonia Sepsis Atrial fibrillation with rapid ventricular response Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You have been admitted to the hospital for treatment of a pneumonia. You have decided to decline further medical treatment and receive hospice care. Please follow the instructions of the Hospice Liason taht will be providing further comfort care. Followup Instructions: Please feel free to follow up with Dr [Last Name (STitle) ] if you decide you want further medical care. His office number is [Telephone/Fax (1) 58832]. Completed by:[2194-11-20]	[ "0389", "51881", "5070", "99592", "4019", "4280", "42731", "41401" ]
Admission Date: [2139-11-28] Discharge Date: [2139-12-29] Date of Birth: [2074-2-1] Sex: F Service: MEDICINE Allergies: Penicillins / Ceftriaxone / Strawberry / Bleach Attending:[First Name3 (LF) 602] Chief Complaint: groin abcess, hypotension Major Surgical or Invasive Procedure: ERCP with stent placement IR procedure(percutaneous cholecystostomy tube placement) History of Present Illness: 65F w/ IDDM, ESRD, morbid obesity, and history of multiple line infections who recently had an I&D of a groin abscess on [11-24]. She presented to the ED today after undergoing HD at [Hospital 7137] per repacking of her abscess but was found to be hypotensive w/ sbps in the 80s. Ms. [Known lastname ] reports recent nausea and vomiting related to her abx (doxy and bactrim). She reports an undocumented fever past wednesday but none since. She has had a productive cough since yesterday with yellowish-brown sputum. She denies any CP, myalgias, pain. per the abscess she has been to the ED twice for dressing and reports improvement. She has a history of constipation and last moved her bowels a few days ago. She has some abdominal discomfort in that she feels bloated, and has localized TTP in the LLQ. No recent dx of diarrhea. In the ED, patient became hypotensive to 80/40, subjectively feels "not right" but no reports of dizziness (no change in symptoms from presentation). Given 250cc bolus of NS X 2. However, she was not felt to be fluid responsive and was started on levophed and central line was placed. Also labs came back acidotic with bicarb of 11, repeat 15 on green top. Her EKG demonstrated junctional rhythm at 62 bpms, LAD, NI, consistent with prior. She had a normal lactate. Was given cipro, flagyl,. CT Abdomen and CXR were "unremarkable". She recieved a total of 2L in ED. . In the MICU, she was vitally stable on a levophed drip. . Review of sytems: (+) Per HPI, + LLQ pain, constipation with last BM 3 days prior (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied shortness of breath. Denied chest pain or tightness, palpitations. Denied diarrhea. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - atrial tachycardia: seen by Dr. [Last Name (STitle) ] in [10-24] and felt to be atrial tachy [2-18] illness, no indication for ablation - hemorrhagic pericardial effusion - Bilateral internal jugular thromboses, restarted on coumadin [8-24] - h/o bilateral lower extremity DVT's - ESRD on HD T, Th, Sat - IDDM - Diastolic heart failure - Pulmonary hypertension - Hypercholesterolemia - OSA, noncompliant with CPAP as outpatient (on 2L home O2) - OA - h/o C. Diff - GERD - Depression - Morbid obesity - Fibroid uterus; vaginal bleeding - h/o Osteomyelitis at the T9 Vertebrae [5-24]; tx with Vanc - h/o Multiple line infections . Micro Hx: [2135-12-17]: Providencia, treated with 4 wk course of aztreonam [2135-4-17]: Staph coag positive, sensitive to both vancomycin and gentamicin [2136-5-17]: Staph bacteremia tx with vanc x 6 weeks [2136-8-17]: Proteius mirabilis and MSSA, treated with ceftaz and vanc Social History: Patient denies tobacco, alcohol or illicit drug use. She lives in a nursing home ([Hospital3 2558]) since the last 4 years. She is separated from her husband. She has 5 children in [Location (un) 86] [Doctor Last Name ] area. Family History: Two children with asthma. Otherwise non-contributory. Physical Exam: On Admission: Vitals: T: 99.4/37.4 BP: 86/58 P: 81 R:17 O2: 100% on 3L NC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley - well healing abscess Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly intact in all extremities Discharge exam: VS - Temp 98.5 F, 83 HR , 15 RR , 116/42 BP , 99 O2-sat % 2L GENERAL - obese woman NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - diminished breath sounds bilat, no r/rh/wh, poor air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/obese, ttp in RUQ with deep palpation, no masses or HSM, no rebound/guarding, +BS EXTREMITIES - WWP, no c/c, mild 1+ edema, 2+ peripheral pulses (radials, DPs), L sided femoral tunnelled dialysis catheter in place CDI SKIN - numerous SC calcifications in b/l LE LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [5-21] throughout, sensation grossly intact throughout, DTRs 2+ Pertinent Results: =================== LABORATORY RESULTS =================== On Admission: WBC-7.1 RBC-3.55* Hgb-11.8* Hct-40.0 MCV-113* RDW-14.0 Plt Ct-327 --Neuts-79.4* Lymphs-14.6* Monos-3.9 Eos-1.8 Baso-0.3 PT-34.1* PTT-34.3 INR(PT)-3.4* Glucose-102* UreaN-17 Creat-3.4# Na-137 K-6.0 Cl-111* HCO3-11* ALT-23 AST-24 AlkPhos-174* TotBili-0.2 Lipase-58 Calcium-9.9 Phos-6.0# Mg-1.9 On Discharge: [2139-12-29] 06:26AM BLOOD ALT-14 AST-11 LD(LDH)-137 AlkPhos-164 TotBili-0.2 [2139-12-29] 06:26AM BLOOD Glucose-111* UreaN-38* Creat-7.0# Na-135 K-4.8 Cl-97 HCO3-29 AnGap-14 [2139-12-29] 06:26AM BLOOD WBC-6.4 RBC-2.28 Hgb-7.2* Hct-24.3* MCV-107* MCH-31.7 MCHC-29.8* RDW-15.6* Plt Ct-337 ============= MICROBIOLOGY ============= Blood Culture * 3 [2139-11-29]: No Growth Urine Culture [2139-11-29]: URINE CULTURE (Final [2139-11-30]): GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. GRAM NEGATIVE ROD(S). ~[2128]/ML. Blood Cultures 1/3 [2139-12-1]: Blood Culture, Routine (Final [2139-12-4]): KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 8021] ([Numeric Identifier 8022]) REQUESTS SNESITIVITY TESTING TO AZTREONAM , TETRACYCLINE AND Tigecycline [2139-12-3]. Tigecycline = 2 MCG/ML = SENSITIVE, Tigecycline Sensitivity testing performed by Etest. AZTREONAM = RESISTANT. AZTREONAM & TETRACYCLINE sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE \| AMIKACIN-------------- 16 S AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- 8 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- I TETRACYCLINE---------- I TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R Aerobic Bottle Gram Stain (Final [2139-12-1]): Reported to and read back by [Doctor First Name ] [Doctor Last Name 10280] @ 1518 ON [12-1] - CC6D. GRAM NEGATIVE ROD(S). Urine Culture [2139-12-1]: URINE CULTURE (Final [2139-12-4]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 16 R CEFTRIAXONE----------- 8 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 4 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R Catheter Tip Culture [2139-12-1]: No Growth Blood Culture 3 [2139-12-3]: No Growth Bile Culture [2139-12-4]: GRAM STAIN (Final [2139-12-4]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2139-12-7]): ESCHERICHIA COLI. SPARSE GROWTH. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- 8 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 2 S MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R ANAEROBIC CULTURE (Final [2139-12-8]): NO ANAEROBES ISOLATED. Blood Culture 4 [2139-12-6]: No Growth ============== OTHER STUDIES ============== ECG [2139-11-28]: Possible junctional rhythm. Left anterior fascicular block. Compared to the previous tracing P waves are no longer visible suggesting junctional rhythm. The other findings are similar. CT Abdomen and Pelvis with Contrast [2139-11-28]: IMPRESSION: 1. Choledocholithiasis and stable dilated CBD to 12 mm. 2. No colonic diverticulitis. 3. Fibroid uterus. CT Chest W/Contrast [2139-11-29]: IMPRESSION: 1. Enlarged pulmonary artery in keeping with pulmonary hypertension. Moderate cardiomegaly. 2. Small bilateral pleural effusions with overlying consolidation and atelectasis within the lower lobes bilaterally. 3. Multinodular goiter with bilateral thyroid nodules. CT Right Lower Extremity With Contrast [2139-11-29] IMPRESSION: 1. Skin thickening and irregularity along the right inguinal fold at site ofprevious I&D. No evidence of abscess. 2. Fibroid uterus. 3. Moderate calcification of the common femoral, superficial femoral and profunda femoral arteries bilaterally. Femoral Line Placement and PTC [2139-12-4]: IMPRESSION: 1. Exchange of the left femoral temporary hemodialysis catheter with a new 14 French, 24 cm temporary hemodialysis catheter. The line is ready for use. 2. Placement of an 8 French internal-external biliary drainage catheter via a right posterior biliary duct with its retention pigtail loop in the duodenum. ERCP: Impression: A peri-ampullary diverticulum was present. A stent was seen extruding from the ampullary orifice - This corresponds to patient's known internal-external PTC drain. Cannulation of the biliary duct was successful and deep with a sphincterotome after a guidewire was placed. Contrast medium was injected resulting in complete opacification. A moderate diffuse dilation was seen at the biliary tree with the CBD measuring 15 mm. Several filling defects were seen in the CBD consistent with stones. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Balloon sphincteroplasty was then performed with a wire-guided CRE balloon and the ampulla/distal CBD was successfully dilated to 15 mm. Several balloon sweeps were then performed with successful extraction of two 8 mm stones. As the bile duct was very large and complete opacificiation was not possible, it was unclear whether there were any retained stones. Thus, a 5cm by 10FR dougle pigtail biliary stent was placed successfully. Recommendations: NPO overnight with aggressive IV hydration with LR at 200 cc/hr. Follow for response and complications. If any abdominal pain, fever, jaundice, gastrointestinal bleeding please call ERCP fellow on call ([Pager number 8437]) Further management of PTC drain as per IR. Repeat ERCP in 1 month for stent removal and complete duct clearance. Pending Studies: Wound Swab Culture from [2139-12-29]. Brief Hospital Course: 65 yo woman presenting from nursing facility with recent well-healing groin abcess, admitted with cholangitis, Klebsiella bacteremia, septic shock, and hypercarbic respiratory failure. Hospital course was also notable for deep venous thrombosis. #Cholangitis/Klebsiella bacteremia/Septic Shock/Choledocholithiasis: Patient was admitted to the Medical Intensive Care Unit in septic shock requiring vasopressor support and found to have Klebsiella bacteremia. LFTs were normal, but an abdominal ultrasound showed a dilated common bile duct. Bedside ERCP was unsuccessful but a percutaneous biliary drain was placed and the patient improved with drainage and antibiotics and was able to be taken off vasopressors. Once the patient was hemodynamically stable a repeat ERCP was performed which was notable for choledocholithiasis and a sphincterotomy with stone extraction was performed and a biliary stent was placed. Patient completed a 2 week course of Meropenem prior to discharge. Patient will return for stent removal in one month from discharge. #Hypercarbic Respiratory Failure/Obstructive Sleep Apnea: This was felt to be related to the patient's sepsis. She was intubated and then extubated when sepsis improved. Following treatment of her infection she was maintained on [1-18] L oxygen by nasal canula. Following second ERCP the patient did require transfer to ICU as anesthesia did not feeel comfortable extubating patient immediately after the procedure. She was extubated without incident however. She has obstructive sleep apnea and was instructed to wear her BIPAP at night once discharged. #Lower extremity Deep Venous Thrombosis/End stage Renal Disease on Hemodialysis: Patient was found to have left lower extremity DVT in the same leg as her femoral hemodialysis line. Given the patient's problems with access in the past, the decision after discussion with Nephrology was to keep the line in and continue anticoagulation. Since Coumadin was held for the patient's ERCP, the patient required a heparin gtt bridge to Coumadin until INR was therapeutic at goal [2-19]. This will be followed by providers at patient's extended care facility. #Groin abcess: The patient has a groin abcess, looked well healed. Wound care was consulted and followed the patient. On day of discharge there was pus noted from around the hemodialysis line. Renal was made aware and cultures were taken but the Renal team did not want to start empiric antibiotics. The cultures will be followed by outpatient Nephrology and antibiotics started as indicated. # Pruritis: Upon transfer to the [Hospital Ward Name ] prior to second ERCP, Ms. [Known lastname ] began to note pruritis of her back. There existed a maculopapular rash on the regions of her back which contact[Name (NI) ] her sheets. She remembers an allergy to bleach. Her pruritis improved with discontinuation of bleached sheets, sarna lotion, and a short course of topical clobetasol. She also was placed on miconazole power for fungal groin rash. . #DEPRESSION: Paxil was continued. #GERD: PPI was continued. #Hx of atrial tach: Amiodarone was continued. #Diabetes mellitus type 2: continued home NPH and ISS TRANSITIONAL ISSUES: - Patient is having intermittent vaginal bleeding, she should be evaluated by GYN as an outpatient for possible endometrial biopsy - Patient's left tunneled line was noted to have mild possibly purulent discharge at dialysis on [2139-12-29]. Cultures were obtained and will need follow up. There were however no other symptoms or signs of infection. Medications on Admission: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Bactrim DS 800-160 mg Tablet Sig: Two (2) Tablet PO at HD. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 7. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One (1) nebulizer Inhalation q8h:prn as needed for shortness of breath or wheezing. 8. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO once a day. 9. Insulin Please continue your previous insulin regimen of NPH 20 units qam and Novolog SS. 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. Paroxetine HCl 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. folic acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing. 5. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 11. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. 12. Outpatient Lab Work Please check daily INR and CBC on [12-31] to ensure that patient is therapeutic on warfarin and that hct is not downtrending (last Hct on discharge was 24.3). 13. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty (20) Subcutaneous qam. 14. insulin lispro 100 unit/mL Solution Sig: as directed by sliding scale Subcutaneous ASDIR (AS DIRECTED). 15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain/fever. 16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 19. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. 20. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 21. diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: One (1) PO Q8H (every 8 hours) as needed for itching. 22. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for pruritus. 23. Coumadin 1 mg Tablet Sig: Five (5) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: 1. Cholangitis 2. Respiratory failure 3. Diabetes Mellitus 4. End stage renal disease requiring dialysis 5. DVT Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname ], It was a pleasure taking care of you at [Hospital1 18]. You were admitted with a severe bacterial infection because of an obstruction of your bile ducts(cholangitis). You had a biliary drain(cholecystostomy) placed by interventional radiology to drain infected bile, but the drain was removed after a few days when you had the ERCP procedure. During the ERCP procedure, a stent was placed in your bile duct. The following changes have been made to your medications: START Warfarin for the clot in your leg (duration to be determined by your primary care physician) START benadryl as needed for itching START nephrocaps for nutrition START sarna lotion as needed for itching START miconazole as needed for itching or skin-based yeast infections Please make sure INR is checked on dialysis days for next two weeks to ensure that it is in therapeutic range. Followup Instructions: 1. You will be admitted to a medical acute care facility where a physician will continue to follow your care. 2. The gastroenterology department will be scheduling a follow up procedure(ERCP) and will contact you with the date/time. Department: TRANSPLANT CENTER When: MONDAY [2140-1-25] at 9:20 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1330], MD [Telephone/Fax (1) 673] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "2762", "4280", "5990", "2767", "99592", "V5867", "32723", "2720", "78552", "51881" ]
Admission Date: [2148-4-26] Discharge Date: [2148-5-3] Date of Birth: [2071-3-19] Sex: F Service: CARDIAC SURGERY CHIEF COMPLAINT: Worsening ejection fraction HISTORY OF PRESENT ILLNESS: Ms. [Known lastname ] is a 77-year-old female with a past history of cardiac disease with an myocardial infarction in [2136]. She had a cardiac catheterization in [2140] and was found to have an RCA lesion which was stented. She also had a 40% lesion in the left main. She was followed with serial echocardiograms that showed worsening ejection fraction, now down to 20%. She was admitted to the hospital for cardiac catheterization. PAST MEDICAL HISTORY: 1. Pituitary tumor, status post XRT which caused hypothyroidism 2. Chronic obstructive pulmonary disease 3. Osteoarthritis 4. Positive PPD, treated with INH 5. INH induced hepatitis in [2134] 6. AVNRT with noted ablation 7. Spinal stenosis 8. Coronary artery disease 9. Hypertension 10. Hyperlipidemia PAST SURGICAL HISTORY: 1. Hernia repair ALLERGIES: None known. ADMISSION MEDICATIONS: 1. Aspirin 81 mg qd 2. Lipitor 40 mg qd 3. Unithroid 100 mcg qd 4. Neurontin 100 mg [Hospital1 ] 5. Prilosec 20 mg qd 6. Ultram 50 mg [Hospital1 ] 7. Toprol XL 25 mg qd 8. Azmacort inhaler 9. Atrovent inhaler 10. Norvasc 5 mg qd 11. Isosorbide mononitrate 20 mg [Hospital1 ] SOCIAL HISTORY: Two pack per day smoker for 40 years, quit 18 years ago. HOSPITAL COURSE: The patient was admitted to the hospital on [2148-4-26] on the medical service. She [Date Range 1834] a cardiac catheterization which revealed an 80% lesion in the LMCA with an ejection fraction of 20%. Cardiac surgery was consulted and decision for coronary artery bypass graft was made. Ms. [Known lastname ] [Last Name (Titles) 1834] a coronary artery bypass graft x1 on [2148-4-29] with a graft from the left internal mammary artery to LAD. Postoperatively, she had high output from the chest tube for which she was treated with replacement of blood products. Despite this, she continued to have high output and she had a total chest tube output of 1.4 liters. She was then taken back to the Operating Room emergently and was re-explored. Bleeding at the RIMA was noted which was repaired. The patient returned to CSR in stable condition. She was extubated on the [1-1]. She was then transferred on postoperative day 1 to the CCU. She continued to make good progress and was transferred to the regular floor on postoperative day 2. She made good progress over the next couple of days. Her pacing wires were discontinued on postoperative day 3. She is ambulating with physical therapy currently and is comfortable on po analgesics. She is now ready for discharge to a rehabilitation facility. DISCHARGE MEDICATIONS: 1. Lopressor 25 mg [Hospital1 ] 2. Lasix 20 mg qd for 1 week 3. KCL 20 milliequivalents qd for 1 week 4. Colace 100 mg [Hospital1 ] 5. Aspirin EC 325 mg qd 6. Plavix 75 mg qd 7. Flovent Metered dose inhaler 110 mcg 2 puffs [Hospital1 ] 8. Captopril 6.25 mg q8h 9. Levothyroxine 100 mcg qd 10. Combivent metered dose inhaler 2 puffs q4h 11. Protonix 40 mg qd 12. Tylenol 650 mg q 4 to 6 hours prn 13. Neurontin 100 mg [Hospital1 ] 14. Lipitor 40 mg qd FOLLOW UP: Primary care physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 1391], in two weeks and with Dr. [Last Name (STitle) 1537] in four weeks. DISCHARGE CONDITION: Stable [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Last Name (NamePattern1) 2209] MEDQUIST36 D: [2148-5-3] 08:52 T: [2148-5-3] 08:57 JOB#: [Job Number 94821]	[ "4280", "41401", "496", "4240", "4019" ]
Admission Date: [2107-9-2] Discharge Date: [2107-9-12] Date of Birth: [2078-9-6] Sex: F Service: MEDICINE Allergies: Cephalexin / Optiray 300 / Nut Flavor / Fruit Flavor / Erythromycin Base / Magnevist / Shellfish / iv contrast dye Attending:[First Name3 (LF) 2782] Chief Complaint: nausea, vomiting, abdominal pain Major Surgical or Invasive Procedure: EGD x 2 History of Present Illness: 28 yo F with a history of alcoholism, several episodes of acute alcoholic pancreatitis, transferred from OSH with 3 days of abdominal pain, nausea and vomiting. She reported that she had been on an alcohol binge for several days, last drink was 3 days prior. She had severe abdominal pain, worse than with prior episodes of pancreatitis. She was vomiting blood tinged emesis. Labs at OSH were notable for lipase of 1000. Patient had an episode of 300 cc of emesis with red blood streaks. Later in the evening, she vomited 1000cc of bright red blood with clots. Her hematocrit dropped from 33.6-28.8 over 4 hours and she received 1U PRBC and was transferred to [Hospital1 18] for further management. In the ED, initial vital signs were 97.7 79 123/80 16 97%. Labs notable for hematocrit 32. KUB was negative for free air. She was started on pantoprazole 80mg IV and given dilaudid for pain control. She had an episode of hematemesis. NG tube was placed and returned bright red blood. Patient was admitted to the MICU for further management. Vital signs prior to transfer were 98.2 104 142/98 18 98%. On arrival to the MICU, vital signs were BP 128/78 HR 123 O2 99% RA. Patient vomited 350cc of bright red blood with clots. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Past Medical History: - Acute alcoholic pancreatitis [6-2], [8-2], [2-2]- No history of pseudocysts - Alcohol abuse - Hematemesis- gastritis on EGD ([7-/2105], [1-/2106]) -HTN Social History: Lives in [Location 3786] with her mother. Used to work at [Hospital1 18] as a clinical auditor. - Tobacco: quit 2 years ago - Alcohol: last drink 3 days ago, h/o abuse for many years, as above - Illicits: denies Family History: Parents - alive, both with DM and HTN Both mother and father were alcoholics, her older brother is an alcoholic. Physical Exam: ADMISSION EXAM Vitals: BP 128/78 HR 123 O2 99% RA General: Well nourished female, actively vomiting HEENT: Sclera anicteric, NGT in place. Neck: supple CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: diffusely tender to mild palpation with guarding. GU: foley in place Ext: WWP, 2+DP/PT pulses b/l, no edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred DISCHARGE: VS - 98 99/64 60 18 98 RA GEN Alert, oriented, NAD HEENT NCAT MMM EOMI sclera anicteric, OP clear NECK supple, no JVD, no LAD PULM Good aeration, CTAB no wheezes, rales, ronchi CV RRR normal S1/S2, no mrg ABD Nontender till sudden voluntary guarding at end of deep palpation in all quadrants. soft, normoactive BS, ND, no organomegaly noted, no ascites EXT WWP 2+ pulses palpable bilaterally, no c/c/e NEURO CNs2-12 intact, motor function grossly normal SKIN no ulcers or lesions Pertinent Results: ADMISSION LABS [2107-9-2] 09:18PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.010 [2107-9-2] 09:18PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [2107-9-2] 09:18PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 [2107-9-2] 09:18PM URINE MUCOUS-RARE [2107-9-2] 09:00PM GLUCOSE-86 UREA N-6 CREAT-0.5 SODIUM-144 POTASSIUM-4.1 CHLORIDE-111* TOTAL CO2-12* ANION GAP-25* [2107-9-2] 09:00PM estGFR-Using this [2107-9-2] 09:00PM ALT(SGPT)-23 AST(SGOT)-119* ALK PHOS-73 TOT BILI-0.3 [2107-9-2] 09:00PM LIPASE-901* [2107-9-2] 09:00PM ALBUMIN-4.2 CALCIUM-7.2* PHOSPHATE-3.3 MAGNESIUM-1.5* [2107-9-2] 09:00PM WBC-6.4 RBC-3.28* HGB-10.3* HCT-32.2* MCV-98# MCH-31.4 MCHC-31.9 RDW-14.7 [2107-9-2] 09:00PM NEUTS-85.9* LYMPHS-10.3* MONOS-3.2 EOS-0.4 BASOS-0.3 [2107-9-2] 09:00PM PLT COUNT-111# [2107-9-2] 09:00PM PT-13.5 PTT-29.3 INR(PT)-1.3* DISCHARGE: [2107-9-12] 07:50AM BLOOD WBC-7.2 RBC-3.24* Hgb-9.7* Hct-30.2* MCV-93 MCH-30.0 MCHC-32.2 RDW-14.4 Plt Ct-613* [2107-9-12] 07:50AM BLOOD Glucose-117* UreaN-11 Creat-0.5 Na-139 K-3.7 Cl-104 HCO3-24 AnGap-15 [2107-9-12] 07:50AM BLOOD Lipase-251* [2107-9-12] 07:50AM BLOOD Calcium-9.4 Phos-4.9* Mg-1.9 IMAGING/STUDIES: EGD [2107-9-3]: Impression: [Doctor First Name ]-[Doctor Last Name ] tear (injection, endoclip) Esophagitis Granularity and erythema in the stomach body Otherwise normal EGD to third part of the duodenum CT ABD/PELVIS W/O CONTRAST: 1. No abdominal/retroperitoneal hemorrhage. 2. Ill-defined peripancreatic stranding is compatible with patient's known history of pancreatitis. No peripancreatic fluid or fluid collection to suggest peripancreatic hemorrhage or pseudocyst formation. This unenhanced exam is limited for the evaluation of necrotizing pancreatitis. 3. Hepatomegaly with diffuse hepatic steatosis. 4. Internal contents of the gallbladder measure 23 [Doctor Last Name ], intermediate density, and may represent sludge. 5. Normal caliber bowel loops and appendix. Normal terminal ileum. Brief Hospital Course: 28 yo F with h/o alcoholism, multiple episodes of acute pancreatitis, presenting with acute pancreatitis and hematemesis from two [Doctor First Name 329] [Doctor Last Name ] tears. # Hematemesis- On admission the patient was admitted to the Medical ICU and underwent an emergent EGD which showed [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] tears likely secondary to profuse vomiting over last 3 days and no evidence of portal gastropathy. She continued to have melenatotic stools with no evidence on CT scan of retroperitoneal bleed and underwent a repeat EGD on [9-5] which showed while one clip was intact, the other had come off and there was a clot on that tear. She was treated with PPI drip x 24 hours and then switched to po BID. She received 5units of pRBC between [9-3] and [9-5]. She was called out of the ICU and remained stable on the med floor. However, she took a long time before she started tolerating POs but was tolerating a regular diet and her exam, while still tender, was back at baseline. The pt refused both CT w/ contrast w/ premedication for her allergy as well as MRI as did not believe they would be useful and did not want to have her lip piercing taken out. She was counselled to have the test done as an outpt. # Alcoholic pancreatitis- BISAP score 0. Patient has a history of 3 prior episodes of alcoholic pancreatitis requiring hospitalization, last in 1/[2106]. Past imaging has been negative for cholelithiasis and pseudocysts. She was treated with aggressive IV hydration, vitamins and was NPO and diet was advanced to clears and then to regular diet before dc. She tolerated regular diet for several days prior to dc. # Thrombocytopenia- Platelets drop >50% from last check in [2106]. In the ICU this was stable and was not further worked up. It is likely due to her alcohol use. Was 613 at time of dc. # Alcohol abuse- she has significant alcohol abuse. She was monitored on a CIWA scale for the first 3 days of her admission. Social work was consulted and recommended rehab. The pt was set up to see rehab as an outpt. TRANSITIONAL ISSUES: 1. THE PT NEEDS [Name (NI) 36068] WITH OUTPT RESIDENT PCP (DR [Last Name (STitle) ]); IS SEEING NP THIS WEEK 2. DURATION OF PPI NEEDS TO BE READRESSED BY GI DOCTOR 3. ALCOHOL ABUSE COUNSELIING AND RESOURCES NEED TO BE PROVIDED 4. CT W/ CONTRAST OR MRI SHOULD BE CONSIDERED AS OUTPT IF STILL HAVING PAIN Medications on Admission: none Discharge Medications: 1. Pantoprazole 40 mg PO Q12H RX pantoprazole 40 mg 1 tablet(s) by mouth Q12 Disp #60 Tablet Refills:0 2. Sucralfate 1 gm PO QID Please start on [2107-9-6] RX Carafate 1 gram 1 tablet(s) by mouth four times a day Disp #80 Tablet Refills:0 3. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN PAIN RX oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth Q8 Disp #15 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: [Doctor First Name ] [Doctor Last Name ] TEAR ACUTE PANCREATITIS ALCOHOL ABUSE Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms [Known lastname 36069], You were admitted to [Hospital1 18] for vomitting up blood which was found to be due to a tear in your esophagus likely due to your alochol intake. You got an endoscopy which clipped your esophageal tears. You were treated medically and improved slowly after several days of bowel rest and intravenous fluids. Followup Instructions: Department: [Hospital3 249] When: THURSDAY [2107-9-15] at 10:20 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 15353], NP [Telephone/Fax (1) 2010] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [2107-10-5] at 8:30 AM With: [First Name4 (NamePattern1) 1386] [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	[ "2762", "2851", "2875" ]
Admission Date: [2113-8-7] Discharge Date: [2113-8-10] Date of Birth: [2069-12-1] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2704] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [2113-8-7] Catherization for Anterior STEMI (3VD, LAD 99%): Cypher drug eluting stent in proximal LAD History of Present Illness: 43 y/o Caucasian man s/p stent [2105] presented to [Hospital1 5979] ED c/o jaw pain beginning 40 minutes prior to presenting to OSH. Pt reports having 2 alcoholic beverages and later had burning in his chest which felt like "heart burn". Pt reports burning in jaw bilaterally and mild diaphoresis. He denied CP, arm pain, or shortness of breath. Pt denies anginal episodes or CP since intervention in [2105]. In [Hospital3 ] ED an EKG show ST elevation in the anterior leads, V1-V5 and ST depression in II, III, and aVF. Pt went into Vfib arrest, shocked (200J, 300J, 360J) and started on amiodarone gtt, integrillin gtt and transferred to [Hospital1 18] cath [Hospital1 ]. Past Medical History: CAD s/p PCI [2105] Social History: Tobacco: 0.5 pack X 15 years EtOH: 1qwk Limited exercise Publisher of a magazine, lives in [Location 5028] with wife Family History: Mother w/ CAD Physical Exam: Physical Exam (on admission) VS T97.1 P76 BP124/69 RR20 O2Sat88%4LNC->93% on face tent GENERAL: NAD, lying flat in bed w/ face tent, speaking in complete sentences. HEENT: PERRL, EOMI, MMM NECK: Supple, JVP 7cm, CARDIOVASCULAR: S1, S2, Reg, no murmurs LUNGS: CTAB by anterior exam only due to sheath in place ABDOMEN: Active bowel sounds, obese, soft, NT, ND, no HSM. EXTREMITIES: DP/PT 2+ bilat. Cool feet bilat. Otherwise, UE warm, well-perfused. NEURO: A/OX3, strength and sensation grossly intact Pertinent Results: [2113-8-7] 11:02PM BLOOD WBC-19.3* RBC-4.48* Hgb-14.5 Hct-41.4 MCV-92 MCH-32.4* MCHC-35.1* RDW-13.2 Plt Ct-352 [2113-8-7] 11:02PM BLOOD Glucose-151* UreaN-15 Creat-1.0 Na-142 K-4.0 Cl-111* HCO3-20* AnGap-15 [2113-8-7] 11:02PM BLOOD ALT-97* AST-194* LD(LDH)-439* CK(CPK)-2665* AlkPhos-72 TotBili-0.7 . [2113-8-8] 06:20AM BLOOD CK(CPK)-3863* [2113-8-8] 01:00PM BLOOD CK(CPK)-3442* [2113-8-9] 06:31AM BLOOD CK(CPK)-1792* . [2113-8-7] 11:02PM BLOOD CK-MB-319* MB Indx-12.0* cTropnT-3.44* [2113-8-8] 06:20AM BLOOD CK-MB-461* MB Indx-11.9* cTropnT-7.30* [2113-8-8] 01:00PM BLOOD CK-MB-308* MB Indx-8.9* cTropnT-7.23* [2113-8-9] 06:31AM BLOOD CK-MB-47* MB Indx-2.6 cTropnT-4.38* . [2113-8-7] 11:02PM BLOOD Calcium-8.4 Phos-2.4* Mg-1.8 [2113-8-8] 06:20AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.2 [2113-8-9] 06:31AM BLOOD Calcium-8.3* Phos-2.3* Mg-1.7 . [2113-8-7] 09:35PM BLOOD Type-ART O2 Flow-10 pO2-57* pCO2-37 pH-7.33* calHCO3-20* Base XS--5 Intubat-NOT INTUBA Comment-NON-REBREA [2113-8-9] 06:31AM BLOOD WBC-13.6* RBC-3.98* Hgb-12.6* Hct-36.7* MCV-92 MCH-31.8 MCHC-34.4 RDW-13.5 Plt Ct-243 . [2113-8-7] ECG Sinus rhythm. There are Q waves in leads VI-V2 with ST segment elevations of one to two millimeters in leads I, aVL and VI-V5 consistent with acute extensive anterolateral myocardial infarction. Generalized low QRS voltage. ST segment depression in leads III and aVF with inverted T waves consistent with reciprocal changes. No previous tracing available for comparison. Clinical correlation is suggested. . [2113-8-7] Cath Report FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Elevated right and left sided filling pressures. 3. Successful treatment of proximal LAD with drug-eluting stent. 4. Successful treatment of ostial D1 with balloon angioplasty. . [2113-8-8] ECHO Conclusions: The left atrium is mildly elongated. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with hypokinesis of the disal half of the anterior septum and anterior walls and of the distal anterior and inferior walls. The apex is near akinetic. The remaining segments contract well. No intraventricular thrombus is seen and the apex is not focally aneurysmal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . IMPRESSION: Regional left ventricular systolic dysfunction c/w CAD (mid-LAD lesion). Mild mitral regurgitation. EF 35%-40% Brief Hospital Course: 43M 3V CAD here w/ anterior STEMI, s/p successful LAD cypher stent. * Ischemia: The patient underwent cardiac catheterization which showed 3 vessel disease. A drug eluting stent was placed in the proximal LAD. The patient had 2 vessel unrevascularized disease, and which may require a re-look once he stabilizes. His enzymes were cycled until they trended downward. His trop peaked at 7.30. At discharge it was 4.38. The [Hospital 228] medical management consistent of the following: integrillin X 18 hrs, ASA 325, Plavix 75, Lipitor 80, Metop 12.5 TID advanced to Toprol 100 at discharge and lisinopril 10mg daily.. * Pump: The patient's cardiac index in the cath [Hospital ] was 1.8, this was of unclear etiology. He received lasix for diuresis in cath [Hospital ] due to PCWP and PAD elevation and increasing O2 requirement. He received Lasix overnight with good response. An ECHO was later done to evaluate pump function and showed an EF on 35-40%, with an akinetic apex. The patient was anticoagulated with Heparin and Coumadin. At the time of discharge he was started on Lovenox. Other medical management included lisinopril 10 mg daily and Toprol 100 daily. * Rhythm: The patient maintained NSR throughout his course, but s/p VF at OSH(suspect ischemic). He was maintained on Amiodarone gtt initially and this was later discontinued. The patient was monitored on telemetry with no ectopy noted. K was kept >4 and Mg was kept >2. * Smoking cessation: The patient was counseled on the importance of smoking cessation as it pertained to his heart disease. * EtOH Use: The patient was kept on a CIWA scale. * High WBC: UA and CXR were negative. Cyst drainage on back prior to admission may have contributed to elevated wbc. The patient remained HD stable throughout his course. * FEN: Cardiac heart healthy diet. K was kept > 4 and Mg was kept > 2. * PROPHYLAXIS: SCDs while in bed. PPI. DISPOSITION: The patient was discharged home with VNA teaching for his Lovenox. He was scheduled to have his INR monitored at his PCPs office. The patient was chest pain free and hemodynamically stable at the time of discharge. Medications on Admission: none Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s)* Refills:2 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:2 5. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:30 Tablet Sustained Release 24HR(s) Refills:2 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 7. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous once a day: 100mg daily . Disp:14 syringes Refills:0 8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual PRN as needed for chest pain. Disp:30 Refills:2 9. Outpatient [Name (NI) ] Work Pt is on Coumadin. INR is 1.2 on discharge [2113-8-10]. Pt must have blood drawn on [2113-8-14]. INR therapeutic range is 1.5-2.0. Pt must have labs drawn every 2 days until therapeutic. Thereafter pt must have weekly blood draws. [Date Range ] results must be reported to PCP's office Dr. [First Name (STitle) 6164] 1-[Telephone/Fax (1) 64400] or 1-[Telephone/Fax (1) 64401]. Discharge Disposition: Home With Service Facility: [Hospital 2255] [Name (NI) 2256] Discharge Diagnosis: Myocardial infarction: Anterior ST elevation myocardial infarction Discharge Condition: Good Discharge Instructions: Pt has been instructed that he can drive and go back to work. He has been advised not to resume any type of strenuos activity. Pt has been instructed to call 911 immediately if he should have any chest discomfort, is diaphoretic, nauseous or becomes short of breath. Pt has been instructed to adhere strictly to medications and to a cardiac heart healthy diet. . VNA services has been set up to provide the patient with instruction on Lovenox. . Pt has been instructed to have blood draws initially every 2 days from date of discharge on [2113-8-14] until INR is therapeutic (1.5-2.0). Thereafter, pt has been instructed to have weekly blood draws. Therapeutic goal is 1.5-2.0 Followup Instructions: 1)Pt must follow up with Dr. [First Name (STitle) 6164] at [Hospital ] Medical Associates on [2113-8-14] at 9:15am.(1-[Telephone/Fax (1) 32949]). Pt also has an appointment at 8:30am with the [Telephone/Fax (1) ] to have his INR checked. The [Telephone/Fax (1) ] is located in the same building as Dr. [Last Name (STitle) 15321] office. 2)Pt must follow up with Dr. [First Name8 (NamePattern2) 487] [Last Name (NamePattern1) ] (cardiologist) in 3 months at [Hospital1 69]. Appt has been made for [11-21] @ 2:45pm. Location: [Hospital Ward Name 23] Building [Location (un) ], [Hospital Ward Name 516] Tel: (1-[Telephone/Fax (1) 920]). Completed by:[2114-9-1]	[ "41071", "41401", "V4582", "V1582" ]
Admission Date: [2177-9-21] Discharge Date: [2177-9-25] Date of Birth: [2118-11-18] Sex: M Service: MEDICINE Allergies: Demerol Attending:[Last Name (NamePattern1) 1572] Chief Complaint: cardiac arrest Major Surgical or Invasive Procedure: Cardiac Catheterization with placement of bare metal stent to LAD. History of Present Illness: 58 yo M with h/o MI no intervention and AFib on coumadin, presented after cardiac arrest that occurred while at gym this morning. Witnesses reported that he slumped over and had labored breathing. CPR was initiated and AED placed on patient and he received shock for "wide complex tachycardia." He was combative with EMS on the scene and received valium. . Patient presented to the ED with VS: 100.6 156/97 87 20 100%. His EKG was notable for AFib with rate in 80s, PVCs, LVH with T wave inversions in aVL and V3-V5. He was emergently taken to the cath lab, where he was loaded with plavix and ASA. He received a BMS for 70% stenosis of his LAD. . On presentation to the CCU, he denied having chest pain or shortness of breath. His vitals were stable and he was in AFib with normal rate. He was given statin and started on a beta-blocker. . Review of systems positive for h/o upper GI bleed in [2168]. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, or hemoptysis. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. Patient had syncopal event as described in HPI. Past Medical History: Outpatient Cardiologist: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] . - HTN - question of MI in past based on [Last Name (NamePattern1) ] results, no intervention done - atrial fibrillation, on coumadin - GI bleed-[2168], received 4 units PRBCs; EGD showed gastritis/esophagitis; repeat EGD in [2173] showed Barrett's esophagus but no gastritis - Zenker's diverticulum s/p Cricopharyngeal myotomy and diverticulopexy - hiatal hernia - L tibial fracture from MVA [2173] - nephrolithiasis - Raynaud's phenomenon . Cardiac Risk Factors: +Hypertension, +Dyslipidemia (LDL 125, HDL 34 in [2166]) . Cardiac History: no CABG, no pacemaker/ICD, no PCI in past Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse; he reports he drinks on social occasions. Ex-policeman; reports he is now in construction. Works out every day and can bench press 380 pounds. Family History: There is no family history of premature coronary artery disease or sudden death. Mother died of "old age," father of asbestosis and carcinoma. Siblings with HTN. Physical Exam: VS: T 97.1, BP 146/85, HR 71, RR 10, O2 100% on 2L NC Gen: Healthy-appearing middle-aged man, wearing C-spine collar in NAD, resp or otherwise. Oriented to place and time, but repeating questions and statements multiple times, unable to recount events of today. HEENT: No obvious trauma to head. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple; difficult to assess JVP with collar in place CV: PMI located in 5th intercostal space, midclavicular line. RRR, normal S1, S2. No S4, no S3. No murmur. Chest: No chest wall deformities. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: +BS, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. No hematoma at R groin (cath site) Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: ETT performed [2173] demonstrated: Good functional exercise capacity. No ECG or 2D echocardiographic evidence of inducible ischemia to achieved workload. Mild aortic regurgitation at rest. Moderate mitral regurgitation at rest. . [Year (4 digits) ] test [2165] not available in OMR, but per discharge summary: "[Year (4 digits) ] echocardiogram thallium with equivocal EKG changes, but moderate reversible defect in the apical inferior wall" . CARDIAC CATH performed on [2177-9-21] demonstrated: LAD with 70% stenosis; normal LMCA, mild luminal irregularities in LCx; RCA with mid 30% stenosis . HEMODYNAMICS: BP 129/75 with HR 49 . LABORATORY DATA: . Significant for K of 3.1 in ED (received 40mEq KCl) Cr 1.3 -> 1.1 Hct 45.7 and WBC 5.7 INR 2.8 CK 329 MB 7 Trop < 0.01 . CT head [9-21]: No acute intracranial hemorrhage or mass effect. . CT C-spine [9-21]: No evidence of an acute fracture. Small osseous fragment adjacent to the left C4-5 facet is likely degenerative. . ECHO [2177-9-22] IMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavity sizes and regional/global biventricular systolic function. Mildly dilated thoracic aorta. Pulmonary artery systolic hypertension. Mild aortic regurgitation. Mild mitral regurgitation. Is there a clinical history to suggest an acute pulmonary process (e.g., pulmonary embolism?). Brief Hospital Course: 58yo man with h/o MI without intervention done, AFib on coumadin presents after cardiac arrest. . 1. s/p Cardiac arrest: Patient presented after having cardiac arrest while exercising on an elliptical machine for over 20 minutes. He has a history of a fib, and was on coumadin at the time. He had not been compliant with his beta blocker. We restarted metoprolol, and the patient remained stable, but going into sinus bradycardia. Pt also has history of Raynauds, and was started on trial of carvedilol instead of metoprolol, with no change in extremities. Patient was switched back to metoprolol 25mg the day before discharge, monitored overnight and discharged on toprol XL 50mg. Pthad 7 beat run of NSVT while in the hospital, and the importance of staying on a bblocker was stressed. Several attempts were made to get the AED recording from the [Location (un) ] sports club gym that he collapsed at, and f/u is being attempted even on discharge. Pt is to followup with outpatient cardiologist, Dr. [Last Name (STitle) ]. Outpatient Cardiac MR has also been ordered to evaluate the contribution of possible LV scar to arrhythmia and cardiac arrest. the patient will followup with Dr. [Last Name (STitle) ]. . 2. CAD: Patient was cathed with the finding of a calcified stenosis of the LAD. BMS to LAD. Patient started on aspirin and plavix. Patient is to have a [Last Name (STitle) ] test as an outpatient, scheduled for [2177-10-10]. . 3. HTN: Patient was hypokalemic, repleted through IV, and HCTZ stopped. Patient started on trial of lisinopril, but BP was controlled and patient discharged on Toprol XL only. 4. atrial fibrillation: patient has a long history of atrial fibrillation. [Country ] score of 1, so coumadin was discontinued given plavix and aspirin, and history of GI bleed. . 5. h/o GI bleed: Coumadin stopped, pt on aspirin and plavix. PPI given [Hospital1 ]. . 6. Possible head trauma: ED note concerned for head trauma during incident and patient with impaired mental status on admission to CCU, as he was alert and oriented, but frequently repeating same questions, phrases. Likely due to period of anoxia during arrhythmic arrest. No acute process on CT imaging of head. Medications on Admission: Coumadin Lopressor--pt admits he has not been taking this HCTZ Lipitor Viagra . ALLERGIES: Demerol--nausea, vomiting 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). Disp:60 Tablet(s) Refills:2 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Cardiac arrest Ventricular arrhythmias Atrial fibrillation Coronary artery disease;Coronary angioplasty and stent placement Hypertension Mitral Insufficiency Raynaud's Phenomenon Discharge Condition: Stable, ambulating Discharge Instructions: You were admitted after a cardiac arrest. You had a cardiac catheterization done, and a stent was placed in one of the arteries that supplies your heart. . 1. Please take all medications as prescribed. . 2. You should never stop taking your Plavix without consulting with your cardiologist. Stopping this medication with your doctor's recommendation may be life threatening. . 3. Please call your doctor or return to the hospital if you have chest pain, palpitations, shortness of breath, fevers, or any other concerning symptom. . 4. We recommend that you refrain from exertional exercise until after your [Hospital1 ] test is reviewed with you. This includes running or any weight lifting. Walking on the treadmill is safe. . 5. According to [State 350] state law you are prohibited from driving for 6 months following cardiac arrest or until you are instructed otherwise by your cardiologist. Followup Instructions: Please follow up with: Your Cardiologist within 1 week: [Last Name (LF) 578],[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 579] [Telephone/Fax (1) 6937] . We recommend that you get a [Telephone/Fax (1) ] test: Provider: [Name10 (NameIs) 10081] TESTING Phone:[Telephone/Fax (1) 1566] Date/Time:[2177-10-8] 2:00 p.m. . You have been referred for an MRI of your heart. You will be contact[Name (NI) ] by Radiology regarding the scheduling of this study. . You are recommended to undergo Cardiac Rehabilitation after your [Name (NI) ] test. Completed by:[2177-9-29]	[ "41071", "41401", "4019", "42731", "V5861" ]
Admission Date: [2131-3-22] Discharge Date: [2131-3-26] Date of Birth: [2087-8-23] Sex: M Service: PSYCHIATRY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1678] Chief Complaint: " there was an alteraction, but I aint' gonna talk about that" Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 43 year old male with a self reported history of bipolar disorder and schizoaffective disorder, who was brought to the ED by ambulance after his mother called 911 expressing that her son was being aggressive and was concered for her safety. Initially upon presenation he denied any complaints to ED doctor and reported that he wanted to be dishcarged. When approaching patient to interview, he reported he wanted to stay in the hospital to focus on his "asthma and psych medications to calm my nerves". He refused to elaborate on the incident that brought him to the ED, becoming very hostile, but reported that "she is trying to pull me down, get me to yell like a fool, but I ain't gonna". Patient was intially hostile to this interviewers, saying " I ain't gonna slap that black pussy.. don't look at me, write this down" He appeared to be responding to internal stimuli and sporactically yelled " shut up" to what may have been halucinations. WHile he denied AH or VH, at one point during the interview reported " that person is trying to make me crazy, being adversarial, stop me from answering your questions" and pointed to the corner of the room. He denied any SI, HI, reported that his mood was good, that he was sleeping and eating well and had not other complaints . Spoke with patient's mother ([Telephone/Fax (1) 103299]) who reports she is very concerned about her son. She reports that he has not been acting like himself recently, has been talking to himself, gets upset and angry very easily, and making accusations that she is "going with a friend", telling her " to shut your mouth". She also notes he has been acting this way on the streets and in public. She expressed she is feeling threatened by him and today, after he raised his voice, yelling for her to shut that, that she called 911. She does not feel safe for him to return home without psychiatric intervention and evaluation. She also expresses concern that he may not have been taking his medications and that while he denies substance use, is worried that he may have been using. Past Medical History: -reports history of bipolar disorder/ schizophrenia diagnosed when he was 17 - two hosptializations at [First Name5 (NamePattern1) 745] [Last Name (NamePattern1) 103300] and [Last Name (LF) 42339], [First Name3 (LF) ] mother, last [Name2 (NI) 103301] was 5 years ago see psychiatrist Dr. [First Name (STitle) 1169] at [Hospital1 2177] -Denies any suicide attempts in past PAST MEDICAL HISTORY (INCLUDE HISTORY OF HEAD TRAUMA, SEIZURES, OR OTHER NEUROLOGIC ILLNESS): - severe complex sleep disordered breathing with severe nocturnal and daytime hyopixa related to hypventiliation, followed by Pulm - secondary erytrocythosis, being following by Haem - asthma - hypertension Social History: SUBSTANCE ABUSE HISTORY (INCLUDE HISTORY OF D.T.'S, WITHDRAWAL SEIZURES, BLACKOUTS, DETOX TREATMENT, I.V. USAGE): patient denies any substance use . SOCIAL HISTORY (FAMILY OF ORIGIN, CHILDHOOD, PHYSICAL/SEXUAL ABUSE HISTORY, EDUCATION, EMPLOYMENT, RELATIONSHIPS, SEXUAL HISTORY/STD RISKS, MILITARY RECORD, LEGAL HISTORY, ETC.): Patient was born in [Location (un) ]. Did not graduated highschool but made it until senior year. Has worked odd jobs but nothing recnetly. Gets SSDI. Lives with his mother and sister, but sister doesn't want them in her house any longer due to his behavior. Reports he spends his time watching TV and grocery shopping. Family History: mother with asthma, otherwise noncontributory Physical Exam: VS: 98.8, P = 80, R = 19, 98% 02 sat, 150/76 MENTAL STATUS EXAM (USE FULL, DESCRIPTIVE SENTENCES WHERE APPLICABLE) APPEARANCE & FACIAL EXPRESSION: overweight male, with NC on POSTURE: lying in bed BEHAVIOR (NOTE ANY ABNORMAL MOVEMENTS):psychomotor agtiation in terms of increased leg movement ATTITUDE (E.G., COOPERATIVE, PROVOCATIVE): uncooperative, hostile and at times almost threatening ( raised voice, used fowl language) SPEECH (E.G., PRESSURED, SLOWED, DYSARTHRIC, APHASIC, ETC.): normal in rate and rhytm MOOD: " good" AFFECT (NOTE RANGE, REACTIVITY, APPROPRIATENESS, ETC.): irritable at times inapparopriate. Starting laughing at one point, when asked why replied " I am thinking of something funny that I can't remember now" THOUGHT FORM (E.G., LOOSENED ASSOCIATIONS, TANGENTIALITY, CIRCUMSTANTIALITY, FLIGHT OF IDEAS, ETC.): Tangential, loosining of associations, very disorganized and difficult to follow. Possible thought blocking. THOUGHT CONTENT (E.G., PREOCCUPATIONS, OBSESSIONS, DELUSIONS, ETC.): denied ABNORMAL PERCEPTIONS (E.G., HALLUCINATIONS): denied, but appeared to be responding to internal stimuli, seemded to be talking and pointing to something in the corner of the room NEUROVEGETATIVE SYMPTOMS (E.G., DISTURBANCES OF SLEEP, APPETITE, ENERGY, LIBIDO): denied SUICIDALITY/HOMICIDALITY (INCLUDE IDEATION, INTENT, PLAN): denied INSIGHT AND JUDGMENT: very poor COGNITIVE ASSESSMENT: SENSORIUM (E.G., ALERT, DROWSY, SOMNOLENT): alert ORIENTATION: x 3 ATTENTION (DIGIT SPAN, SERIAL SEVENS, ETC.): DOMBI MEMORY (SHORT- AND LONG-TERM): [4-2] registation [3-4] recall CALCULATIONS: 7 quarters in $1.75 FUND OF KNOWLEDGE (ESTIMATE INTELLIGENCE): fair PROVERB INTERPRETATION: grass is greener: What you think is greener sometimes is a little less green SIMILARITIES/ANALOGIES: table and chair: they both have legs . Obese HEENT: mmm Pulm: decreased excursions and decreased breathing sounds Cor: distant heart sounds, regular, no murmurs Abd: obese, nl bs Ext: no edema or ecchymoses Pertinent Results: [2131-3-21] 09:39AM URINE HOURS-RANDOM [2131-3-21] 09:39AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2131-3-21] 04:30AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.013 [2131-3-21] 12:15AM estGFR-Using this [2131-3-21] 12:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG . [2131-3-26] 04:06PM BLOOD Type-ART Temp-36.7 pO2-55* pCO2-92* pH-7.23* calTCO2-41* Base XS-7 Intubat-NOT INTUBA Comment-O2 DELIVER Brief Hospital Course: Patient is a 43 year old male with a self reported history of bipolar disorder and schizoaffective disorder, who was brought to the ED by ambulance after his mother called 911 expressing that her son was being aggressive and was concered for her safety. Pt initially wanted to be discharged, but eventually agreed to admission to have his "meds evaluated" as they are making him "rambunctious". The patient continued to indicate that his medications are not working. He signed CV upon admission. . Abilify and perhenazine were discontinued, VPA was increased to 500BID and he was started on geodon at 60BID. He became somewhat less agitated, but appeared to continue to respond to internal stimuli. There were no outburst of violence. The plan was to increase to geodon to 80BID, but due to respiratory decompenstation (see below) his dose was kept at 60mg [Hospital1 ]. For the same reason, VPA was held. A DMH application was submitted, as he is longer able to live with his sister, and his mother has no place to live herself. . With respect to his medical problems, he has severe hypoventilation syndrome, followed by Pulmonary (dr [Last Name (STitle) 15371]). For polycythemia (baseline Hct of 62) he had been seen by Dr [Last Name (STitle) 2455]. Both services were contact[Name (NI) ] this admission. Asthma medications and antihypertensives were continued, a statin was added for hyperlipidemia. At home, Mr [Known lastname 732] in on 2L NC O2 during the day, and is supposed to wear BiPAP at night. Per his mom, there may be non-compliance with BiPAP and he often walks around with an empty O2 tank. On [3-26], Mr [Known lastname 732] became very somnulent and was hard to arouse. He denied any shortness or breath or chest pain, and did not have a fever. An ABG was obtained, showing severe hypercarbic respiratory failure. A pulmonary consult was called, and Mr [Known lastname 732] was transferred to the ICU for close monitoring and titration of CPAP/O2. In retrospect, the underlying cause may have been that Mr [Known lastname 732] received too much O2. The events were discussed with his mother. . The plan is for Mr [Known lastname 732] to return to [Hospital1 ] 4 when medically cleared. Medications on Admission: per patient: Vanceil 84 mcq puff depakote 500 mg po qhs HCTZ 25 mg po dialy Lisinopril 10 mg po daily Abilify 30 mg po dialy Perphenazine 8 mg po dialy Discharge Medications: HCTZ 25 mg po dialy Lisinopril 10 mg po daily simvastatin 20mg PO daily Albuterol INH Ipratropium INH geodon 60mg [Hospital1 ] PO depakote 500mg [Hospital1 ] PO on hold Discharge Disposition: Extended Care Facility: [Hospital1 22160] transfer to ICU Discharge Diagnosis: schizoaffective disorder, psychosis, mania hypoventilation syndrome morbid obesity asthma hyperlipidemia Discharge Condition: respiratory failure, guarded Discharge Instructions: discharge to ICU Followup Instructions: discharged to ICU Completed by:[2131-3-29]	[ "49390", "32723", "4019" ]
Admission Date: [2109-3-5] Discharge Date: [2109-3-12] Date of Birth: [2051-9-26] Sex: F Service: SURGERY Allergies: Protamine Attending:[First Name3 (LF) 2597] Chief Complaint: B/L Debilitating intermittent claudication Ischemic rest pain in her right foot Major Surgical or Invasive Procedure: Aortobifemoral bypass with 12 x 6 aortobifemoral femoral Dacron graft. History of Present Illness: This 57-year-old lady has had severe debilitating intermittent claudication of both her extremities for quite some time. She recently developed ischemic rest pain in her right foot. A CT angiogram was done which showed her infrarenal aorta to be open with total occlusion of her left iliac system from the aortic bifurcation to the groin, and a patent right common iliac artery, but a totally occluded right external iliac artery. She reconstituted common femoral arteries with patent superficial femoral arteries distally. Because of her young age and her severe symptoms, she has been recommended to have bypass surgery. Past Medical History: PMH HTN,(echo - nl EF), PVD, Murmur, s/p tubal ligation Social History: rare alcohol approximately Q month and denies other substances. Quit smoking 15 days ago after 40 years. Pt lives with husband and one of her 3 adult sons in [Name (NI) ] MA. employed as a secratary Family History: n/c Physical Exam: VSS: 114/45, 62, 98.8, 97%RA, 18 GEN: NAD CARD: RRR, +SEM Lungs: CTA, diminished at bases ABD: +BS, soft Wound: Incisions C/D/I. Staples removed Pulses: palp B/L DP/PT Pertinent Results: [2109-3-11] 05:30AM BLOOD WBC-10.4 RBC-3.59* Hgb-11.9* Hct-34.3* MCV-95 MCH-33.0* MCHC-34.6 RDW-14.0 Plt Ct-427 [2109-3-11] 05:30AM BLOOD Plt Ct-427 [2109-3-11] 05:30AM BLOOD Glucose-87 UreaN-12 Creat-0.8 Na-137 K-4.2 Cl-99 HCO3-28 AnGap-14 [2109-3-7] 10:50AM BLOOD ALT-18 AST-22 AlkPhos-50 Amylase-37 TotBili-0.4 [2109-3-6] 05:09AM BLOOD CK(CPK)-370* [2109-3-11] 05:30AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.1 Brief Hospital Course: Pt underwent aortobifemoral bypass on [3-5]. During surgery she developed rapid SVT, hypotension and hypoxia, cardioverted with restoration of a sinus brady and stabilized- possible protamine rxn; she was kept intubated and sedated overnight. Cardiology-Dr. [Last Name (STitle) ] consulted. Echo obtained POD 1: Patient extubated. Lopressor continued. Palpable DP pulses. Remained in ICU- metabolic acidosis and T wave inversion on ECG. Dr. [Last Name (STitle) ] following patient for possible silent ischemia in setting of SVT/ operative procedure. T wave inversion resolved. POD 2: VSS, pain controlled with MSO4 PCA. Diet advanced to sips. Diuresis, OOB. POD 3: Transient desaturation to 87% on 3L NC. Denies SOB. Chest x-ray showing pulmonary congestion and right pleural effusion. Lasix X 2 given . CTA to r/o PE performed. Negative for PE. CTA showing mucous plug with total RLL collapse. Patient remained in VICU, aggressive pulmonary toilet. Bronchoscopy performed. POD 4: No overnight events, breathing improved. Psychiatry consulted as patient is requesting DNR/DNI. patient deemed competent and DNI ordered. Ambulating on oxygen with physical therapy. POD 5: VSS. No overnight events. Ambulating with physical therapy not requiring oxygen. O2 sats >93% on room air and while ambulating. Levaquin discontinued. POD 6: VSS. No overnight events. B/L palpable DP/PT pulses. Discharge to home with physical therapy. Staples removed. Will follow up with Dr. [Last Name (STitle) ] in [1-27] weeks. Medications on Admission: ASA 81, plavix 75, atenolol 25, dyazide Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. [Date Range ]:1 1 Refills:3 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Obtain refill authorization from primary MD. [Last Name (Titles) ]:30 Tablet(s) Refills:0 5. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [3-29] hours as needed for pain. [Month/Day (3) ]:40 Tablet(s) Refills:0 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [Month/Day (3) ]:30 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital1 1474] VNA Discharge Diagnosis: B/L Debilitating intermittent claudication Ischemic rest pain in her right foot Discharge Condition: Good. VSS. Cr 0.8, HCT 34.3 Palpable B/L DP pulses Discharge Instructions: Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm (AAA) Discharge Instructions Medications: ?????? Take Aspirin 81mg once daily ?????? Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [1-26] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [3-29] weeks for post procedure check and CTA What to report to office: ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ?????? Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Call Dr.[Name (NI) 5695] office at [Telephone/Fax (1) 3121] to schedule post op visit to be seen in [1-26] weeks. Completed by:[2109-3-12]	[ "486", "2762", "5180", "9971", "4280", "42789", "2859", "3051" ]
Admission Date: [2196-1-28] Discharge Date: [2196-2-7] Date of Birth: [2148-11-11] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1257] Chief Complaint: Pericardial effusion Major Surgical or Invasive Procedure: vagus nerve stimulator generator replacement [2196-1-28] pericardiocentesis with pericardial drain [2196-1-29] History of Present Illness: Please see original Neurology Admission Note and MICU [Location (un) ] Transfer Note for details. . Briefly, 47 y/o man with long standing history of epilepsy s/p right temporal lobectomy (at age 19) and VNS placement (7 years ago), h/o EtOH and cocaine abuse who was having increased seizure frequency in the setting of VNS malfunction. He was admitted on [1-28] for elective replacement of the vagus nerve stimulator generator. The procedure went without complication. Overnight he developed AF with RVR to the 180s with hypotension to the 80s. CIWA was 17 with last drink approximately 72 hours prior. Patient was also noted to be [Doctor Last Name ] with a CIWA of 17 and is thought that last EtOH drink was 72 hours ago. He received 2mg IV ativan with somnolence and apenea afterwards. He was subsequently transferred to the MICU. . His MICU course was notable for an echocardiogram which showed a large pericardial effusion on [1-29]. He was seen by the cardiology fellow and subsequently underwent pericardial window. 450cc of bloody pericardial fluid was drained. Patient developed SVT in the cath lab and was treated with 9 mg IV metoprolol. He was transferred to CCU postprocedurally for monitoring. . On arrival, patient complained of spinal back pain from lying on the operating table. He also reports that his lungs feel "collapsed" but denied shortness of breath. . Review of systems was otherwise negative. Past Medical History: - epilepsy and nonelectrographic seizures (petite mal with rare secondary generalization) - s/p right temporal lobectomy - s/p VNS placement - Mood disorder and likely borderline personality organization - Multiple suicide attempts in past (largely overdose) - DM due to medication, now apparently resolved - cervical strain - Rosacea - [Last Name (un) 865] esophagus - Polysubstance abuse: EtOH, MJ, cocaine/crack binges with resultant unsafe sexual practices - h/o atrial fibrillation (not on medication) Social History: Unemployed, lives alone. Smokes 1pk/day, occasional ETOH and OMR records indicate some history of Crack Cocaine use. Family History: States has FH of diabetes and 'cancer in everyone' but no FH of CAD, HTN, sudden death or cardiac dysrhythmias Physical Exam: ON TRANSFER TO CCU: VS: HR:90 BP:128/82 O2sat:93% 2L(NC) GEN: agitated, in fetal position, not tachypneic HEENT: PERRL. MM dry. NECK: neck supple. Left neck dressing with dried blood. No active bleeding or discharge. Mild tenderness on palpation. PULM: Moving air appropriately, diffuse crackles. Left upper chest (VNS) site c/d/i. CARD: Soft heart sound, RRR, s1/s2 present, no m/g/r, with pericardial window draining frank blood ABD: +bs, soft, NT/ND EXT: wwp, no edema, 2+PD bilaterally SKIN: warm BACK: tenderness to palpation along the spine NEURO: AOx3, agitated, but agreeable. On discharge: VS: 96.6 118/62 (94-130/64-90) 64 16 97% RA Tele: HR in 160s yesterday afternoon, otherwise 60s, sinus this morning, short runs of SVT to 130s <30 seconds GEN: AOx3, NAD HEENT: PERRLA, MMM NECK: neck supple PULM: CTAB CARD: RRR, normal s1/s2, no m/g/r ABD: soft, nontender, nondistended EXT: wwp no edema. L calf TTP, no swelling or cords noted. Pertinent Results: ADMISSION LABS: . [2196-1-28] 07:11PM BLOOD WBC-9.3# RBC-4.12* Hgb-13.3* Hct-40.2 MCV-98 MCH-32.3* MCHC-33.1 RDW-14.2 Plt Ct-189 [2196-1-28] 07:11PM BLOOD Glucose-115* UreaN-25* Creat-1.1 Na-138 K-4.4 Cl-102 HCO3-27 AnGap-13 [2196-1-28] 07:11PM BLOOD Calcium-9.0 Phos-4.7* Mg-2.2 [2196-1-29] 06:27AM BLOOD T4-4.7 [2196-1-29] 06:27AM BLOOD TSH-5.8* CARDIAC BIOMARKERS . [2196-1-29] 05:55AM BLOOD CK-MB-2 cTropnT-<0.01 [2196-1-29] 06:27AM BLOOD CK-MB-2 cTropnT-<0.01 . MICRO: . -Urine cx [1-29]: neg -Pericardial fluid culture [1-29]: NGTD, but pending as of transfer to MICU -Pericardial fluid cytology: PND STUDIES: . ECHO [2196-1-28]: . LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Increased IVC diameter (>2.1cm) with 35-50% decrease during respiration (estimated RA pressure (10-15mmHg). LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Depressed LVEF. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Borderline normal RV systolic function. AORTIC VALVE: No AS. MITRAL VALVE: No MS. [Name13 (STitle) ] MR. TRICUSPID VALVE: Indeterminate PA systolic pressure. PERICARDIUM: Moderate to large pericardial effusion. No RA diastolic collapse. No RV diastolic collapse. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. The rhythm appears to be atrial flutter. Echocardiographic patient. Poor image quality.The estimated right atrial pressure is 10-15mmHg with IVC dilation (2.5 cm). Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. LV systolic function appears mildly depressed. There is no ventricular septal defect. RV with borderline normal free wall function. There is no aortic valve stenosis. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a moderate to large sized pericardial effusion (greatest anteriorly and best seen in the subcostal view). No right atrial diastolic collapse is seen. No right ventricular diastolic collapse is seen (mild RV compression in the subcostal view is suggestive of elevated intrapericardial pressure). . Cardiac cath [1-29]: COMMENTS: Under fluoroscopic guidance, 450 CC of bloody pericardial fluid was obtained through subxiphoid approach. Intrapericardial origin of fluid was confirmed with contrast injection and intrapericardial pressure measurement. Initial pericardial pressure was elevated at 21 mm Hg and dropped to 3 mm Hg after remorval of fluid. Pericaridal drain was sutured in place for 24 hours. FINAL DIAGNOSIS: 1. Successful urgent pericardiocentesis through subxiphoid approach for impending pericardial temponade . ECHO [2196-1-30] IMPRESSION: Small amount of echodense pericardial material/fluid is seen. No evidence of tamponade. Probable regional LV systolic dysfunction. Moderately dilated and hypokinetic right ventricle. Compared with the prior studies (images reviewed) of [2196-1-29] and [2194-7-23], the appearance of the pericardium is similar to that of the post-tap echo yesterday. The basal to mid inferior/inferolateral hypokinesis was probably present in [2194] but image quality is poor on all studies. The right ventricle appears dilated on studies from yesterday and today - it was probably normal in [2194]. . LENI'S [2196-2-1] BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale, color, and Doppler images of the bilateral common femoral, superficial and deep femoral, and popliteal veins were obtained. There is non-occlusive thrombus in the mid left popliteal vein and left peroneal veins, as well as the right posterior tibial vein. The bilateral common femoral, superficial femoral, and right popliteal veins demonstrated normal compressibility and wall-to-wall color flow. IMPRESSION: Non-occlusive thrombus in left popliteal, left peroneal, and right posterior tibial veins. . CT TORSO [2196-2-1] (PRELIM) 1. Pulmonary embolism involving right lower [Month/Day/Year 3630] posterior basal segmental and subsegmental branches, and subsegmental branch of left lower [Month/Day/Year 3630] anterior basal pulmonary artery. 2. Bilateral moderate-sized pleural effusions with adjacent atelectasis. 3. Evidence of right heart strain, manifest as reflux of IV contrast into the IVC and hepatic veins. 4. Mediastinal and right hilar adenopathy with right hilar soft tissue causing some narrowing of the airways and vessels, concerning for malignancy. Bronchial wall thickening noted, particularly along right middle [Month/Day/Year 3630] and right lower [Month/Day/Year 3630] bronchi. 5. Perifissural consolidation in posteromedial right middle [Last Name (LF) 3630], [First Name3 (LF) ] represent atelectasis or infection; however, underlying tumor or extension of right hilar mass not excluded. 6. 11 mm spiculated nodule in the right upper [First Name3 (LF) 3630] is suspicious for malignancy. 7. Predominantly paraseptal emphysema in the right upper [First Name3 (LF) 3630] with largest bulla measuring 3.5 x 5.9 cm. 8. Tiny pericardial fluid and possible pericardial thickening. 9. No evidence of malignancy in the abdomen and pelvis. 10. Intraabdominal findings include aortic and iliac artery calcifications, colonic diverticulosis, and tiny bubble of gas within the urinary bladder, which could be due to recent catheterization (correlate clinically). 11. No bony destruction concerning for malignancy. 12. Evidence of right femoral head avascular necrosis, without significant collapse. . CT HEAD [2-2] No evidence of an acute intracranial process. Postoperative changes of right temporal lobectomy. . Pathology, pericardial effusion: POSITIVE FOR MALIGNANT CELLS, Consistent with metastatic adenocarcinoma. \ Repeat echo, [2-2]: LV systolic function appears depressed. The right ventricular cavity is borderline dilated with mild global free wall hypokinesis. There is a small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. Brief Hospital Course: 47 yo M with history of epilepsy admitted for elective vagal nerve stimulator replacement, transferred to MICU for management of tachycardia, hypotension, and hypoxia, found to have pericardial effusion, now s/p pericardiocentiesis with drain in place, transferred to CCU for post-operative monitoring, with frequent agitation, now found to have bilateral PEs . # Pericardial effusion: In the MICU, pt noted to be tachycardic with hypotension, and found to have pericardial effusion. He underwent pericardiocentesis with drain placement with drainage of bloody fluid. Hct stable despite profuse bloody drainage. Etiology is likely malignancy given that CT torso showing RUL lung spiculated nodule. Effusion cytology and micro showed cells c/w metastatic lung adenocarcinoma. Drain was eventually pulled without complication and without any further hemodynamic instability. Pulsus checked for several days after drain pulled and resolved effusion on Echo, was ~8 mmHg on discharge. . # PE/DVT: Pt noted to have enlarged RV on repeat echo [1-31], so CTA was obtained for concern of PEs which confirmed b/l subsegmental PEs. LENIs also positive for b/l DVTs. He was started on heparin ggt in house and transitioned to an anticoagulation regimen of coumadin, with a lovenox bridge. He will f/u with his PCP on [Name9 (PRE) 2974] [2-12] after discharge. . # Agitation: Patient with history of EtOH, marijuana, cocaine/crack binges. He was significantly agitated throughout admission which was initially thought to be secondary to ETOH withdrawal. He was maintained on a valium CIWA and klonipin 1mg TID. However, agitation persisted despite being well out of the acute withdrawal window. He had several code purples called for him and was often violent towards nurses. Of note, pt would be lucid and engaging often during the day with decompensation at night. Psych was consulted who felt that this was less likely to be withdrawal and instead a behavioral issue/delerium, likely in setting of supratherapeutic valproate level. They recommended haldol for his agitation which was continued 5mg PRN along with 10mg QHS standing, these were discontinued on discharge, takes no psych meds at home and delirium apparently cleared. Evaluated by psychiatry prior to discharge, appeared to understand importance of f/u. He was started on MVI, thiamine, folate. . # Afib with RVR: Patient oscillates between HR of 70s ?????? 170s with frequent episodes of RVR on tele, asymptomatic. Based on old records, has a history of Afib with RVR, a flutter, was treated with diltiazem and flecainide, and was supposed to be on Metoprolol. Increased metoprolol to 75 mg po qid standing which has controlled rate well, though still with frequent episodes of rapid ventricular response that respond to IV lopressor 5 mg x 1. Because of continued episodes of RVR (likely in the setting of pericardial effusion and multiple PEs) pt started on diltiazem drip, weaned off and started on diltiazem ER 120 mg daily, and metoprolol changed to 200 mg of metoprolol succinate on discharge. HR in the 60s with these changes, with short bursts of SVT to 130s prior to discharge. Would consider uptitrating rate control as an outpatient. . #. h/o epilepsy and seizure activity: VNS placed and was re-activated about 1 week after placement. He was continued home AEDs. Depakote ER 1250/1500/1500 and Oxcarbazepine 600 mg [Hospital1 ] which was often given IV due to inability to take POs from agitation. Depakote level was found to be elevated in setting of delirium, however unclear if this was true trough. Was discharged on home meds and advised to f/u with his outpatient neurologist for management of his depakote. . # Foley self-d/c: Pt pulled own foley overnight [1-30]. Of note there was blood around the uerethral meatus after he pulled it. Urine output was monitored and foley ended up being replaced on [2-2] given that he was put back into 4pt restraints. Foley dc'ed and was able to void on his own with no hematuria for remaineder of admission. Medications on Admission: - Clonazepam 1 mg QID - Divalproex 250 mg Sustained Release qAM - Depakote ER 500 mg tab- tabs qAM, 3 tabs in the afternoon and 3 tabs qPM - Omeprazole 20 mg delayed release daily - Oxcarbazepine 600 mg [Hospital1 ] - ASA 81 mg daily (not taking as prescribed) Discharge Medications: 1. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous twice a day for 10 days. Disp:20 syringe Refills:0 2. oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. clonazepam 1 mg Tablet Sig: One (1) Tablet PO four times a day. 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:30 Tablet(s) Refills:2 6. diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:30 Capsule, Sustained Release(s) Refills:2 7. divalproex 250 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO QAM: use in addition to the depakote 500 mg strength tabs for total dose of 1250/1500/1500 mg . 8. divalproex 500 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO QAFTERNOON (). 9. divalproex 500 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO QHS (once a day (at bedtime)). 10. divalproex 500 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO QAM: take in addition to 250 mg dose for a total 1250 mg every morning. 11. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:30 Patch 24 hr(s) Refills:2 12. metoprolol succinate 200 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 13. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Seizure disorder Atrial fibrillation Lung adenocarcinoma, pericardial effusion Deep vein thrombosis, pulmonary embolism Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were seen in the hospital to have your vagal nerve stimulator replaced, which has been turned on again, for your seizures. You were also found to have a very fast heart rate from your atrial fibrillation (irregular heart rate) and for this we started diltiazem and metoprolol, which slow your heart rate. In addition, you were found to have a pericardial effusion (fluid around your heart) which is likely due to spreading of lung cancer, which was discovered on a CT scan. You were seen by the oncologists here who recommended that you go to clinic for follow up to discuss further workup and treatment. You were also found to have a pulmonary embolism and deep vein thrombosis (blood clots in your lung and legs) for which you were started a blood thinner. You will be taking a blood thinner called Coumadin to prevent more clots from forming and to treat the ones you already have, and you should take this medication every day. You will be taking Lovenox, another blood thinner which works immediately, temporarily until your blood level of Coumadin reaches the therapeutic range. Changes to your medications: START diltiazem 120 mg every day START taking metoprolol 200 mg daily START taking warfarin 5 mg daily START taking lovenox shots twice a day until you are told to stop by your doctor Followup Instructions: In addition to the appointments below, the oncologists are trying to schedule you an appointment in clinic. The phone number to call with questions is [0-0-]. Department: [Hospital3 249] When: FRIDAY [2196-2-12] at 4:00 PM With: MARK [Initials (NamePattern4) ] [Last Name (NamePattern4) ], LICSW [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 249] When: FRIDAY [2196-2-19] at 3:00 PM With: MARK [Initials (NamePattern4) ] [Last Name (NamePattern4) ], LICSW [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: [Hospital3 249] When: THURSDAY [2196-3-17] at 4:50 PM With: [First Name11 (Name Pattern1) 1980] [Last Name (NamePattern4) 1981], MD [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) 895] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Completed by:[2196-2-7]	[ "42731" ]
Admission Date: [2126-1-16] Discharge Date: [2126-1-20] Date of Birth: [2044-9-4] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2901] Chief Complaint: Patient was admitted for hypotension post-catheterization Major Surgical or Invasive Procedure: Cardiac catheterization with Graftmaster stenting x 5 History of Present Illness: Ms. [Known lastname 75926] is a 81yoF w/h/o CAD s/p prior MIs and CABG [2110](SVG->[Last Name (LF) 8714],[First Name3 (LF) ], LIMA->diagonal, LAD) c/b pseudoaneurysm formation at her SVG. In [2118-4-4] she underwent thrombectomy and stenting x 4 of the SVG to the OM at [Location (un) 20338] Community Hospital with three Wall stents and one Tristar stent. In [2118] the patient had her proximal RCA stented. Prior catheterization in [2120] had revealed [2-5] pseudoaneurysms (1-1.5cm) of the SVG to the OM. Most recently a CXR revealed evidence of a hilar mass. Follow up CT reported the pseudoaneurysms to be enlarging. She was referred for cardiac catheterization at [Hospital1 18] on [2125-12-3] which confirmed these aneurysms. Cardiac MR was then completed which showed 6.3x5x5cm pseudoaneurysm w/ significant thrombus accumulation w/ mild compression of the main and left pulmonary artery as well as a smaller pseudoaneurysm but preserved intraluminal flow. Plavix and aspirin were discontinued and she was discharged to home with plans for return for compassionate use of a Jomed covered stent. She was reloaded with 300mg Plavix on [2126-1-15] and Aspirin was restarted. . She returned for [Hospital1 18] for catheterization today. In the cath lab she had evidence of extravasation of contrast into the mediastinum which resolved following Graftmaster stents x5. Following cath, patient became vagal and hypotensive with groin pressure and was noted to have a significant hematocrit drop to 21.2. Her Hct on admission was 41 and most recent value of 39 [2125-12-4]. . Upon arrival to the CCU, patient complaining of significant nausea which improved w/ IV Zofran. The patient otherwise denies any recent complaints. She has felt well recently except for "the flu" a few weeks ago. She denies any chest pain, SOB, orthopnea, PND, LE swelling, presyncope or syncope, joint pains, cough, hemoptysis, black stools or red stools. Past Medical History: PAST MEDICAL HISTORY: Cardiac Risk Factors: Hypertension, Hyperlipidemia . Cardiac History: CABG ([Hospital1 2025]) in 4/93 anatomy as follows: SVG to OM, LIMA to diagonal and LAD (70% narrowing of proximal second marginal artery, 60% narrowing of anterior descending artery, 70% narrowing of first septal and first diagonal branch) -s/p MI x3 -s/p PTCA [4-/2118]: 3 Wall stents and 1 TriStar stent placed in severely diseased and degenerated SVG to OM, EF >60% -s/p Cardiac Cath [8-5]: patent LIMA to LAD, patent SVG to AOMB with 50-60% stenosis at the ostium (not hemodynamically significant), RCA 75% stenosis proximally s/p Penta stent placement -s/p Cardiac Cath [1-6]: patent LIMA to LAD, patent SVG to OM with 60% stenosis at the ostium, and patent RCA, EF >60% -[2-5] aneurysms/pseudoaneurysms of proximal mid segment of SVG to OM found in [1-6] cardiac cath . Other Past History: -COPD (mild) -h/o Factor 8 Deficiency -h/o asthma -h/o depression -s/p endovascular stent graft repair of infrarenal AAA [1-6], stents placed endovascularly in aorta and in left common iliac artery -"head aneurysm" -s/p lumbar disc surgery -s/p left breast biopsy for lump -s/p total abdominal hysterectomy, bilateral salpingo-oophorectomy -s/p appendectomy Social History: Social history is significant for the absence of current tobacco use as of 1/[2125]. Prior to that she smoked 6 cigarettes/day for many years. She has a history of alcohol abuse, but is currently sober for [5-11] yrs. Denies illicit drug use. Lives in [Hospital3 ] w/her husband. There is no family history of premature coronary artery disease or sudden death. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T 95.0, BP 127/68, HR 97, RR 23, O2 97% on RA Gen: Elderly female in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP low. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2.2/6 holosys murmur at LLSB. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi appreciated anteriorly. Abd: Midline lower surgical scar. +BS. Soft, NTND, No HSM or tenderness. Mobile superficial 2-3 cm mass below the umbilicus which is nontender. No abdominial bruits. Groin: Sheath in place in R groin. R groin soft w/o obvious hematoma. Scar over L groin. Ext: LE warm. No cyanosis or edema. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. +actinic keratoses on LE Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP 1+ PT [Name (NI) 2325]: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP 1+PT Pertinent Results: ADMISSION LABS: [2126-1-16] 06:01PM BLOOD WBC-11.6* RBC-3.50* Hgb-10.2# Hct-29.8# MCV-85 MCH-29.3 MCHC-34.4 RDW-13.7 Plt Ct-114* [2126-1-16] 11:45AM BLOOD Plt Ct-101* [2126-1-16] 06:01PM BLOOD K-4.0 CARDIAC ENZYMES [2126-1-19] 11:30PM BLOOD CK-MB-NotDone cTropnT-0.20* [2126-1-20] 07:30AM BLOOD CK-MB-NotDone cTropnT-0.18* [2126-1-19] 11:30PM BLOOD CK(CPK)-28 [2126-1-20] 07:30AM BLOOD CK(CPK)-26 ECG [2126-1-16]: Sinus tach @ ~100. Nl axis and intervals. TWF in I, aVL. CARDIAC CATH performed on [2126-1-16] (see report for further details): PA sat 69%, CO 3.39, CI 2.18, RA 2, RV 17/2, PA [11-6], PCWP 1 SVG->OM w/ large aneurysmal disease w/ serial dilation and free extravasation into the mediastium. Ostial 80% stenosis s/p Graftmaster stenting x 5 w/ stoppage of all angiographic evidence of leakage Brief Hospital Course: Ms. [Known lastname 75926] was admitted after her cardiac catheterization with hypotension, likely multifactorial in origin. Low filling pressures were noted on right heart catheterization, and her Hct was significantly lower on admission than prior values suggesting blood loss and hypovolemia. She was also in considerable pain after the procedure, and it is possible increased vagal tone also contributed to her hypotension. Following the cathterization, she was transfused three units of RBC's. Hct stabilized overnight and blood pressures normalized to 100-110's/50-60's with the transfusions and IVF boluses. On [2126-1-19], Ms. [Known lastname 75926] complained of substernal chest pain that came on at rest. Two sets of cardiac enzymes were negative and she had no new EKG changes concerning for ischemia. Her chest pain was relieved with morphine and Imdur (she gets headaches with SLNG), and no further intervention was performed. Medications on Admission: asa 325 mg daily plavix 75 mg daily (300 mg on [2126-1-15]) lipitor 80 mg daily lasix 20 mg daily Toprol XL 50 mg daily Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Primary Diagnoses 1. Vein graft aneursym s/p stenting 2. Anemia 3. CAD Secondary Diagnoses 1. COPD Discharge Condition: HD stable, Hct stable. Discharge Instructions: You were admitted to the hospital for a cardiac catheterization. Your blood pressure was low after the catheterization likely from blood loss, and you were given 2 units of red blood cells. Your blood pressure improved. The following changes have been made to your medications: 1. You are now taking Toprol XL 25 mg daily (half of your previous dose) 2. You should not take your lasix. You should discuss restarting this with Dr. [Last Name (STitle) 911] 3. You were started on Imdur 30 mg daily. If you develop chest pain, shortness of breath, dizziness, bleeding from your groin site, fevers, or any other concerning symptoms, you should call your doctor or come to the emergency room. Please take all of your medications as directed. Please keep all of your follow up appointments. Followup Instructions: You should follow up with your cardiologist, Dr. [Last Name (STitle) 911], in [1-6] weeks. Please call([Telephone/Fax (1) 24798] to schedule an appointment if you are not contact[Name (NI) ] by his office directly. Please follow up with your Primary Care Provider [Last Name (NamePattern4) ]. [Last Name (STitle) ] in [12-5] weeks. You can call [Telephone/Fax (1) 10688] to schedule an appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909]	[ "41401", "2875" ]
Admission Date: [2161-3-26] Discharge Date: [2161-4-4] Date of Birth: [2106-6-29] Sex: F Service: CARDIOTHORACIC Allergies: Wellbutrin / Lipitor Attending:[First Name3 (LF) 1406] Chief Complaint: chest pain and shortness of breath Major Surgical or Invasive Procedure: [2161-3-30] Coronary artery bypass graft x3 (Left internal mammary artery > left anterior descending, saphenous vein graft > obtuse marginal, saphenous vein graft > posterior descending artery) History of Present Illness: 54 year old woman who has been increasingly short of breath. She was recently cathed and found to have multi-vessel coronary artery disease. She was transferred to [Hospital1 18] for surgical evaluation. Past Medical History: Coronary artery disease OSA using CPAP Diabetes mellitus type 2 hyperlipidemia hypothyroidism pernicious anemia bilateral S1 radiculopathy tubal ligation tonsillectomy Social History: Lives with:husband, sons Occupation:office worker Tobacco:smoked 1-1/2 packs per day for 30 years, quit 8 years ago ETOH:does not drink EtOH Family History: mother died at 51 yrs old of MI father with CABG at unknown age sister with multi-vessel angioplasty age 58 brother diagnosed with heart disease at age 61 years Physical Exam: Pulse:89 Resp:18 O2 sat: 89 B/P 122/74 Height: 5'3" inches Weight:252 lbs. General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact[x] Pulses: Femoral Right:1+ Left:1+ DP Right:1+ Left:1+ PT [Name (NI) 167]:1+ Left:1+ Radial Right:2+ Left:2+ Carotid Bruit Right: - Left: - Discharge VS: T: 98.5 HR: 88-97 SR BP: 103/60 Sats: 94% RA WT: 112 Kg General: NAD HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRR normal S1,S2 Resp: decreased breath sounds with bibasilar crackles GI: obese, bowel sounds positive, abdomen soft non-tender Extr: warm 1+ edema, LLE VV site at knee sm hematoma Incision: sternal c/d/i stable Neuro: AA&O x 3 Pertinent Results: [2161-4-3] 04:24AM BLOOD WBC-6.5 RBC-3.31* Hgb-9.9* Hct-29.0* MCV-88 MCH-29.9 MCHC-34.2 RDW-14.6 Plt Ct-262# [2161-3-30] 01:55PM BLOOD PT-13.6* PTT-33.7 INR(PT)-1.2* [2161-3-30] 12:30PM BLOOD PT-15.7* PTT-30.7 INR(PT)-1.4* [2161-3-26] 07:49PM BLOOD PT-13.6* PTT-41.7* INR(PT)-1.2* [2161-4-3] 04:24AM BLOOD Glucose-93 UreaN-14 Creat-0.8 Na-143 K-4.2 Cl-106 HCO3-30 AnGap-11 Intra-op echo [2161-3-30] Conclusions PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. There is no pericardial effusion. Dr.[Last Name (STitle) ] was notified in person of the results before surgery incision POST-BYPASS: Preserved biventricular systolic function. EF 55%. Intact thoracic aorta. Wall motions and valvular functions are all similar to prebypass. CXR [2161-4-3]: IMPRESSION: PA and lateral chest Atelectasis at the lung bases and small left pleural effusions are mild compared to the usual postoperative appearance. Normal postoperative cardiomediastinal silhouette. No pulmonary edema. No pneumothorax. Brief Hospital Course: Transferred in from outside hospital after undergoing cardiac catheterization that revealed coronary artery disease. She underwent evaluation for surgery and on [3-30] was brought to the operating room for coronary artery bypass graft surgery. See operative report for further details. She was transferred to the intensive care unit for post operative management. In the first twenty four hours she was weaned from sedation, awoke neurologically intact, and was extubated without complications. She was started on betablockers and gently diuresed toward preoperative weight. On post operative day one she was transferred to the floor. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: ASA 81mg daily Fish oil 1000mg daily Imdur 30mg daily Lescol XL 80mg QHS Toprol XL 50mg daily MVI Nitrostat 0.4mg PRN Synthroid 137mcg daily Vitamin B12 1000/1ml SQ once per week (Sundays) Vitamin D [2149] units daily Discharge Medications: 1. Lescol XL 80 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO daily (). Disp:30 Tablet Extended Release 24 hr(s) Refills:0 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 6. levothyroxine 137 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:0 7. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 10. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours) for 7 days. Disp:28 Tablet Extended Release(s) Refills:0 11. buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 13. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. Discharge Disposition: Home With Service Facility: [Hospital6 486]/[Hospital6 89815] Discharge Diagnosis: Coronary artery disease s/p cabg OSA using CPAP Diabetes mellitus type 2 hyperlipidemia hypothyroidism pernicious anemia Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Left EVH site with slight erythema, no drainage Edema 1+ bilateral LEs Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [Last Name (STitle) ] - [Telephone/Fax (1) 170] [2161-4-22] 1:00 Cardiologist: Dr [Last Name (STitle) ] on [4-29] at 2:30pm Wound check appt. [2161-4-14], 10:15am Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) ],[First Name3 (LF) 2482] G. [Telephone/Fax (1) 89816] in [3-31] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2161-4-4]	[ "41401", "25000", "5990", "V1582", "32723", "2724", "2449", "2859" ]
Admission Date: [2101-1-14] Discharge Date: [2101-1-26] Date of Birth: [2031-1-31] Sex: F Service: SURGERY Allergies: Shellfish Derived / IV Dye, Iodine Containing Attending:[First Name3 (LF) 695] Chief Complaint: RUQ pain, portal vein thrombus, leukocytosis, rigors Major Surgical or Invasive Procedure: [2101-1-14]: CTA Abdomen [2101-1-14]: IJ line placement [2101-1-17]: Thrombolysis via TPA infusion catheter via the left portal venous branch [2101-1-18]: AngioJet assisted clot lysis [2101-1-21]: Sigmoidoscopy; removal of foreign body History of Present Illness: 69 year-old female presenting with a 1-week history of diffuse abdominal pain, chills and subjective fevers. Initially her pain started epigastric and after 2-3 days it radiated to her entire abdomen. She denies any nausea or vomiting, has been mildly constipated lately, but her last bowel movement was yesterday and it was normal. She is being transferred from [Hospital3 4107] with a RUQ U/S suspicious for PV thrombosis. She had a WBC of 20.8 and was having rigors in the [Last Name (LF) ], [First Name3 (LF) ] received 3g of Unasyn for concerns for cholangitis. Past Medical History: None . Past Surgical History: tubal ligation 40 years ago Social History: Lives at home with ill husband, Smokes 1PPD for >50 years. Denies any Alcohol Family History: Father died of bladder cancer Physical Exam: VS 101.4 107 108/66 22 91% RA General: No acute Distress Neuro: Awake, alert, cooperative with exam, normal affect, oriented to person, place and date. Lungs: Clear to Auscultation bilaterally Cardiac: Regular rate and rhythm, S1/S2 Abd: Soft, nondistended, very mildly tender on the RUQ. No guarding or [Doctor Last Name ] sign. Extrem: Warm, well-perfused, no edema Pertinent Results: On Admission: [2101-1-13] WBC-19.0* RBC-3.61* Hgb-11.4* Hct-33.2* MCV-92 MCH-31.5 MCHC-34.2 RDW-14.3 Plt Ct-285 PT-14.4* PTT-35.9* INR(PT)-1.3* Fibrino-673* Glucose-91 UreaN-31* Creat-1.1 Na-126* K-7.9* Cl-93* HCO3-20* AnGap-21* ALT-36 AST-84* AlkPhos-191* TotBili-1.9* Lipase-22 Albumin-3.0* Calcium-8.6 Phos-3.7 Mg-2.4 [2101-1-14] HBsAg-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [2101-1-16] CEA-4.9* AFP-1.6 CA [09]-9 33 WBC trend: [2101-1-14] WBC-11.5* [2101-1-17] WBC-16.2* [2101-1-19] WBC-24.5* [2101-1-20] WBC-20.7* [2101-1-21] WBC-25.8* [2101-1-24] WBC-20.0* [2101-1-25] WBC-27.4* [2101-1-26] WBC-14.8* Brief Hospital Course: 69 y/o female who presents from OSH with evidence of portal vein thrombus on ultrasound. An ultrasound was performed on admission to [Hospital1 18] showing thombosed left portal vein. Main portal and right portal veins are patent. there is a normal gallbladder with no gallstones. The liver is diffusely echogenic compatible with fatty infiltrate. A CTA was then obtained to further delineate the extent of thrombus, which showed the left portal and anterior right portal vein thrombosis. Small thrombus extends into the main portal vein. The posterior right portal vein remains patent. The SMV and the splenic veins are patent. No discrete pancreatic mass. There is also a 6 mm left lower lobe pulmonary nodule which would be concerning due to patients 50 pack year history of smoking. The patient was immediately started on a heparin drip and was given 2 days of Unasyn due to concerns for cholangitis. Blood and urine cultures taken on admission have been finalized with no growth. In the meantime coverage was broadened to Vanco and Levaquin. An echo was performed showing no evidence of vegetations and an EF > 65%. She was noted to have worsening abdominal pain, and on [1-16], a repeat abdominal CT was obtained showing progression of the previously noted portal vein thrombosis, which now involved the posterior right portal vein. There was marked delayed periportal enhancement without biliary dilatation, with findings concerning for septic thrombophlebitis. Perforation of sigmoid colon by an intraluminal foreign body is suggested as etiology by the imaging findings; as there is no provided history of any hepatobiliary stenting, there is the possibility of an ingested foreign body. On [2101-1-17] the patient underwent attempted thrombolysis. Portal venogram demonstrating completely occluded left portal vein. Partial filling defect noted in a branch of the right portal vein suggestive of partial thrombus. She had successful placement of a TPA (Alteplase) infusion catheter via the left portal venous branch for overnight thrombolytic infusion and was transferred to the SICU overnight for monitoring. On [1-18] a pre-procedure venogram showed no decrease in the clot. She then had a Post-AngioJet clot lysis venogram demonstrating total clot lysis in the branches of the right portal vein. Residual clot is still noted in the left portal vein. The left portal vein appears small in caliber, with little forward flow. The heparin drip was restarted and she was able to be transferred back to the regular surgical floor. The thrombus remnant was sent for culture, there was no growth obtained from this specimen. On [1-19] the antibiotic coverage was changed, the levaquin was d/c'd and Zosyn was started. Her respiratory status was worsening, she had developed inspiratory and expiratory wheezes, and chest xrays indicated concern for new bilateral opacities, likely pneumonia with para pneumonic effusions, right greater than left. Lasix was started. Over the next few days her respiratory status improved and on [1-25] a chest xray was obtained showing there is some decrease in the still present bilateral pleural effusions with compressive atelectasis at the bases. The pulmonary vascularity has returned to an almost normal state. Another CT of the abdomen was done on [1-25] showing increased perihepatic and perisplenic ascites. Since [2101-1-16], there has been interval removal/resolution of thrombi at the distal main portal vein and the proximal right posterior branch, the right posterior portal vein is now widely patent and the left portal vein and anterior branches of the right portal vein are not opacified with IV contrast and likely thrombosed. This is unchanged since [2101-1-16]. As the patient was having persistently elevated WBC, with all negative blood and urine cultures as well as the thrombus, the central line was removed, and she was also switched to PO Augmentin which should continue for an additional two weeks. The WBC came down to 14.8 and she remained afebrile. Medications on Admission: None Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 3. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 14 days. Disp:42 Tablet(s) Refills:0 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) VIAL Inhalation Q6H (every 6 hours). 5. ipratropium bromide 0.02 % Solution Sig: One (1) vial Inhalation Q6H (every 6 hours). 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 8. warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day: PLEASE CHECK INR EVERY 2 DAYS UNTIL INR STABLE. THEN PER ROUTINE. . Disp:150 Tablet(s) Refills:2 Discharge Disposition: Extended Care Facility: [Hospital1 ] Discharge Diagnosis: Portal vein thrombosis Pneumonia Diverticulitis Foreign body removal from colon Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). With oxygen requirement Discharge Instructions: Please call Dr [Last Name (STitle) 4727] office at [Telephone/Fax (1) 673] for fever, chills, nausea, vomiting, diarhea, constipation, signs of bleeding to include nosebleed, dark/tarry stool or bright red blood per rectum or easy bruising, inability to take or keep down food, fluids or medications, increased abdominal pain or any other concerning symptoms. Be on lookout for worsening pulmonary status Monitor the INR at least twice a week until stable, patient will need anticoagulation for the foreseeable future, and will need follow up with a coumadin clinic or her PCP once discharged to home No heavy lifting Followup Instructions: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2101-2-9] 10:00 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707] MD, [MD Number(3) 709] Completed by:[2101-1-26]	[ "486", "5119", "3051" ]
Admission Date: [2143-4-8] Discharge Date: [2143-4-11] Service: MEDICINE Allergies: Augmentin / Tetanus / Biaxin / Clindamycin / Zometa / Enoxaparin / hydrochlorothiazide Attending:[Last Name (NamePattern1) 13129] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 86 F with PMH of metastatic breast ca, HTN, and dCHF who presented to the ED with respirtory distress and HTN to the 190's. . She recently presented with similar symptoms of hypertensive urgency c/b pulmonary edema requiring a brief intubation from [Date range (3) 96701], then again from [Date range (1) 96702] for similar presentation. During her admission on [2143-3-6], her home nifedipine was discontinued and she was started on a BP regimen of carvedilol/ lasix/ lisinopril. She was readmitted about a week after with similar symptoms and findings consistent with CHF exacerbation in setting for fluid overload, hypertension, and flash pulmonary edema. She responded to BIPAP, lasix, nitro gtt. She was discharged on Carvedilol 25mg by mouth twice a day. The lisinopril was stopped at the time. Her discharge wt was 58.9 kg. She recently saw her PCP, [Name10 (NameIs) 1023] [Name11 (NameIs) 15618] her lasix to 40mg on [2143-3-29], and planned to restart her lisinopril later. . On the day of this admission, pt was shopping when she felt sudden onset of SOB. She was BIBEMS placed on BIPAP in the field. Found to be hypertensive to 190s sbp. . In the ED: VS: HR115 BP170/90 RR35 100% on BIPAP. EKG with no acute changes with an old LBB and CXR with pulm edema. Pt was given Aspirin, Nitro gtt, vancomycin, and 40 mg iv furosemide. She also got vanc and zosyn as CXR could not exclude PNA. She put out 950cc. She was initially going to be admitted to the CCU for Bipap, but she was able to be weaned off the bipap and was conversing comfortably on 4L NC. She was felt to be appropriate for the floor. VS prior to transfer: 150/75 75 18 97% on 4L. On nitro gtt with bp in the 130's . On arrival to the floor patient reports she is feeling much better and no longer feel short of breath. She reports that she has had no weight gain at home (weight was 60kg at home, dry weight here 59kg). She denies increased [Location (un) ] but states that her legs are always swollen and slightly red on both sides.. At baseline she sleeps in a recliner. . On review of systems, she denies any prior history of stroke, TIA, 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, paroxysmal nocturnal dyspnea, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS:(-)Diabetes,(-)Dyslipidemia,(+)Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Breast Cancer with mets to lung and bone, including skull bone, stable on anti-estrogen therapy, primary oncologist (Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 96699]) at [Company 2860]. Has lumpectomy and left-sided LN dissection. - H/o DVT on Fragmin (has h/o allergy to Lovenox), currently dosed via [Company 2860] as part of a study protocol - Hypertension - [Company ] cancer leading to a sigmoid resection in [2109]/[2110] - OA - severe glenohumeral osteoarthritis plus other joints - LUMBAR SPONDYLOSIS/SPINAL STENOSIS - GERD - Mild [Doctor First Name ] Pos (1:40 titer) - clinically insignificant - Past Cdiff Pos ([2139]) . PAST SURGICAL HISTORY - per OMR - s/p bilateral TKA - L hip replacement, pins in right hip, most recent surgery [1-17] yr ago - S/p TAH in [2098] Social History: She lives alone in [Location (un) 96700] and is very active at baseline, independant in all ADL's, dives. Ambulates without assisance. Spends Mon/Fri at the cultural center, Tues playing trumpet in a band, and Weds/Thurs running erands. Has 3 cars at home and drives. Retired teacher. Never married and without children. Smoked 2ppd x 10-15 years until [2094], glass of wine <1x/week. No other drug use. No services at home currently. -Tobacco history: Past use, stopped [2094] -ETOH: <1 glass/wk -Illicit drugs: None Family History: Mother had [Name2 (NI) 499] cancer, died at age [Age over 90 ]. Father died at 49 from coronary thrombosis. Sister with [Name2 (NI) 499] cancer. Another sister with pancreatic cancer. Niece and nephew (in same family) both with [Name (NI) 4278]. She is last surviving relative. HCP is his lawyer. Physical Exam: On Admission: VS: T=98 BP=159/66 on 215mcg nitro gtt HR=72 RR=24 O2 sat=97% on 4L GENERAL: Well apeparing elderly F in NAD, breathing comfortably and talking in complete sentences without difficulty HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Slightly dry MM NECK: Supple with JVP of 8 cm. CARDIAC: S1 S2 heard but difficult to discern over 4/6 systolic murmurs heard best at LUSB LUNGS: MOderate kyphosis, XRT mapping on skin, hard breast tissue. Crackles at bases but otherwise good air movement. ABDOMEN: Soft, NTND EXTREMITIES: Warm, well perfused, 2+ pitting edema to knees bilaterally with chronic venous stasis changes. SKIN: no rashes, + venous stasis changes PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ On Discharge: VS: T=98.3 BP= 149/62 (120s - 140s/50s -70s) HR= 55 (65s-70s) RR=18 O2 sat=97% on RA Is&Os: Yesterday - 1620/2450 First 8 hour shift - 0/600 Weight: 61.8 <- 61.5 GENERAL: Well apeparing elderly F in NAD, breathing comfortably and talking in complete sentences without difficulty HEENT: NCAT. Sclera anicteric. NECK: Supple, JVP not elevated. CARDIAC: S1 S2, 3/6 systolic murmur LUNGS: Moderate kyphosis. No accessory muscle use. Few basilar crackles. ABDOMEN: Soft, NTND EXTREMITIES: Warm, well perfused, 1+ pitting edema SKIN: no rashes, + venous stasis changes on LE b/l GU: Foley catheter in place, urine appears grossly bloody PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ Pertinent Results: Admission labs: [2143-4-8] 08:10PM BLOOD WBC-8.2# RBC-4.61 Hgb-12.3 Hct-39.4 MCV-85 MCH-26.8* MCHC-31.4 RDW-15.7* Plt Ct-332 [2143-4-8] 08:10PM BLOOD Glucose-202* UreaN-29* Creat-1.2* Na-136 K-6.0* Cl-96 HCO3-26 AnGap-20 [2143-4-8] 08:10PM BLOOD Calcium-9.0 Phos-6.7# Mg-2.7 Discharge labs: [2143-4-11] 04:35AM BLOOD WBC-6.3 RBC-3.58* Hgb-9.7* Hct-29.6* MCV-83 MCH-27.0 MCHC-32.6 RDW-16.4* Plt Ct-261 [2143-4-11] 04:35AM BLOOD Glucose-107* UreaN-36* Creat-0.9 Na-138 K-4.1 Cl-100 HCO3-26 AnGap-16 [2143-4-11] 04:35AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.2 Other pertinent labs: [2143-4-9] 03:30PM BLOOD CK(CPK)-92 [2143-4-9] 05:35AM BLOOD CK(CPK)-106 [2143-4-9] 03:30PM BLOOD CK-MB-4 cTropnT-0.02* [2143-4-9] 05:35AM BLOOD CK-MB-6 cTropnT-0.04* [2143-4-8] 08:10PM BLOOD cTropnT-0.01 proBNP-[2104]* [2143-4-9] 05:35AM BLOOD TSH-2.9 [2143-4-8] EKG: Very marked baseline artifact. Sinus tachycardia, rate 103. Intraventricular conduction delay with left bundle-branch block pattern and secondary ST-T wave changes. Compared to the previous tracing of [2143-3-18] probably no diagnostic interval change. [2143-4-8] Portable CXR: CHEST, AP: There has been increase in diffuse interstitial and airspace pulmonary opacities, with confluent opacification in the left upper lobe and lingula, as well as the right perihilar region. Moderate cardiomegaly is unchanged, with a tortuous and calcified aorta. There are probable small bilateral pleural effusions. The bones are diffusely demineralized, with multilevel degenerative changes. IMPRESSION: Increased pulmonary opacities, likely representing worsening congestive heart failure, although underlying consolidation from infection/aspiration, mass is not excluded. Renal ultrasound with doppler: IMPRESSION: 1. Normal kidney size bilaterally. Incidental 8-mm right angiomyolipoma. Incomplete assessment of right renal vasculature but normal brisk upstroke arterial waveforms noted. 2. Normal left kidney with normal arterial and venous waveforms. 3. No evidence of renal arterial stenosis in either kidney. Brief Hospital Course: 86 F with PMH of metastatic breast ca, HTN, and dCHF who presented to the ED with respirtory distress and hypertensive urgency initially requiring bipap. Patient now breathing comfortably, blood pressure improved. ACTIVE ISSUES 1. Acute Pulmonary Edema: Likely related to hypertensive emergency as patient presented with SBPs in 190's. Patient had crackles to mid lung field, peripheral edema, and evidence of volume overload on CXR. Initially patient was placed on bipap in ED, butro gtt and iv lasix. Weaned quickly off bipap in ED and was admitted to the cardiology service. Patient initially diuresed with IV lasix and blood pressure was controlled with nitro gtt. Weaned off nitro gtt. Blood pressure control improved (see below). Patient diuresed well with IV lasix boluses and was transitioned to PO lasix. At discharge she was breathing comfortably on room air and her peripheral edema had improved. She was instructed to reduce sodium intake and weigh herself every day. 2. Hypertensive emergency: Patient has had three recent hospitalizations for CHF likely related to hypertensive emergency/urgency. Patient was initially treated with nitro gtt. Her home dose of carvedilol was continued. Lisinopril dose was increased from 10 mg daily to 30 mg daily. Patient was started on spironolactone 25 mg daily. Prior to discharge patient's blood pressure control improved. Work-up for secondary causes of hypertension was initiated in hospital. Patient had normal TSH. She also had renal artery ultrasound without evidence of renal artery stenosis. 3. Anemia: Patient had HCT drop on admission, but remained stable in the 29 - 30 range after admission. She had some hematuria with from foley trauma at admission, but not enough hematuria to explain drop. Patient's HCT remained stable. Stools were guaiac negative. Please continue outpatient anemia work-up. 4. Acute Renal Failure: On admission, creatinine was slightly elevated likely from poor forward flow in setting of acute diastolic CHF. Improved to baseline on day 2 of admission. 5. CAD: No documented cath in report, low suspicion for CAD. Troponin elevated likely in setting of demand ischemia. Peaked at 0.04 and came down to 0.02. Patient had no chest pain. CHRONIC/INACTIVE ISSUES 1. Breast CA: patient had been on oupatient regimen of Fluoxymesterone but unable to obtain from manufactuer. Patient's oncologist is aware and she will follow-up with her oncologist. 2. CODE: Patient wished to be DNI but not DNR. This was discussed with patient as it is difficult to resuscitate someone without intubating. This should be further addressed with patient. TRANSITIONAL ISSUES: 1. Hypertensive emergency: Initiated work-up for secondary causes of hypertension with TSH (normal) and Renal ultrasound with dopplers that did not show renal artery stenosis. Patient to continue endocrine work-up for secondary causes of hypertension as outpatient. Medications on Admission: Aspirin 81 mg qd Omeprazole 20 mg qd Fluoxymesterone 10 mg [Hospital1 ] - unable to get from manufactuer for last several months, so not taking Carvedilol 25 mg [Hospital1 ] Furosemide 40 mg qd Scopolamine base 1.5 mg Patch q72 hr Roxicet 5-325 mg q6 prn pain - patient states she is not taking Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 4. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 5. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 7. Outpatient Lab Work Monday [2143-4-15]. Please check chem 10. Fax results to: Name: [Last Name (LF) 2204], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Phone: [Telephone/Fax (1) 2205] Fax: [Telephone/Fax (1) 7922] Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: PRIMARY: Acute on chronic diastolic congestive heart failure exacebation, hypertensive emergency SECONDARY: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to participate in your care Ms. [Known lastname 96703]. You were admitted to the hospital because your blood pressure was very high, you had too much fluid in your lungs, making it difficult for you to breathe. You were given medications to help remove the fluid from your body as well as lower your blood pressure. You felt much better and did not need any supplemental oxygen to breath. You blood pressure is also much better. Please have your blood drawn on Monday [4-15] prior to your doctor's appointment on Tuesday [4-16] so that your doctor has the information prior to your appointment. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. Please make the following changes to your medications: 1. Increase your dose of lisinopirl to 30 mg daily from 10 mg daily 2. Increase your dose of lasix to 40 mg twice a day from 40 mg daily 3. ADD aldactone 25 mg daily Please see below for your follow-up appointments. Followup Instructions: Department: [State ]When: TUESDAY [2143-4-16] at 4:40 PM With: [First Name11 (Name Pattern1) 2946] [Last Name (NamePattern4) 6564], MD [Telephone/Fax (1) 2205] Building: [State ] ([Location (un) ], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: On Street Parking Department: CARDIAC SERVICES When: WEDNESDAY [2143-4-24] at 3:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "5849", "4280", "4019", "2859", "53081" ]
Admission Date: [2133-11-9] Discharge Date: [2133-11-12] Date of Birth: [2054-4-30] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[First Name3 (LF) 2901] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: Patient is a 79 yo female with PMH significant for HTN, COPD who presented to OSH with acute onset of SOB on [2133-11-5]. She was C/o of mild discomfort on the sides of her upper abd after which the SOB started suddenly. Initially she thought that she was having a panic attack but then she became diaphoretic and cold. Daughters called 911 and she was taken to [Hospital3 934] hospital. Her initial O2 sat were 88% on 4L O2 and was afebrile. CXR showed extensive B/l alveolar infiltrates more on the rt side. A prelim diagnosis of CHF with COPD exacerbation was made and she was started on morphine, lasix and solumedrol levaquin, ceftriaxone and nebulizers. She was put on BiPaP for her resp distress and subsequently was intubated. CTA was negative for PE. An echo performed revealed MVP with severe MR. At the request of the family the pt is transferred to [Hospital3 ]. ROS: Generalized fatigue for the past few months. Cough with blood for about 2 months. Abd gas pain. No h/o CP, palpitaions, dizziness, syncope, orthopnea, PND or pedal edema. Daughters say that the pt has lost significant weight in the last few months. Past Medical History: 1)COPD predominant emphysema 2)Hypertension 3)Glaucoma 4)Cataract 5)Osteoporosis 6)Seasonal Allergies 7)Anxiety 8)Arthritis Social History: Lives alone. Daughter lives nearby. Very active and current smoker with 1ppd since age 16. Family History: Non-contributory Physical Exam: vitals Temp 100 HR 93 RR 24 BP 96/56 O2 sat 94% (Vent with 50%FiO2 and 7 PEEP) Gen-Intubated and sedated. Responds to commands HEENT - PERRL, neck supple, JVD not appreciated Lungs - CTA b/l CVS - S1 soft, S2 normal, regular, palpable systolic thrill in apex which is displaced laterally. Grade [4-2] holosystolic murmur at apex Abd - soft, nontender, BS+ Neuro - Sedated but arousable (unable to perform further neuro exam) Ext - B/l pedal edema, pulse++ Pertinent Results: [2133-11-9] 06:50PM BLOOD WBC-8.3 RBC-3.25* Hgb-10.7* Hct-30.0* MCV-92 MCH-33.0* MCHC-35.8* RDW-13.1 Plt Ct-183 [2133-11-9] 06:50PM BLOOD PT-12.8 PTT-21.8* INR(PT)-1.1 [2133-11-9] 06:50PM BLOOD Glucose-139* UreaN-29* Creat-0.6 Na-143 K-4.1 Cl-108 HCO3-30 AnGap-9 [2133-11-9] 06:50PM BLOOD CK(CPK)-295* [2133-11-9] 06:50PM BLOOD Mg-2.5 [2133-11-10] 02:55AM BLOOD Triglyc-111 HDL-50 CHOL/HD-2.8 LDLcalc-67 [2133-11-9] 07:01PM BLOOD Type-ART Temp-37.8 pO2-87 pCO2-55* pH-7.35 calTCO2-32* Base XS-2 . ECHO [2133-11-10] The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF 80%). 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. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is severe mitral valve prolapse. There is partial mitral leaflet flail. Severe (4+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. The tricuspid valve leaflets are mildly thickened. Tricuspid valve prolapse is present. Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is a small to moderate sized pericardial effusion. The effusion appears loculated. There is brief right atrial diastolic collapse. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. Impression: mitral and tricuspid valve prolapse with flail mitral leaflets; severe mitral and tricuspid regurgitation with hyperdynamic left ventricular contractile function . Brief Hospital Course: This is 79 y/o f with wide open MR, CHF and pnumonia. She was admitted to the CCU. . 1) Cardiac: Patient was admitted to the coronary care unit for management. Her fentanyl drip was increased to provide sedation for the insertion of an arterial line. After the procedure the patient developed hypotension which was subsequently reversed by naloxone. She was later started on nipride drip for persistent hypotension. Pt had cardiac cath which showed normal coronaries with elevated pressures. A decision to take the patient for mitral valve replacement surgery was made after discussion with the family and therefore B/l chest tubes were placed to drain the pleural effusion post cath. Hct dropped from 26.4 to 24.6 after chest tube insertion and the pt received 1 unit of PRBC. Later the family reconsidered their decison and the patient's daughter who is also the health care proxy refused surgery. With the wishes of the family the patient was then extubated and she maintained spontaneous ventilation. We were able to communicate with her and she expressed that she did not want any kind of intervention to prolong her life including ET tube, chest tube or any surgery. Subsequently after discussion with the family the pt's status was changed to comfort measures only and she was started on morphine drip. . 2) Pulmonary: She was also started on antibiotics (Ceftriaxone and Azithromycin for pneumonia) and maintained on the ventilator. She was oxygenating adequately. As noted previously she was extubated and code status changed to CMO. . The patient expired on comfort measures only on Thursday evening ([2133-11-12]). Medications on Admission: Zyrtec 10mg daily Lorazepam 0.5mg 1 daily Timolol gel 1 drop each eye Alphagan eye drops Mavik 4mg daily Fosamax 1 weekly Rhinocort nasal spray Tylenol Vit E and C Calcium + Vit D Aspirin 81 mg daily Mucinex Discharge Medications: (Expired) Discharge Disposition: Expired Discharge Diagnosis: Severe Mitral Regurgitation with congestive heart failure Pneumonia Chronic Pulmomary Obstructive disease Discharge Condition: Expired [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909] Completed by:[2133-11-16]	[ "51881", "486", "4280", "4240", "5119", "4019" ]
Admission Date: [2149-5-27] Discharge Date: [2149-6-3] Date of Birth: [2085-5-14] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 458] Chief Complaint: bradycardia Major Surgical or Invasive Procedure: Cardioversion History of Present Illness: Mr [Known lastname ] is a 63 year old gentleman with recent CABG x 2 and MVR (OnX mechanical valve)/ MAZE/PFO closure admitted for hypotension and bradycardia s/p DC cardioversion for aflutter/atach. Per [Name (NI) ], pt was recently admitted in [2149-4-5] for subtherapeutic INR. During that admission, he was found to be in aflutter. At that time he was on Toprol Xl and amiodarone. Per the patient, amiodarone was then discontinued. Given his multiple recent surgeries, DC cardioversion was thought to be the best option for rhythm control. The patient himself has not had symptoms of tachycardia, no CP, no SOB. . The patient underwent DC cardioversion with sedation. He then became hypotensive and was bradycardic in a junctional rythm. He was placed on dopamine and recovered his blood pressure. He was subsequently admitted to the ICU for observation. Currently he states that he felt dizzy after cardioversion, but now feels well. Past Medical History: [1-14] complex cardiac surgery: -- artifical MV placed -- Coronary Artery Bypass Graft x 2 (LIMA to LAD, SVG to Diag) -- Patent Foramen Ovale closure -- [Name Prefix (Prefixes) ] [Last Name (Prefixes) 1916] ligation -- MAZE procedure Atrial Fibrillation Endocarditis - source thought to be dental abscesses Chronic Obstructive Pulmonary Disease Asthma Gout Anxiety s/p cataract surgery Social History: Quit smoking in [10/2148] after 2ppd x 50yrs. Denies ETOH use. Family History: Non-contributory Physical Exam: Vitals: afebrile BP 114/89 HR 83 R 14 Sao2 97% RA GEN: well appearing in NAD HEENT: no JVD CVS: well healed, midline chest scar RRR, mechanical S2, [3-12] diastolic murmur Resp: CTAB, no labored breathing EXT: no edema Neuro: Aox3 Pertinent Results: [2149-5-27] 09:54PM BLOOD WBC-10.4 RBC-4.83 Hgb-13.6* Hct-40.5 MCV-84 MCH-28.1 MCHC-33.6 RDW-16.8* Plt Ct-254 [2149-5-29] 04:10AM BLOOD WBC-8.7 RBC-4.15* Hgb-11.9# Hct-34.7 MCV-84 MCH-28.8# MCHC-34.4# RDW-16.7* Plt Ct-225# [2149-5-27] 09:54PM BLOOD Neuts-68.3 Lymphs-24.1 Monos-6.1 Eos-1.1 Baso-0.4 [2149-5-27] 12:10PM BLOOD INR(PT)-2.0* [2149-5-28] 06:00AM BLOOD PT-13.7* PTT-21.6* INR(PT)-1.2* [2149-5-29] 04:10AM BLOOD PT-22.6* PTT-63.7* INR(PT)-2.2* [2149-5-27] 09:54PM BLOOD Glucose-133* UreaN-21* Creat-1.1 Na-141 K-3.8 Cl-104 HCO3-30 AnGap-11 [2149-5-29] 04:10AM BLOOD Glucose-95 UreaN-17 Creat-0.8 Na-142 K-4.2 Cl-107 HCO3-26 AnGap-13 [2149-5-28] 06:00AM BLOOD CK(CPK)-54 [2149-5-28] 06:00AM BLOOD CK-MB-NotDone cTropnT-<0.01 [2149-5-27] 09:54PM BLOOD Calcium-9.0 Phos-3.7 Mg-2.0 [2149-5-29] 04:10AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.1 Brief Hospital Course: This 69 year old gentleman with a history of afib, COPD and endocarditis underwent CABG x 2, mechanical MVR, closure of patent foramen ovale, [Name Prefix (Prefixes) ] [Last Name (Prefixes) 1916] ligation and MAZE procedure on [2149-1-13] s/p DC cardioversion with subsequent hypotension and bradycardia. . # Rhythm: The patient was admitted with afib/flutter for DC cardioversion. After cardioversion the patient was hypotensive to SBp 80's and bradycardic with a junctional rhythm of 40's. He was placed on dopamine. Just after cardioversion, he felt dizzy but was assymptomatic from then on. He was weaned off the dopamine. Intially, he remained in a junctional rythm but he sinus node then recovered to a sinus bradycardia with occaisonal pauses. He was able to increase his HR to 60's with walking and did not feel lightheaded or weak with excercise. Pacemaker implantation was discussed with the pt who declined and strongly desired to avoid device implantation. His beta blocker was stopped. . # Valves: Prosthetic Mitral Valve, no acute issues. His goal INR is 2.5-3.5. Heparin gtt was started with a low INR and coumadin held in setting of possible pacemaker placement. Coumadin was restarted when it was decided not to place a pacemaker. He was kept in hospital on heparin until his INR reached 2.5; it reached 2.6 on the day of discharge. . # CAD/Ischemia: no acute issues. He was maintained on ASA and statin. BB was discontinued. . # Pump: Mild chronic systolic heart failure at baseline w/o exacerbation. No signs of fluid overload on exam. Intially lasix was held in the setting of hypotesion. It was restarted when his blood pressure recovered. - holding lasix and BB in setting of hypotension . # COPD: No excerbation. The patient was maintained on home regimen. . #Contact: [Name (NI) 553] [Last Name (NamePattern1) 174] (Friend) [Telephone/Fax (1) 9003] Medications on Admission: Aspirin 81mg daily Ranitidine 150mg [Hospital1 ] Toprol xl 75mg daily Lasix 40mg daily Multivitamin daily Singulair 10mg daily Coumadin as per the [Hospital 18] [Hospital 197] clinic Lipitor 20mg daily Colace 100mg PRN [Doctor First Name ] 180mg daily Ambien 10mg PRN for sleep Albuterol inhaler Advair disc 250-50 1 disc twice a day Colchicine prn for gout flares Spiriva inhaler daily Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:0 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:90 Tablet, Chewable(s) Refills:2 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:90 Tablet(s) Refills:2 5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:180 Capsule(s) Refills:0 7. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:270 Tablet(s) Refills:2 8. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. Tablet(s) 9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:3 inhalers Refills:0 10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). Disp:3 Disk with Device(s) Refills:2 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:90 caps Refills:2 12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:15 Tablet(s) Refills:2 13. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY16 (Once Daily at 16). Disp:90 Tablet(s) Refills:2 14. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Disp:90 Tablet(s) Refills:0 15. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day. Disp:90 Tablet(s) Refills:2 16. Outpatient Lab Work Please check INR and notify the [Company 191] coumadin clinic of results. Discharge Disposition: Home Discharge Diagnosis: atrial fibrillation/Atrial Flutter Junctional Rhythm Bradycardia Hypotension Hypertension anticoagulation for mechanical valve Discharge Condition: Good. Ambulating, afebrile, tolerating PO. Discharge Instructions: You were admitted to the hospital to undergo a procedure which would eliminate your atrial fibrillation. After the procedure, your heart rate was extremely low and you needed to be transferred to the CCU for closer monitoring. Over 48 hours, your heart rate gradually increased. . Please take your medications as prescribed. Please do not take your metoprolol XL (toprol XL) because this will slow your heart rate even further. Your doctors [Name5 (PTitle) ] [Name5 (PTitle) 9004] to restart this medication at some point later. You were started on a new blood pressure medication called lisinopril. . You should have your INR checked on Thursday [2149-6-5] and sent to your coumadin clinic/PCP [Name Initial (PRE) 3726]. . Please follow-up as described below. Please see your PCP or go to the emergency room if you have fevers over 102, chills, chest pain, trouble breathing, lightheadedness or any other symptoms which are concerning to you. Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 9001], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2149-6-10] 2:40 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 5003] Date/Time:[2149-6-17] 1:40 PM Provider: [Name10 (NameIs) 6821] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 1971] Date/Time:[2149-9-23] 9:45 . Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], cardiology: make an appointment in six months by calling [Telephone/Fax (1) 285].	[ "4280", "42731", "42789", "V4581", "4019" ]
Admission Date: [2135-12-21] Discharge Date: [2135-12-28] Date of Birth: [2070-5-2] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4679] Chief Complaint: Esophageal Adenocarcinoma Major Surgical or Invasive Procedure: [2135-12-21] 1. [First Name9 (NamePattern2) 12351] [Doctor Last Name ] esophagectomy. 2. Laparoscopic jejunostomy. 3. Buttressing of intrathoracic anastomosis with thymic fat. 4. EGD 5. Bronchoscopy History of Present Illness: The patient is a 65-year-old gentleman with a T2, N0 cancer of the gastroesophageal junction. He is being admitted for esophageal resection. Past Medical History: Hypertension CVA without residual Social History: He quit smoking 15 years ago. He was also a heavy alcohol user, but quit 25 years ago. He lives at home with his wife. [Name (NI) ] states that he does some yard work, but is not that physically active. Family History: Significant for mother with heart problems, father with a stroke. Brother with cancer, which she believes is a melanoma. Physical Exam: VS: T 98.0 HR: 72 SR BP: 112/66 Sats: 97% RA General: 65 year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRR normal S1,S2 no murmur/gallop or rub Resp: crackles right 1/3 up, left crackles LLL GI: benign. J-tube site clean Incision: Right minimal invasive site clean well approximation Neuro: non-focal Pertinent Results: [2135-12-26] WBC-9.4 RBC-3.85* Hgb-12.0* Hct-34.8 Plt Ct-182 [2135-12-24] WBC-9.4 RBC-3.69* Hgb-11.3* Hct-33.3 Plt Ct-132 [2135-12-21] WBC-15.1 RBC-4.23* Hgb-13.1* Hct-38.7 Plt Ct-154 [2135-12-27] Glucose-132* UreaN-19 Creat-0.8 Na-142 K-4.1 Cl-105 HCO3-30 [2135-12-26] Glucose-136* UreaN-17 Creat-0.8 Na-142 K-4.5 Cl-104 HCO3-32 [2135-12-21] Glucose-159* UreaN-18 Creat-1.1 Na-140 K-4.2 Cl-103 HCO3-28 [2135-12-27] Calcium-8.5 Phos-2.8 Mg-2.1 [2135-12-27] Esophagus Study: 1. No evidence of leak. 2. Free flow of barium through to the third part of duodenum. [2135-12-27]: CXR: sm right basilar hydropneumothorax, small bilateral effusions. Brief Hospital Course: Mr. [Known lastname 3321] was underwent successful, [Known lastname 12351] [Doctor Last Name ] esophagectomy, Laparoscopic jejunostomy, Buttressing of intrathoracic anastomosis with thymic fat, EGD Bronchoscopy. He transferred to the SICU intubated and subsequently extubated. Respiratory: Aggressive pulmonary toilet, nebs and IS were continued. Over the course of his hospitalization the nasal cannula O2 was titrated off. His room oxygen saturations were in the high 90's. Chest-tube: the right chest tube was removed on [2135-12-27] following the esophagus study. The chest tube site required suturing. Cardiac: he remained in sinus rhythm 70's. Prophylactic beta-blocker were continued. Immediately postoperative he required a fluid challenged for hypovolemia. Once stabilized his blood pressure remained stable in the 112-130's. GI: The NGT continued intermittent irrigation to maintain patency. He had a moderate amount of bilious output. It remained in place until [2135-12-27]. J-tube in place. Esophagus study was done on [2135-12-27] which showed passage of contrast into the small bowel without anastomotic leak. Nutrition: He was seen by nutrition. The J-tube feeds were started on [2135-12-23] Replete titrated to Goal 110 mL x 18 hrs was well tolerated. Pain: well controlled by Bupivacaine/Dilaudid Epidural was managed by the acute pain service. He was converted to PO Roxicet once the Chest tube was removed. Incision: Right minimal invasive incisions were clean margins well approximated. The anastomotic JP drain was removed on [2135-12-27]. Neuro: he had no neurological events during this hospitalization. Disposition: He was followed by physical therapy who deemed him safe for home. He continue to make steady progress and was discharged home with VNA and tube feeds on [2135-12-28] Medications on Admission: Lipitor 80 mg daily, ASA 325 mg daily, HCTZ 25 mg daily, lisinopril 5 mg daily, Ascorbic Acid 500 mg daily, MVI daily, Omega-3 1,000mg daily, Vitamin E 400 unit daily Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [Date Range ]: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. Disp:400 ML(s) Refills:0 2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). Disp:30 Tablet,Rapid Dissolve, DR(s) Refills:2 3. Docusate Sodium 50 mg/5 mL Liquid [Last Name (STitle) ]: Ten (10) mL PO BID (2 times a day): while taking narcotics. 4. Osmolite Osmolite Full strength; Goal rate:110 ml/hr Cycle: start:3pm Cycle end:9am 5. Aspirin 325 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 6. Plavix 75 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 7. Lipitor 80 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day: crush and take with apple sauce. 8. Metoprolol Tartrate 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Lisinopril 5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. 10. Hydrochlorothiazide 25 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital ] Home Health Care Discharge Diagnosis: Esophageal adenocarcinoma Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Call Dr.[Name (NI) 5067] office [Telephone/Fax (1) 2348] If your feeding tube sutures become loose or break: please tape tube securely. If your feeding tube falls out, save the tube, call the office immediately. The tube needs to be replaced in a timely manner because the tract will close within a few hours. Do not put any medication down the tube unless they are in liquid form. Daily weights: keep a log and bring it to your appointment with Dr. [First Name (STitle) ] Followup Instructions: Follow-up with Dr. [First Name4 (NamePattern1) ] [1-10] 9:30am on the [Hospital Ward Name 516] [Hospital Ward Name 23] Clinical Center [Location (un) 24]. Chest tube suture remvoval at time of visit Report to the [Location (un) 861] Radiology Department for a Chest X-Ray 45 minutes before your appointment Completed by:[2135-12-28]	[ "4019" ]
Admission Date: [2155-1-27] Discharge Date: [2155-1-31] Date of Birth: [2108-5-5] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 905] Chief Complaint: Wheezing Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 46 year old male with PMH of asthma and morbid obesity, who presented to an OSH on [2155-1-27] with complaint of wheezing and DOE x 2 days. Patient reports onset of SOB, wheezing, and fevers on [1-25]. His PCP had prescribed amoxicillin, but patient denied any improvement in his symptoms. On presentation to the OSH, the patient was noted to be in respiratory distress, with a room air O2 sat of 91%. ABG was noted to be 7.34/53/69. He was placed on a 50% face mask, and he was administered prednisone, Levofloxacin, and bronchodilators. He was transferred to [Hospital1 18] for further management. Past Medical History: 1. Asthma- no history of intubation. Last flare ~7 years ago. 2. HTN 3. Morbid obesity Social History: The patient lives with his wife, children, and mother-in-law. [Name (NI) ] quit smoking on [2154-1-25]. He smoked 1.5 packs per day x 20-30 years. He drinks alcohol occasionally. Denies illicit drug use. Family History: NC Physical Exam: VS: T: 100.4 BP: 154/64 HR: 101 RR: 20 O2 sat: 95% on 50% face mask General: Obese male lying in bed in mild respiratory distress. Patient is able to speak in full sentences HEENT: MMM. Oropharynx clear. Neck: Supple. No LAD. CVS: Distant heart sounds, tachy. No murmurs appreciated. Lungs: Diffuse insp and exp wheezes throughout, moderate air movement. Abd: Obese, soft, NT, +BS. Extr: No c/c/e. Warm. Pertinent Results: WBC Hgb Hct MCV Plt Ct 10.5 14.1 40.5 91 293 Neuts Bands Lymphs Monos Eos 78.4* 16.9* 4.0 0.3 0.3 Glucose UreaN Creat Na K Cl HCO3 113* 12 0.8 138 3.7 100 30* Calcium Phos Mg 8.6 3.7 2.2 UA ([1-28]): Color Appear Sp [Last Name (un) ] Straw Clear 1.025 Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks NEG NEG TR NEG NEG NEG NEG 6.5 NEG Micro: [1-27]: Influenza A DFA: POS Sputum ([1-27]) GRAM STAIN (Final [2155-1-28]): [10-28] PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Pending): Blood cx x 2 ([1-28]): pending Urine cx ([1-28]): pending Radiology: CHEST (PORTABLE AP) [2155-1-27] 10:54 AM Large size habitus of patient, but no evidence of CHF or acute infiltrates on portable single view examination. CHEST (PORTABLE AP) [2155-1-28] 6:06 AM Hypoventilation involving the lower lobes. No evidence of active congestion or infiltration. No evidence of pleural effusion or pneumothoraces. EKG: Sinus tach 107. Nl int, nl axis. Q III. No ST/TW changes. Brief Hospital Course: 46 year old male with PMH of asthma, HTN, and morbid obesity, admitted to MICU on [1-27] with wheezing/SOB. 1) Asthma exacerbation/influenza A: The patient was admitted to the MICU for management of his respiratory distress. He was placed on BiPAP overnight on [1-27]. He was treated for an asthma exacerbation with steroids and bronchodilators. He continued on Levofloxacin for treatment of tracheobronchitis. On [1-28], the patient spiked a temperature of 102.4 His nasopharyngeal aspirate came back positive for influenza A. The patient was maintained on continous nebulizers, which have been tapered to q 4 hours. Since the patient did not tolerate BiPAP, so he was placed on nasal CPAP (12-15 cm H2O) for likely obstructive sleep apnea. In addition, the patient was administered Wellbutrin and a nicotine patch to assist with smoking cessation. Given improvement in his respiratory status, the patient was transferred to the medical floor. 2) Smoking cessation: The patient was srtarted on Wellbutrin and Nictoine patch. 3) OSA: He was placed on nocturnal CPAP 12-15 cm H2O with a nasal mask. Patient's PCP (Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]) has been contact[Name (NI) ] and outpatient sleep study was recommended. 4) HTN: Captopril was titrated as necessary and the dose was converted to Lisinopril at the time of discharge. 5) Steroid-induced hyperglycemia. Glycemic control was maintained with RISS. 6) FEN: Low Na diet. Medications on Admission: Medications on admission: Azmacort Albuterol Avalade Amoxicillin Guiafenescin Discharge Medications: 1. Fexofenadine HCl 60 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:6 Tablet(s) 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) for 2 weeks. Disp:14 Tablet, Delayed Release (E.C.)(s) Refills:0 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 7. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QD (). Disp:30 Tablet Sustained Release(s) Refills:2 8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [Hospital1 ] (2 times a day). Disp:1 inhaler Refills:2 11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 12. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:7 Patch 24HR(s) Refills:0 13. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day for 2 days: 0n [2-1] and [2-2]. Disp:6 Tablet(s) Refills:0 14. Prednisone 50 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: on [2-3] and [2-4]. Disp:2 Tablet(s) Refills:0 15. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for 2 days: on [2-5] and [2-6]. Disp:4 Tablet(s) Refills:0 16. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day for 2 days: [2-7] and [2-8]. Disp:6 Tablet(s) Refills:0 17. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: [2-9] and [2-10]. Disp:2 Tablet(s) Refills:0 18. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: [2-11] and [2-12]. Disp:2 Tablet(s) Refills:0 19. Respitory Therapy please supply 1 CPAP machine with all accessories necessary for daily overnight use. 20. oxygen please supply continuous oxygen @ 2L nasal canula. * Pt is hypoxic at rest 89% (RA) and desaturates to <88% (RA) on ambulation. 21. CPAP settings please set CPAP @ 12 cm and 10 L/minute 02 in-line for nightly use. Discharge Disposition: Home With Service Facility: Respiratory Solutions Discharge Diagnosis: 1. asthma exerbation 2. tracheobroncitis 3. obstructive sleep apnea 4. hypetension Discharge Condition: good Discharge Instructions: 1. call 911 or go to the nearest ER if you experience increased shortness of breath, chest pain, fevers, chills, or feel unwell. Followup Instructions: 1. please call your primary care physician and pulmonologist, Dr. [Last Name (STitle) ], to follow up on your recent admission in the next 1-2 weeks @ [Telephone/Fax (1) 693]. 2. You are schedule to see Dr. [First Name (STitle) ] on [Last Name (LF) 2974], [4-11] at 2:00 pm for sleep study @ 2:00 pm on [Location (un) ] [Hospital Ward Name 23] Center; call ([Telephone/Fax (1) 9525] for questions. [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910] Completed by:[2155-6-1]	[ "4019" ]
Admission Date: [2105-12-8] Discharge Date: [2105-12-12] Date of Birth: [2039-2-10] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 37083] is a 66-year-old man with a history of multiple sclerosis, deep venous thromboses status post inferior vena cava filter, and hypertension, who was without any past cardiac history, who initially complained of substernal chest pain at his rehabilitation facility on the day of admission. The patient was given three sublingual nitroglycerins and presented to the [Hospital1 1444] Emergency Room, where an electrocardiogram was taken and demonstrated [Street Address(2) 4793] elevations in Leads II, III, AVF and V3 through V6. His blood pressure was in the 80s/50s, and his electrocardiogram changes persisted. Therefore, the patient was taken to the cardiac catheterization laboratory emergently. Cardiac catheterization results indicated a left main coronary artery without disease, a left anterior descending artery with a 99% stenosis and thrombus. The left circumflex artery had a 95% distal stenosis. The right coronary artery had a 90% mid-right coronary artery lesion. The left anterior descending and left circumflex lesions were successfully stented, however, the procedure was complicated by several factors: 1. The patient required defibrillation x 2 for an episode of ventricular fibrillation at the beginning of the case. 2. The patient sustained a distal aortic dissection as the catheter was threaded through a tight, diseased iliac artery. The patient was brought to the Coronary Care Unit for observation and post-catheterization care, given his instability in the catheterization laboratory, aortic dissection, and remaining tight lesions in his coronary anatomy. A heparin bolus of 5000 units was given in the Emergency Department prior to catheterization. PAST MEDICAL HISTORY: 1. Multiple sclerosis 2. Deep venous thrombosis 3. Inferior vena cava filter x 12 years 4. Hypertension 5. Right arm fasciotomy status post intravenous dye injection 6. Left-sided Port-a-Cath for multiple sclerosis medications 7. Personality disorder 8. Chronic constipation 9. History of pancreatitis ALLERGIES: The patient states no known drug allergies. MEDICATIONS ON ADMISSION: Prilosec, amoxicillin, Coumadin 2 mg by mouth daily at bedtime, Phenergan, Diltiazem 180 mg by mouth once daily, Antivert, Baclofen, and Vicodin. SOCIAL HISTORY: The patient is a resident at [Location (un) 2716] Point. He denies smoking or alcohol use. FAMILY HISTORY: The patient was unable to give any history of cardiac illness in the family. PHYSICAL EXAMINATION: The patient was afebrile, with a heart rate of 81, respiratory rate of 13, and blood pressure of 112/68, with oxygen saturation of 100% on room air. In general, the patient was lying in bed, alert and appropriate, and in no acute distress. Head, eyes, ears, nose and throat examination indicated pupils equal, round and reactive to light, extraocular movements intact. There was no jugular venous distention. The lungs were clear to auscultation bilaterally, with no wheezes, rales or rhonchi. The neck was supple, with no jugular venous distention. Coronary examination indicated normal S1 and S2, regular rate and rhythm, no murmurs, gallops or rubs. The abdomen was soft, nontender, nondistended, with normal bowel sounds. On extremity examination, the patient had 3+ edema in his lower extremities bilaterally, and Dopplerable pulses. His groin site was without hematoma or bruit. Neurologically, the patient was alert and oriented x 3. LABORATORY DATA: Initial laboratory studies post-catheterization indicated a white count of 5.0, hematocrit 29.1 which was down from 39.1 prior to catheterization, and a platelet count of 200. Chem 7 was unremarkable. Magnesium was 1.7, and free calcium was 1.15. CK #1 was 51, with a troponin of 1.4. CK #2 was 386 with an MB fraction of 63 and an index of 16.3. HOSPITAL COURSE BY SYSTEM: 1. Cardiac: The patient was observed in the Cardiac Intensive Care Unit for arrhythmia or other signs of hemodynamic instability following his complicated cardiac catheterization. With the exception of one episode of five beats of nonsustained ventricular tachycardia, no further episodes of arrhythmia were observed, and the patient was weaned off of a lidocaine drip. The patient did not receive Integrilin following cardiac catheterization secondary to a recent history of gastrointestinal bleeding. On further questioning, the patient indicated that he has had a chronic problem with gastrointestinal bleeding, and has had a recent colonoscopy and upper endoscopy which were reportedly negative. The patient was started on a beta blocker, ACE inhibitor, Lipitor, aspirin and Plavix following cardiac catheterization. His CK peaked at 635, with an MB fraction of 106. Troponin peaked at greater than 50. A lipid panel was sent, which indicated total cholesterol of 157, triglycerides of 73, HDL of 41, and LDL of 101. With regard to the patient's aortic dissection, he remained hemodynamically stable, with good distal pulses. Transthoracic echocardiogram was obtained and indicated a 30% ejection fraction, mildly dilated left atrium, mild left ventricular hypertrophy, apical akinesis, inferoseptal hypokinesis, 1+ mitral regurgitation, and an anterior pericardial fat pad. The patient was sent for a second cardiac catheterization on hospital day number four, with a goal of intervening upon the right coronary artery, which had not been intervened upon in the prior catheterization due to the various complications during that initial study. The right coronary artery was successfully stented in the second catheterization procedure. Given the patient's apical akinesis, poor ejection fraction, and history of deep venous thrombosis and inferior vena cava filter, it was decided that the patient should be started on long-term anticoagulation. He was therefore started on a heparin drip as well as Coumadin 5 mg by mouth daily at bedtime. At the time of this discharge dictation, it was planned that the patient would be discharged on Lovenox and Coumadin until reaching a therapeutic INR of 2 to 3, at which point the Lovenox would be discontinued. Throughout the hospital course, the patient reported several episodes of chest and abdominal pain. However, with each episode, the patient reported pain in a new location, and the patient was not able to give a consistent description of these various pains. Furthermore, there were no electrocardiogram changes associated with these episodes of pain, and the pain was thought to be non-cardiac in origin. At the time of this dictation, it was planned that the patient would be discharged on a regimen including aspirin, beta blocker, ACE inhibitor, lipid-lowering therapy, Plavix, and Coumadin. He was to follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. 2. Hematology: The patient required three transfusions of one unit of packed red blood cells during his hospital stay in order to keep his hematocrit above 30. At the time of dictation, the patient had been stable from a hematologic standpoint for 24 hours. 3. Neurology: The patient was continued on Antivert for multiple sclerosis. 4. Infectious Disease: The patient completed a ten day course of amoxicillin for a urinary tract infection diagnosed prior to admission, during his hospital course. DISPOSITION: At the time of this dictation, the patient was to be discharged to a rehabilitation facility at [Location (un) 2716] Point. He was to receive daily INR checks until he reached a therapeutic level of 2 to 3, at which point Lovenox would be discontinued. DISCHARGE DIAGNOSIS: 1. Myocardial infarction 2. Coronary artery disease 3. Hypercholesterolemia 4. Hypertension 5. Multiple sclerosis 6. Deep venous thrombosis DISCHARGE MEDICATIONS: Coumadin 5 mg by mouth daily at bedtime on the evening of [12-12], then 2 mg by mouth daily at bedtime, Lovenox 80 mg subcutaneously every 12 hours until INR equals 2 to 3, Plavix 75 mg by mouth once daily for 30 days, enteric-coated aspirin 325 mg by mouth once daily, Captopril 6.25 mg by mouth three times a day, Lopressor 50 mg by mouth twice a day, Lipitor 10 mg by mouth daily at bedtime, Antivert 25 mg by mouth three times a day, Peri-Colace one tablet by mouth twice a day, Protonix 40 mg by mouth once daily. CONDITION ON DISCHARGE: Improved. [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 7169] Dictated By:[Last Name (NamePattern1) 194] MEDQUIST36 D: [2105-12-12] 03:16 T: [2105-12-12] 03:37 JOB#: [Job Number 37084]	[ "9971", "42731", "5990", "4280", "2859" ]
Admission Date: [2153-3-19] Discharge Date: [2153-3-22] Date of Birth: [2078-8-1] Sex: M Service: UROLOGY HISTORY OF PRESENT ILLNESS: The patient is a 74 year-old male with a history of benign prostatic hypertrophy, coronary artery disease who presented initially to the Emergency Room in [2152-12-29] due to hematuria. A cystoscopy revealed an enlarged prostate in some areas of friability possibly causing hematuria. A CT scan was done as part of a hematuria workup, which revealed a left adrenal mass 7.3 by 6.0 cm. Urine catecholamines were negative for a 24 hour urine collection. PAST MEDICAL HISTORY: 1. Benign prostatic hypertrophy. 2. Coronary artery disease with an EF of 45%. 3. History of hypercholesterolemia. 4. Sleep apnea with BIPAP. 5. Status post knee surgery. 6. Status post carpal tunnel release. 7. Depression. MEDICATIONS: Zoloft 50 q.d., Terazosin 10 q.d, Lipitor 20 q.d., Diovan 160 q.d., Diltiazem 240 q.d., aspirin 81 q.d., Flovent spray two puffs b.i.d. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Afebrile. Vital signs are stable. Cor regular rate and rhythm. Abdomen soft, nontender, nondistended, mildly obese. Lungs clear to auscultation. Extremities on edema. HOSPITAL COURSE: The patient was brought to the Operating Room on [3-19], where he had a left adrenalectomy performed. The procedure was tolerated well. The patient was transferred to the Intensive Care Unit postoperatively for close monitoring. Upon transfer to the Intensive Care Unit the patient was extubated on the same day. The patient received one unit of packed red blood cells for a hematocrit of 28. He was hemodynamically stable throughout and required no vasopressors. The patient was transferred to the floor on postoperative day one. The patient was also started on a Hydrocortisone taper, which was completed by postoperative day three. The patient was ruled out postoperatively for a myocardial infarction by enzymes. Serial electrocardiograms postoperatively and those all showed no acute changes. On the floor the patient was started on a clear liquid diet on postoperative day two. This was tolerated well and he was advanced to a regular diet. All of his medications were changed to oral form and his pain was adequately controlled. Physical therapy evaluation was obtained and it was decided that Mr. [Known lastname 11188] would benefit from a short stay at a rehabilitation facility. The patient was afebrile throughout the admission. During his hospital course his Foley catheter was removed on postoperative day three. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS: Zoloft 50 mg q.d., Lipitor 20 mg q.d., Diltiazem 240 mg po q.d., Diovan 160 mg q.d., Flomax .4 mg q.d., aspirin 81 mg q.d., Isordil 60 mg t.i.d., Percocet one to two tab po q 4 to 6 hour, Flovent two puffs b.i.d., Colace 100 mg b.i.d. DISCHARGE STATUS: Rehabilitation facility. The patient will follow up with Dr. [Last Name (STitle) 11189] in approximately two to three weeks. DISCHARGE DIAGNOSES: 1. Status post adrenalectomy. 2. Coronary artery disease. 3. Sleep apnea. 4. Benign prostatic hypertrophy. 5. Depression. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 11190], M.D. [MD Number(1) 11191] Dictated By:[Name8 (MD) 1308] MEDQUIST36 D: [2153-3-22] 08:35 T: [2153-3-22] 08:44 JOB#: [Job Number 11192]	[ "41401", "2720", "4019", "49390" ]
Admission Date: [2178-1-31] Discharge Date: [2178-2-17] Date of Birth: [2178-1-31] Sex: F Service: NEONATOLOG HISTORY OF PRESENT ILLNESS: 32 [4-27] week twin #2 female admitted secondary to prematurity. 32 [4-27] week twin #2 female born to a 32 year old gravida 6, para 0, now 2, woman. PRENATAL SCREENS: O positive; antibody, positive (anti E); RPR, nonreactive; hepatitis B surface antigen, negative; GBS, negative. Mother with chronic hypertension treated with Aldomet. Intravenous in [Last Name (un) 5153] fertilization diamniotic/dichorionic twin pregnancy. Pregnancy complicated by cervical shortening which was treated with a cerclage at eighteen weeks gestation. Mother presented with premature labor beginning two days prior to delivery which was treated with Magnesium Sulfate. Betamethasone complete on [2178-1-17]. Antepartum testing on the day of delivery revealed discordant growth and concern for fetal well being of twin #1. Twin A #1 with a biophysical profile of [4-28], nonreassuring, nonstress test, absent diastolic flow. Therefore, proceeded to Cesarean section under spinal anesthesia. Vigorous female who required free flow oxygen and suctioning. Apgars were 8 at one minute and 9 at five minutes. The infant transferred to the Neonatal Intensive Care Unit for further evaluation and treatment for prematurity. PHYSICAL EXAMINATION ON ADMISSION: Weight, 1,730 grams (50th percentile); head circumference, 30 cm (40th percentile); length, 42.5 cm (50th percentile). Anterior fontanel, soft, flat, nondysmorphic, palate intact. Clear breath sounds bilaterally. No murmur. Normal pulses. Soft abdomen. No hepatosplenomegaly. Three vessel cord. Normal female genitalia. No hip click. No sacral dimple. Patent anus. Active with normal tone. Good perfusion. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Infant has remained in room air throughout this hospitalization. Initially, infant presented with tachypnea with respiratory rate to the 80s which resolved by day of life #1. Respiratory rates have been 40 to 60 with oxygen saturations greater than 95%. Infant was not treated with Methylxanthine this hospitalization. The last apnea and bradycardia was on [2178-2-12]. Cardiovascularly, the infant has remained hemodynamically stable this hospitalization. No murmur. Heart rate, 140 to 150 with mean blood pressures 45 to 50. Food, electrolytes and nutrition, the infant was initially nothing by mouth and was receiving 80 cc per kg per day of D10W. Enteral feedings were started on day of life #1 and was advanced to full volume feedings by day of life #2. Total fluids were advanced to 150 cc per kg per day by day of life #9. Maximum caloric density of premature Enfamil 26 calories per ounce was achieved by day of life #14. Infant tolerated feeding advancement without difficulty. Calories were decreased on [2-16] and were changed to Enfamil 24 calories per ounce or breast milk 24 calories per ounce with Enfamil powder, taking a minimum of 130 cc per kg per day p.o. The most recent weight is 1,985 grams. Head circumference, 30.75; length, 42.5 cm. Gastrointestinal, the infant received phototherapy for a total of four days. Maximum bilirubin level of 7.3 with a direct of 0.3. Hematology, the infant did not receive blood transfusion this hospitalization. The most recent hematocrit on day of delivery was 48.4 percent. Blood type, O positive; Coombs, negative. Infectious Disease, the infant had an initial CBC, differential and blood culture sent on admission which showed a white blood cell count of 13.5; hematocrit, 48.4 percent; platelets, 357,000; 23 neutrophils; one band. Due to improvement in respiratory status, the infant was not treated with antibiotics. Blood cultures have remained negative to date. The infant was treated with Miconazole from day of life #7 to day of life #11 for a monilial diaper rash. Neurology, a head ultrasound on [2178-2-4], showed no interventricular hemorrhage. Sensory, hearing screening was performed with automated auditory brain stem responses. The infant passed both ears. Ophthalmology, the infant does not meet criteria for eye examination. Psychosocial, [Hospital6 256] Social Work involved with family. The contact Social [Name2 (NI) 16633] can be reached at ([Telephone/Fax (1) 24237]. Parents involved. CONDITION AT DISCHARGE: Former 32 [4-27] week twin #2, now 35 weeks corrected, stable on room air. DISCHARGE DISPOSITION: Home with parents. NAME OF PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) 45979] [Last Name (NamePattern1) 21056], phone number ([Telephone/Fax (1) 45983]. CARE RECOMMENDATIONS: FEEDINGS AT DISCHARGE: Breast milk 24 calories per ounce mixed with Enfamil powder or Enfamil 24 calories per ounce, minimum 130 cc per kg per day p.o. MEDICATIONS: Fer-In-[Male First Name (un) ] 2 mg per kg per day p.o. CAR SEAT: The infant passed car seat position screening. State newborn screens were sent on [2-3] and [2-14]. Results are pending. IMMUNIZATIONS: The infant received hepatitis B vaccine on [2178-2-16]. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] 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 plans for day care during RSV season, with a smoker in the household or with preschool sibs. 3. With chronic lung disease. FOLLOW UP APPOINTMENTS: Primary Pediatrician. DISCHARGE DIAGNOSIS: 1. Prematurity, twin #2. 2. Status post rule out sepsis. 3. Status post transitional tachypnea as a newborn. 4. Status post apnea of prematurity. 5. Status post hyperbilirubinemia. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 36142], M.D. [MD Number(1) 36143] Dictated By:[First Name3 (LF) 45984] MEDQUIST36 D: [2178-2-16] 22:42 T: [2178-2-16] 23:13 JOB#: [Job Number ]	[ "7742", "V053", "V290" ]
Admission Date: [2128-12-30] Discharge Date: [2129-1-8] Date of Birth: [2049-12-27] Sex: M Service: SURGERY Allergies: Latex / morphine Attending:[First Name3 (LF) 1390] Chief Complaint: reversal of [Doctor Last Name 3379] Major Surgical or Invasive Procedure: [2128-12-31] Ex lap [2128-12-30] [Doctor Last Name 3379] Reversal [2128-12-31] left subclavian catheter (d/c [1-8]) History of Present Illness: HISTORY: Mr. [Known lastname 91526] is well known to the acute care surgery service and to me status post Hartmann procedure. He is a 78-year-old gentleman with myasthenia [Last Name (un) 2902] on high-dose steroids who had a perforated sigmoid diverticulitis on [2128-10-12] status post Hartmann procedure. His postoperative course was complicated by a pulmonary embolus, and he was placed on Coumadin and subsequently developed some GI bleeding which was found to be superficial venous bleeding at the level of the stoma that was treated. He is currently on Coumadin and low-dose steroids for suppression of his myasthenia. He presents today for routine followup, feels well, and is anxious to have the stoma taken down. He has some fatigue, but otherwise doing well. The stoma is functioning properly. He is eating well and moving his bowels otherwise without Past Medical History: PMH: 1. Myasthenia [Last Name (un) 2902] 2. Hypertension 3. Asthma 4. Pulmonary embolism 5. Remote history of reflux per patient PSH: 1. radical prostatectomy for benign BPH in [2127-11-12] 2. R TKR 10 years ago 3. Sigmoid colectomy with creation of hartmann's pouch Social History: Lives with wife who is a nurse. Retired manager of electric company. Drinks 3 glasses wine/week. Denies tobacco or illicit drug use. Family History: Father deceased [1-13] stomach CA. Mother deceased [1-13] PNA, both in 80s. Physical Exam: PHYSICAL EXAMINATION: upon follow-up office visit [2128-11-9] VITAL SIGNS: His temperature is 97.4, pulse is 73, blood pressure is 130/78, respiratory rate is 14, and saturating 96%. He has no pain. He is 5 feet 10 inches and weighs 235 pounds. HEENT: Within normal limits. NECK: Supple. HEART: Regular. LUNGS: Clear. ABDOMEN: Soft. The stoma is pink and brown stool and gas in the bag. The midline incision has healed well with small area that is granulating. It was superficially debrided of some fibrinous tissue and covered with a wet-to-dry dressing. The remainder of the incision is intact. There is no hernia or cellulitis. EXTREMITIES: Warm and well perfused. Pertinent Results: [2129-1-6] 04:42AM BLOOD Hct-30.1* [2129-1-5] 04:45AM BLOOD WBC-8.3 RBC-3.01* Hgb-9.0* Hct-26.9* MCV-89 MCH-30.0 MCHC-33.6 RDW-15.5 Plt Ct-168 [2128-12-30] 07:18PM BLOOD Neuts-82.3* Lymphs-12.7* Monos-4.3 Eos-0.5 Baso-0.2 [2129-1-6] 04:42AM BLOOD PT-12.9* INR(PT)-1.2* [2129-1-5] 04:45AM BLOOD Plt Ct-168 [2129-1-5] 04:45AM BLOOD PT-13.5* INR(PT)-1.3* [2129-1-4] 04:00PM BLOOD PT-12.6* PTT-26.0 INR(PT)-1.2* [2129-1-6] 04:42AM BLOOD Glucose-97 UreaN-22* Creat-1.0 Na-144 K-3.1* Cl-111* HCO3-29 AnGap-7* [2129-1-5] 04:45AM BLOOD Glucose-141* UreaN-27* Creat-1.1 Na-139 K-3.1* Cl-100 HCO3-34* AnGap-8 [2129-1-4] 05:50AM BLOOD Glucose-104* UreaN-27* Creat-1.1 Na-145 K-3.6 Cl-108 HCO3-32 AnGap-9 [2129-1-4] 05:06AM BLOOD Glucose-100 UreaN-30* Creat-1.1 Na-144 K-4.7 Cl-108 HCO3-29 AnGap-12 [2129-1-2] 02:36AM BLOOD ALT-1126* AST-608* LD(LDH)-241 AlkPhos-27* TotBili-0.6 [2129-1-1] 04:09AM BLOOD ALT-1361* AST-872* LD(LDH)-385* AlkPhos-22* TotBili-1.1 [2129-1-6] 04:42AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.8 [2129-1-5] 04:45AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.0 [2128-12-31] 05:39PM BLOOD Lactate-1.6 [2128-12-31] 05:39PM BLOOD freeCa-1.16 [2128-12-31] 09:11AM BLOOD freeCa-1.10* [2127-12-31] EKG: Sinus rhythm. Possible inferior wall myocardial infarction of indeterminate age. Compared to the previous tracing of [2128-10-16] heart rate is slower. TRACING #1 [2128-12-30]: chest x-ray: FINDINGS: In comparison with the study of [10-19], there are lower lung volumes with elevation of the left hemidiaphragm and bibasilar atelectasis. Small pleural effusions probably are present bilaterally. In the appropriate clinical setting, the possibility of a basilar pneumonia would have to be considered. Upper lungs are clear and there is no vascular congestion. [2128-12-31]: ECHO: Overall left ventricular systolic function is normal (LVEF>55%). The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. No aortic regurgitation is seen. No mitral regurgitation is seen. There is no pericardial effusion. [2128-12-31]: EKG: Sinus rhythm. Compared to tracing #1 there is no significant diagnostic change. [2128-12-31]: chest x-ray: FINDINGS: In comparison with the study of [12-30], there has been placement of Foley left subclavian catheter that extends to the mid-to-lower portion of the SVC. Continued bibasilar opacifications most likely reflecting a combination of atelectasis and effusion. No evidence of pulmonary congestion or definite pneumonia. [2129-1-1]: chest x-ray: CHEST: Since the prior chest x-ray, the endotracheal has been removed. The tip of the subclavian line lies in the mid-to-lower SVC. Lung fields appear clear, no evidence of pneumonia or failure is seen. Brief Hospital Course: 78 year old gentleman admitted to the acute care service for reversal of [Doctor Last Name 3379] pouch. His operative course was stable with a 20 cc blood loss. He required 1 liter crystalloid intra-op. He was extubated after the procedure and monitored in the recovery room. His post-operative course was complicated by hypotension and a decreased urine output despite additional intravenous fluids. For this reason, he was transferred to the intensive care unit for monitoring where he required 4 liters of fluid for blood pressure support. Neosynephrine was added to maintain his tone. Because he had an increasing lactate level, he was taken back to the operating room on POD # 1 for an exploratory laparotomy. He was found to have approximately 3500 mL of old and a new clot throughout the abdomen as well as active hemorrhage from the left side of the distal mesocolon in the area of the previous dissection. [Initials (NamePattern4) ] [Last Name (NamePattern4) ] drain was placed in the area of the hemorrhage. During this procedure he required 3.5 liters of crystalloid, 2 u PRBC, and 1 u FFP as well as neosynephrine. Afte the procedure, he was transported to the intensive care unit for further monotoring. A bedside ECHO was done which showed good LV and RV function. On POD #1 from the exploratory laparotomy, he was extubated and his pressors were weaned off. His hematocrit remained stable. Because of the additional fluids, he was started on lasix. His vital signs stabilzed and he was transferred to the surgical floor on POD #2. On POD #2, his [Last Name (un) ]-gastric tube was discontinued. He continued on his lasix because of his generalized body edema and later changed to diamox. The diamox was discontinued on POD #7 after he reported feeling lightheaded. At this time, he was also having occasional atrial and ventricular ectopy. His electrolytes have been monitored and repleted. He was started on clears and resumed his home medications. His intravenous prednisone was weaned down and he transitioned to his oral home dose. He was noted to have a bloody ooze from his drain site and from the lower aspect of his surgical wound. This resolved with the application of pressure. His hematocrit has remained stable at 30.0. His vital signs are stable and he is afebrile. He is tolerating a regular diet without complaints of nausea or vomitting. He has resumed his daily coumadin with an INR of 1.2. He has been encouraged to use the incentive spirometer and has maintained on oxygen saturation of 95% on room air. His [Doctor Last Name 406] drain was discontinued on POD #7 after he was found to have a decreased amount of drainage. The foley catheter was also discontinued on POD #7. He has had 2 isolatd bouts of diarrhea and a c.diff culture was ordered. Because of his deconditioning, he was evaluated by physical therapy for assessment of his mobility status. He is preparing for discharge home with VNA assistance. Though his INR is 1.3 at time of discharge, up from 1.1 but not yet therapeutic; he does not wish to restart lovenox for bridging. We discussed with his PCP coverage, and he will return home on his home dose of coumadin, and will call his PMD first thing on Monday morning to assess INR. Medications on Admission: [Last Name (un) 1724]: coumadin 2.5', lovenox 120', prednisone 10', atenolol 25 mg daily, pantoprazole 40 mg daily, mestanon 30 mg QID, Bactrim 800/160 mg M/W/F, Ca + VitD 600' Discharge Medications: 1. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO EVERY MON, WED, FRI (). 2. pyridostigmine bromide 60 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours). 3. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: may cause increased sedation. [Last Name (un) ]:25 Tablet(s) Refills:0 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: hold for loose stool. 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 10. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: please monitor PT/INR . Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: reversal of [Doctor Last Name 3379] pouch Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital for closure of your ostomy. You had a low blood pressure afte the procedure and you required additional fluid and monitoring in the intensive care unit. Your system was slow to respond to the fluids, and you were taken back to the operating room for an exploration. You were found to have a collection blood in your abdomen which was removed. You did require additional blood products after the procedure and you were monitored in the intensive care unit. Your vital signs stabilized and you were transferred to the surgical floor where you continued to improve. You did retain some fluid after the procedure and you were given medication to remove it. You are eating a regular diet and your [Doctor Last Name ] work has normalized. YOu are now preparing for discharge home with the following instructions: Please call your doctor or return to the emergency room if you have 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. * 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. Activity: No heavy lifting of items [9-26] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Completed by:[2129-1-8]	[ "2762", "2851", "5849", "4019", "53081", "49390" ]
Admission Date: [2148-9-30] [Month/Day/Year ] Date: [2148-10-13] Date of Birth: [2090-7-16] Sex: M Service: MEDICINE Allergies: Cefepime / ciprofloxacin / Levofloxacin Attending:[Last Name (NamePattern4) 290] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: - removal of tunneled line History of Present Illness: Mr. [Known lastname 47367] is a 58-year-old man with a history of AML s/p allogeneic transplant [2142] complicated by graft-versus-host disease, multiple vertebral fractures and ultimately development of paraplegia in the setting of a vertebral fracture during a code situation. Admitted multiple times, most recently [8-/2148] for bacteremia and upper resp infection (cx: staph epi) and completed a course of vancomcyin, aztreonam. Discharged from rehab and home (wheelchair bound) with recent clinic followup [9-26] noting baseline health. Wife also states he was in his usual state of health until the morning of admission when she went to wake him he was more somnolent than usual and seemed to be having difficulty breathing taking rapid shallow breaths. His wife attributed his somnolence to recently starting Ambion and Valium 3 days prior to admission in addition to his home narcotic regimen of oxycontin and dilaudid. She also noted that he looked more pale than usual. She reports that he had a cough starting over the weekend productive of yellow sputum. No history of fevers, and outside of baseline pain, he had no complaints. Given his somnolence, EMS was called and administereed narcan in the field without improvement so he was admitted to Study hospital on [9-30] for acute respiratory failure. On arrival he was afebrile, tachycardic to 160s (sinus), hypotensive to 91/58 (though fell to 60s-70s per wife), RR of 8, and was satting 94% on BIPAP. He was bolused 500cc with improvement of HR to 130s. He was bolused more NS (unclear how much) and remained hypotensive so was started on norepinephrine 2mcg/min and given stress dose hydrocortisone. He does have a triple lumen port, but given poor peripheral access, an intraosseous was placed. He was given an additional dose of narcan given continued somnolence and transferred to the [Hospital1 18] at the family's request given that all of his care has been here. In the ED, initial VS were T 98.6 HR 128 BP 89/69 RR 17 99% on BIPAP and initial ABG was 7.27/61/83. Labs were notable for leukocytosis to 14.2, Trop-T: 0.18, Lactate:3.4, creatinine of 1.1 (baseline 0.6-0.8), and a grossly positive urinalysis with > 182 whites and moderate bacteria. He has an indwelling foley catheter that was changed this past Thursday. A chest x-ray was notable for LLL consolidation. He had received emperic vancomycin at the OSH and received a dose of Zosyn in the ED here. On arrival to the MICU, patient's VS were T: 99.5 HR: 115 BP 121/69 RR 20, O2 sat 93% 100% NRB and was receiving levo at 1mcg/min on arrival. He was somnolent but arousable and oriented x 3, but slow to answer questions. Complained of pain from the chest up, but otherwise no complaints. Review of systems: (+) Per HPI. His wife notes that he did a few episodes of loose stools. Morning headaches recently. (-) Denies fever, chills, chest pain, chest pressure, palpitations. Denies dark or bloody stools. Past Medical History: Past Medical History: - CKD (baseline Cr 0.6-0.7) - Hyperlipidemia - HTN - Type 2 DM (last A1c 6.8 [2144]) - Depression - Chronic pain - Pericardial effusion s/p [3-23] drainage. - Nephrolithiasis, lithotripsy and previous nephrostomy tube and emergent surgery to repair ureteral damage. - Left interpolar renal lesion, followed with MRs - Basal cell carcinoma, resected. - Squamous cell carcinoma left cheek, s/p Mohs' 6/[2143]. - Multiple back surgeries: Lumbar L5-S1 surgery x 3, and cervical spine fusion (bone graft, no hardware). - Anterior cervical diskectomy and instrument arthrodesis at C5-C6 and C6-C7 for degenerative cervical spondylitic disease with spinal cord compression and foraminal stenosis at C5-C6 and C6-C7 [2-/2144]- Dr. [Last Name (STitle) 548]. - Chronic numbness, neuropathic pain in left upper extremity. - Sleep Apnea, planned BIPAP, followed by Dr. [Last Name (STitle) 4507]. - Lower extremity wound, s/p debridement by plastics, grew [Last Name (un) 2830] resistent pseudomonas [7-/2147] ONCOLOGIC HISTORY: - diagnosed with AML in 04/[2142]. - [2143-6-24] underwent unrelated allogeneic stem cell transplant with busulfan and cyclophosphamide as his conditioning regimen. - continues bactrim, voriconazole, acyclovir ppx POST TRANSPLANT COMPLICATIONS: - GVHD of the liver and skin. Question of pulmonary cGVHD as often requires oxygen and steroids in the setting of respiratory infections (h/o RSV, parainfluenza) - paraplegia [1-18] vertebral fractures during code [2147] - Chronic lower extremity and abdominal edema, refractory to lasix, suspected to be GVHD - abdominal spasm - on valium (?etiology paraplegia) - COP/BOOP: home O2 1-2liters - Avascular necrosis (bilateral hips and left shoulder) - Multiple compression fractures of the spine with chronic pain - Pulmonary embolus in [11/2144] and [5-/2146], no with IVC [Year (4 digits) 7448] not on anticoagulation - s/p L5 vertebroplasty [3-/2145] - Ruptured left calf hematoma ([9-/2146]) complicated by MRSA wound infection - Influenza A [1-/2147] - bilateral Achilles tendon rupture [2147-5-23] ( attributed to levoflox). Social History: Discharged from rehab in [2148-6-16] and has now been living at home wiht VNA services and aid from his wife. [Name (NI) ] is retired, worked as a [Company 22957] technician. He smoked for 40 pack years, now quit. He denies EtOH or drugs. Family History: Mother died suddenly in 70s. Father died of unknown cancer. One sister with thyroid cancer. One brother has diabetes. One sister has [Name (NI) 5895]. Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T: 99.5 HR: 115 BP 121/69 RR 20, O2 sat 93% 100% NRB General: Somnolent, but arousable, oriented x 3, no acute distress, answers one question before falling asleep HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, copious secretions Neck: supple, JVP not elevated, no LAD CV: Tachycardic regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Transmitted upper airway sounds bilaterally, good air movement Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: foley in place Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Skin laceration on dorsum of left wrist Neuro: CN 2-12 intact, strength 5/5 in UE; paralyzed from the waist down. [Name (NI) 894] PHYSICAL EXAM Pertinent Results: Admission labs: [2148-9-30] 11:00AM BLOOD WBC-14.2* RBC-3.56* Hgb-12.5* Hct-39.2* MCV-110* MCH-35.1* MCHC-31.9 RDW-17.7* Plt Ct-334 [2148-9-30] 11:00AM BLOOD Neuts-78* Bands-7* Lymphs-6* Monos-8 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [2148-9-30] 11:00AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-NORMAL Macrocy-3+ Microcy-NORMAL Polychr-1+ [2148-9-30] 11:00AM BLOOD PT-9.1* PTT-28.5 INR(PT)-0.8* [2148-9-30] 11:00AM BLOOD Glucose-174* UreaN-17 Creat-1.1 Na-140 K-4.0 Cl-103 HCO3-27 AnGap-14 [2148-9-30] 05:51PM BLOOD CK(CPK)-111 [2148-10-1] 02:30AM BLOOD ALT-46* AST-56* AlkPhos-106 TotBili-0.3 [2148-9-30] 11:00AM BLOOD cTropnT-0.18* [2148-9-30] 05:51PM BLOOD CK-MB-7 cTropnT-0.16* [2148-10-1] 02:30AM BLOOD Calcium-8.7 Phos-4.2 Mg-1.5* [2148-9-30] 06:29PM BLOOD Type-ART O2 Flow-15 pO2-91 pCO2-70* pH-7.23* calTCO2-31* Base XS-0 Intubat-NOT INTUBA [2148-9-30] 11:31AM BLOOD Glucose-167* Lactate-3.4* K-4.0 [Month/Day/Year ] labs: Micro: [2148-10-6] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE: PENDING [2148-10-5] CATHETER TIP-IV WOUND CULTURE- NO SIGNIFICANT GROWTH (PRELIMINARY) [2148-10-5] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PENDING; BLOOD/AFB CULTURE-PENDING [2148-10-4] URINE URINE CULTURE- NO GROWTH [2148-10-4] BLOOD CULTURE Blood Culture, Routine-PENDING [2148-10-4] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PENDING; BLOOD/AFB CULTURE-PENDING [2148-10-3] BLOOD CULTURE Blood Culture, Routine-PENDING [2148-10-3] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-NO GROWTH; BLOOD/AFB CULTURE-NO GROWTH [2148-10-2] BLOOD CULTURE Blood Culture, Routine-PENDING [2148-10-1] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PRELIMINARY {[Female First Name (un) ] (TORULOPSIS) GLABRATA}; BLOOD/AFB CULTURE-FINAL; Myco-F Bottle Gram Stain-FINAL BLOOD/FUNGAL CULTURE (Preliminary): [Female First Name (un) ] (TORULOPSIS) GLABRATA. BLOOD/AFB CULTURE (Final [2148-10-3]): DUE TO OVERGROWTH OF YEAST, UNABLE TO CONTINUE MONITORING FOR AFB. Myco-F Bottle Gram Stain (Final [2148-10-3]): BUDDING YEAST. [2148-10-1] URINE URINE CULTURE-FINAL {YEAST} URINE CULTURE (Final [2148-10-2]): YEAST. 10,000-100,000 ORGANISMS/ML.. [2148-10-1] BLOOD CULTURE Blood Culture, Routine-PENDING [2148-10-1] BLOOD CULTURE Blood Culture, Routine-PENDING [2148-9-30] URINE Legionella Urinary Antigen -FINAL - NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. [2148-9-30] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-PRELIMINARY {YEAST} Source: Expectorated. GRAM STAIN (Final [2148-9-30]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): BUDDING YEAST. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Preliminary): MODERATE GROWTH Commensal Respiratory Flora. YEAST. MODERATE GROWTH. [2148-9-30] BLOOD CULTURE Blood Culture, Routine-PENDING Studies: [2148-10-6] CT CHEST W/O CONTRAST: [2148-10-6] CHEST (PORTABLE): Right pleural effusion has decreased in size with associated improvement in adjacent right basilar atelectasis. Multifocal areas of heterogeneous consolidation involving the left lung to a greater degree than the right, have slightly improved. A small hyperlucency is present in the periphery of the left upper lobe at the level of the second and third anterior ribs, but no discrete visceral pleural line is identified. This may represent an area of spared lung parenchyma from the presumed multifocal pneumonia, but attention to this area on short-term followup radiograph may be helpful to exclude an atypical presentation of pneumothorax, given clinical suspicion for this entity. [2148-10-6] CHEST (PORTABLE AP): Widespread combined alveolar and interstitial opacities affecting the left lung to a greater degree than the right have progressed in the interval, particularly in the right lower lung where there is also an increasing pleural effusion with adjacent consolidation and/or atelectasis. Small left pleural effusion also appears increased from prior radiograph. [2148-10-5] CHEST (PORTABLE AP): Status post removal of right subclavian vascular catheter. Widespread heterogeneous combined alveolar and interstitial opacities affecting the left lung to a greater degree than the right, have progressed in the interval, and may represent a multifocal pneumonia with or without coexisting pulmonary edema. Pulmonary hemorrhage is also possible in the appropriate clinical setting. [2148-10-4] CT ABD & PELVIS W & W/O 1. No evidence of IVC or iliac vein thrombosis. IVC [Month/Day/Year 7448] in place. 2. Stable lung base findings include, lingular pneumonia and bibasal peribronchovascular nodular opacities suggestive of aspiration. Bilateral small effusions and right lower lobe pulmonary emboli. 3. Hepatic steatosis. [2148-10-2] CTA CHEST W&W/O C&RECON 1. Right lower lobe lobar to subsegmental pulmonary acute embolism. The most proximal portion of the filling defect is peripheral in the artery raising the question if this could be chronic but new since [2148-6-16]. There is no dilatation of main pulmonary artery or right heart [Doctor Last Name 1754]. 2. Worsening of bilateral multifocal pneumonia. [2148-10-2] CT HEAD W/O CONTRAST 1. Limited study due to motion artifact, within this limitation, no acute intracranial pathology. 2. Multifocal paranasal sinus and bilateral mastoid air cell opacification. [2148-10-2] BILAT LOWER EXT VEINS No deep venous thrombosis in right or left lower extremity. Bilateral calf edema. [2148-10-2] ECHO The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Right ventricular cavity dilation with free wall hypokinesis. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Compared with the prior study (images reviewed) of [2147-5-24], the right ventricular cavity is now dilated with free wall hypokinesis c/w an acute pulmonary process (e.g., pulmonary embolism, bronchospasm, etc.). [2148-10-2] ECG Sinus tachycardia with increase in rate as compared to the previous tracing of [2148-6-27]. Diffuse non-specific ST-T wave changes are more prominent in the context of wandering baseline and much baseline artifact. There appears to be more ST segment depression in leads V3-V6 without diagnostic interim change. [2148-10-2] EEG This is an abnormal EEG due to disorganized and slow background mostly consisting of mixed delta and theta suggestive of moderate encephalopathy but non-specific etiologically. There was no focal slowing or epileptiform discharges seen. Study limited by electrode artifact. Recommend repeat study if clinical concern for seizures persists. [2148-10-1] CHEST (PORTABLE AP) Previous pulmonary vascular congestion has improved, but there is still very extensive consolidation in the left lung due to pneumonia, without improvement, possibly worsened. Smaller region of consolidation in the right lower lung medially is either a second focus of pneumonia or atelectasis. Mild cardiomegaly is stable. Dual-channel right supraclavicular central venous set ends in the region of the superior cavoatrial junction. No pneumothorax. [2148-10-1] CHEST (PORTABLE AP) Progressive heterogeneous opacification in the left mid and lower lung zone is most likely pneumonia worsening since [9-30]. There could be a second focus of right infrahilar pneumonia, also advancing. Cardiomediastinal silhouette is essentially unchanged over several years. Dual-channel right supraclavicular central venous set ends close to the superior cavoatrial junction. No pneumothorax. [2148-9-30] CHEST (PORTABLE AP) 1. Worsening opacification in the left lung base with associated bronchial wall thickening concerning for infection. 2. Slight interval improvement in previously noted airspace disease within the right upper lobe. 3. No definite pulmonary edema. Brief Hospital Course: 57-year-old man with AML s/p matched unrelated allogeneic stem cell transplant in [2142], complicated by GVHD on chronic prednisone with multiple admission for infections now presents with somnolence in the setting if increased sedative medication use, hypercarbic respiratory distress, cough and CXR with LLL consolidation found to have segmental PE. # Goals of care: After frequent discussions with family and physicians involved in the pt's case and gradual reduction in number of interventions performed, it was decided to transition to comfort measures only on [10-12]. The below medical treaments, lab draws, and imaging procedures were held. The pt was kept in IV morphine, tylenol, and ativan to keep comfortable. He died peacefully on the morning of [2148-10-13]. # PE: Patient with tachycardia, hypoxemia, hypotensive on admission and history of PE not anticoaguated, with IVC [Date Range 7448] in place. TTE on [10-2] revealed large and hypokinetic RV and CTA showed segmental PE. Unclear if acute vs. subacute given appearance of clot on CTA. This was not present in [Month (only) ], however. [Month (only) ] is a potential source of clot as LENIs were negative. CTV showed no evidence of clot in IVC [Month (only) 7448]. Non contrast head CT was without hemorrhage, so started on heparin drip with intention to bridge to lovenox. Per discussion with inpatient heme attending and outpatient hematologist, it was decided that the pt's risk of hemorrhage was greater than his risk of clot given the negative LENIs and clean IVC [Last Name (LF) 7448], [First Name3 (LF) ] heparin gtt was held. He was continued on prophylactic heparin subc. # Pneumonia: Productive cough followed by somnolence in the setting of starting Ambien and Valium in addition to his home oxycontin. CXR with LLL consolidation. Sputum gram stain with GPCs in clusters, GPCs in pairs and chains and GNRs and yeast. Started on vanco, [Last Name (un) 2830] (day 1: [9-30]), mica (day 1: [10-3]) in consultation with ID. Due to worsening CXR, vanco was changed to linezolid (day 1: [10-6]) per ID recs. Also question of possible pulmonary congestion, so pt was started on IV lasix. On [10-8], the pt appeared to have worsening WBC and respiratory distress. He was started on ambisome and given a dose of tobramycin. The tobramycin was thereafter uptitrated with little effect. Antibiotics were continued despite little improvement. # Fungemia: Yeast in urine, sputum and mycolytic blood cultures positive. Ophtho consulted and did not see evidence of fungal retinitis. Patient does have GVHD of conjunctiva, however. He was continued on micafungin (day 1 = [10-3]) and will need two week course following clearance of fungus. Mycolitic blood cultures were sent daily. CXR showed nodular areas, which was conserning for a mold pneumonia. Pt was started on ambisone for presumed fungal pneumonia. An MR head was performed which ruled out fungal brain extension. ENT was consulted for possible involvement of nasal sinuses, who recommended nasal irrigation as tolerated given sedation. # Hypotension: He was hypotensive to 60s-70s at OSH and required pressor support prior to transfer to the [Hospital Unit Name 153]. Possible sepsis as patient met SIRS criteria with tachycardia and leukocytosis with possible sources of infection including pulmonary given LLL opacity on CXR and productive cough. Urine source also possible given dirty urinalysis in the setting of indwelling catheter. Cardiogenic shock was considered given rising troponins, but they trended down and were likely elevated in the setting of tachycardia. ECG was without evidence of ischemia. Hypovolemic shock also possible given that his PO intake had been down prior to admission and his BP was fluid responsive on admission. He was started emperically on vancomycin and meropenem (day 1 = [9-30]) for pneumonia to complete an 8 day total course (through [10-7]). His urine, blood, and sputum cultures all returned positive for budding yeast (ID is [Female First Name (un) ] (TORULOPSIS) GLABRATA), so he was initially started on IV fluconazole and was later transitioned to micafungin (day 1 = [10-3]). Ambisome was started and uptitrated as above. # Hypercarbic respiratory failure/somnolence: Patient difficult to arouse at home on AM of admission, and may have worsened since arriving to ICU. Likely multifactorial with hypercarbia from hypoventilation in the context of new sedating medications (ambien and valium, in addition to home narcotics), untreated OSA with likely CO2 retention at baseline, pneumonia, underlying GVHD of lung and PE. Pt has expressed wishes not to be intubated. His pneumonia and PE were treated as per above. His dyspnea was treated with either non-rebreather, venti mask, or bipap as tolerated in order to achieve sat > 90%. Ambien and valium were held. However, pt continued to complain of chest wall pain thought to be secondary to PNA and was continuously requesting more pain medication. After a goals of care discussion was held with pt, family, and specialists, it was decided to make the pt comfortable and give ativant and morphine despite hypercarbia. # Tachycardia: Continues to be in sinus tachycardia in the 130s. Initially in the 160s, but has improved with fluids. Likely multifactorial with PE, pain, hypovolemia, and withdrawal from opioids all contributing. He was given several doses of narcan at OSH and his home narcotics were initially held in the setting of hypotension. Morphine drip was started to relieve any pain without any improvement in tachycardia. # [Last Name (un) ]: Cr 1.1 from baseline of 0.6-0.7. Unclear etiology, but likely prerenal in the setting of septic shock (above) with hypotension and tachycardia. Creatinine improved back to baseline with treatment of septic shock. # UTI: Patient has indwelling foley catheter, so would be considered complicated infection. Has grown E. coli most recently, though did have a negative urine culture on [9-26]. Continue with vancomycin and meropenem as per above. # Troponinemia: Patient with elevated troponin at OSH, which has risen on arrival to the [Hospital1 18] ED. He denies chest pain and ECG with sinus tachycardia without ischemic changes. Likely troponin leak in the setting of tachycardia to the 160s. # AML s/p MUD SCT in [2142]: Daily CBCs were checked and there was no evidence of reoccurance. He was continued on bactrim, acyclovir, and azithromycin. Dr. [Last Name (STitle) ], outpatient oncologist following. # Chronic GVHD : In the past his chronic GVHC has primarily involved liver and lungs. His LFT's were mildly elevated at OSH, but has trended down while at [Hospital1 18]. He was continued on prednisone 10 mg PO daily, and ppx with with acyclovir, bactrim, and azithromycin. - IVIG monthly (last dose Thursday) # Type 2 DM on insulin: Most recent A1c is 6.8 from [2144]. His NPh was decreased to 10 units (from 15) due to low sugars. He was also placed on a sliding scale. # Hypertension: metoprolol was held given hypotension # Clot history: Prior PEs for which he was previously anticoagulated. Anticoagulation was discontinued in the setting of back surgery and an IVC [Year (4 digits) 7448] was placed. Now with segmental PE treated with heparin as per above. # Right axillary mass: Noticed by oncologist Dr. [Last Name (STitle) ] and was planning on working up as outpatient with CT scan. # Paraplegia: Stable during this admission. A spine consult was called regarding further management. Per Spine, lumbar and thoracic spine x-rays were ordered -- these showed no significant interval change. # Transitional issues: deceased Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H 3. Atorvastatin 10 mg PO DAILY 4. Azithromycin 250 mg PO Q24H 5. Bisacodyl 10 mg PO DAILY constipation 6. Bisacodyl 10 mg PR HS 7. Duloxetine 30 mg PO DAILY 8. Fluticasone Propionate NASAL 1 SPRY NU [Hospital1 ] 9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [Hospital1 ] 10. FoLIC Acid 1 mg PO DAILY 11. Gabapentin 300 mg PO BID 12. Hydrocortisone Cream 1% 1 Appl TP QID apply to affected areas 13. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain 14. NPH 15 Units Breakfast NPH 15 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 15. Ipratropium Bromide Neb 1 NEB IH Q6H 16. MethylPHENIDATE (Ritalin) 5 mg PO NOON 17. Metoprolol Tartrate 12.5 mg PO BID 18. Montelukast Sodium 10 mg PO DAILY 19. Multivitamins 1 TAB PO DAILY 20. MethylPHENIDATE (Ritalin) 5 mg PO QAM 21. Oxycodone SR (OxyconTIN) 40 mg PO BID 22. Pantoprazole 40 mg PO Q24H 23. PredniSONE 10 mg PO DAILY 24. Senna 2 TAB PO HS 25. Sodium Chloride Nasal [12-18] SPRY NU QID:PRN nasal congestion 26. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 27. Zolpidem Tartrate 10 mg PO HS:PRN insomnia 28. Docusate Sodium 100 mg PO BID 29. Diazepam 5 mg PO Q8H:PRN anxiety, spasm [Month/Day (2) ] Medications: deceased [Month/Day (2) ] Disposition: Expired [Month/Day (2) ] Diagnosis: pneumonia, fungemia [Month/Day (2) ] Condition: deceased [Month/Day (2) ] Instructions: deceased Followup Instructions: deceased [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "0389", "78552", "51881", "5849", "99592", "42789", "25000", "4019", "V5867" ]
Admission Date: [2107-6-17] Discharge Date: [2107-6-26] Service: CME CHIEF COMPLAINT: The patient was admitted with a chief complaint of hypotension and bradycardia. HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old gentleman with a past medical history significant for hypertrophic obstructive cardiomyopathy (HOCM), type 2 diabetes mellitus, hypertension, polymyalgia rheumatica, and osteoporosis who presents with fatigue and nausea after taking an accidental extra dose of 240 mg of sustain release verapamil and his first ever dose of atenolol (12.5 mg). The patient was home alone and confused about whether he had taken his medications. He took atenolol and began to feel fatigued and nauseated with substernal chest pain. The patient also has been complaining of increased palpations and vision dimming lately which precipitated the addition of atenolol in the setting of the patient's history of hypertrophic obstructive cardiomyopathy. The patient denies any recent fevers, chills, sweats, shortness of breath, or dyspnea on exertion. After the patient began to experience these symptoms, he phoned [Pager number ]. On arrival of Emergency Medical Service arrival, he was found to be hypotensive with a blood pressure of 80/60. The patient was also found to be bradycardic with a rate of 45. In the Emergency Department, the patient was found to have severe sinus bradycardia versus sinus arrest and junctional escape. He was then given calcium, insulin, glucose, 7 liters of normal saline, Glucagon, and dopamine. The patient was subsequently intubated for airway protection. He also had a transcutaneous temporary wire placed and was then in a normal sinus/an accelerated junctional rhythm. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Verapamil sustain release 240 mg by mouth once per day (as noted, the patient took and extra dose on the morning of admission). 2. Atenolol 12.5 mg by mouth once per day (which the patient started today). 3. Glucovance 5/500 mg by mouth in the morning and 2.5/500 mg by mouth in the evening. 4. Hydrochlorothiazide 12.5 mg by mouth once per day. 5. Prednisone 5 mg by mouth once per day. 6. Prilosec. 7. Aspirin 81 mg by mouth once per day. 8. Novolog 6 units in the morning and 4 units in the evening. SOCIAL HISTORY: The patient lives with his wife. [Name (NI) ] denies any drugs or a history of digoxin use. FAMILY HISTORY: Family history was not able to be obtained. PHYSICAL EXAMINATION ON PRESENTATION: The patient was afebrile, his pulse was 80 (which was paced), his blood pressure was 40 to 113/19 to 70, and he was on 100 percent FiO2 and intubated with a respiratory rate of 12, tidal volume was 600, and positive end-expiratory pressure of 5. The patient was intubated and agitated. He had pessary muscle contractions consistent with transcutaneous pacing. The lungs were clear. He had a 2/6 systolic ejection murmur. The abdomen was soft and distended. There were positive bowel sounds. There was no hepatosplenomegaly. The rest of his examination was not pertinent. LABORATORY VALUES ON PRESENTATION: Initial laboratory data revealed his white blood cell count was 17.1, his hematocrit was 36.7, and his platelets were 243. Chemistry-7 revealed his sodium was 138, potassium was 5.8, chloride was 102, bicarbonate was 22, blood urea nitrogen was 31, creatinine was 1.3, and his blood glucose was 234. A creatine kinase was obtained which was 86. A troponin was negative. Coagulations were unrevealing. PERTINENT RADIOLOGY-IMAGING: An electrocardiogram revealed a likely high junctional escape rhythm at 40 with sinus node activity. QRS of 118, and no ST-T wave changes. A chest x-ray showed pulmonary edema and endotracheal tube in good position. The pacing wire was also well positioned. Of note, the patient had a recent echocardiogram in [2106-10-4] which showed an ejection fraction of 55 percent to 60 percent and symmetric left ventricular hypertrophy, a severe resting outflow tract obstruction of the left ventricle, as well as 3 plus mitral regurgitation, 1 plus tricuspid regurgitation, and moderate pulmonary hypertension. The findings were consistent with hypertrophic obstructive cardiomyopathy. SUMMARY OF HOSPITAL COURSE BY ISSUES-SYSTEMS: 1. HYPERTENSION AND BRADYCARDIA ISSUES: It was felt by the Coronary Care Unit team that the most likely explanation of his hypertension and bradycardia was from the extra dose of verapamil he took on the day of admission. The patient was admitted to the Coronary Care Unit intubated with a temporary pacing wire. The patient was initially started on dopamine and then transitioned to phenylephrine for blood pressure support. His nodal blocking agents were subsequently held. Given the high white blood cell count and hypotension, there was also some concern for sepsis. The patient had an infections workup which included blood and urine cultures which were all negative. The patient was initially maintained on broad spectrum antibiotics to cover for possible infection. He was also initially given stress-dose steroids as there was concern that he may have possible adrenal insufficiency given he is on chronic steroids. Furthermore, he had a set of cardiac enzymes which were obtained which were negative. The patient also had a subsequent echocardiogram done while in house which showed severe concentric left ventricular hypertrophy, an ejection fraction of 60 percent, and left ventricular outflow tract obstruction. Additionally, there was mild-to-moderate mitral regurgitation seen. Eventually, the patient's blood pressure began to recover as the nodal agents worked off and his pacemaker was functioning. He was initially started on a labetalol drip as well as hydralazine for blood pressure control. It was felt that after a few days that his nodal blocking agents had eventually worn off. Therefore, he was started on metoprolol and verapamil for blood pressure control and heart rate control. The Coronary Care Unit team felt that it was extremely important he be on nodal blocking agents in the future, as this is the treatment for hypertrophic obstructive cardiomyopathy. The patient was eventually continued on verapamil 40 mg by mouth q.8h. and was then switched from metoprolol to labetalol for further blood pressure control; however, the patient stated that he felt extremely dizzy, and the team attributed this to his beta blocker dose. Therefore, he was continued on just verapamil 40 mg by mouth q.8h., and his blood pressures subsequently returned to [Location 213]. On [2107-6-24], the patient had a dual-chamber pacemaker inserted. The patient tolerated the procedure well and did not have any evidence of hematoma around the pacemaker pocket. 1. OTHER ISSUES: As noted, the patient was initially intubated for airway protection in the setting of receiving 7 liters of fluid. The patient was eventually weaned from intubation and was extubated without incident. He was given Lasix as needed as he was clearly volume overloaded from having received large volume resuscitation. As mentioned previously, none of the numerous blood cultures that were obtained were revealing for any type of infection. The patient was continued on an insulin sliding scale for his type 2 diabetes mellitus. DISCHARGE DIAGNOSES: 1. Hypertrophic obstructive cardiomyopathy. 2. Calcium channel overdose with resultant intubation and large volume resuscitation. 3. Pacemaker insertion. 4. Type 2 diabetes mellitus. 5. Polymyalgia rheumatica. 6. Hypertension. DISCHARGE INSTRUCTIONS-FOLLOWUP: The patient was instructed to contact his primary care physician should he develop any chest pain, shortness of breath, nausea, vomiting, dizziness, or lightheadedness, as well as any other serious complaints. MAJOR SURGICAL-INVASIVE PROCEDURES PERFORMED: 1. Intubation. 2. Pacemaker insertion. 3. Temporary pacemaker wire placement. CONDITION ON DISCHARGE: Stable. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg by mouth once per day. 2. Several eyedrops which the patient takes at home. 3. Prednisone 5 mg by mouth once per day. 4. Protonix 40 mg by mouth once per day. 5. Metformin 1000 mg by mouth in the morning. 6. Pravastatin 40 mg by mouth once per day. The exact verapamil dose that he will be taking will be dictated as an Addendum as well as the remainder of his endocrine medications. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [MD Number(2) 13600] Dictated By:[Doctor Last Name 10457] MEDQUIST36 D: [2107-6-25] 17:43:03 T: [2107-6-25] 19:51:29 Job#: [Job Number 103355]	[ "4240", "4280", "42789", "4168" ]
Admission Date: [2147-3-7] Discharge Date: [2147-3-11] Date of Birth: [2097-8-23] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5552] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Central line placement, peritoneal dialysis, lumbar puncture History of Present Illness: 49 yo F w/met colon ca, ESRD on PD s/p transplant with diarrhea N/V/D x 5 days who was found to be hypotensive and tachycardic in IR the day admission after coming in for large volume LP to evaluate for possible leptomeningeal spread of her cancer. Sent to ER for hypotension. In the ED, initial vitals 66/55, 20, 100%. Rectal temp 101.8. Received 6L NS, Vancomycin and Ceftazidime, R IJ placed. Started on levophed. Admitted to ICU for septic shock. PD fluid sent for anaylsis but no obvious source. Lactate 2.4 -- > 1.3. On arrival to the MICU, she stated that she feels tired and did feel light-headed in the IR suite. She also endorses nausea and vomiting for the past few days but no other localizing sympotms. No fevers although some chills. No sore throat, runny nose, cough, abdominal pain, diarrhea, SOB. Confirms anorexia. States that she had a similar admission with similar symptoms but this time she does not have a headache. During her short ICU admission, she had Levophed weaned off, recieved further boluses of IVF, continued ceftazidime and repleted K. The day after admission she was transferred to the OMED service once hemodynamically stable. Upon arrival to the floor she confirms a recent history of N/V/D that has all since resolved the day priot to admission except one epsidoe of emesis [2-18] pain while in the ICU. Denies any other localizing symptoms. Confirms poor po intake for several weeks due to swallowing difficulties. Intermittently gets lightheaded with prolonged standing and has been very weak - only able to go from bed to couch most of the day. Eager to have LP performed and get 'an answer'. Past Medical History: -ESRD on PD -SLE and associated renal failure status post two kidney transplants with recent worsening of her kidney function concerning for transplant failure. -peritoneal dialysis catheter placed in preparations to begin peritoneal dialysis. -seizure disorder status post CVA in [2137] -osteoporosisarthritis status post bilateral lower extremity fracture in [2144] after a fall -Metastatic Colon CA: C1D1 of xeloda, xelox, and oxiplatin on [2147-1-23]. Her original colon cancer,diagnosed in [2143], presented with a bowel obstruction. -Multiple CN palsies -Dysphagia Social History: Lives in [Location ] alone, independent w/ ADLs, works as med records librarian and pharmacy manager. Denies smoking. Drinks 6 drinks/month. No illicit drugs. Family History: Multiple relatives with cancer, including GM with stomach cancer and grandfather with unknown type of cancer. Physical Exam: VS: Temp: 97.9 BP: 127/82 HR:117 RR: 18 O2sat 99% on RA GEN: tired appearing, NAD, A & O, able to relate history without difficulty HEENT: PERRL, EOMI, anicteric, MMM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd RESP: CTA b/l anteriorly with occasional rhonchi posteriorly CV: tachy, RR, S1 and S2 wnl, III/VI systolic murmur at LUSB ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly; PD cath w/ clean dry dressing EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice NEURO: L-sided facial paralysis Pertinent Results: [2147-3-7] 08:45AM WBC-18.2# RBC-3.48 HGB-11.4# HCT-32.9 MCV-95 MCH-32.6* MCHC-34.5 RDW-16.2* [2147-3-7] 08:45AM NEUTS-80.7* LYMPHS-14.1* MONOS-4.9 EOS-0.3 BASOS-0.1 [2147-3-7] 08:45AM PLT COUNT-435 [2147-3-7] 08:45AM GLUCOSE-123* UREA N-10 CREAT-3.6* SODIUM-142 POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-29 ANION GAP-16 [2147-3-7] 10:03AM LACTATE-2.4* [2147-3-7] 02:00PM ASCITES WBC-6* RBC-2* POLYS-5* LYMPHS-39* MONOS-43* MACROPHAG-10* OTHER-3* [2147-3-7] 02:00PM ASCITES TOT PROT-<0.2 GLUCOSE-174 LD(LDH)-29 [2147-3-7] 04:12PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.016 [2147-3-7] 04:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2147-3-7] 04:12PM URINE RBC-0-2 WBC-[3-22] BACTERIA-OCC YEAST-NONE EPI-0-2 [2147-3-11] 05:35AM BLOOD Glucose-85 UreaN-12 Creat-2.3* Na-139 K-3.4 Cl-111* HCO3-25 AnGap-6* [2147-3-11] 05:35AM BLOOD WBC-7.7 RBC-3.30* Hgb-10.2* Hct-30.5* MCV-93 MCH-30.9 MCHC-33.4 RDW-15.5 Plt Ct-310 [2147-3-11] 05:35AM BLOOD Plt Ct-310 CSF Analysis WBC, CSF 14 #/uL RBC, CSF 3* #/uL 0 - 0 Polys 0 % Lymphs 93 % Monocytes 7 % [2147-3-9] 2:57 pm CSF;SPINAL FLUID Source: LP #3. GRAM STAIN (Final [2147-3-9]): 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 [2147-3-12]): NO GROWTH. LUMBAR PUNCTURE [2147-3-9] 12:39 PM The patient was placed prone on the procedure table. Access to the lumbar subarachnoid space at L3/4 was obtained with a 22-gauge spinal needle under fluoroscopic guidance, using aseptic precautions and 1% lidocaine for local anesthesia. Approximately 12 cc of clear fluid were collected. The needle was removed, and hemostasis was achieved by manual compression. The patient tolerated the procedure well without any immediate complications. The patient was sent back to the floor with post-procedure orders. The fluid was sent for laboratory analyses as requested by the referring physician. Brief Hospital Course: A/P: 49 female with PMH of metastatic colon cancer, ESRD on peritoneal dialysis presents with recurrent fever, hypotension, nausea and vomiting. # Fever: Unclear etiology. DDX initially included pneumonia vs peritoneal cavity vs urine vs line infection but no evidence of any of these. Presentation with nausea and vomiting consistent with a viral gastroenteritis. Symptoms resolved with aggressive rehydration and seem most consistent with a self-limiting viral gastroenteritis. Continued initial antibiotics of Vancomycin and Ceftazidime for 48 hrs (dosed for GFR < 10), and then discontinued given that cultures were negative. Afebrile for 48 hours prior to discharge. # Hypotension: DDX septic shock vs cardiogenic vs hypovolemic. Initially considered to be most consistent with septic shock based on CVP being low and fever. Received 5 L of NS in the ED and received additional IVF in ICU for MAP > 65 and UOP > 50cc/hr. Given rapid improvement after volume resuscitation with little evidence for persistent infection, likely hypovolemia from vomiting and diarrhea and prolonged poor po intake. Blood pressure was monitored and she was normotensive throughout her floor stay. # ESRD on peritoneal dialysis, s/p transplant: Renal following. Peritoneal dialysis per Renal. Continued immunosuppression with Rapamune and prednisone. Continued Bactrim for PCP [Name Initial (PRE) 1102]. # Anemia: Anemic at baseline likely due to chronic kidney disease. Monitored Hct throughout her inpatient stay. # HTN: Held nifedipine given hypotension, and did not require prior to discharge. Instructed to follow-up with primary oncologist prior to restarting medication. # Metastatic colon cancer: Was to have a large volume LP the day of admission by IR to evaluate for meningeal spread in setting of bulbar palsy. Previously had extensive work-up on prior admission including consults from ID, Rheum and Neurology. Only work-up remaining on discharge was large volume LP for cytology, though leptomeningeal spread from colon cancer is exceedingly rare. Large volume LP performed by Interventional Neuroradiology [3-9] without complication. Cytology pending on discharge and will follow-up with primary oncologist to discuss results. # Dysphagia: Patient states that this is at her baseline. Given inability to eat larger quantities of food, and with complaint of weight loss, she was given supplemental shakes while inpatient. Per ENT consult obtained on last admission, vocal [Last Name ] problem may resolve with time. They additionally recommended outpatient follow-up (patient was unable to keep appointment). ENT re-evaluated patient while in the hospital and reported no interval improvement. Rescheduled for outpatient appointment upon discharge. Medications on Admission: Rapamune 2 mg qam Prednisone 5 mg daily ASA 81 mg daily Bactrim three times per week Nifedipine 60 mg daily Iron daily Supposed to be taking nephrocaps Discharge Medications: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Daily dose to be administered at 6am . 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). Discharge Disposition: Home Discharge Diagnosis: Primary: Metastatic colon cancer, sepsis Secondary: End Stage Renal Disease, prior renal transplant Discharge Condition: Hemodynamically stable and afebrile. Discharge Instructions: You were admitted following a viral illness that left you very dehydrated, and subsequently you had very low blood pressure during your outpatient procedure. You were treated with antibiotics and IV fluids until your blood pressure improved. Given no bacterial culture growth, you were not continued on antibiotics. You also had a lumbar puncture for further evaluation of your neurological problems and the results of this study were pending at the time of your discharge. Please take all medications as prescribed. Your nifedipine has been held while you were in the hospital. You should not restart this medication until discussing it with Dr. [Last Name (STitle) 4253]. Please keep all outpatient appointments. Return to a hospital or seek medical advice if you notice fever, chills, shortness of breath, progressive weakness, cough or any other symptom which is concerning to you. Followup Instructions: Provider: [Name10 (NameIs) 5005] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2147-3-17] 9:30 You should also have follow-up with Dr. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) 1837] for your vocal cord issues. Please call his office at ([Telephone/Fax (1) 72400] on Monday [3-13] to confirm you appointment date/time for the following week.	[ "0389", "78552", "40391", "99592" ]
Admission Date: [2155-10-13] Discharge Date: [2155-10-21] Date of Birth: [2155-10-13] Sex: F Service: NB DICTATOR: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], NP HISTORY: Baby Girl [Known lastname 8976] is the 1.815 kg product of a 31 week gestation, both to a 26 year old primigravida, with a history of GBS bacteruria, depression, smoking. Prenatal screens: O-positive, antibody negative, RPR non-reactive, rubella-immune, hepatitis surface antigen negative, GBS unknown. Pregnancy complicated by first SVT at 8 weeks gestation, treated with adenosine and digoxin, then placenta previa and preterm labor. Admitted to [Hospital3 ] on [9-2] at 25 weeks with bleeding and preterm labor, treated with magnesium sulfate and a complete course of betamethasone. Remained in house on bedrest since. On day of delivery, further bleeding noted, therefore delivered by cesarean section. Abdominal rupture of membranes at delivery for clear fluid. No maternal fever. Positive nuchal cord times one. Baby emerged with spontaneous cry, required blow-by O2, and some CPAP to maintain pink color. Apgars were assigned at 7 and 8. PHYSICAL EXAMINATION ON ADMISSION: Non-dysmorphic with overall appearance consistent with estimated gestational age, weight 1815, head circumference 29 cm, length 44.5 cm. Anterior fontanel soft, open and flat. Facial bruising. Red reflex present bilaterally. Palate intact. Intermittent grunting. Subcostal, intercostal retractions. Breath sounds symmetric, diminished bilaterally. Regular rate and rhythm without murmur. 2+ peripheral pulses including femorals. Abdomen benign, nontender, without hepatosplenomegaly or masses. Three-vessel cord. Normal female genitalia for gestational age. Normal back and extremities with hips deferred. Skin pink and well perfused. HISTORY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Infant was admitted to the newborn intensive care unit and placed on CPAP for management of respiratory distress. She remained on CPAP for 72 hours, at which time she transitioned to room air and has been stable on room air since that time. CARDIOVASCULAR: Has had no issues. EKG was performed in light of maternal digoxin use and EKG was within normal limits. FLUID/ELECTROLYTES: Infant's birth weight was 1815 grams. The infant was initially started at 80 cc/kg per day of D10/W. Enteral feedings were initiated on day of life number 3. Infant is currently receiving 150 cc/kg per day of Premature Enfamil 22 calorie, breast milk 22 calorie, tolerating feeds fine. GI/GU: Peak bilirubin was on day of life number 3 of 12.0/0.3. She was treated with phototherapy and her most recent bilirubin is ___ on [10-22]. Infant noted to have a 2- vessel cord on admission. HEMATOLOGY: Hematocrit on admission was 48.7. Infant has not required any blood products. INFECTIOUS DISEASE: CBC and blood culture obtained on admission. CBC was benign and blood cultures remained negative at 48 hours. Ampicillin and gentamicin were discontinued at that time. NEURO: Has been appropriate for gestational age. Head ultrasound at day of life 9 showed question of small right germinal matrix hemorrhage.. Sensory: Hearing screen was not performed but is suggetsed prior to ultimate discharge home. PSYCHOSOCIAL: Parents are involved with this infant. Mother is a nurse in the adult medical field. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To [Hospital3 ]. PRIMARY PEDIATRICIAN: [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 50617] ([Telephone/Fax (1) 38385]). FEEDS AT DISCHARGE: Continue 150 cc/kg per day. Breast milk 24 or Premature Enfamil 24 calorie. Advance in calories as appropriate to maintain weight gain. MEDICATIONS: Not applicable. Physician screening has not been performed. State newborn screens have been sent per protocol. Repeat was sent in light of the initial having an elevated 17-OHP of 138. The repeat was sent on [10-20]. IMMUNIZATIONS RECEIVED: The infant has not received any immunizations. IMMUNIZATIONS RECOMMENDED: 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 week; 2) Born between 32 and 35 weeks with two of the following: Day care during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings, or 3) 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 contact and out of home care-givers. DISCHARGE DIAGNOSES: Premature infant, both at 31 weeks, corrected to 32-2/7. Respiratory distress. Rule out sepsis with antibiotics. 2-vessel cord. [First Name11 (Name Pattern1) 449] [Last Name (NamePattern1) ], [MD Number(1) 54604] Dictated By:[Last Name (NamePattern1) 56160] MEDQUIST36 D: [2155-10-21] 21:34:50 T: [2155-10-21] 22:17:49 Job#: [Job Number 62611]	[ "7742", "V290" ]
Admission Date: [2126-6-19] Discharge Date: [2126-6-26] Date of Birth: [2047-9-8] Sex: F Service: CARDIOTHORACIC Allergies: tramadol Attending:[First Name3 (LF) 165] Chief Complaint: Chest heaviness and dyspnea Major Surgical or Invasive Procedure: Coronary artery bypass grafting x4 1. Left internal mammary artery to left anterior descending artery. 2. Reverse saphenous vein graft from the aorta to the obtuse marginal 1 branch of the circumflex artery. 3. Bypass from the ascending aorta to the diagonal artery branch off the anterior descending artery using reversed autogenous saphenous vein graft. 4. Bypass from the ascending aorta to the distal right coronary artery using reversed autologous saphenous vein graft. History of Present Illness: 78 year old female who reports progressive, exertional chest discomfort over the past 4 months and relieved with rest. Walking up 2 flights of stairs, water aerobics and walking at a brisk pace will bring on the chest pain and is associated with shortness of breath. A stress echo was performed and she developed chest pain at 5 minutes, borderline ischemic EKG changes and no regional wall motion abnormality. She was referred for a cardiac catheterization and was found to have coronary artery disease and is now being referred to cardiac surgery for revascularization. Past Medical History: Coronary artery disease Secondary: Diabetes mellitus type 1 Hypertension Hyperlipidemia Spinal stenosis Osteoarthritis Osteoporosis Abnormal Mammogram/Calcium Deposits Social History: Race:Caucaisan Last Dental Exam:[12/2125] Lives with:Husband Contact:[Name (NI) ] (husband) Phone #[Telephone/Fax (1) 61124] Occupation:retired Cigarettes: Smoked no [x] yes [] Other Tobacco use:denies ETOH: < 1 drink/week [x] [3-5] drinks/week [] >8 drinks/week [] Illicit drug use:denies Family History: non-contributory Physical Exam: Admission Physical Exam Pulse:72 Resp:20 O2 sat:99/RA B/P Left: 157/52 Height:5'1.75" Weight:145 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds +, stretch marks [] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: +1 Left:+1 DP Right:+2 Left:+2 PT [Name (NI) 167]: +2 Left:+2 Radial Right: cath site Left:+2 Carotid Bruit Right: None Left:none Pertinent Results: Intra-op TEE [2126-6-19] Conclusions PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). There are focal calcifications in the aortic root. 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. There is no aortic valve stenosis. No aortic regurgitation is seen. The posterior mitral valve leaflet is moderately to severely thickened and calcified. The anterior mitral valve leaflet is moderately thickened with a morphology suggestive of rheumatic mitral disease. No mitral stenosis is seen. Physiologic mitral regurgitation is seen (within normal limits). The anterolateral papillary muscle & cords are thickened. Tips appear calcified. There is a trivial/physiologic pericardial effusion. POSTBYPASS: The patient is A paced on low dose norepinephrine infusion. Biventricular function is maintained. Valves appear unchanged. The aorta remains intact after decannulation [2126-6-26] 03:56AM BLOOD WBC-9.5 RBC-3.46* Hgb-10.3* Hct-31.0* MCV-90 MCH-29.6 MCHC-33.0 RDW-13.7 Plt Ct-341# [2126-6-19] 01:52PM BLOOD WBC-12.1# RBC-2.42# Hgb-7.0# Hct-21.4# MCV-88 MCH-28.8 MCHC-32.7 RDW-12.5 Plt Ct-152 [2126-6-26] 03:56AM BLOOD PT-18.2* INR(PT)-1.7* [2126-6-19] 01:52PM BLOOD PT-14.1* PTT-26.5 INR(PT)-1.3* [2126-6-26] 03:56AM BLOOD UreaN-20 Creat-0.8 Na-137 K-4.6 Cl-98 [2126-6-19] 03:30PM BLOOD UreaN-11 Creat-0.5 Na-142 K-4.0 Cl-116* HCO3-21* AnGap-9 Brief Hospital Course: On [2126-6-19] Ms.[Known lastname 61125] was taken to the operating room and underwent Coronary artery bypass grafting x4 (Left internal mammary artery to left anterior descending artery/ Reverse saphenous vein graft from the aorta to the obtuse marginal 1 branch of the circumflex artery, Bypass from the ascending aorta to the diagonal artery branch off the anterior descending artery using reversed autogenous saphenous vein graft, Bypass from the ascending aorta to the distal right coronary artery using reversed autologous saphenous vein graft) with Dr.[First Name (STitle) ]. Please see operative report for further surgical details. She tolerated the procedure well and was transferred to the CVICU intubated and sedated. She awoke neurologically intact and extubated postop night without difficulty. She received packed red blood cells for a hematocrit of 21 likely due to volume resucitation. She was weaned off pressor support and beta-blocker, statin, aspirin were initiated. Chest tubes and pacing wires were discontinued per protocol. On POD#1 she was transferred to the step down unit for further monitoring and recovey. Physical Therapy was consulted for evaluation of strength and mobility. She developed post-op AFib and was started on amiodarone and coumadin. She continued to progress and on POD#7 she was discharged to Newbridge on the [Hospital ] rehabilitation. All follow up appointments were advised. Medications on Admission: ENALAPRIL MALEATE 20 mg [Hospital1 ] GLUCAGON 1 mg Kit - use as directed for severe hypoglycemia as educated HYDROCHLOROTHIAZIDE 25 mg Daily LANTUS 9 units q am and 12 units q hs INSULIN LISPRO [HUMALOG] [Name8 (MD) ] md sliding scale SIMVASTATIN 20 mg Daily ASPIRIN 162.5 mg Daily EXCEDRIN EXTRA STRENGTH 250 mg/250 mg/65 mg [Name8 (MD) 8426] - 2 Tablets [Hospital1 ] PRN TUMS 1000 mg Daily VITAMIN D3 1,000 unit daily VITAMIN B-12 1,000 mcg daily FOLIC ACID 400 mcg daily MAGNESIUM 250 mg daily MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] 1 [Hospital1 8426] daily NIACIN 250 mg daily FISH OIL 1,000 mg [Hospital1 ] Discharge Medications: 1. potassium chloride 10 mEq [Hospital1 8426] Extended Release Sig: Two (2) [Hospital1 8426] Extended Release PO Q12H (every 12 hours). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. aspirin 81 mg [Hospital1 8426], Delayed Release (E.C.) Sig: One (1) [Hospital1 8426], Delayed Release (E.C.) PO DAILY (Daily). 4. acetaminophen 325 mg [Hospital1 8426] Sig: Two (2) [Hospital1 8426] PO Q4H (every 4 hours) as needed for pain/fever. 5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 6. simvastatin 10 mg [Hospital1 8426] Sig: Two (2) [Hospital1 8426] PO DAILY (Daily). 7. niacin 250 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). 8. oxycodone-acetaminophen 5-325 mg [Hospital1 8426] Sig: One (1) [Hospital1 8426] PO Q4H (every 4 hours) as needed for pain. Disp:45 [Hospital1 8426](s) Refills:0 9. ranitidine HCl 150 mg [Hospital1 8426] Sig: One (1) [Hospital1 8426] PO DAILY (Daily). 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 11. metoprolol tartrate 25 mg [Hospital1 8426] Sig: One (1) [Hospital1 8426] PO TID (3 times a day). 12. warfarin 1 mg [Hospital1 8426] Sig: [Name8 (MD) ] MD [First Name (Titles) 8426] [Last Name (Titles) ] Once Daily at 4 PM. 13. amiodarone 200 mg [Last Name (Titles) 8426] Sig: Two (2) [Last Name (Titles) 8426] PO BID (2 times a day): x 7 days then decrease to 200 mg [Hospital1 ] x 7 days then decrease to 200 mg daily. 14. insulin lispro 100 unit/mL Cartridge Sig: One (1) Subcutaneous ACHS: Per HISS. 15. warfarin 1 mg [Hospital1 8426] Sig: One (1) [Hospital1 8426] PO ONCE (Once) for 1 doses. 16. enalapril maleate 20 mg [Hospital1 8426] Sig: One (1) [Hospital1 8426] PO DAILY (Daily). 17. Lasix 80 mg [Hospital1 8426] Sig: One (1) [Hospital1 8426] PO twice a day: wean dose as weight/edema resolves. Discharge Disposition: Extended Care Facility: Newbridge on the [Doctor Last Name ] - [Location (un) 1411] Discharge Diagnosis: Coronary artery disease Secondary: Diabetes mellitus type 1 Hypertension Hyperlipidemia Spinal stenosis Osteoarthritis Osteoporosis Abnormal Mammogram/Calcium Deposits Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema 1+ Discharge Instructions: Shower Daily including washing incisions gently with mild soap, No baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage NO lotions, cream, powder, or ointments to incisions Daily weights: keep a log 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 Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours* Followup Instructions: You are scheduled for the following appointments Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 62] Date/Time:[2126-7-17] 10:40 on the [Hospital Ward Name 516] [Hospital Ward Name 23] Clinical Center [Location (un) ] Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 170] Date/Time:[2126-7-23] 1:45 in the [Hospital 2577] Medical Building [Last Name (NamePattern1) 10357] [Hospital Unit Name ] Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) ], MD Phone:[Telephone/Fax (1) 719] Date/Time:[2126-8-20] 11:00 in the [Hospital 2577] Medical Building [Location (un) ] GERONTOLOGY [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2126-6-26]	[ "41401", "9971", "42731", "4019", "2724", "V5867" ]
Admission Date: [2129-10-6] Discharge Date: [2129-10-15] Date of Birth: [2050-12-14] Sex: M Service: CARDIOTHORACIC Allergies: IV Dye, Iodine Containing Attending:[First Name3 (LF) 165] Chief Complaint: new onset angina Major Surgical or Invasive Procedure: [2129-10-7] cardiac catheterization [2129-10-11] AVR ( 21mm CE pericardial)/ cabg x1 (LIMA to LAD) History of Present Illness: 78 yo male awakened from sleep with sharp chest spasm that radiated down right arm. It lasted approx. 30 seconds and then he had multiple episodes over 10 minutes. Has had several episodes per day. Also noted to have left sided twitching over precordial area. Had associated nausea. Past Medical History: severe PVD with multiple aneurysms in LE COPD- in pulm. rehab OSA on CPAP CHF [5-10] multiple PNAs AS carotid stenosis elev. chol. PSH: bil. LE bypass procedures x 6; last bypass with goretex due to unusable vein eye surgery as a child Social History: lives with wife 100 pack-year history-quit 22 years ago 12 beers a month/ one shot of sambuca per week drives school bus Family History: son with MI at 46 Physical Exam: 5'3" 74.8 kg SR 83 RR 15 123/78 NAD diminshed BS bilat.;increased AP diameter RRR 2/6 harsh SEM heard best at left axilla soft NT, ND + BS warm, well-perfused, trace edema, several well-healed scars BLE no varicosities noted 1+ bil. fems trace to 1+ right DP/PTs dopplerable left DP/PTs 2+ bil. radials no carotid bruits Pertinent Results: COMMENTS: 1. Selective coronary angiography of this right-dominant system demonstrated one-vessel coronary artery disease. The LMCA, LCX, and RCA were all free of angiographically-appareny flow-limiting stenoses. The LAD had a proximal eccentric and likely ulcerated 70% stenosis. 2. Resting hemodynamics demonstrated moderate aortic stenosis with a gradient of 19 mmHg. Right- and left-sided filling pressures were high-normal with an RVEDP of 8 mmHg and a PCWP a-wave of 10. There was mild pulmonary hypertension with an RVSP of 36 mmHg. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Moderate aortic stenosis. 3. Mild pulmonary arterial hypertension. ATTENDING PHYSICIAN: [Name10 (NameIs) 2052],[Name11 (NameIs) 2053] [Name Initial (NameIs) ]. REFERRING PHYSICIAN: [Name10 (NameIs) 2052],[Name11 (NameIs) 2053] [Name Initial (NameIs) ]. CARDIOLOGY FELLOW: [Last Name (LF) ],[First Name3 (LF) ] B. [Last Name (LF) ],[First Name3 (LF) ] ATTENDING STAFF: [Last Name (LF) 2052],[First Name3 (LF) 2053] J. ([Numeric Identifier 79780]) Conclusions PREBYPASS A patent foramen ovale is present with left-to-right shunt at rest. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with borderline normal free wall function. The ascending aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis (area ~1.2 cm2 Mild to moderate ([2-2]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). POSTBYPASS Patent has poor windows post bypass, LV function appears to remain good with EF 55% but segmental motion hard to identify. The aortic contour is smooth post decannulation. An prostetic aortic valve is well seated in the aortic annulus. Trace perivalvular leak is seen. Mitral regurgitation is seen post bypass but remains unchanged from prior study. I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [Known firstname ] [Last Name (NamePattern1) 168], MD, Interpreting physician Radiology Report CHEST (PORTABLE AP) Study Date of [2129-10-13] 3:06 PM [Last Name (LF) ],[First Name3 (LF) ] CSURG FA6A [2129-10-13] SCHED CHEST (PORTABLE AP) Clip # [Clip Number (Radiology) 79781] Reason: ? ptx s/p mt removal [Hospital 93] MEDICAL CONDITION: 78 year old man with s/p cabg REASON FOR THIS EXAMINATION: ? ptx s/p mt removal Provisional Findings Impression: IPf [Doctor First Name ] [2129-10-13] 4:53 PM No pneumothorax. Final Report PROCEDURE: Portable AP chest radiograph. Comparison done with chest radiograph from [10-13] at 1:27 p.m. 78-year-old man with status post CABG, questionable pneumothorax status post mid thoracic chest tube removal. _____: Mid thoracic chest tube removed. No pneumothorax. The rest of the lungs appear unchanged. IMPRESSION: No pneumothorax. The study and the report were reviewed by the staff radiologist. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] DR. [First Name (STitle) ] [Initials (NamePattern5) 3250] [Last Name (NamePattern5) 3251] Approved: [Doctor First Name ] [2129-10-13] 5:26 PM Imaging Lab ?????? [2124] CareGroup IS. All rights reserved. [2129-10-15] 08:20AM BLOOD WBC-14.9* RBC-3.47* Hgb-9.9* Hct-29.1* MCV-84 MCH-28.6 MCHC-34.1 RDW-14.7 Plt Ct-180# [2129-10-6] 11:50PM BLOOD WBC-9.0 RBC-4.87 Hgb-13.6* Hct-39.4* MCV-81* MCH-28.0 MCHC-34.6 RDW-14.0 Plt Ct-275 [2129-10-13] 02:02AM BLOOD PT-12.8 PTT-25.0 INR(PT)-1.1 [2129-10-6] 11:50PM BLOOD PT-13.2 PTT-25.1 INR(PT)-1.1 [2129-10-15] 08:20AM BLOOD Glucose-140* UreaN-20 Creat-0.9 Na-135 K-4.1 [2129-10-6] 11:50PM BLOOD Glucose-134* UreaN-23* Creat-1.3* Na-139 K-4.0 Cl-98 HCO3-30 AnGap-15 [2129-10-12] 02:05AM BLOOD Type-ART pO2-100 pCO2-42 pH-7.37 calTCO2-25 Base XS-0 Brief Hospital Course: Admitted [10-6] and had a cardiology consult done. Cath the next day showed AS and LAD dz. Carotid US showed [Country ] 60-69%. Vein mapping,echo, and pulm consult also done pre-op. Underwent CABG x1/AVR (#21mm [Doctor Last Name ]) with Dr. [First Name (STitle) ] on [10-11]. Please refer to Dr[Doctor First Name ] operative report for further details. Transferred to the CVICU in stable condition on titrated phenylephrine and propofol drips. Extubated late that night and steroid taper started. Aggressive pulmonary toilet done. POD#1 he was transferred to the SDU for further telemetry monitoring ans recovery. The remainder of his postoperative course was essentially unremarkable.POD#3 small serous drainage seen on his sternotomy incision. Prior to discharge his sternum was stable, C/D/I. He continued to progress and on POD#4 was discharged to home with VNA. He was advised on all followup appointments. Medications on Admission: prednisone 5 mg every other day singulair 10 mg daily dyazide 25/37.5 mg dialy xopenex nebulizer TID lovastatin 40 mg daily ECASA 81 mg daily plavix 75 mg daily spiriva one daily advair 250/50 2 puffs [Hospital1 ] albuterol prn ( uses 2-3x /day) Discharge Medications: 1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:30 Tablet(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. 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 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for PVD. Disp:30 Tablet(s) Refills:0 7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for continuous doses. Disp:30 Tablet(s) Refills:0 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 5 days. Disp:10 Tab Sust.Rel. Particle/Crystal(s) Refills:0 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:10 Tablet(s) Refills:0 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:45 Tablet(s) Refills:0 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:30 Cap(s) Refills:0 12. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: Two (2) Disk with Device Inhalation [Hospital1 ] (). Disp:120 Disk with Device(s) Refills:0 13. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed. Disp:1 1 Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: AS/CAD s/p AVR/CABG x1 COPD (in pulm. rehab) OSA on BiPAP CHF [5-10] multiple PNAs carotid stenosis severe PVD with multiple aneurysms in bil. LE s/p 6 bypass procedures elev. chol. Discharge Condition: good Discharge Instructions: shower daily and pat incisions dry no lotions, creams or powders on any incision no driving for one month AND until off all narcotics call for fever greater than 100.5, redness, or drainage no lifting greater than 10 pounds for 10 weeks Followup Instructions: see Dr. [Last Name (STitle) 79782] in [2-2] weeks see Dr. [Last Name (STitle) 7659] in [3-6] weeks see Dr. [First Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2129-10-15]	[ "4241", "5180", "41401", "4168", "4280", "2724", "32723" ]
Unit No: [Numeric Identifier 74822] Admission Date: [2162-10-22] Discharge Date: [2162-11-3] Date of Birth: [2162-10-22] Sex: M Service: NB DATE OF BIRTH: [2162-10-22]. SEX: Male. DATE OF ADMISSION: [2162-10-22]. DATE OF DISCHARGE: [2162-11-3]. HISTORY OF PRESENT ILLNESS: Baby by [Name2 (NI) 74823] [Known lastname ] is a former 1.895 kg product of a 33 and [5-8] week gestation pregnancy, born to a 41-year-old, G4, P2, now 3 woman. Prenatal screens: [Month/Day (4) ] type O-, antibody negative, Rubella immune, RPR nonreactive, hepatitis B surface antigen negative, group beta strep status unknown. This pregnancy was complicated by advanced maternal age and premature, prolonged rupture of membranes. Mother initially presented to [Hospital3 ] with leakage of fluid on [2162-10-19]. At that time she was started on erythromycin and clindamycin and was given a course of betamethasone. Her prior OB history was notable for a delivery at 33 weeks gestation with a history of a placenta abruption. That child is now 7 years old and alive and well. This mother proceeded to have a spontaneous vaginal delivery after unstoppable preterm labor. Apgars were 8 at one minute and 8 at five minutes. She had a total of 4 days ruptured membranes prior to delivery. The infant was admitted to the neonatal intensive care unit for treatment of prematurity. ANTHROPOMETRIC MEASUREMENTS: Upon admission to the neonatal intensive care unit- weight 1.895 kg, 50th percentile. Length 44 cm, 50th percentile. Head circumference 31 cm, 50th percentile. PHYSICAL EXAMINATION: At discharge, weight 2.025 kg, length 45 cm, head circumference 31.25 cm. General: Alert and non- dysmorphic infant, comfortable in room air. Skin warm and dry. Color pink. Head, ears, eyes, nose and throat: Anterior fontanelle open and flat. Sutures opposed. Symmetric facial features. Palate intact. Neck supple. Clavicle is intact. Chest: Breath sounds equal and clear bilaterally. Easy respirations. Cardiovascular: Regular rate and rhythm, no murmur, normal S1, S2, 2+ femoral pulses. Abdomen soft, nontender, nondistended, no masses, active bowel sounds. GU: Circumcision healing, normal male genitalia, testes descended bilaterally, patent anus. Spine straight, no sacral anomalies. Hips stable. Extremities pink and well perfused. Neuro: Appropriate tone and reflexes, positive suck, positive grasp, positive Moro. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: 1. RESPIRATORY: This baby has been on room air for his entire neonatal intensive care unit admission. He did not have any episodes of spontaneous apnea or bradycardia. At the time of discharge, he is breathing comfortably with a respiratory rate of 30-40 breaths per minute. 2. CARDIOVASCULAR: This baby has maintained normal heart rates and [Year (4 digits) ] pressures. No murmurs have been noted. Baseline heart rate is 150-170 beats per minute with a recent [Year (4 digits) ] pressure of 69/40 mmHg and a mean, arterial pressure of 50 mmHg. 3. FLUIDS/ELECTROLYTES/NUTRITION: This infant was initially started on intravenous fluids and feedings were begun by gavage. He was gradually advanced to full volume and feedings have been well tolerated. He has been breast feeding or taking breast milk with Enfamil powder 24 kcal/ounce all p.o. for the 48 hours prior to discharge. Weight on the day of discharge is 2.025 kg. Serum electrolytes were checked on the second day of life and were within normal limits. 4. INFECTIOUS DISEASE: Due to the preterm labor and unknown group beta strep status of the mother, this baby was evaluated for sepsis upon admission to the neonatal intensive care unit. The initial white [Year (4 digits) ] cell count was 7,700 with 2% polymorphonuclear cells and 0% band neutrophils. A repeat CBC at 24 hours of life had a white [Year (4 digits) ] cell count of 8,700 with 47% polymorphonuclear cells, 4% band neutrophils. A [Year (4 digits) ] culture was obtained prior to starting intravenous ampicillin and gentamycin. The [Year (4 digits) ] culture was no growth at 48 hours and the antibiotics were discontinued. 5. HEMATOLOGICAL: This baby is [Name2 (NI) ] type A+ and was Coombs positive. His hematocrit at birth was 52.9%, repeat hematocrit at 24 hours was 52.6%. He did not require any transfusions of [Name2 (NI) ] products. 6. GASTROINTESTINAL: This baby was treated for unconjugated hyperbilirubinemia with phototherapy. Peak serum bilirubin occurred on day of 1, total of 9.1 mEq/dl. He was treated with phototherapy for 6 days. His most recent rebound bilirubin was on [2162-10-31], a total of 7.6 mg/dl. 7. NEUROLOGY: This baby has maintained a normal neurological exam during admission. There are no neurological concerns at the time of discharge. 8. SENSORY/AUDIOLOGY: Hearing screening was performed with automated auditory brain stem responses. This baby passed in both ears on [2162-11-2]. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with the parents. PRIMARY PEDIATRICIAN: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], MD, [Hospital ] Pediatrics, [Location (un) 8170], [Location (un) ], [Numeric Identifier ]. Phone [Telephone/Fax (1) 43701]. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. Feeding: Ad lib breast feeding or breast milk fortified to 24 kcal/ounce with Enfamil powder. 2. Medications: Goldline baby vitamins 1 ml p.o. once daily, ferrous sulfate 25 mg/ml dilution 0.2 ml p.o. once daily. 3. Iron and vitamin D supplementation: Iron supplementation is recommended for preterm and low birthweight infants until 12 months corrected age. All infants fed predominantly breast milk should receive vitamin D supplementation at 200 international units (may be provided as a multivitamin preparation) daily until 12 months corrected age. 4. Car seat position screening was performed. This baby was observed in his car seat for 90 minutes without any episodes of bradycardia or oxygen desaturation. 5. State newborn screen was done on [2162-10-25]. There has been no notification of abnormal results to date. A repeat screen was sent on the day of discharge, [2162-11-3]. 6. Immunizations: Hepatitis B vaccine was administered on [2162-11-2]. 7. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following 4 criteria: First- born at less than 32 weeks; Second- born between 32 and 35 weeks with 2 of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings; Thirdly- chronic lung disease; or Fourth, hemodynamically significant congenital heart 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. This infant has not received Rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at, or following discharge from the hospital if they are clinically stable and at least 6 weeks but fewer than 12 weeks of age. FOLLOWUP: Follow-up appointments scheduled or recommended: Appointment with Dr. [Last Name (STitle) 8651] within 3 days of discharge. DISCHARGE DIAGNOSES: 1. Prematurity at 33 and 4/7 weeks gestation. 2. Suspicion for sepsis ruled out. 3. ABO [Last Name (STitle) ] incompatibility. 4. Status post ritual circumcision. Dictated by:[Last Name (Titles) ] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 48738], MD [MD Number(2) 55708] Dictated By:[Last Name (NamePattern4) 56030] MEDQUIST36 D: [2162-11-3] 01:35:42 T: [2162-11-3] 11:09:34 Job#: [Job Number 74824]	[ "V290", "V053" ]
Admission Date: [2191-1-25] Discharge Date: [2191-1-30] Date of Birth: [2143-7-12] Sex: F Service: MEDICINE Allergies: Zidovudine Attending:[First Name3 (LF) 2745] Chief Complaint: hypotension in addition to cough and green sputum Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [Known lastname ] is a 47F with AIDS, HCV, cardiomyopathy, and antiphospholipid antibody syndrome who presents with cough and green sputum, subjective fevers at home. She is circumferential as a historian, but it seems that she never recovered to her baseline functional status after admission in [Month (only) ]-early [Month (only) ], in terms of feeling tired all the time and complaining of mild dyspnea. In the ED, arrival vital signs 95.3, 89, 75/50, 36, 95% RA; received 4L IVF, refused central line for hypotension. Received levofloxacin and vancomycin for pna. ROS: The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: 1. HIV/AIDS, diagnosed [2176], off HAART. - acquired via heterosexual intercourse. - CD4 184, VL 254k [2190-12-5] - nadir CD4 69 [6-11] 2. HCV antibody+ 3. [Doctor First Name ] [1-/2182] - was not complaint with Rx. 4. Oral thrush 5. Recurrent episodes of pneumococcal pneumonia. 6. Lymphocytic pneumonitis - diagnosed by trans-bronchial bx. 7. Dilated cardiomyopathy-EF20-25%, last echo [4-13]. 8. LV thrombus 9. Antiphospholipid antibody syndrome 10. Lower extremity arterial thrombus 11. Asthma/bronchiectasis 12. Myocardial infarction [2184], clean coronaries at that time 13. L MCA stroke, residual right hemiparesis 14. Cocaine abuse 15. Pulmonary Nodules on chest CT 16. Zoster 17. Cholelithiasis Social History: smokes "occassionally" X many years, no recent alcohol, h/o cocaine abuse, but none recently, and has been homeless in the past Family History: mother with DM Physical Exam: Vitals: T:97.0 BP:92/69 HR:98 RR:30 O2Sat:98% RA GEN: chronically ill appearing woman [Year (4 digits) 4459]: anicteric, edentulous except for lower incisors, + oral thrush NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs scattered crackles, but esp at the L lower [1-8], where there are also rhonchi ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [2191-1-25] 07:06PM GLUCOSE-82 UREA N-56* CREAT-1.6* SODIUM-139 POTASSIUM-3.1* CHLORIDE-114* TOTAL CO2-15* ANION GAP-13 [2191-1-25] 07:06PM MAGNESIUM-1.8 [2191-1-25] 07:06PM PT-99.5* PTT-54.3* INR(PT)-13.2* [2191-1-25] 02:25PM [Month/Day/Year 14246] HOURS-RANDOM UREA N-828 CREAT-107 SODIUM-37 POTASSIUM-23 CHLORIDE-14 [2191-1-25] 02:25PM [Month/Day/Year 14246] [Month/Day/Year 3143]-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2191-1-25] 02:25PM [Month/Day/Year 14246] RBC-[3-10]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [2191-1-25] 01:04PM GLUCOSE-79 LACTATE-1.4 NA+-135 K+-3.5 CL--102 TCO2-20* [2191-1-25] 01:04PM HGB-11.3* calcHCT-34 [2191-1-25] 01:03PM ALT(SGPT)-27 AST(SGOT)-55* LD(LDH)-430* ALK PHOS-52 TOT BILI-0.7 [2191-1-25] 01:03PM ALBUMIN-2.6* [2191-1-25] 01:03PM DIGOXIN-0.4* [2191-1-25] 01:03PM WBC-3.4* RBC-3.46* HGB-10.6* HCT-29.5* MCV-85 MCH-30.7 MCHC-36.0* RDW-15.7* [2191-1-25] 01:03PM NEUTS-74* BANDS-0 LYMPHS-23 MONOS-3 EOS-0 BASOS-0 [2191-1-25] 01:03PM PLT COUNT-143* ECG: SR LVH by voltage, TWI II, III, flat in aVF, V4-V6; no significant change from [2190-11-28]. Imaging: CXR: AP supine, compared to [2190-11-28]. LLL opacity, concerning for infection. Reticulonodular pattern relatively unchanged from [Name (NI) ]. Slightly enlarged cardiomediastinal silhouette, unchanged from [Month (only) ]. Brief Hospital Course: Assesment: Ms. [Known lastname ] is a 47F with AIDS, HCV, cardiomyopathy, and antiphospholipid antibody syndrome who presents with ~6 weeks of fatigue and dyspnea, now worse in the last 3-4 days, with productive cough . Plan: # Pneumonia: SIRS criteria of hypotension (note that outpt/ambulatory [Known lastname ] pressures have been 100-110s), T95.3 on arrival, RR 36; plus symptoms of resp infection and infiltrate on CXR. She was covered initially for CAP with CTX and azithro. She was ruled out for TB by 3 negative AFBs. DFA was negative for [Known lastname ]. Bronch was considered but as she improved on this treatment, it was not done. She was followed by ID who recommended changing CTX to cefpodoxime on discharge to complete a 10-day course and to complete a 5-day course of azithro. # HIV: not on HAART [2-7] poor compliance. Has been taking atovaquone sporadically (reports taking for 2 of last 6 weeks); this was restarted in-house. Social work was consulted to help identify barriers to outpatient followup and compliance, and she was set up with a food program. # antiphospholipid syndrome: Her INR was supratherapeutic on admission, so coumadin was held. The importance of compliacne with INR monitoring was emphasized to her, and she was discharged on coumadin 5 mg to be restarted on [2-1] with close ouptaient monitoring. Of note, closer monitoring of the INR in a patient with APA syndrome is required. # cardiomyopathy: held ACE-I, BB, digoxin [2-7] hypotension, infection. # ARF: likely prerenal in setting of febrile illness. This improved with volume resuscitation. # oral thrush: continued fluconazole 100mg po daily # Depression/anxiety: continued ativan . # Social: asked SW to see re: poor social supports, difficulty with outpt med compliance. As she reported she had difficulty getting food at home, she was set up with a food program. Medications on Admission: Medications--she reports that she filled a 2 week supply of these in early [Month (only) 1096], then ran out until 2 days ago: Lorazepam 0.5 mg PO BID Fluconazole 100 mg PO Q24H Senna 8.6 mg [Hospital1 ] Digoxin .0625 mg one half Tablet PO DAILY Warfarin 5 mg Daily Metoprolol Succinate 12.5mg Sustained Release PO DAILY Lisinopril 2.5 mg PO DAILY Atovaquone 1500 mg PO once a day Discharge Medications: 1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Atovaquone 750 mg/5 mL Suspension Sig: One (1) PO DAILY (Daily). 5. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 4 days. Disp:8 Tablet(s) Refills:0 6. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: Restart this medication on [2-1]. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary: pneumonia Secondary: HIV, anxiety, cardiomyopathy, hypertension Discharge Condition: good, stable, ambulating independently, not requiring oxygen Discharge Instructions: You were evaluated for shortness of breath and cough and found to have a pneumonia. This is improving with antibiotics. It is VERY important for you to follow up with your outpatient providers to be sure you are improving. Several of your medications were stopped during the admission, and you must follow up with your doctors to know when to restart them. Do not take your digoxin, metoprolol, or lisinopril for now as your [Location (un) ] pressure is low-normal. Finish your antibiotics as prescribed. It is VERY important to have your INR checked so that your coumadin can be dosed appropriately. If you have fevers, chills, shortness of breath, chest pain, lightheadedness, worsening cough, episodes of loss of consciousness, or any other concerning symptoms, call your doctor or seek medical attention immediately. Followup Instructions: You have an appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] of Infectious Disease on [2191-2-11] at 11:00am. Call his office at [Telephone/Fax (1) 457] with any questions.	[ "486", "5849" ]
Admission Date: [2120-10-10] Discharge Date: [2120-10-20] Date of Birth: [2040-9-1] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) / Ferrous Sulfate Attending:[First Name3 (LF) 1505] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Coronary artery bypass graft x4 (Left internal mammary artery > left anterior descending, saphenous vein graft > diagonal, saphenous vein graft > obtuse marginal, saphenous vein graft > right coronary artery) [2120-10-10] History of Present Illness: 80F, Russian speaking. Reports chest discomfort over the previous two months, worse with humidity, and responsive to nitroglycerin. Describes discomfort in the left shoulder radiating to the left chest and down left arm. Stress test was abnormal. Cath reveals severe 3 vessel Coronary Artery Disease. She is referred for surgical revascularization. Past Medical History: Coronary Artery Disease Bilateral Patellofemoral Osteoarthritis Hypertension Hemolytic Anemia Hyperlipidemia Anxiety Social History: She is married and lives with her husband, She emigrated to US 3.5 years ago. Cigarettes: Smoked no [x] ETOH: denies Family History: non contributory Physical Exam: Pulse: 61SR Resp: 12 O2 sat: 100%RA B/P Right: Left: 140/68 Height: Weight: 133lb General: NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] none_ Varicosities: minor Neuro: Grossly intact [x] Pulses: Femoral Right: Left: DP Right: 1+ Left:1+ PT [Name (NI) 167]: 1+ Left:1+ Radial Right: cath Left:2+ Carotid Bruit no bruits Pertinent Results: CXR [10-14] PA AND LATERAL CHEST: Chest tubes and mediastinal drains have been removed. A right IJ line again extends to the cavoatrial junction. There is decreased pulmonary vascular congestion and edema. There is a persistent small right subpulmonic effusion and likely trace left pleural effusion. There is no pneumothorax. Right hemidiaphragm remains elevated, with atelectasis at the right lung base. Additional atelectasis is seen in the left base, though the aeration here is improved from prior study. Cardiomediastinal contour is unchanged. Sternotomy wires remain aligned. IMPRESSION: 1. Interval removal of mediastinal drains and chest tubes. Persistent right and likely trace left pleural effusions. No pneumothorax. 2. Decreased atelectasis, with improved aeration of the left base compared to prior study. 3. Resolution of pulmonary edema. Echocardiogram [10-10] LEFT ATRIUM: No spontaneous echo contrast in the body of the [Name Prefix (Prefixes) ] [Last Name (Prefixes) ] LAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness. Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. [First Name (Titles) ] [Last Name (Titles) ]S. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. PRE-BYPASS: No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results at time of surgery. POST-BYPASS: The patient is AV paced. The patient is on no inotropes. Biventricular function is unchanged. Mitral regurgitation is unchanged. Tricuspid regurgitation is unchanged. The aorta is intact post-decannulation. [2120-10-15] 04:32AM BLOOD WBC-5.0 RBC-3.72* Hgb-11.0* Hct-33.1* MCV-89 MCH-29.5 MCHC-33.2 RDW-14.8 Plt Ct-179 [2120-10-11] 02:09AM BLOOD PT-13.3 PTT-30.3 INR(PT)-1.1 [2120-10-18] 06:13AM BLOOD Glucose-106* UreaN-22* Creat-0.8 Na-143 K-4.8 Cl-107 HCO3-26 AnGap-15 Brief Hospital Course: Ms [Known lastname 79959] was admitted for same day surgery and underwent coronary artery bypass graft surgery. Of note she had issues with bleeding in her endovein harvest site from her left leg in the operating room and postoperatively. See operative report for further details. She received cefazolin for perioperative antibiotics and was transferred to the intensive care unit for post operative management. She remained intubated overnight and on neosynephrine for blood pressure management. The leg continued to ooze and it was monitored overnight with a hemovac for drainage. Blood transfusions were required for a decreased hematocrit. On post operative day one she had no further bleeding from the leg, she was weaned from sedation, awoke, and was extubated without complications. She was started on betablockers and then on post operative day two started on lisinopril for blood pressure management. Additionally she was started on lasix for diuresis. She was transferred to the floor on post operative day two for the remainder of her care. Physical therapy was consulted for strength and mobility. She continued to progress slowly and was ambulating with a walker. Wound care was consulted for skin impairment of left leg with no evidence of infection.Twice daily softsorb dressing changes were recommended. Keflex was re-started prophylactically. She will be seen early next week for a wound check. The wound service stated that they would be happy to be paged for consultation during that out-patient wound check if there continue to be concerns. By post-operative day eight she was ready to be discharged to home. All appropriate follow-up appointments were advised. Medications on Admission: Norvasc 5 mg po daily Atenolol 25 mg po daily Folic acid 1 mg daily Propranolol 80 mg daily Simvastatin 20 mg daily Aspirin 81 mg daily Santura XR 60 mg daily Nitrostat 0.4 prn Discharge Medications: 1. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 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. Sanctura XR 60 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. 6. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 9. cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 2 weeks. Disp:56 Capsule(s) Refills:2 10. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 14 days. Disp:28 Tablet(s) Refills:2 11. wound care Softsorb dressing to left leg wounds two times each day for two weeks. Wash wounds gently with soap and pat dry daily with a towel. Discharge Disposition: Home Facility: tbd Discharge Diagnosis: Coronary artery disease s/p CABG Hypertension Hyperlipidemia Anxiety Hemolytic anemia Osteoarthritis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with walker Incisional pain managed with Tramadol Incisions: Sternal - healing well, no erythema or drainage Leg Left - with multiple abrasions along medial calf Edema - 1 to 2+ bilat Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for one month or while taking narcotics. Driving will be discussed at follow up appointment 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. 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 Wound check cardiac surgery office - [Telephone/Fax (1) 170] Date/Time:[2120-10-22] 11:00 Surgeon: Dr [Last Name (STitle) ] [Telephone/Fax (1) 170] on [2120-11-13] 1:30 PCP/Cardiologist: Dr [Last Name (STitle) 3357] [Telephone/Fax (1) 4606] on [2120-11-14] 2:45pm Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2120-10-18]	[ "41401", "2859", "4019", "2724" ]
Admission Date: [2157-6-20] Discharge Date: [2157-7-5] Date of Birth: [2097-2-13] Sex: F Service: [Last Name (un) 7081] HISTORY OF PRESENT ILLNESS: The patient is a 50-year old female with a history of hypertension, diabetes mellitus, hypercholesterolemia, and glottic/subglottic stenosis with an esophageal by computer tomography who was admitted for a workup of this mass. The patient first developed neck pain and persistent phlegm and a hoarse voice approximately six months ago. The patient was initially treated conservatively with antibiotics and saline mist with some improvement in the hoarseness of her voice, but no complete resolution of symptoms. Evaluation by bronchoscopy showed a laryngeal mass. The mass was biopsied but reportedly was benign. A follow-up neck computer tomography showed a high-grade narrowing of the glottic and subglottic airway with extensive edema and soft tissue thickening as well as an esophageal mass impinging on the trachea. She has recently noticed worsening neck pain with the left greater than right and odynophagia. However, the patient denies any fevers, chills, chest pain, or shortness of breath. PAST MEDICAL HISTORY: Hypertension. Type 2 diabetes mellitus. Chronic sinusitis. Asthma. Hypothyroidism. Hypercholesterolemia. Gastroesophageal reflux disease. Glaucoma. History of kidney stones. PAST SURGICAL HISTORY: Status post total abdominal hysterectomy. Status post toe surgery. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. TriCor 54 mg once per day. 2. Prednisone 5 mg by mouth every other day (for asthma). 3. Levoxyl 75 mcg by mouth once per day. 4. Albuterol as needed. 5. Protonix 40 mg by mouth once per day. 6. Lipitor 40 mg by mouth once per day. 7. Avapro 300 mg by mouth once per day. 8. Metolazone 5 mg by mouth once per day. 9. Potassium chloride 10 mEq by mouth twice per day. 10. Lasix 80 mg by mouth once per day. 11. Actonel 35 mg by mouth every week. 12. Vitamin D. 13. Calcium. 14. Humalog sliding scale. 15. Lantus 27 units in the evening. 16. Flovent 2 puffs twice per day. 17. Alphagan 0.15 percent twice per day. 18. Actos 30 mg by mouth once per day. 19. Albuterol nebulizers as needed. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed temperature was 98, heart rate was 86, blood pressure was 136/64, respiratory rate was 20, and 96 percent on room air. In general, in no acute distress. Awake and alert. Head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic, anicteric. Pupils equal, round and reactive to light. OC/OP clear. The chest was clear to auscultation bilaterally. Cardiovascular examination revealed a regular rate and rhythm. The abdomen was soft, nontender, and nondistended. Extremities revealed 1 plus pitting edema of the bilateral lower extremities. RADIOLOGY: A computer tomography from [2157-6-1] showed high-grade narrowing of the glottic and subglottic airway with extensive edema and soft tissue thickening. There was a soft tissue density at the level of the glottis which appeared to cause obstruction of laryngeal cartilage and extended laterally to the cartilage. There was a proximal esophageal mass displacing the trachea anteriorly. SUMMARY OF HOSPITAL COURSE: The patient was admitted to undergo an ENT evaluation and possible biopsy. This took place on [2157-6-21]. The patient was taken to the operating room and underwent a laryngoscopy, esophagoscopy, and three biopsies. The patient was noted to have a normal esophageal mucosa. No lesions or masses were seen. There was a sluggish right vocal cord, a normal right vocal cord, and a normal left vocal cord. There was no glottic or subglottic mass seen. The [Doctor Last Name 19634] formed sinuses were clear. This was an essentially a normal examination. Please see the dictated Operative Note for further details. Postoperatively, the patient was found to have right-sided back pain - pleuritic in nature - and difficulty breathing. The patient denied any chest pain, abdominal pain, nausea, or vomiting. The patient received albuterol and Atrovent nebulizers without improvement. A bedside laryngoscopy showed laryngeal edema; unchanged from appearance in the Operating Room. A chest x-ray showed dulled costophrenic angles consistent with effusions, but no pneumomediastinum. Because the patient had undergone a rigid esophagoscopy, there was some concern that the patient may have received an esophageal perforation; however, the chest x-ray did not show this. The other concern was that the patient was having possible bronchospasm. The patient was therefore given Decadron 10 mg intravenously and kept nothing by mouth. The patient was also continued on her nebulizer treatments. A chest computer tomography was obtained later that day which showed an interval development of a right-sided pneumothorax and pneumomediastinum with ill-definition of the inferior esophagus and new bilateral pleural effusions. Therefore, the patient was returned to the Operating Room with the Thoracic Surgery Service and underwent a right thoracotomy with repair of an esophageal perforation along with an open gastrostomy and open jejunostomy. The perforation was approximately 1 cm long in the right anterolateral mid esophagus. A right neck mass was also removed and sent for pathology. The pathology on that mass later came back showing a benign cyst outlined by respiratory epithelium with acute and chronic inflammation with fibrosis; most consistent with a bronchogenic cyst. Please see the dictated Operative Note for further details of the operations. The patient was started on imipenem postoperatively, and the endotracheal tube was switched from a double to a single lumen tube. On postoperative day one, the patient spiked a temperature to 101.9 degrees and was pan-cultured. All cultures taken in the Operating Room came back negative; however, the Operating Room cultures taken during the repair of the esophagus later showed methicillin-resistant Staphylococcus aureus along with sparse growth of Enterococcus and Streptococcus viridans. As a consequence, the patient was switched from imipenem to vancomycin; to which imipenem was then added back. The patient was ultimately discharged on vancomycin and meropenem for a total 6-week course. On postoperative day three, the patient continued to be stable and was extubated without incident. On postoperative day five, the patient's tube feeds were started via the jejunostomy tube. Over the course of the next several days tube feeds were advanced without incident. The patient's chest tubes were changed from bulb suction to water seal on postoperative day seven. Also on postoperative day seven, the patient was noted to have some right arm swelling. The patient underwent a right upper extremity ultrasound which showed no deep venous thrombosis. The swelling in the leg resolved by the time of the patient's discharge. On postoperative day eight, the patient underwent an upper gastrointestinal swallowing evaluation which showed no evidence for a leak. On postoperative day nine, as the patient continued to do well, the patient's chest tube was removed. An Infectious Disease consultation was obtained; in which the total 6-week course of vancomycin and imipenem/meropenem was recommended. The patient was also started on a clears diet, which she tolerated well. Over the next several days, the patient was kept in house due to continual spiking of fevers. As noted above, all blood cultures were negative. However, the patient did have chest x-rays showing right middle lobe and right lower lobe parenchymal opacities consistent with either atelectasis or pneumonia. Therefore, the patient received aggressive chest physical therapy; especially on the right. On postoperative day eleven, the patient was noted to have a hematocrit of 22.5, for which she received 1 unit of packed red blood cells - bringing her hematocrit up to 30.5. On postoperative day thirteen, the patient underwent a chest computer tomography with and without contrast in which loculated pleural effusions were seen at the right lung base. One of these effusions was drained using computed tomography- guidance and later showed no growth on culture. DISCHARGE DISPOSITION: As the patient's temperature spikes had subsided, a peripherally inserted central catheter line was placed on postoperative day fourteen, and the patient was discharged to home with services in good condition. DISCHARGE DIAGNOSES: In addition to the admission diagnoses listed above, the patient had an esophageal perforation; status post esophageal repair and a benign right mediastinal cyst outlined by respiratory epithelium (most consistent with a bronchogenic cyst). CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home with services. MEDICATIONS ON DISCHARGE: 1. Prednisone 5 mg by mouth every other day. 2. Levoxyl 75 mcg by mouth once per day 3. Albuterol 1 to 2 puffs q.4h. as needed. 4. Fluticasone 2 puffs twice per day. 5. Protonix 40 mg by mouth once per day. 6. Lipitor 40 mg by mouth once per day. 7. Irbesartan 300 mg by mouth once per day. 8. Metolazone 5 mg by mouth once per day. 9. Lasix 80 mg by mouth once per day. 10. Potassium chloride 10 mEq by mouth twice per day. 11. Actonel 35 mg by mouth every week. 12. Lantus 37 units subcutaneously in the evening. 13. Humalog insulin sliding scale. 14. Pioglitazone 30 mg by mouth once per day. 15. TriCor 54 mg by mouth once per day. 16. Brimonidine tartrate 0.2 percent 1 drop ophthalmic twice per day. 17. Metoprolol tartrate 25 mg by mouth twice per day. 18. Meropenem 1000 mg intravenously q.8h. (times 28 days). 19. Vancomycin 1000 mg intravenously q.12h. (times 28 days). DISCHARGE FOLLOWUP: The patient was instructed to call and schedule a follow-up appointment in one to two weeks with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 175]. The patient was instructed to call and schedule a follow-up appointment in one to two weeks with Dr. [First Name (STitle) ] [Name (STitle) ]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 7082] Dictated By:[Last Name (NamePattern1) 15517] MEDQUIST36 D: [2157-7-14] 16:41:36 T: [2157-7-14] 17:53:12 Job#: [Job Number 55988]	[ "4019", "25000", "2449", "53081", "49390" ]
Admission Date: [2111-6-12] Discharge Date: [2111-6-29] Date of Birth: [2029-11-22] Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[Doctor Last Name 1350] Chief Complaint: Unstable neck fracture Major Surgical or Invasive Procedure: Occipito cervical fusion O to C4 fusion History of Present Illness: 81M with PMHx of primary speech apraxia, DM2, COPD, asbestosis, and recent fall for which he was admitted and placed in a [Location (un) 2848]-J collar (noted to have an old C1-C2 fracture) who presents from rehab with concern for ill-fitting collar and possible mental status changes. Patient was discharged to rehab yesterday to rehab, and was reportedly complaining of nausea, anorexia, dizziness, and headache. There was a question of worsening of his apraxia. He required a 1:1 sitter last night for agitation and was sent to the ED from his rehab for further evaluation. In the ED, initial VS were 98 90 157/70 15 95%. Labs were significant for stable hyponatremia & anemia. Preliminary read of non-contrast head CT showed no acute process. U/A was negative. Patient did not receive any medications or fluids in the ED; they did note that the patient fell asleep twice during interview. Patient was seen by neurosurgery who felt that his mental status was at baseline. They determined that there was no acute neurosurgical issues and that his C-collar was appropriately fit. Patient reportedly denied weakness or gait abnormalities. Patient was admitted to medicine for placement, as his rehab facility refused to take him back. Vital signs on transfer were 98.5 ??????F (36.9 ??????C), Pulse: 99, RR: 16, BP: 139/70, O2Sat: 94%RA. On arrival to the floor, patient appears calm and comfortable. Communication is difficult [1-29] apraxia, but pt able to answer yes/no. He correctly circled (on a piece of paper) that he is at the hospital and said "no" when asked if he was in pain. Past Medical History: Copd, Asbestosis, Diabetes, primary speech apraxia Social History: Widowed, Remote ETOH and Smoking history, lives in [Hospital3 ] in [Location 7182] : [Street Address(2) 101207]. Family History: NC Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: O: T: 98 BP: 157/70 HR:90 R 15 O2Sats 95% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: EOMs 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, place, and date. Language: at baseline dysarthria. Primarily communicates by writing 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 [5-2] throughout. No pronator drift Sensation: Intact to light touch bilaterally. Reflexes: B T Br Pa Ac Right: + + + + + Left + + + + + PHYSICAL EXAMINATION ON DISCHARGE: same Pertinent Results: [2111-6-12] Head CT: IMPRESSION: No evidence of acute intracranial process. [2111-6-12] CXR: IMPRESSION: Extensive bilateral calcified pleural plaque, likely reflecting prior asbestos exposure. No signs of superimposed pneumonia. [2111-6-12] 07:56PM URINE HOURS-RANDOM [2111-6-12] 07:56PM URINE GR HOLD-HOLD [2111-6-12] 07:56PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.020 [2111-6-11] 07:02AM GLUCOSE-101* UREA N-10 CREAT-0.5 SODIUM-126* POTASSIUM-4.3 CHLORIDE-88* TOTAL CO2-29 ANION GAP-13 [2111-6-11] 07:02AM WBC-8.0 RBC-4.18* HGB-12.8* HCT-38.7* MCV-93 MCH-30.7 MCHC-33.1 RDW-13.6 [2111-6-11] 07:02AM PLT COUNT-266 Brief Hospital Course: Initially, the patient was admitted to the medical service. An extensive conversation with the HCP was had, who felt the patient was at his baseline. He was noted to be hypovolemic, no worse than previous admission, and this was felt to be secondary to hypovolemia, so he was managed with gentle IV hydration. He was transferred to the neurosurgery service for work-up of his cervical spine fracture. On [6-14], after discussion with the HCP, it was determined that the patient would be electively intubated on [6-15] and placed in traction prior to undergoing occipital-cranial fusion. He remained hyponatremic with a sodium of 125. On [6-16], patient remained intubated. He was taken out of traction in CT scanner for a CT c-spine which showed stable c1/c2 fracture with good reduction. On exam, MAE and squeezes hand. He was pre-oped for OR on [6-17]. On [6-17] he was stable in the ICU, intubated, and on cervical traction while awaiting OR for occipital to C2 fusion. C0-C4 fusion was performed on [6-17] without any intraoperative complications.On [6-18] patient remained stable, intubated in the ICU. He was leethargic, but opened his eyes, squeezes hands and moves toes bilaterally on command. Bronchoscopy showed airway edema necesitating General Surgery consult for tracheostomy. Traheostomy was performed on [6-20], he remained in the ICU until [6-23] when he was transferred to floor. He was evaluated by Speech Therapy prior to his transfer, on [6-22] and was seen again once he was on the floor. On [6-24] he failed the speech and swallow study and poorly tolerated his PMV. At that time PEG was suggested but both patient and his HCP/nephew declined the PEG citing limited evidence that it would improve his survival. After further discussion on [6-25] the patient changed his mind and agreed to have the PEG placed. PEG was placed on [6-26], tube feeds were started on [6-27] and stopped. Tube feeds restarted on [6-28] and found to be at goal per GI. Staples removed from incisional wound on [6-29]. Medications on Admission: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Albuterol 0.083% Neb Soln 1 NEB IH TID copd 3. Aspirin 81 mg PO DAILY 4. Docusate Sodium 100 mg PO BID Patient may refuse. Hold if patient has loose stools. 5. FoLIC Acid 1 mg PO DAILY 6. Ipratropium Bromide Neb 1 NEB IH TID copd 7. MetFORMIN (Glucophage) 500 mg PO BID 8. Multivitamins 1 TAB PO DAILY 9. Nitroglycerin SL 0.4 mg SL PRN chest pain 10. Omeprazole 20 mg PO DAILY 11. Quinapril 10 mg PO DAILY 12. Simvastatin 20 mg PO DAILY 13. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain 14. Tamsulosin 0.4 mg PO HS 15. Vitamin D 800 UNIT PO DAILY Discharge Medications: 1. Vitamin D 800 UNIT PO DAILY 2. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain RX Ultram 50 mg 1 Tablet(s) by mouth Q6H:PRN Disp #100 Tablet Refills:0 3. Tamsulosin 0.4 mg PO HS 4. Simvastatin 20 mg PO DAILY 5. Senna 1 TAB PO BID 6. MetFORMIN (Glucophage) 500 mg PO BID 7. Quinapril 10 mg PO DAILY Hold for SBP < 100 8. Multivitamins 1 TAB PO DAILY 9. Heparin 5000 UNIT SC TID 10. FoLIC Acid 1 mg PO DAILY 11. Docusate Sodium 100 mg PO BID Patient may refuse. Hold if patient has loose stools. 12. Bisacodyl 10 mg PO/PR DAILY 13. Ipratropium Bromide Neb 1 NEB IH Q6H Discharge Disposition: Extended Care Facility: [Hospital ] Hospital - [Hospital1 8] Discharge Diagnosis: Odontoid type 2 fracture unstable. Discharge Condition: Level of Consciousness: Alert and interactive. Mental Status: Confused - sometimes. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: ?????? Do not smoke. ?????? Keep your wound(s) clean and dry / No tub baths or pool swimming for two weeks from your date of surgery. ?????? Dressing may be removed on Day 2 after surgery. ?????? If you have steri-strips in place, you must keep them dry for 72 hours. Do not pull them off. They will fall off on their own or be taken off in the office. You may trim the edges if they begin to curl. ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? Limit your use of stairs to 2-3 times per day. ?????? Have a friend or family member check your incision daily for signs of infection. ?????? If you are required to wear one, wear your cervical collar or back brace as instructed. ?????? You may shower briefly without the collar or back brace; unless you have been instructed otherwise. ?????? Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? Do not take any medications such as Aspirin unless directed by your doctor. ?????? Unless you had a fusion, you should take Advil/Ibuprofen 400mg three times daily ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? 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, and drainage. ?????? Fever greater than or equal to 101?????? F. ?????? Any change in your bowel or bladder habits (such as loss of bowl or urine control). Physical Therapy: activity as tolerated. Brace to be worn out of bed while ambulating. No need of brace in bed or in chair. Treatments Frequency: see discharge instructions. Keep incisions dry Followup Instructions: Follow Up Instructions/Appointments ??????Please return to the office in [7-7] days (from date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Physician Assistant or [Name9 (PRE) ] 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. ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [Last Name (STitle) ] to be seen in 2 weeks. ??????You will need x-rays/CT-scan prior to your appointment. Completed by:[2111-6-29*]	[ "2761", "496", "25000", "2859", "V1582" ]
Admission Date: [2143-7-12] Discharge Date: [2143-7-24] Date of Birth: [2093-7-6] Sex: F Service: MEDICINE Allergies: Protonix / Cephalosporins / Penicillins / Tetracycline / Gentamicin / Heparin Agents / Benzodiazepines / Trusopt / Clindamycin / Dipivefrin / Lovenox / Erythromycin Base / Etanercept / Remicade / Versed / Pantoprazole / Sulfa (Sulfonamides) / Trimethoprim / Doxycycline Attending:[First Name3 (LF) 1666] Chief Complaint: OSH tranfter for antibiotics and access. Major Surgical or Invasive Procedure: Portacath Placement Femoral Line Placement s/p Cardiopulmonary Resuscitation Intubation History of Present Illness: 50 y.o. female with a past medical history of idiopathic clotting disorder with known subclavian DVT and IJ thrombus and multiple antibiotic allergies was transferred from an OSH for further treatment of bacteremia and needing IV access on [7-12]. . Patient was recently admitted to [Hospital1 18] from [Date range (1) 92890] with complaints of hip pain secondary to bilateral avascular necrosis of hip. According to the discharge summary, there was much discussion regarding whether she would have surgery at [Hospital1 15204] (who would not admit her for urgent surgery and recommended outpatient surgery), at [Hospital1 18] (evaluated by ortho who recommended outpatient surgery), [Hospital1 2025] (who declined accepting her), or [Hospital1 112]. She ultimately was discharged to the [Hospital1 112] ED for immediate surgical evaluation. During that admission, she had chronic pain requiring IV dilaudid. She had a PICC line placed for administration of IVIg for her common variable immunodeficiency. . Patient then presented to OSH on [2143-7-10] with fever and bilateral lower extremity cellulitis. An additional source was thought to be PICC line infection, so the line was pulled; however, no additional access was obtained despite attempts by surgery and IR at OSH. Possible sources for patient's fever included RUE septic thrombophlebitis (at site of old PICC line) and bacteremia (blood culture growing GPC on [2143-7-11]). ID at OSH was recommending IV vancomycin, although no access could be obtained. Patient was reportedly receiving IM daptomycin, although it is unclear if she actually received a dose. . Since admission to [Hospital1 18] on [7-12], she was treated for possible cellulitis at PICC line site. She was treated with Vancomycin/Daptomycin for possible sepsis from this same line. OSH culture grew Gram + rods found to be Staph Epi, likely contamination. The site was deemed unlikely cellulitis as she had no warmth, and it was blancheable. Blood cultures were negative x 5 days and on [7-18], vancomycin was discontinued. As she has CVID, she had a port-a-cath placed in place of her PICC for IVIg on [7-17]. There was a question of whether this line could be used or not. She developed LLE pain thought to be cellulitis vs. RSD. . On the evening of [2143-7-18], the patient refused her PO pain medications at approximately 8:05 PM. Per Ms. [Known lastname ] RN, the patient was shaking and shivering, although she was alert and oriented. She had a temp of 102. At approximately 10 PM, the patient was given IV dilaudid 0.5 mg for chronic pain and then was "babbling," hyperventilating, and praying with the hospital Chaplain in broken speech. Workup for AMS included CXR, blood cultures, and urine cultures. Haldol 25 mg was given at midnight and again 20 minutes later (NOTE: on review of [Month (only) 16], no record of Haldol was seen in chart for that date). 2 mg Ativan was given for possible seizure activity as witnessed by leg tremulousness and eye rolling. The patient then became blue and unresponsive, pulseless, and arrested for approximately 20 seconds. CPR was begun; a CODE BLUE was called. She was found in PEA arrest and quickly restored pulse and spontaneous breathing. A femoral line was placed and the patient was intubated for airway protection. She was then transferred to the MICU for further care. . MICU Course: She was initially hypercarbic on initial ABG after intubation. She was oxygenating fine and tolerated a PSV trial and was extubated on [2143-7-19]. She is currently comfortable on 2 L NC. She was febrile and placed on empiric antibiotics. These were stopped her second day in the MICU. All of her culture data remained negative. Her sedation and opiods were stopped and then gradually reintroduced. She was eventually stable on oxycontin 60 [Hospital1 ] and Dialudid 4 mg po prn. Interventional radiology reassessed her port, which they deemed patent, uninfected, and useable. She completed her treatment for cellulitis. . She was transferred to the Medicine team on [7-21] for pain control. Past Medical History: Morbid Obesity Common variable immune deficiency Vasculitis (on Prednisone for 15 years) Bilateral upper ext dvt (on fondaparinux for 4 years) Pickwickian syndrome Depression Sleep apnea (home O2 1.5L) Hashimoto's thyroid disease hx of VRE, MRSA hx of ERCP Social History: 27 years x 1 ppd tobbacco, denies alcohol, IVDU Family History: Father with DM and CAD in 70s Physical Exam: ADMISSION: =========== 101.4 93/44 88 22 96% O2 Sat on AC 100% 500 x 16 Gen: morbid obesity intubated and sedated HEENT: MMM NECK: Supple, No LAD, Cannot assess JVD CV: very distant heart sounds RR, NL rate. NL S1, S2. could not appreciate murmurs/rubs/gallops LUNGS: CTA, BS BL, No W/R/C ABD: + BS, obese, Soft, NT, ND. NL BS. No HSM EXT: left lower extremity with slight erythema with no warmth or induration; SKIN: NEURO: Sedate and intubated, [12-18]+ reflexes, equal BL. TRANSFER TO MEDICINE: ===================== 98 102/54 66 12 96% O2 Sat on 2 L NC Gen: morbidly obese, comfortable appearing, sleepy, NAD HEENT: MMM, anicteric, pupils 3 mm, equal, reactive NECK: supple, no LAD, cannot assess JVD CV: very distant heart sounds, RR, NL rate. NL s1, s2. Could not appreciate any murmurs/rubs/gallops. LUNGS: CTA, BS BL, no w/r/c, port in [Doctor Last Name ] chest. ABD: + BS, obese, soft, NTND, no HSM. EXT: left lower extremity with slight erythema and no warmth or induration. NEURO: AAO x 3, no focal findings. Pertinent Results: ADMISSION LABS: ================= 10.5 7.7 >-----< 346 MCV 88 32.0 Neuts 51.8 Lymphs 31.8 Monos 10.2 Eos 5.2 Baso 1.0 138 93 15 -----\|-----\|------< 88 3.5 40 1.1 Ca 9.4 Phos 5.1 Mg 1.7 Fe 28 TIBC 339 Hapto 271 Ferritin 26 . PERTINENT LABS DURING ADMISSION: ================================== WBC trend: 7.7 - 10.6 - 6.1 - 8.5 - 7.6 - 9.0 - 12.3 - 11.9 - 9.3 - 6.9 Bicarbonate (range) 33 - 42 . Potassium ([7-19]): 2.7 - 2.9 . ABG (from earliest ABG to most recent): 7.76/27/104 7.48/55/74 7.47/60/41 7.47/57/339 7.40/66/118 . Lactate ([7-19]): 3.9 - 1.7 - 0.9 - 0.9 . Blood Cultures: 4 sets negative; 1 pending Urine Culture: negative x 2 . STUDIES: ======== CHEST (PORTABLE AP) [2143-7-13] IMPRESSION: Line placement as described. . US GUID FOR VAS. ACCESS [2143-7-17] FLUORO GUID PLCT/REPLCT/REMOVE CENTRAL LINE [2143-7-17] IMPRESSION: Successful placement of a single lumen port catheter through the left IJ . The tip of the catheter is located in the distal SVC. The line is ready for use. . CHEST PORT. LINE PLACEMENT [2143-7-18] Left Port-A-Catheter tip is in the mid SVC. Aside from discoid atelectasis in the left lower lung, the lungs are clear. Cardiomediastinal contour is unchanged compared to prior study dated [2143-7-13] and is unremarkable. There is no pneumothorax or pleural effusion. . CHEST (PORTABLE AP) [2143-7-18] IMPRESSION: Low lung volumes with left lower lung zone atelectasis. . CHEST (PORTABLE AP) [2143-7-19] IMPRESSION: Low lung volumes, status post nasogastric tube and endotracheal tube placement. . CT HEAD W/O CONTRAST [2143-7-19] FINDINGS: There is no hemorrhage, mass effect, shift of the normally midline structures, or major vascular territorial infarct. The [Doctor Last Name 352]-white matter differentiation is preserved. There is no hydrocephalus. The overlying soft tissues are unremarkable. There is focal hyperostosis extending off the outer table of the left occipital bone. Polypoid mucosal thickening is seen within the left maxillary sinus and there is mild mucosal thickening of the ethmoid air cells. The frontal sinuses are hypoplastic. An endotracheal and nasogastric tube are partially visualized. . IMPRESSION: 1. No hemorrhage or mass effect. . EKG [2143-7-19] Sinus bradycardia. Modest prolonged QTc interval. Intraventricular conduction defect. Non-specific inferolateral ST-T wave changes. No previous tracing available for comparison. . EEG [2143-7-20] IMPRESSION: This is a normal portable EEG in the primarily sleeping states. There were no regions of focal, lateralized, or epileptiform features noted. . RIB BILAT, W/AP CHEST [2143-7-21] FINDINGS: Comparison to [2141-7-19]. There is a Port-A-Cath in place with tip in the SVC. Linear subsegmental atelectasis is seen at the lung bases, particularly on the left. No pleural effusion or pneumothorax is noted. Cardiomediastinal silhouette is within normal limits. No acute displaced rib fracture is identified. Osseous structures are otherwise intact. . IMPRESSION: No evidence of displaced rib fracture. Brief Hospital Course: Ms. [Known lastname 4702] is a 50 y.o. F with CVID, idiopathic clotting d/o with known subclavian DVT and IJ thrombus, morbid obesity, and several allergies admitted for BLE cellulitis and inability to obtain access from OSH on [7-12], transferred to MICU s/p PEA arrest (presumed [1-18] medication), and then transferred to medicine floor for pain management. . # S/P Respiratory failure and PEA arrest: On [7-18], patient s/p episode of incoherent speech with ?seizure activity. She also received antipsychotics and benzodiazapene which would depress her respiratory drive. Also, considered infectious process because of CVID. A pre-code ABG was 7.76/27/104, and her hyperventillation induced respiratory alkalosis contributed to tiring out with associated electrolyte imbalances. She was intubated for airway protection and was weaned off the ventilator quickly. After extubation, she maintained O2 saturations in the upper 90's on 2L NC (her home oxygen therapy). . # Acute mental status changes ([7-18]) of unknown etiology: Possible mechanisms include sundowning, delirium in setting of fevers/possible infection, medications (she received dilauded before her delerium), stroke, seizures, electrolyte disturbances. Head CT was negative. EEG negative. Her electrolytes were repleted as needed, specifically her potassium (unknown cause with accompanying anion gap lactic acidosis). Her lactic acidosis was unlikely due to be sepsis with normal BP, but she was febrile. Her mental status returned to baseline quickly. . # Fevers, resolved: Possible etiologies include drug fevers, infection, inflammatory process. Her blood cultures and her urine cultures remained negative throughout her hospitalization. Vancomycin and levoquin were empirically started while in the MICU, but quickly stopped after patient remained afebrile without an elevated WBC. Her WBC trend spiked at 12.3, but returned to WNL without any signs or symptoms of infection while on the medicine floor. . #. Cellulitis in LE: She completed a full course of antibiotics. . #. Bilateral AVN: Patient with persistent and longterm pain. AVN most likely from long-term use of steroids. Continued her home regimen of oxycontin 60 [Hospital1 ] and dilaudid 4 mg po q4 hours prn. Continued Vitamin D. Upon discharge, pt's pain at its baseline. . # Chest pain secondary to chest compressions: Pt with MSK pain. Rib series negative for displaced fractures. Continued her home regimen of oxycontin and dilaudid prn. Counseled on slow healing of bruising to chest. . # Common variable immune deficiency: Stable during hospitalization. IVIG given on [7-14]. Next IVIG due this [Month/Year (2) 1017] [2143-7-28]. She will receive this at her rehab center. . # BLE edema, improving: With 1-2+ pitting edema to ankles. Pt's toresemide was re-started at a low dose upon return to the floor due to somewhat low BPs. She tolerated this well, and her edema improved. She may need to be placed back on her potassium pills now that her diuretic has been restarted. . # HTN: Pt's SBPs in 100-120's, so all BP meds except toresamide (restarted for edema) were held. She can follow up with her PCP to consider need for BP meds. . # Clotting Disorder: Patient with multiple DVTs in the past. Unknown etiology. As pt is nonambulatory, she was given Fondaparinux 10 mg SC daily for weight-based dosing. . # Vasculitis: Unknown etiology. No active issues during hospitalization. Continued methylprednisolone 8 mg PO every other day . # Depression: Stable during hospitalization. Continued seroquel and duloxetine. . # Hypothyroidism: History of Hashimoto's. Stable. Continued on outpatient levothyroxine. . # Anemia: Has been stable at 28-30 while in hospital. Continued folate and iron supplementaion. . # Sleep apnea (home O2 2L): Pt states that she had a sleep study completed recently and was told that she did not need CPAP. . # Nosebleed x 2 during hospitalization: Was relieved with pressure and Afrin. Pt stated that she occasionally has nosebleeds. HCT always stable. . # Dry Cough: Started after extubation; most likely secondary to intubation. Also consider bronchitis, but lung exam CTAB. No WBC and afebrile, so did not treat with antibiotics. Cephacol lozenges prn. . # Hypercholesterolemia: stable. Continued zocor and zetia. . # Aphthous Ulcers: viscous lidocaine prn . # Seasonal allergies: continued singulair . #. CODE: FULL CODE . #. COMM: [Name (NI) ], [Name (NI) ] [Name (NI) 4702] (Mother) - [Telephone/Fax (1) 92891] . #. Access: Portacath. TO DO: Check electrolytes now that diuretic has been restarted on Thursday [2143-7-25]. [Month (only) 116] need to be on oral potassium replacement now that diuretic has been restarted. [Month (only) 1017] [2143-7-28] she needs IVIG. Medications on Admission: Folate 2mg PO daily Spironolactone 25mg PO daily Trazodone 200mg PO qhs prn sleep Esomperazole 20mg PO bid Calcium Carbonate 500mg PO qid Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Duloxetine 40mg PO bid Vytorin [10-5] 10-20mg PO daily Fondaparinux 7.5mg SC daily Methylprednisolon 8mg PO qod Levothyrxoine 188mcg PO daily Docusate 100mg PO bid Simethicone 80mg PO qid Vitamin D3 800U PO daily Oxycontin SR 60mg PO bid Seroquel 100mg PO qhs Tylenol 650mg PO q6h Benadryl 50mg PO q6h prn Ondansetron 4mg PO q8h prn nausea Discharge Medications: 1. Methylprednisolone 2 mg Tablet Sig: Four (4) Tablet PO QODHS (every other day (at bedtime)). 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO once a day. 9. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 12. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO every twelve (12) hours. 13. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for chronic pain- home med. 15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 16. Fondaparinux 5 mg/0.4 mL Syringe Sig: Two (2) Subcutaneous DAILY (Daily). 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 18. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2) Spray Nasal DAILY (Daily). 19. Torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 21. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: [12-18] puffs Inhalation Q6H (every 6 hours) as needed. 22. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 23. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: [12-18] Lozenges Mucous membrane Q4H (every 4 hours) as needed. 24. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed. 25. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane TID (3 times a day) as needed. 26. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical once a day as needed for pain for 1 doses. 27. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed. 28. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day) as needed for 3 days. 29. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for itching. 30. Sodium Chloride 0.65 % Aerosol, Spray Sig: [12-18] Sprays Nasal QID (4 times a day) as needed. 31. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary: s/p Cardiopulmonary arrest Common Variable Immunodeficiency Avascular necrosis of Bilateral Hips Bilateral Lower Extremity Cellulitis . Secondary: Morbid Obesity Vasculitis Bilateral Upper Extremity Deep Venous Thrombosis Depression Discharge Condition: Stable. Discharge Instructions: You came into the hospital after being transferred from another hospital for a possible infection. We tested your blood, urine and lungs, and we found no source of infection. You also got a Portacath which provides permanent access for your IVIG treatments. . Please keep all medical appointments and take all your medications as prescribed. We decreased your Demadex dose to 20 mg daily as your blood pressure was a little on the low side. Please follow up with your primary care physician for further management. . If you get a fever>102, significant chills, constant nausea or vomiting, severe abdominal pain, constant diarrhea, or any other concerning symptoms, please call your primary care physician and report to the nearest Emergency Room. Followup Instructions: Please follow up with your primary care physician [Last Name (NamePattern4) ] [12-18] weeks. Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Telephone/Fax (1) 21748]. . Please get your next IVIG treatment this [Last Name (LF) 1017], [7-28]. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1672] MD, [MD Number(3) 1673] Completed by:[2143-7-26]	[ "0389", "2762", "51881", "32723", "2449" ]
Admission Date: [2155-5-23] Discharge Date: [2155-5-28] Date of Birth: [2101-12-1] Sex: F Service: MEDICINE Allergies: Ciprofloxacin / Keflex / Lisinopril / Insulin Glargine Attending:[First Name3 (LF) 106] Chief Complaint: palpitations and flushing Major Surgical or Invasive Procedure: pacemaker insertion History of Present Illness: The patient is a 53 yoF w/ a h/o CAD s/p CABG in [2141], DM II c/b renal failure s/p renal tx in [2132] and again in [2148] presented to [Hospital6 4287] initially on [5-22] with symptomatic bradycardia. She had some flushing, warmth, palpitations and abdominal discomfort (initially she attributed this to Thai food which is unusual for her to eat). . At [Hospital3 ] she was noted to have complete heart block with a rate of 38. Her rhythm improved slowly to 1:1 conduction and she was transferred to the [Hospital1 ] for continued medication washout. (she was on lopressor 100mg po qam and 150mg po qpm). . She states prior to her admission she felt palpitations while changing and getting ready for bed, she said her pulse was fast and would skip a beat every 4 or so beats. She did not feel presyncope, no sycope then or recently. She felt warm and asked her husband to call 911. She denies CP. She has had DOE upon ambulation > 1 block x 1 week, stable [2-26] pillow orthopnea, no PND, no leg edema. Her normal weight is 136-139 lbs, current weight is 141.5 lbs. No abdominal pain, one episode of diarrhea in the hospital the day prior to transfer to the [Hospital1 ]. . Initial VS: 98.3 38 150/50 12 100% RA Transfer VS: 39 151/55 17 99% RA . In the ER she was given calcium gluconate 2g for CCB reversal (also on nifedipine). She was admitted from the ER to the floor with a diagnosis of 2:1 block and bradycardia, but a normal blood pressure. Upon transfer from the ER stretcher to her floor bed she was noted to become more bradycardia, from a rate of 40 to 28. Her block had worsened from 2:1 to 3:1. Her SBP was 150. She had been experiencing nausea for 1 hour prior to her transfer (after taking aspirin). Past Medical History: Diabetes Mellitus, Coronary Artery Disease s/p CABG, HTN, s/p CRT failed '[32], [Name8 (MD) ] CRT [2148], anemia, HCV Social History: lives with husband, works full time for [Name (NI) 25120] department at [Location (un) 25121] AFB doing administrative desk work. Recent loss of mother. [Name (NI) 25122] care of father at home. Normally does not use any assistive devices. Family History: non contributory Physical Exam: PHYSICAL EXAMINATION: VS: T= 98.5 BP= 150/100 HR= 30 RR= 13 O2 sat= 98% RA GENERAL: NAD, AOx3 HEENT: unable to evaluate JVP, MMM, OP clear, EOMI, sclera anicteric, conjunctiva pink CARDIAC: bradycardic, 2/6 SEM best heard at USB LUNGS: rales [1-25] way up bilaterally, no wheezes ABDOMEN: Soft, mildly distended, non tender, no masses or organomegaly EXTREMITIES: WWP, no c/c/e SKIN: stasis dermatitis of LE Pertinent Results: [2155-5-28] 05:10AM BLOOD WBC-5.2 RBC-3.38* Hgb-10.4* Hct-31.4* MCV-93 MCH-30.7 MCHC-33.0 RDW-14.3 Plt Ct-165 [2155-5-28] 05:10AM BLOOD Glucose-158* UreaN-60* Creat-2.0* Na-140 K-5.1 Cl-107 HCO3-23 AnGap-15 [2155-5-24] 07:05PM BLOOD T4-11.3 [2155-5-24] 07:05PM BLOOD TSH-0.036* [2155-5-28] 05:10AM BLOOD tacroFK-9.0 [2155-5-27] 05:44PM BLOOD tacroFK-8.1 . Renal ultrasound [2155-5-26]: HISTORY: 53-year-old woman with renal transplant. COMPARISON: Renal ultrasound, [2152-5-24]. FINDINGS: Renal ultrasound was performed of the renal transplant in the left hemipelvis. The renal transplant measures 12.3 cm. There is no evidence of hydronephrosis or perinephric fluid. Doppler evaluation of the transplant shows symmetric flow through the kidney, and resistive indices range from 0.85 at the upper pole, 0.82 to 0.88 at the mid pole, and 0.81 to 0.83 at lower pole, and in the main renal artery of 0.89. Normal flow is seen in the renal vein. IMPRESSION: 1. Slight increase in resistive indices in all poles of the transplant kidney compared to prior study, now ranging from 0.81 to 0.89. 2. No hydronephrosis or perinephric fluid. . CXR [2155-5-24]: FINDINGS: Left-sided permanent pacemaker is present, with leads terminating in the right atrium and right ventricle, with no visible pneumothorax. Heart remains enlarged, and there is mild pulmonary vascular congestion. Small pleural effusion is demonstrated on the right. Bones are demineralized and demonstrate mild decreased height in the mid thoracic spine without change since [2154-3-13]. IMPRESSION: 1. Pacing leads in standard position with no pneumothorax. 2. Mild CHF. . EP: placement of [Company 1543] ADAPTA [Company ] Brief Hospital Course: #Complete Heart Block s/p [Name (NI) 19721] Pt was admitted from [Hospital6 2561] with bradycardia, found to be complete heart block at rate of 38. Received Calcium IV. to reverse calcium channel blocker and beta blocker was discontinued. Pt rec'd a BiV [Hospital6 ] on [2155-5-23] with no complications. Her Nifedipine and Metoprolol was resumed after the [Date Range ] was placed for BP control. She will follow up at the device clinic at [Hospital1 18] 1 week after placement and with her cardiologist, Dr. [Last Name (STitle) ] for continued treatment of her CAD and hypertension. Activity restrictions were reviewed with pt before discharge. #Acute on chronic Renal Failure s/p Transplant: Creatinine increased to max of 2.4 during hospital stay and was 2.0 at discharge. It was thought that she was pre-renal and her lasix was initially held. She was followed by the renal transplant team and her Prograf was decreased for high levels. She will be followed by Dr. [Last Name (STitle) ] after discharge and her creatinine and prograf level will be checked at her device appt. Bactrim and Prednisone was continued at previous dose. #Acute on Chronic Diastolic congestive Heart Failure: Fluid overload on lung exam over course of hospitalization in setting of acute renal failure. Responded well to low dose IV lasix. PO Lasix was restarted before discharge. Weight at discharge was 64.7 kg. #Hyperglycemia [3-4] A1C 7.4, likely due to dietary indiscretion. Insulin regimen from home was continued during hospital stay. #Hypertension: Pt was restarted on previous doses of Nifedipine and Metoprolol after pacemaker was placed. Clonidine was decreased to 0.1 mg daily. Medications on Admission: Lasix 20mg po daily Nifedipine 60mg po bid Prednisone 5mg po daily Prograf 2mg po bid Metoprolol 150mg po qpm, 100mg po qam HISS and NPH Clonidine 0.1mg po daily Pravachol 10mg po daily Levothyroxine 250 mcg po daily Bactrim DS one tab 3x/week Aspirin 81 mg daily Discharge Medications: 1. Outpatient Lab Work Please check Chem 7 and Tacrolimus level on Friday [5-30] with results to Dr. [Last Name (STitle) ] at ([Telephone/Fax (1) 3618] 2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 6. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (3 times a week). 9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 10. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale units Subcutaneous four times a day: Resume sliding scale and NPH dose from before admission. . 11. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 12. Levothyroxine 125 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO twice a day. Disp:180 Capsule(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Complete Heart block s/p Pacemaker Acute on Chronic Renal Failure Acute on chronic Diastolic Congestive Heart Failure diabetes mellitus Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a very slow heart rate and a pacemaker was placed. No lifting your left arm over your head or lifting more than 5 pounds for 6 weeks. You will have the device checked on [5-30] and will then go every 6 months. We were also concerned about your kidneys as your creatinine rose to 2.4 but is decreasing now. The Nephrology team followed you and decreased your Prograf to 1.5 mg twice daily. Please get your creatinine and Prograf level checked on Friday when you come in for your pacemaker check. Medication changes: 1. Decrease Metoprolol to 100mg twice daily 2. Decrease Tacrolimus dose to 1.5 mg twice daily. You should get your level drawn on Friday when you are at the device clinic appt. Make sure that is has been 12 hours after your last dose of Tacrolimus when you get the blood drawn. As your appt is at 9am, please take your Tacrolimus at 8pm the night before, get the blood drawn at [Hospital Ward Name 23] before the device clinic and then take the Tacrolimus after. 3. Decrease Clonidine to 0.1 mg once daily . Please check your blood pressure at home and call Dr. [Last Name (STitle) ] if your blood pressure is more than 160 or less than 100. You may have to adjust your medicine. Weigh yourself every morning, call Dr. [Last Name (STitle) ] if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Followup Instructions: Electrophysiology: DEVICE CLINIC Phone:[Telephone/Fax (1) 62] Date/Time:[2155-5-30] 9:00am. [Hospital Ward Name 23] [Location (un) 436]. . Cardiology: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone: [Telephone/Fax (1) 62] Date/time: Wed [6-25] at 2:40pm. Pulmonary: Provider: [Name10 (NameIs) 1571] FUNCTION LAB Phone:[Telephone/Fax (1) 609] Date/Time:[2155-8-13] 2:10 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 612] Date/Time:[2155-8-13] 2:30 . Nephrology: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone: ([Telephone/Fax (1) 3618] Date/time: [6-16] at 4:20pm. . Completed by:[2155-6-3]	[ "5845", "40390", "5859", "25000", "2449", "4280", "V4581", "V5867" ]
Admission Date: [2200-10-19] Discharge Date: [2200-10-30] Date of Birth: [2127-2-9] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 73 year-old female who presented to the medical center six weeks status post ascending aortic aneurysm repair with aortic valve replacement and coronary artery bypass graft times one with a one day history of brownish drainage from a pin point opening at the inferior pole of her sternal incision. The patient reported that there had been no drainage from the incision during her hospitalization here at [Hospital1 190] and during her subsequent discharge to a rehab facility. There had been some moistness to the wound. The patient denied any history of fevers, chills, increasing pain, increasing erythema to the incision, respiratory symptoms or warmth. She did report that the wound had sometimes been moist at the area. PAST MEDICAL HISTORY: Hypertension, depression, peptic ulcer disease, valvular heart disease. PAST SURGICAL HISTORY: Aortic aneurysm repair. MEDICATIONS: Prevacid 30 mg po q day, Percocet, Lactulose, Remeron 15 mg po q.h.s., Trazodone 100 mg po q.h.s., Ativan .5 mg po, Metoprolol 150 mg po b.i.d., aspirin 325 mg po q day and Imipramine 25 mg po q.h.s. PHYSICAL EXAMINATION: Vital signs 98.6, 88 and sinus, 135/64, 98% on room air. In general, the patient was well appearing elderly female in no acute distress. Neck no lymphadenopathy, supple. Cardiovascular regular rate and rhythm, normal S1 and S2. Chest/lungs clear to auscultation bilaterally. Healing sternal incision with minimal erythema, approximately 5 mm open spot near the distal end of the incision. Watery brownish fluid draining spontaneously with thick brown pus expressible. Area soft, but not fluctuant. Abdomen soft, nontender, nondistended. Extremities, the right shoulder minimally tender to palpation, but with an area of tenderness noted near the medial edge of the scapula posteriorly with normal range of movement. The right calf vein harvest site was healing well with a 5 cm gap at the distal end with a healing rim of erythema. LABORATORIES ON ADMISSION: CBC was 18.5, 27.9, 473. IMAGING: Chest x-ray on admission showed no acute cardiopulmonary process, left middle lobe atelectasis unchanged from prior examination. HOSPITAL COURSE: On arrival in the Emergency Department the patient was seen by the Cardiothoracic Surgery team. Antibiotic treatment was initiated in the Emergency Department with the patient receiving a dose of Ancef. Following transfer to the floor the patient's antibiotic regimen was changed to Vancomycin and Levaquin. The decision was made to incise and drain the patient's sternal wound in the Emergency Department. This was done with expression of moderate amount of brownish purulent material. The wound was thereafter packed with gauze. The patient was transferred to the Cardiothoracic Surgery floor for continued management. On hospital day number two the wound was further explored with pocket of purulent material drained. Antibiotic therapy remained unchanged. On hospital day number three, which was [2200-10-21] the decision was made to place a PICC line given the fact that the patient would need long term antibiotic therapy following discharge. Plastic Surgery consultation was also requested. A decision was ultimately made to take the patient to the Operating Room for sternal debridement and rewiring of her sternum, which was noted to be separated. This was documented on CAT scan with air being noted deep to the sternum. The plastic surgery team would be involved and would perform a pectoral flap. The patient was taken to the Operating Room on [2200-10-24] and the patient's sternum debrided, rewired and pectoral flap constructed. The patient was extubated without complications and transferred to the Cardiac Surgery Recovery Unit for continued monitoring. Please note that although the patient preoperative urinalysis was negative, the patient's urine culture ultimately grew Vancomycin resistant enterococcus. Cultures from her sternal wound ultimately grew MRSA. The patient was transferred back to the Cardiothoracic Surgery Floor on postoperative day number one. She had an uncomplicated recovery. Her sternal wound was inspected daily and was noted to be improving by the time of discharge. She was continued on Vancomycin and Levaquin. Her white blood cell count was monitored and noted to be decreasing by the time of discharge. The drainage from her two [First Name8 (NamePattern2) 1661] [Last Name (NamePattern1) 1662] drains was also monitored. The JP drains are expected to remain in place until the patient's follow up appointment with the Plastic Surgery team on the week following discharge. The patient's appetite remained good during her entire admission. By postop day number five the patient was deemed stable and ready for discharge to a skilled nursing facility. The patient is expected to require several weeks of intravenous antibiotic therapy following discharge. No treatment was initiated specifically for the VRE noted to be growing in the patient's urine given the fact that the patient was entirely asymptomatic. It was suspected that the organisms might have been a contaminant. The patient's serum creatinine remained stable during the entire admission. The patient's hypertension was noted to be poorly controlled early during her admission. She was at that time only on Metoprolol. The decision was made to add Labetalol to the patient's hypertensive medication regimen. The Metoprolol was later discontinued and the Labetalol dose was increased with apparent good control of her blood pressure. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: Labetalol 600 mg po b.i.d., Colace 100 mg po b.i.d., Vancomycin 750 mg intravenous q 24 hours. Heparin 5000 units subQ b.i.d. Prevacid 30 mg po q day. Enteric coated aspirin 325 mg po q day. Folic acid 1 mg po q day. Levofloxacin 500 mg po q day. Imipramine 25 mg po q.h.s. 11. Senna two tablets po b.i.d. prn. Percocet one to two tablets po q to 6 hours prn. Ativan .25 to .5 mg po q 4 to 6 hours prn. Simethicone 40 to 80 mg po q.i.d. prn. Trazodone 100 mg po q.h.s. Milk of Magnesia 7 milliliters po q 6 hours prn. FO[Last Name (STitle) 996]P: 1. The patient is to call Dr. [Last Name (STitle) ] [Last Name (Prefixes) 2546] office for follow up appointment following discharge. 2. The patient is to follow up with Plastic Surgery team in clinic on [2200-11-4]. She needs to call [Telephone/Fax (1) 274] for an appointment. 3. The patient is to follow up with her primary care physician [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] following discharge. DISCHARGE DIAGNOSIS: Sternal wound infection following coronary artery bypass graft. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Name8 (MD) 997] MEDQUIST36 D: [2200-10-30] 11:31 T: [2200-10-30] 11:35 JOB#: [Job Number 10100]	[ "5180", "5990", "4019" ]
Admission Date: [2131-5-23] Discharge Date: [2131-6-28] Date of Birth: [2064-7-16] Sex: M Service: MEDICINE Allergies: Levofloxacin / Cefazolin / Coreg / Dopamine Attending:[First Name3 (LF) 1881] Chief Complaint: foot infection, sepsis Major Surgical or Invasive Procedure: L toe ulcer debridement thoracentesis History of Present Illness: Mr. [Known firstname ] is a 66 y/o male patient of Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) ] with diabetes c/b peripheral neuropathy, ulcers, and amputation, a history of a pro-coaguable disorder requiring chronic prophylaxis with enoxaparin and a neuropathic heel ulcer presents with a week of fever, malaise, nausea/vomiting, and change in mental status. According to the family the patient was in his usual state of health until one week PTA, when he had an episode of emesis. The following day he went to [Hospital3 ] but again had nausea and emesis. Two nights PTA the patient began to have worsening of his great toe ulcer with redness and drainage. In addition he developed a low grade temperature and increase malaise. In the emergency room he was given ceftazidime and vancomycin. A code sepsis was called and a central line was placed. Dopamine was started for pressure support. The patient was sent to the ICU for further management. Upon arrival to the floor the patient was slightly lethargic but alert & oriented x 3. An arterial line was placed, and the patient was noted to have monomorphic ventricular tachycardia on an EKG, during which the patient dropped his blood pressures. He was changed from dopamine to neosynephrine and an EP consult was obtained. The patient received a total of 1250cc of NS. Once on neosynephrine his ventricular tachycardia resolved. Vascular surgery came to evaluate the patient and incised his toe wound. They isolated three pockets of pus and cultures were sent. Past Medical History: DMII CAD, ischemic cardiomyopathy EF 20% Afib s/p ablation, pacemaker SMA thrombosis with small bowel and large bowel infarcts status post small bowel and large bowel resection and resulting short gut syndrome Bacterial peritonitis PVD s/p R BKA Hypercoagulable state, DVTs Peripheral neuropathy Plantar fasciitis CVA PV Nonhealing anal fissure Social History: Mr. [Known lastname 21212] is a retired systems programmer for a management consulting firm. He is married with no children. He denies alcohol, tobacco or drug use. Prior 3 yrs of tobb abuse. Family History: Family history is negative for hypercoagulable state, PVD Physical Exam: PE: HR 75, ABP 102/61, O2 97% Gen: Lying in bed in mild distress. HEENT: NCAT, MMM. RIJ in place. CV: RRR Chest: CTA bilaterally on anterior exam other than slight crackles at right lower base. Abd: Scaphoid, benign. Ext: Patient with BKA on left foot. Right toe is ulcerated and erythematous with streaking cellulitis 2/3 up shin to knee. Neuro: Complaining, arousable, A&O x 3. Pertinent Results: [2131-5-23] 08:33AM BLOOD WBC-18.6* RBC-5.43# Hgb-14.6# Hct-44.5# MCV-82# MCH-26.9# MCHC-32.8 RDW-20.2 Plt Ct-287 [2131-5-23] 08:33AM BLOOD Neuts-91.7* Bands-0 Lymphs-5.7* Monos-1.8* Eos-0.6 Baso-0.2 [2131-5-23] 02:34PM BLOOD WBC-24.1* RBC-5.68 Hgb-15.5 Hct-47.1 MCV-83 MCH-27.4 MCHC-33.0 RDW-20.3* Plt Ct-350 [2131-5-24] 04:13AM BLOOD WBC-20.1* RBC-5.05 Hgb-14.0 Hct-41.2 MCV-82 MCH-27.7 MCHC-33.9 RDW-20.6* Plt Ct-384 [2131-5-25] 04:36AM BLOOD WBC-14.6* RBC-4.76 Hgb-12.6* Hct-39.0* MCV-82 MCH-26.6* MCHC-32.4 RDW-20.5* Plt Ct-335 [2131-5-24] 04:13AM BLOOD PT-21.8* PTT-39.1* INR(PT)-2.1* [2131-5-25] 04:36AM BLOOD PT-18.2* PTT-78.8* INR(PT)-1.7* [2131-5-25] 11:15AM BLOOD PT-17.6* PTT-44.1* INR(PT)-1.6* [2131-5-23] 08:40AM BLOOD Glucose-222* UreaN-60* Creat-1.8* Na-133 K-4.5 Cl-103 HCO3-15* AnGap-20 [2131-5-23] 02:34PM BLOOD Glucose-149* UreaN-60* Creat-1.9* Na-133 K-4.3 Cl-101 HCO3-17* AnGap-19 [2131-5-25] 04:36AM BLOOD Glucose-118* UreaN-47* Creat-1.7* Na-136 K-4.4 Cl-111* HCO3-15* AnGap-14 [2131-5-23] 08:40AM BLOOD ALT-25 AST-18 LD(LDH)-423* CK(CPK)-116 AlkPhos-84 TotBili-0.9 [2131-5-24] 04:13AM BLOOD ALT-22 AST-13 LD(LDH)-335* AlkPhos-76 TotBili-0.6 [2131-5-23] 08:40AM BLOOD CK-MB-6 cTropnT-0.07* proBNP-[Numeric Identifier 23738]* [2131-5-23] 08:40AM BLOOD Lipase-27 [2131-5-23] 08:40AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.6 [2131-5-23] 02:34PM BLOOD Calcium-8.1* Phos-3.8 Mg-1.8 [2131-5-24] 04:13AM BLOOD Albumin-3.4 Calcium-7.9* Phos-5.3* Mg-2.9* [2131-5-23] 08:40AM BLOOD Cortsol-29.9* [2131-5-23] 08:40AM BLOOD CRP-85.4* [2131-5-24] 03:58PM BLOOD Vanco-19.2 [2131-5-23] 02:34PM BLOOD Digoxin-0.8* [2131-5-23] 03:02PM BLOOD Type-ART Temp-35.7 Rates-/14 O2 Flow-6 pO2-84* pCO2-35 pH-7.26* calTCO2-16* Base XS--10 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] [2131-5-24] 04:29PM BLOOD Lactate-1.4 [2131-5-23] 03:02PM BLOOD Lactate-0.9 [2131-5-23] 08:49AM BLOOD Lactate-1.6 FOOT 2 VIEWS LEFT [2131-5-23] 8:51 AM FINDINGS: Bedside AP and lateral views (the former, degraded by motion- blurring) are compared with the study dated [2130-11-28]. There is now a small soft tissue defect at the tibial (medial) aspect of the plantar soft tissues, overlying the base of the 1st distal phalanx. However, this does not appear to reach bone on either view, with no subjacent subcutaneous emphysema or retained radiopaque foreign body. There is no evidence of periosteal reaction, cortical erosion or medullary lucency in subjacent bone to specifically suggest osteomyelitis, and the appearance of the remainder of the foot is unchanged, including vascular calcification and prominent dorsal calcaneal enthesophyte. IMPRESSION: Known ulcer in the plantar soft tissues of the 1st digit does not reach bone, with no radiographic sign of osteomyelitis. . CHEST (PORTABLE AP) [2131-5-23] 8:51 AM SINGLE PORTABLE SEMI-UPRIGHT VIEW OF THE CHEST: A dual-lead pacing device remains in unchanged position. Moderate cardiomegaly, reaccumulation of an asymmetric large right pleural effusion, and associated right perihilar hazy opacity are suggestive of asymmetric pulmonary edema, and represent decompensated mitral valve regurgitation. The left lung is relatively clear. No discrete focal airspace consolidation is identified. The bony thorax again demonstrates an S-shaped scoliosis of the thoracic spine. IMPRESSION: Asymmetric right-sided largely parahilar airspace disease and re- accumulated large pleural effusion, as on previous episodes. This may represent "atypcial" edema related to decompensation of known mitral regurgitation; alternatively, a pneumonic process cannot be completely excluded. CHEST (PORTABLE AP) [2131-5-24] 3:36 AM Allowing the difference in position of the patient, large right pleural effusion. There has been interval increase in moderate left pleural effusion. Mild asymmetric pulmonary edema, greater on the right side, is stable. Right IJ catheter tip is in the upper to mid SVC. Cardiomegaly is unchanged. Left transvenous pacemaker leads remain in standard positions. CHEST (PORTABLE AP) [2131-5-25] 3:36 AM In the interim, there is severe worsening of a right extensive pleural effusion with adjacent atelectasis and airspace disease in the collapsed right lung. There is also worsening of perihilar airspace disease in the left lung. Small left pleural effusion is also new. The heart size is mild-to-moderately enlarged, but stable. The left-sided subclavian pacemaker leads are stable. IMPRESSION: 1. Severe worsening of right pleural effusion with almost collapse of the right lung. 2. Bilateral airspace disease in both lungs, worsening on the left lung, likely edema. 3. Mild-to-moderate cardiomegaly. Brief Hospital Course: 66 y/o male with diabetes, cardiomyopathy, foot ulcer presenting with toe infection, septic physiology, and ventricular tachycardia. Hospital course by problem: # Sepsis/Toe Wound: Patient's exam was consistent with infected L 1st toe ulcer and leg cellulitis and he was hypotensive. He was admitted to the medical intensive care unit, and was started on a neosynephrine drip which was weaned [5-24] and he was started on vancomycin and zosyn. Vascular surgery and podiatry evaluated him and debrided the ulcers. Surgery initially thought he might need an amputation, but he clinically improved and this was deferred in favor of [Hospital1 ] WTD dressing changes. He was soon transferred to the floor. His blood grew proteus mirabilis (pan-sensitive) and streptococcus (penicillin-sensitive but clindamycin and erythromycin-resistant). Zosyn was changed to unasyn, but the patient clinically worsened and with concern for an undetected element of the likely polymicrobial sepsis which started his course, unasyn was discontinued and zosyn restarted. Of note, no pseudomonas grew out at any time in his wound or blood cultures. Gram-positive cocci and more Proteus grew out of a wound culture as vascular surgery continued to follow, drain abscesses and debride tissue. The GPCs ultimately proved to be pan-sensitive MSSA, and once this sensitivity was available, vancomycin was discontinued. Eventually, zosyn was discontinued and unasyn was restarted, with no ill effects. Flagyl was added for C. diff protection although he did not grow out C. diff--see below. In terms of ongoing management, on the initial evaluation the wound had probed to bone in the earliest portion of this hospital course. There was some concern, particularly from the infectious disease service (which had been consulted, and which had followed the patient in the past for recurrent C. diff) that he would not be able to endure a six-week course of antibiotics because of his short gut, past history of recurrent C. diff, and that an operation might be superior. In consultation with the surgeons and the primary care physician (who also served as the hospital attending), and after the primary care physician had [Name9 (PRE) 103662] discussion with the patient of risks and benefits of non-operative management, amputation was deferred in favor of medical management. Given his high risk of recurrent C. diff and his short gut, and the potentially dire consequences for this patient of not being able to tolerate a long course of antibiotics, and in consultation with the infectious disease service, we took the unusual step of treating C. diff empirically despite negative toxins. The total course of antibiotics will be six weeks, with day 1 of effective antibiosis = [5-29]. Therefore last doses should be on [7-10]. Weekly labs should be sent to the infectious disease clinic; follow-up lab instructions are in the outpatient orders (med list) of this discharge summary. Flagyl should be continued through this time, and then for seven days after (until [7-17]). In detail, starting dates were: Zosyn and vanco: [5-23] (on admission) Zosyn replaced with unasyn: [5-26] Flagyl: [5-26] (pt has had recurrent C diff as above) Unasyn stopped and replaced again with Zosyn: [5-27] Vancomycin stopped [6-3] Zosyn stopped and replaced with Unasyn: [6-3] Ending dates for Unasyn and Flagyl: [7-10] and [7-17] respectively, as above. Podiary has said that he is full weight-bearing. # Chronic systolic heart failure and cardiomyopathy: In the MICU, the patient had an increased O2 requirement, 93% on 6L NC O2, with large R sided pleural effusion. He had an US-guided thoracentesis on [5-25] (therapeutic and diagnostic) which revealed a transudative sterile fluid which carried signs of neither infection nor malignancy. He has a lasix requirement at home and ultimately as sepsis and hypotension resolved, he was started back on lasix, first prn, and then 40 [Hospital1 ] (his home dose); on [6-9] this was changed to 60 [Hospital1 ]. He had several incidents in which he more acutely desaturated, each of which was solved by extra doses of lasix. He did continue to have an oxygen requirement, associated with what appeared to be his fluid status, but was stable. We would expect with increasing activity he might be able to mobilize more of this fluid; however, reconsideration of his diuretic dose might be necessary if he is not able to decrease and then wean his oxygen requirement. At home prior to this admission he has been on digoxin and lisinopril. In light of his continuing renal insufficiency these were not restarted though the lisinopril in particular should be given consideration for restarting at the earliest opportunity. Earlier in admission transudative effusion c/w heart failure when tapped, with large drainage. Pain control was adquate with Oxycontin, Oxycodone, and Dilauidid for breakthrough pain. # Ventricular Tachycardia: Early in the admission, the patient had one episode of asymptomatic VT that developed in the setting of dopamine and low Mg, and in the setting of the immediate post-sepsis period. This resolved with no further episodes while on the floor, until [6-11], when he had a series of runs of NSVT in the morning. He was asymptomatic with these events. The electrophysiology service was consulted. He does not have an ICD in place but given that he is being treated for infection, EP felt it would be better to keep him on telemetry but defer ICD placement if indicated. In the meantime, the EP service recommended putting him on amiodarone, on the schedule listed below in the medication orders. A follow-up appointment with a nurse practitioner in [Name (NI) 103663] office was made (shown below); additionally the patient should have direct follow-up with Dr. [Last Name (STitle) ] arranged within the next 2-6 weeks. The amiodrone has been tapered down to 200mg PO daily, and after one week without active issue the patient was removed off telemetry. # Renal Failure: Acute on Chronic. Acute from CHF hypoperfusion and contrast interaction and chronic from diabetes. Early in the admission, Mr [Known lastname 21212] had elevated creatinine as far up as 1.9 on [5-24] in the context of his early sepsis and MICU stay, which had trended down. It declined to 1.3 and 1.4 in early [Month (only) ], but after an angiographic study gave him a large contrast load, it went back up to the 1.7-2.0 range peaking at 2.1 on [6-7]. This was wavering in the period of [5-26] with an uncertain direction. This should be followed in the rehabilitation setting. Although it likely had the effect of raising the Cr, we continued to give lasix, feeling that it was likely best to support renal perfusion, and because it was necessary for respiratory function. He has been tolerating a high dose of lasix, 120mg [Hospital1 ], and sometimes still requires an additional 60mg IV to maintain negative fluid balance. The patient has not had any signs of ototoxicity. On [6-25] mg of po HCTZ was added to his diuretic regimen, and was given [Hospital1 ], 30 minutes prior to furosemide administration. Following this change, LUE edema decreased significantly. On [6-27], HCTZ was decreased to once daily. HCTZ was discontinued upon hospital discharge. # Diabetes: Maintained patient on insulin sliding scale; his NPH was restarted and was titrated up as the patient's PO intake increased and his scale requirements increased. # Hypercoagulability: The patient has had disastrous sequelae of clotting in the past including ischemic bowel and resulting short gut, and stroke; thus anticoagulation was scrupulously maintained. The patient was kept on a heparin sliding scale for much of the admission in order to preserve operative options while also continuing anticoagulation which is provided by lovenox as an outpatient. On [6-11], with anticipation of discharge and no further operations planned, [Hospital1 ] Lovenox was started. Factor Xa level was drawn in the pm of [6-12] after the third dose of lovenox was given, and found to be 0.43 U/mL. It was rechecked [6-16] and [6-23], and found to be 0.71 and 0.80 U/mL respectively. # Depression: citalopram was continued. Mr [Known lastname 21212] had various periods of frustration with his care. He likely also has some element of depression and perhaps small cognitive losses from past stroke. Given the very real stressors of his hospitalization here, including the ongoing possibility that he might lose his foot and his mobility, it was assumed that some portion of his mood was reactive, management was not changed. As his medical situation stabilizes and improves, if his mood does not improve simultaneously, he may benefit from revisiting his treatment for depression. # Leukocytosis- most likely secondary to a myeloproliferative disorder, previously characterized as polycythemia [Doctor First Name ]. # Neuropathy: The patient was maintained on oxycontin, neurontin, and vicodin. # PPX: The patient was given heparin for thrombosis prophylaxis which was converted to LMWH as above, as well as a PPI per home regimen. Medications on Admission: Hydrocodone/Acetaminophen 5/235 Captopril 25 Furosemide 20 Fosamax 70 Digoxin 250mcg Oxycontin 10 [Hospital1 ] Neurontin 800 Folic Acid 1mg Ranitidine 150 tab Toprol Xl 25 Daily Loperamide 2mg Q6PRN Lovenox 60mg Daily Citalopram 40 daily Discharge Medications: 1. Outpatient Lab Work Laboratory monitoring required; frequency: weekly. Draw: Creat, BUN, Alt, Ast, WBC, Hct/Hgb All laboratory results should be faxed to Infectious disease R.Ns. at ([Telephone/Fax (1) 6313]. All questions regarding outpatient or rehabilitation antibiotics should be directed to the infectious disease R.Ns. at ([Telephone/Fax (1) 14199] 2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day for 7 days: To be given [6-11] through [6-18]; then followed by 200 mg [Hospital1 ] for one week thereafter; and then 200 mg daily after that. Follow up closely with Dr[Name (NI) 7914] office. 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 7. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 8. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [12-27] Drops Ophthalmic PRN (as needed). 13. Psyllium 1.7 g Wafer Sig: [12-27] Wafers PO BID (2 times a day). 14. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 15. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection Subcutaneous [Hospital1 ] (2 times a day). 16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 17. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. . 18. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea. 19. Hydromorphone 2 mg/mL Solution Sig: 0.5-2 mg Injection Q3H (every 3 hours) as needed: for breakthrough pain. hold for sedation or RR <12. 20. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 21. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours): until [7-17]. 22. Ampicillin-Sulbactam 3 gram Recon Soln Sig: Three (3) grams Injection Q8H (every 8 hours) for 14 days: Give through [7-10]. Disp:42 doses Refills:0 23. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1) injection Subcutaneous qAM: gradually increasing dose; likely to need further increases as PO intake increases; currently at 20 mg in AM. 24. Humalog 100 unit/mL Solution Sig: One (1) injection Subcutaneous qACHS: before breakfast, lunch and dinner, and at bedtime (4 x /day). Use scale: If <60, crackers and juice or [12-27] amp D50. 60-160 mg/dL 0 Units 161-200: 2 Units. 201-240: 4Units. 241-280: 6 Units. 281-320 8 Units. 321-360 10 Units. 361-400 12 Units. 25. oxygen 2L continuous via nasal cannula pulse dose for portability. 26. semi-electric bed with rails, equipped for patient's height and weight 27. PICC line care per NEHT protocol, saline and heparin flushes Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: PRIMARY: OSTEOMYELITIS CONGESTIVE HEART FAILURE 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: 1500 mL fluid per day Followup Instructions: Provider: [Last Name (NamePattern4) ]. [First Name (STitle) ] [Doctor Last Name 9406] Phone:[Telephone/Fax (1) 457] Date/Time:[2131-7-5] 11:00 Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2131-7-11] 2:30 Provider: [Name10 (NameIs) 251] [Name Initial (NameIs) ] [Last Name (NamePattern4) ], CARDIOLOGY Phone:[Telephone/Fax (1) 62] Date/Time: [2131-7-11] 3:00 Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) 1111] Phone:[Telephone/Fax (1) 3121] Date/Time:[2131-9-2] 2:00 Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 250] Call to schedule appointment [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1882] MD, [MD Number(3) 1883] Completed by:[2131-7-27]	[ "0389", "5849", "78552", "5119", "4280" ]
Admission Date: [2110-4-2] Discharge Date: [2110-4-4] Date of Birth: [2030-7-23] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2901] Chief Complaint: elective carotid stent Major Surgical or Invasive Procedure: carotid stents History of Present Illness: Mr. [Known lastname 95068] is a 79 year-old man with a history of a TIA about 3-4 years ago. On [2110-3-8], he was sitting at the breakfast table when he an acute onset of decreased vision and blurriness in the right eye. He was found to have approximately 75% stenosis of his right carotid artery. He denies any slurred speech or right sided weakness. There was no change in vision in the left eye. A Carotid U/S on [2109-7-23] showed diffuse right ICA isoechoic wall thickening associated with a 60-69% ICA stenosis. Similar plaque on the left, but to a lesser extent and unassociated with any significant stenosis. [2109-7-26] Echo: [Name Prefix (Prefixes) ] [Last Name (Prefixes) 3841] dilated. LV wall thickness, cavity size, and systolic function normal (LVEF >55%). [2110-3-14] Head/Brain/Carotid MRI/MRA: High grade stenosis involving the right internal carotid artery just superior to the common carotid bifurcation. (+) HTN (+) hyperlipidemia (-) DM (-) cigarette smoking Mf. denies claudication, PND, orthopnea, edema. He reports occasional lightheadedness when he gets up too quickly. ROS: (+) TIA (-) CVA (-) melana/GIB Past Medical History: prostate ca right upper lobectomy for Stage I adencarcinoma of the lung [2109-8-5] right central retinal artery occlusion carotid artery disease left fem-[Doctor Last Name ] bypass [2096] - per pt, no info found CCC gallstones TIA 3-4 years ago that lasted 20 seconds (slurred speech) Social History: He has been married 52 years. Family History: (-) FHx CAD Physical Exam: T 97.6, HR 49 BP 111/51 98% on RA, I/O 3800/1800 Gen: sleeping but pleasant and cooperative when awake HEENT: MMM CN II-XII individually tested and intact except CN II on the right which is chronic Cor: RRR no M/R/G Pulm: CTAB anteriorly Abd: obese, soft NT ND Ext: WWP, right groin with dressings C/D/I no hematoma or bruit, DP 1+ bilaterally Pertinent Results: [2110-4-4] 05:35AM BLOOD WBC-5.2 RBC-3.93* Hgb-11.6* Hct-33.7* MCV-86 MCH-29.5 MCHC-34.4 RDW-13.8 Plt Ct-192 [2110-4-4] 05:35AM BLOOD PT-13.4 PTT-25.6 INR(PT)-1.1 [2110-4-4] 05:35AM BLOOD Glucose-96 UreaN-19 Creat-1.2 Na-139 K-4.0 Cl-107 HCO3-27 AnGap-9 [2110-4-3] 02:03AM BLOOD CK(CPK)-61 [2110-4-4] 05:35AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.7 COMMENTS: 1. Retrograde access was obtained via the right common femoral artery for selective angiography of the subclavian, vertebral, and carotid arteries. 2. Limited resting hemodynamics revealed central hypertension with opening blood pressures of 180/74 mmHg. 3. Angiography demonstrated a type 1 aortic arch. Subclavian arteries were without angiographically significant, flow-limiting disease or gradient. The right common carotid artery was without flow limiting disease. The right internal carotid artery had an eccentric 90% lesion and filled the ACA and MCA. The right vertebral artery was small and totally occluded at the level of the basilar artery. The left common carotid arteyr and internal carotid artery were without flow-limiting disease. The left vertebral was without significant disease and filled the cerebellar circulation. 4. Successful placement of [6-25] x 40 mm AccuLink stent postdilated with a 4.5 mm balloon in the right internal carotid artery (ICA) using AccuNet filter distal embolic protection. Final angiography demonstrated a 20% residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). 5. Successful placement of 6 French Angioseal device in right femoral arteriotomy without complications. FINAL DIAGNOSIS: 1. Severe right internal carotid artery stenosis. 2. Successful placement of stent in right internal carotid artery. 3. Successful use of filter embolic protection device. 4. Central hypertension. 5. Successful placement of Angioseal in right femoral arteriotomy. Brief Hospital Course: Mr. [Known lastname 95068] is a 79 year-old man with a h/o TIA, recent right eye vision loss, high grade stenosis of the right ICA, referred for carotid revascularization. The carotid stents were placed without complication. The patient's blood pressures were extremely labile overnight, requiring both pressor support and intermittently labetolol drip. As much as possible, his SBP was kept from 100-140. He was also continued on plavix and aspirin. His neosynephrine was weaned after one day and his blood pressure remained normotensive with fewer swings. He was restarted on home medications except for antihypertensives. Mr. [Known lastname 95068] was discharged on day 2 with strict instructions to return to the cath holding area for a blood pressure check and lab draw. Medications on Admission: Isordil 5mg TID Lipitor 20mg daily ASA 325mg daily Plavix 75mg daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: carotid stenosis Discharge Condition: stable Discharge Instructions: Please take aspirin and plavix. Call your doctor for head ache, changes in vision, drooping face, loss of sensation, weakness, or if there are any concerns at all. Come back to the cath lab holding area on Monday for a blood pressure check and to have labs drawn. Followup Instructions: Provider: [Name10 (NameIs) ] THORACIC MULTI SPEC-CC9 MULTI-SPECIALTY THORACIC UNIT-CC9 Where: CLINICAL CTR. - 9TH FL. MULTI Date/Time:[2110-4-17] 2:45 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2695], MD Where: [Hospital6 29] HEMATOLOGY/ONCOLOGY Phone:[Telephone/Fax (1) 22] Date/Time:[2110-9-18] 10:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908], MD Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 920] Date/Time:[2111-2-16] 2:15 Please call [Last Name (LF) ],[First Name3 (LF) ] L [Telephone/Fax (1) 82541] for an appointment in the next 2 weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909]	[ "42789", "4019", "2720" ]
Admission Date: [2167-11-16] Discharge Date: [2167-11-17] Date of Birth: [2097-9-6] Sex: M Service: VASCULAR DATE OF EXPIRATION: [2167-11-17]. HISTORY OF PRESENT ILLNESS: The patient is an unfortunate 70 year old gentleman with a past medical history that is significant for a coronary artery bypass graft times three that was done in [2167-2-28] here at [Hospital1 190]. He had a history of a right carotid endarterectomy done in [2156] and a history of mitral valve regurgitation and atrial fibrillation that was cardioverted in [2165], and the patient was taking Amiodarone. He also had a history of gout and hypertension. He was found to have an abdominal aortic aneurysm and most recently he underwent an abdominal CT scan for surveillance and it revealed that his abdominal aortic aneurysm had increased ins size to 5 cm. He was evaluated in the office on the Vascular Service and he was found to be not an adequate candidate for a usual stent graft repair of this aneurysm. He was offered an open elective repair for which the patient agreed. He was scheduled to have this operation electively on [2167-11-16]. He had a cardiac and medical clearance by his primary care physician as well as his Cardiologist and he was deemed to be in good condition to undergo this operation. On [2167-11-16], the patient was taken to the Operating Room and underwent an open abdominal aortic aneurysm repair with an aorta [Hospital1 ]-iliac Dacron graft. The operation was complicated with a lower pole splenic tear that was tried to be repaired primarily and which ultimately required a splenectomy for persistent bleeding. In the Operating Room he received 11 liters of crystalloid and made only 150 cc of urine and there was an estimated blood loss of 4.5 liters. He received a total of four units of packed red blood cells and [Pager number ] cc of Cellsaver. He was transferred to the Recovery Room where he persistent aneuric and acidotic requiring pressors and fluid in order to maintain his hemodynamics. Ultimately, he was transferred to the Surgery Intensive Care Unit on the sixth floor to continue his monitoring by the surgical house staff as well as the attending. Once in the Intensive Care Unit, his acidosis worsened and despite aggressive intravenous fluid resuscitation and pressor medications, the patient remained hypotensive. An emergent Cardiology consultation and a transthoracic echocardiogram was obtained but unfortunately at that time, this study revealed poor windows and there was no obvious or acute evidence of hypokinesis nor pericardial effusion. Despite these results, because once again due to poor windows and due to the body habitus of this patient, a transesophageal echocardiogram was recommended and obtained. This study revealed marked left ventricular hypokinesis as well as an akinetic septum with severe left ventricular function depression. There was a very poor ejection fraction despite the pressor medications. Renal was consulted as well because the patient was anuric for many hours and he had a worsening acidosis. The recommendation for the nephrologist was to start him on a Dopamine drip, trying to improve perfusion to his kidneys. In spite of all the above mentioned measures, the patient remained hypotensive and his hematocrit drifted down, becoming progressively more distended in the abdominal region. At that time, upon discussion with Dr. [Last Name (STitle) ], the attending of record, the decision was made to take him back to the Operating Room for a re-exploration. Upon taking him back to the Operating Room, approximately [2163] cc of blood and clot were found in the left upper quadrant but upon evacuating this hematoma, there was no obvious source of bleeding identified. The patient was closed loosely with a rubber [Doctor Last Name ] and a big Ioban and it was elected to leave the abdomen open with two medium sized [Location (un) 1661]-[Location (un) 1662] drains on the lateral aspect. Once again, the patient was transferred to the Intensive Care Unit on multiple pressors including Levophed, Neo-synephrine, vasopressin, dopamine and intravenous fluids running at 200 cc an hour. Within the next couple of hours, the acidosis persisted and the patient continued to bleed extensively from his [Location (un) 1661]-[Location (un) 1662] drains. A new set of coagulation studies was sent and the INR at this point was found to be 11.0 with a PTT in the mid 100s and an elevated PT. The fibrinogen was low and further repletion with fresh frozen plasma, Cryo, and more units of packed red blood cells were also started and initiated. The case was discussed again with the attending of record and upon consultation with the Surgical attendings on the vascular service. It was decided to continue to fully support him and try to correct his coagulopathy before trying to explore him again in the Operating Room as he was very unstable to be transferred anywhere. The patient's abdomen progressively became more distended and a Foley catheter pressure was transduced and came back high on 33 mm of water. Because he was markedly unstable to be moved to the Operating Room, the decision was made to open his abdomen in the Intensive Care Unit for which purpose an abdominal kit and a bulb electrocardia as well as pulse suction and multiple canisters were brought to the Intensive Care Unit to do the abdominal wound exploration. At this point, the patient had received 26 units of packed red blood cells, 14 units of fresh frozen plasma, 6 units of platelets, one unit of cryo, 5 gram load of Amicar as well as a continuous rip and a Factor VII that included 4800 micrograms infused. Upon opening the abdomen, we found about 3000 cc of half clotted blood that was evacuated with a bulb sucker. Once again, no obvious source of bleeding was found nor identified. The aorta repair appeared to be intact with no clot extravasation. The bowel was noted to be diffusely edematous with multiple patches of ischemia all along its length. There was a feculent smell in the abdomen with no obvious bowel perforation identified. Upon packing all four quadrants, the abdomen was closed again with a rubber [Doctor Last Name ] and an Ioban and two medium sized [Location (un) 1661]-[Location (un) 1662] drains were left on the lateral aspect of the wound. At his point, the patient was still on Levophed, epinephrine, dopamine and pitressin to keep his systolic blood pressure barely above 90s. He remained anuric and his acidosis progressively worsened despite bicarbonate infusions. The patient's family was aware of the patient's condition and upon their request, they were allowed to enter the Intensive Care Unit room to see the patient. Despite full support, the patient expired and was pronounced at 12:14 p.m. [2167-11-17]. The family was present as well as a catholic priest and the Surgery Intensive Care Unit staff. Medical examiner was notified and he declined the case. The family was offered a post mortem examination which was accepted. We will arrange for this to happen in our Pathology Department. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) ], M.D. [MD Number(1) 19472] Dictated By: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. MEDQUIST36 D: [2167-11-17] 14:23 T: [2167-11-17] 14:56 JOB#: [Job Number 106555]	[ "5849" ]
Admission Date: [2140-5-20] Discharge Date: [2140-5-25] Date of Birth: [2100-4-8] Sex: M Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 11415] Chief Complaint: cyclist struck Major Surgical or Invasive Procedure: [2140-5-20]: ORIF Left tibia, ORIF left hip, I&D right elbow laceration, I&D left shoulder laceration. History of Present Illness: Mr. [Known lastname 78400] is a 40 year old man who was a cyclist struck. He was taken to the [Hospital1 18] for further evaluation and care. Past Medical History: denies Social History: Lives with wife [Name (NI) 1403] as a computer programmer Very active Family History: n/a Physical Exam: Upon admission Alert and oriented Cardiac: Regular rate rhythm Chest: Lungs clear, intubated for airway protection Abdomen: Soft non-tender non-distended Extremities: LLE Angulated L ankle with obvious fx, shortned externall rotated, + sensation/moevement. R elbow large laceration, + pulses/sensation. Pertinent Results: [2140-5-25] 04:55AM BLOOD WBC-5.6 RBC-3.60* Hgb-10.3* Hct-30.2* MCV-84 MCH-28.5 MCHC-34.0 RDW-14.4 Plt Ct-208 [2140-5-24] 04:35AM BLOOD Hct-24.4* [2140-5-23] 06:25AM BLOOD WBC-6.9 RBC-3.07* Hgb-9.0* Hct-25.4* MCV-83 MCH-29.3 MCHC-35.3* RDW-13.0 Plt Ct-140* [2140-5-22] 02:20AM BLOOD WBC-8.8 RBC-3.40* Hgb-10.1* Hct-28.4* MCV-83 MCH-29.6 MCHC-35.4* RDW-13.2 Plt Ct-138* [2140-5-21] 03:19PM BLOOD Hct-29.3* [2140-5-21] 03:39AM BLOOD WBC-8.0# RBC-3.67# Hgb-10.7# Hct-30.3# MCV-83 MCH-29.2 MCHC-35.3 RDW-13.5 Plt Ct-129* [2140-5-20] 10:38PM BLOOD WBC-17.5* RBC-5.00 Hgb-14.5 Hct-42.0 MCV-84 MCH-28.9 MCHC-34.5 RDW-13.5 Plt Ct-216 [2140-5-23] 06:25AM BLOOD PT-13.3 PTT-33.1 INR(PT)-1.1 [2140-5-20] 07:41PM BLOOD PT-13.2 PTT-23.1 INR(PT)-1.1 [2140-5-25] 04:55AM BLOOD Glucose-95 UreaN-12 Creat-0.9 Na-139 K-3.8 Cl-106 HCO3-26 AnGap-11 Brief Hospital Course: Mr. [Known lastname 78400] is a 40 year old man who was a cyclist struck. He was taken to the [Hospital1 18] emergency department and evaluated by the orthopaedic and trauma surgery departments. He was found to have a left tibia and hip fracture. He was also found to have a left shoulder laceration and right elbow laceration. He intubated, admitted to the ICU for further monitoring. He was later taken to the operating room and underwent and I&D of both lacerations and ORIF of his hip and tibia. He tolerated the procedures well and was transferred back to the ICU. On [2140-5-21] he was extubated without difficulty. On [2140-5-22] he was transferred to the floor under the care of the orthopaedics. He was seen by physical therapy to improve his strength and mobility. On [2140-5-24] he was transfused with 2 units of packed red blood cells due to acute blood loss anemia. The rest of his hospital stay was uneventful with his lab data and vital signs within normal limits and his pain controlled. He is being discharged today in stable condition. Medications on Admission: denies Discharge Medications: 1. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a day for 1 weeks. Disp:21 Capsule(s) Refills:0 2. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) 40mg syringe Subcutaneous Q 24H (Every 24 Hours) for 4 weeks. Disp:28 40mg syringe Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:90 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: s/p cyclist struck Left tibia fracture Left intertrochanteric fracture Right elbow laceration Left shoulder laceration Acute blood loss anemia Discharge Condition: Stable Discharge Instructions: Continue to be weight bearing as tolerated on your left leg Continue to take your medications as prescribed by your doctor If you notice 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. Physical Therapy: Activity: Ambulate Right lower extremity: Full weight bearing Left lower extremity: Full weight bearing Right upper extremity: Full weight bearing Left upper extremity: Full weight bearing Treatment Frequency: Staples/sutures out 14 days after surgery or at follow up appointment Dry sterile dressing daily or as needed for drainge or comfort Followup Instructions: Please follow up with [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 78401], NP in orthopaedics in 2 weeks, please call [Telephone/Fax (1) 1228] to schedule that appointment. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235] MD, [MD Number(3) 11417] Completed by:[2140-5-26]	[ "2851" ]
Admission Date: [2178-1-14] Discharge Date: [2178-1-25] Date of Birth: [2149-11-25] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 2344] Chief Complaint: Fever, Rigors Major Surgical or Invasive Procedure: endotracheal intubation ([Date range (1) 85753]) transesophageal echocardiogram (TEE, [1-21]) History of Present Illness: 28yo F with no significant past medical history said that 4 days prior to admission she started to have fevers to 103 and drenching diaphoresis. At that time she also had a diffuse headache that was different from her migraines. She noted at that time she had some pain with eye and neck movement associated with the high fevers. Symptoms were relieved with advil 3-4 per day. When the fevers were not present, she did not have any pain as described above. She also noted general muscular pain with chills and shivering. She was going to work on the day of admission and felt so cold and shivering that she went home and felt she needed to come to the hospital. She travelled to [Country 4574] in [Month (only) ] and received all the proper vaccinations. She has not been sexually active in over a year and a half and last kissed someone over one month ago. She does not smoke or use drugs. She has never had any blood transfusions. She is unaware of any recent sick contacts. She denies any rhinorrhea, sore throat, odynophargia, SOB, DOE, pleuritic pain, chest pain, n/v/d or joint pain. Did not get flu shot this year. . In ED VS were: 102.9 159 111/52 18 100% RA 1.5gm of tylenol was given as well as 5L of NS, CXR and cultures were done. Current VS: T 100.5HR 119, SBP 91 with IVF running, RR: 20, 100%RA. . Lactate 4.5 -> 2.4 with 4L IVF. K+ 3.0 WBC 1.1, Plt 44. Menstrual period 5 days ago. No petichae. . Influenza DFA pending - not enough cells Monospot pending Urine culture, blood culture pending . Equivocal UA - trace leuk, mod blood, 25 protein, tr ketones, 0-2 RBC, [2-21] wbc, mod bacteria, [11-8] epi . Review of systems: (+/-) Per HPI Past Medical History: - Panic disorder, Anxiety - Cyclothymia - Recurrent UTIs - Genital HSV - Migraines - Alcohol abuse Social History: Denies tobacco use. Former alcoholic, last drink was new years. Marijuana use few times a year. No IVDU or other recreational drugs. Works as software designer. Family History: Grandmother had heart disease and was a chronic smoker. No history of cancer, hyperlipidemia, diabetes. No sick contacts in her family. Physical Exam: ADMISSION EXAM: DISCHARGE EXAM: VS: Tm 100.4, Tc 98.6, BP 88/46 (88-112/46-59), HR 94, RR 18 Gen: alert, oriented x3, NAD HEENT: EOMI, moist MM CV: Tachycardic, no m/r/g Pulm: CTAB Abd: soft, nt/nd; active bs; no organomegaly Extremities: no edema; 2+ PTs, DPs Neurologic: alert and oriented x3; motor and sensation grossly intact, no visual field deficits. Pertinent Results: DISCHARGE LABS [2178-1-25] 05:41AM BLOOD WBC-5.3 RBC-3.14* Hgb-9.1* Hct-27.0* MCV-86 MCH-29.0 MCHC-33.7 RDW-13.3 Plt Ct-590* [2178-1-21] 06:15AM BLOOD Neuts-72.9* Lymphs-19.9 Monos-4.2 Eos-2.6 Baso-0.4 [2178-1-25] 05:41AM BLOOD Glucose-102* UreaN-13 Creat-0.7 Na-141 K-4.5 Cl-102 HCO3-30 AnGap-14 [2178-1-24] 11:37AM BLOOD CK(CPK)-56 [2178-1-25] 05:41AM BLOOD Calcium-9.3 Phos-4.6* Mg-2.2 [1-21] TEE No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve is functionally bicuspid (fusion of the right and left coronary leaflets). There is a echodensity seen at the tips of the aortic valve leaflets that measures 0.7 x 0.8 cm and could reporesent a vegetation or partial flail leaflet. This is best seen in clips 77, 78 and 81 (also 10,13, 28, 31, 37-47). Severe (4+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Probable moderate sized vegetation on bicuspid aortic valve. Severe (4+) aortic regurgitation. No intracardiac shunt identified. Normal global left ventricular systolic function. Brief Hospital Course: 28 yo F with no significant PMHx who presented with 4 days of influenza-like illness and developed ARDS requiring intubation [1-16]. Extubated successfully on [1-19]. Found to have endocarditis & severe (4+) aortic regurgitation. . # Culture-negative endocarditis: Patient found to have moderate sized vegatation on bicuspid aortic valve. Likely embolic source of occipital lobe infarct. Cardiac surgery recommends re-evaluation after antibiotic course is complete in 6 weeks. Patient was discharged on ceftriaxone, gentamicin & daptomycin. Microbiology was pending at discharge, but patient will follow up with Infectious Disease clinic as an outpatient. . # Jaw dislocation: Completely resolved. Patient's jaw was dislocated during TEE. Dental consult reset it and placed brace. Patient currently denies any jaw pain or discomfort. Dental team recommended a soft diet & jaw brace x 1 week . # Occipital lobe embolic infarct: Head MRI showed left occipital lobe infarct which occurred within the past week per radiology. Etiology of septic embolus likely vegetation on aortic valve. Patient had no focal neurologic symptoms or visual field defects. . # Anemia: DIC & hemolysis labs were negative in ICU. Possibly secondary marrow suppression from acute illness. Other cell lines were initially low, but recovered. . # Depression/Anxiety: Patient has anxiety which occasionally manifested as sinus tachycardia. Continued her buspirone, lamotrigine and clonazepam. Medications on Admission: BUSPIRONE - 30 mg Tablet - 1 Tablet(s) by mouth three times a day CLONAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth twice a day DULOXETINE [CYMBALTA] - 60 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth in am and [12-21] tab in pm LAMOTRIGINE - 100 mg Tablet - 2 Tablet(s) by mouth once a day ZOLMITRIPTAN [ZOMIG] - (Dose adjustment - no new Rx) - 5 mg Tablet - 1 Tablet(s) by mouth w/ ha onset, MR in 2 hr prn --max 2 tabs in 24hs--- MULTIVITAMIN - (OTC) - Capsule - 1 Capsule(s) by mouth once a day Discharge Medications: 1. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig: Two (2) grams Intravenous Q24H (every 24 hours) for 6 weeks: Last dose 3/17. Disp:qs Refills:0 2. gentamicin in NaCl (iso-osm) 80 mg/100 mL Piggyback Sig: Eighty (80) mg Intravenous every eight (8) hours for 6 weeks: Last dose 3/17. Disp:qs Refills:0 3. lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Outpatient Lab Work -Weekly: CBC, BUN, Crea, LFTs, CK. -Twice weekly: Gentamicin trough. -All laboratory results should be faxed to Infectious disease R.Ns. at ([Telephone/Fax (1) 4591]. -All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([Telephone/Fax (1) 21403] 5. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 7. daptomycin 500 mg Recon Soln Sig: Four [Age over 90 1230]y (450) mg Intravenous once a day for 6 weeks: D1= [1-24], last dose = [3-7]. Disp:qs Refills:0 8. buspirone 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Zomig 5 mg Tablet Sig: One (1) Tablet PO prn as needed for headache: may repeat in 2 hrs as needed; max 2 tabs in 24hs. 11. duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO qAM. 12. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO qPM. Discharge Disposition: Home With Service Facility: [Company 4916] Discharge Diagnosis: Primary diagnosis: 1. infectious endocarditis 2. hypoxic respiratory failure 3. occipital lobe infarct Secondary diagnosis: 1. anemia 2. anxiety Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: # You were admitted to the hospital for flu-like illness and developed acute respiratory failure requiring intubation in the intensive care unit. . # You were found to have an embolic infarct in your brain on MRI, so an echocardiogram was performed to evaluate your heart valves & see if there was a source for the embolism to your brain. The TEE showed a growth on your aortic valve, also known as endocarditis. As a result of this growth, your aortic valve is leaky, a condition called aortic regurgitation. This likely contributed to your respiratory failure. Incidentally, you were found to have a biscupid aortic valve. . # You were started on three antibiotics (ceftriaxone, gentamicin & daptomycin) which you will need to take for 6 weeks (last dose [3-5] for ceftriaxone & gentamicin; last dose 3/19 for daptomycin). It is very important that you take all of your medications as prescribed, keep your appointments with the infectious disease doctors & get the appropriate lab work checked weekly and twice weekly. - Weekly: CBC, BUN, Crea, LFTs, CK - Twice weekly: Gentamicin trough - All lab results should be faxed to Infectious disease R.Ns. at ([Telephone/Fax (1) 1353]. - Any questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([Telephone/Fax (1) 21403] or to the [Name8 (MD) 11582] MD in when clinic is closed. . # On admission your platelet count, as well as red & white blood cell counts, was low. It is possible that your acute illness caused suppression of your bone marrow, which produces these cells. Your cell counts improved during your admission, although you are still anemic. You should follow this up with your primary care doctor. . # It is very important that you follow up with cardiothoracic surgery after your antibiotic course is complete to have them re-evaluate your aortic valve. It is possible that you will need a valve replacement. . # During your echocardiogram on [1-21], your jaw was dislocated. You were seen by oral/maxillofacial surgery who reset your jaw and gave you a jaw brace. They recommended that you wear the brace and eat a soft diet until Wed, [1-28]. Followup Instructions: Department: [State ]When: WEDNESDAY [2178-1-28] at 10:30 AM With: [Name6 (MD) ] [Name8 (MD) 9862], MD [Telephone/Fax (1) 2205] Building: [State ] ([Location (un) ], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: On Street Parking Department: [Last Name (un) 12214] [Doctor Last Name ] MED GRP When: THURSDAY [2178-1-29] at 11:30 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1013], MD [Telephone/Fax (1) 5068] Building: [Location (un) ] ([Location (un) 86], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: On Street Parking Department: INFECTIOUS DISEASE When: THURSDAY [2178-2-5] at 2:10 PM With: [Doctor First Name 1412] [Name Initial (MD) ] [Name8 (MD) 1413], M.D. [Telephone/Fax (1) 457] Building: LM [Hospital Unit Name ] [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2178-1-31]	[ "0389", "486", "2762", "5990", "4241" ]
Admission Date: [2199-12-30] Discharge Date: [2200-1-20] Date of Birth: [2141-3-16] Sex: M Service: SURGERY Allergies: Anspor / Wellbutrin Attending:[First Name3 (LF) 1234] Chief Complaint: Abdominal aortic aneurysm. Major Surgical or Invasive Procedure: [2199-12-30]: 1. Repair of juxtarenal abdominal aortic aneurysm with 14 mm tube graft. 2. Splenectomy for bleeding. . [2200-1-8]: Over the scope clip to gastric perforation by endoscopy History of Present Illness: The patient is a male with history of aortic aneurysms had progressive increase in size; now has an aortic aneurysm greater than 5.5 cm. Due to his young age and his family history, the decision was made to repair. Due to his anatomy, it was felt that he would not be a good stent graft candidate. Past Medical History: PMH: 5.7cm infra-renal/juxta-renal AAA, COPD, obesity, asthma, hypercholesterolemia, BPH, lumbosacral radiculopathy, colonic adenoma . PSH: multiple skin grafts on left ankle after burn ([2159]), multiple knee surgeries on L. and arthroscopic on R. ([2159]), R. rotator cuff repair ([2168]) Social History: Current smoker. Family History: Familial history of AAA. Physical Exam: Physical Exam on Discharge: AVSS Abdomen, soft, non-distended, non-tender Vertical midline incision with small eschar patches, without induration or signs of infection Pulses: R: p/p/p/p L: p/p/weakly palp/p Pertinent Results: [2199-12-30] 02:35PM BLOOD WBC-12.7* RBC-3.36# Hgb-10.7# Hct-30.2# MCV-90 MCH-31.9 MCHC-35.5 RDW-13.8 Plt Ct-188 [2200-1-8] 04:29AM BLOOD WBC-22.4* RBC-3.93* Hgb-11.7* Hct-34.4* MCV-88 MCH-29.9 MCHC-34.1 RDW-14.0 Plt Ct-855* [2199-12-30] 02:35PM BLOOD PT-15.7* PTT-46.9* INR(PT)-1.5* [2200-1-8] 04:29AM BLOOD PT-19.2* PTT-28.1 INR(PT)-1.8* [2199-12-30] 06:21PM BLOOD Glucose-134* UreaN-13 Creat-1.0 Na-139 K-4.6 Cl-109* HCO3-26 AnGap-9 [2199-12-30] 06:21PM BLOOD ALT-48* AST-59* LD(LDH)-301* CK(CPK)-1703* AlkPhos-43 TotBili-2.2* [2199-12-30] 06:21PM BLOOD CK-MB-21* MB Indx-1.2 cTropnT-<0.01 [2199-12-31] 02:40AM BLOOD CK-MB-102* cTropnT-<0.01 [2199-12-31] 12:04PM BLOOD CK-MB-145* MB Indx-1.3 cTropnT-<0.01 [2199-12-31] 08:30PM BLOOD CK-MB-188* MB Indx-1.1 cTropnT-<0.01 [2200-1-1] 12:00PM BLOOD HEPARIN DEPENDENT ANTIBODIES- NEGATIVE [2200-1-19] 07:02AM BLOOD WBC-15.0* RBC-3.65* Hgb-11.2* Hct-32.9* MCV-90 MCH-30.7 MCHC-34.1 RDW-14.0 Plt Ct-792* [2200-1-20] 06:45AM BLOOD WBC-14.7* RBC-3.74* Hgb-11.1* Hct-33.0* MCV-88 MCH-29.8 MCHC-33.8 RDW-14.2 Plt Ct-697* [2200-1-9] 08:59AM BLOOD PT-15.2* PTT-25.3 INR(PT)-1.4* [2199-12-30] 02:35PM BLOOD Fibrino-120* [2200-1-20] 06:45AM BLOOD Glucose-113* UreaN-14 Creat-1.0 Na-135 K-4.8 Cl-99 HCO3-27 AnGap-14 [2200-1-14] 06:06AM BLOOD ALT-30 AST-19 AlkPhos-71 TotBili-0.2 [2200-1-20] 06:45AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.3 [2200-1-9] 06:34AM BLOOD Triglyc-146 [2200-1-15] 06:07AM BLOOD Vanco-22.8* [2200-1-6] 07:56AM BLOOD K-3.3 . [2200-1-7] CT Torso with NGT and IV contrast: IMPRESSION: 1. Leakage of contrast from the posterosuperior aspect of the gastric fundus with oral contrast present within the left upper quadrant and splenectomy bed. 2. Satisfactory postoperative appearance of open abdominal aortic aneurysm repair. 3. Scattered colonic diverticulosis. 4. Moderate prostatic enlargement. 5. Left sided varicocele. . [2200-1-8] Endoscopy/Over the Scope Clipping by GI service: Findings: Esophagus: Normal esophagus. Stomach: Mucosa: A few areas of erythema and erosions were noted in the antrum consistent with NG tube induced injury. Other A small 8 mm opening was noted at the fundus surrounded by an area of erythema and mucosal edema s/o site of the perforation. Turbid fluid could be aspirated through the opening. An over the scope clip (12mm, T-type, OTSC) was loaded over the scope and the scope advanced to the region of the perforation. The opposing ends of the defect were suctioned into the clip cap. The OTSC was then successfully deployed at the perforation. The clip appeared in good position. No fluid could be suctioned through this region. Duodenum: Normal duodenum. Other findings: After the OTSC placement, an NG tube was placed under endoscopic vision successfully into gastric antrum. Impression: A few areas of erythema and erosions were noted in the antrum consistent with NG tube trauma. A small opening was noted at the fundus surrounded by an area of erythema and mucosal edema c/w the site of the perforation. An over the scope clip (OTSC) was successfully deployed to close the perforation. Another NG tube was then placed in the antrum. Otherwise normal EGD to third part of the duodenum . [2200-1-9] CT a/p: IMPRESSION: 1. No oral contrast extravasation on today's exam. No evidence of leak. 2. Residual about 9 x 2.7 x 3.4 cm low to intermediate density fluid in the subphrenics space with drain in place. 3. Moderate left pleural effusion and left basilar atelectasis. . [2200-1-14] UGI: IMPRESSION: No extraluminal oral contrast. No fluoroscopic evidence of gastric perforation. . [2200-1-15] CT a/p: IMPRESSION: 1. No evidence of extraluminal oral contrast. 2. Small, 3.6 cm peripherally enhancing collection abutting the posterior aspect of the fundus as described above. 3. Two perigastric surgical drains as described above. 4. Post-surgical appearance following abdominal aortic aneurysm repair. 5. Right lower lobe lung nodule. This likely represents inflected or inflamed lung, though recommend followup to resolution to exclude an underlying nodule. 6. Diverticulosis. Brief Hospital Course: SUMMARY: 58M with 5.7cm infra-renal/juxta-renal AAA who presented for open AAA resection-suprarenal cross clamp, with intraoperative course complicated splenic laceration requiring splenectomy, and post-operative course complicated by small gastric fundal perforation requiring endoclipping. . BRIEF HOSPITAL COURSE: The patient was brought to the OR on [2199-12-30] for open repair of juxtarenal abdominal aortic aneurysm with 14 mm tube graft. A perioperative epidural was placed. Reader referred to operative note for full details. Intraoperative bleeding with splenic laceration was noted, for which the ACS service was consulted, and ultimately performed a splenectomy during the same procedure (attending surgeon, Dr. [Last Name (STitle) ]. 2 [Doctor Last Name ] drains were placed post operatively in the left flank, and the patient was transferred to the PACU and the ICU intubated, with an NGT, in stable condition. . ICU Course: The patient had an uneventful ICU course. He was appropriately diuresed with a lasix drip, and transfused as necessary. Tube feeds were begun on POD 4, and HIT panel returned negative. His epidural was removed, and he was weaned off the ventilator, extubated on POD5. On POD5 erythema surrounding his midline vertical abdominal incision was noted and he was begun on cefazolin given concern for a superficial skin infection. He was transferred to the floor (VICU) on [2200-1-6] in stable condition, tolerating clears which were begun on [2200-1-6] (POD 7). . VICU and floor course: Prior to initiating clears on HD8, the patient had serosanguineous output from his 2 flank JP drains in the splenic bed. Following initiation of clears on POD7, however, JP output markedly increased to over a liter per day from each drain. The color of the drains also became bilious. Given the change in JP output and a persistently uptrending WBC count, the patient underwent a CTA torso on POD 8, [2200-1-7], which showed a small gastric perforation along the greater curvature of the stomach. In discussion between the ACS service and the gastroenterology service, the patient underwent an endocscopy-guided clipping (over the scope clipping, OTSC) of the gastric fundus perforation on [2200-1-8] by the GI service, without complication. JP output markedly decreased post procedure. Day 1 of TPN was initiated thereafter on [2200-1-9] (POD 10), and the patient underwent 7 days total of TPN. CT a/p on [2200-1-9] (POD 10) with contrast via NGT showed no active extravasation, UGI series on [2200-1-14] confirmed no extravasation, and the NGT was removed on [2200-1-14] (POD 15). He received post-splenectomy vaccinations on [2200-1-10] (POD 11). Fluconazole was added to his emperic vancomycin/ciprofloxacin/flagyl on [2200-1-14] when budding yeast returned from one of his JP drains. He completed a total 2 week course of v/c/f, and 5 days of fluconazole. Repeat CT a/p on [2200-1-15] again showed no active extravasation, and demonstrated a small residual peri-splenic bed collection (residual 9 x 2.7 x 3.4 cm subphrenic collection). The collection was thought not ammenable to additional drainage at that time given potential injury to pancreas/lung. It will be monitored in the future with repeat CT as necessary as an outpatient to evaluate progression/resolution. The patient was again started on clears [2200-1-15], which he tolerated, and his diet was advanced slowly. JP output remained stable during this time. One flank JP was removed on [2200-1-17], and the second and final JP on [2200-1-19]. His central line was removed, and tip culture returned negative. On discharge he was tolerating a regular diet, ambulating independently, with pain well controlled on oral medications. Regarding his pulse-exam post operatively, he had palpable distal pulses throughout his post-operative period. Vertical midline staples were removed prior to discharge. He was discharged home on HD22 with instructions to follow up with Dr. [Last Name (STitle) ] of vascular surgery and the ACS service. Medications on Admission: Fluticasone (FLOVENT HFA) 220 mcg 1 puff [Hospital1 ], albuterol sulfate (Proair) 90 mcg 2 puffs q4-6 hrs, lipitor 80 mg po qd, Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 4. metformin 500 mg Tablet Sig: 1-2 Tablets PO twice a day: 1 tab twice daily for 7 days then increase to 2 tabs twice daily. . Disp:98 Tablet(s) Refills:2 5. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation every 4-6 hours as needed for wheeze: shortness of breath, wheezes. 7. Lipitor 80 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Nicoderm CQ 21 mg/24 hr Patch 24 hr Sig: One (1) patch Transdermal once a day: wean to 14mg/hr patches when tolerable. Discharge Disposition: Home Discharge Diagnosis: Abdominal aortic aneurysm, status post open repair Splenectomy Gastric Perforation, status post endoscopic repair Dyslipidemia COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital after a repair of your abdominal aortic aneurysm on [2199-12-30]. Your spleen was also removed, and a small perforation in your stomach was repaired with an endoclip. . We have started you on several new medications, metoprolol (lopressor) for high blood pressure, pantoprazole (protonix) for stomach acid, aspirin for your blood vessels and metformin for high blood sugars. Additionally, please continue all your regular home medications. . It is imperative than you remain smoke free! While you were in the hospital we gave you nicotine patches at 21mg/day. Please continue to use the patches if needed and wean the dosage as tolerable. . Division of Vascular and Endovascular Surgery Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions . What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [5-2] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! . 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [12-27] 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: ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered. ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed. Followup Instructions: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in 2 weeks at [First Name9 (NamePattern2) 2287] [Location (un) ], his office will call you to arrange. . Please call and make an appointment to be seen by your PCP for monitoring of the new medications we started you on in the hospital. . Please follow up with the acute care surgeons (who removed your spleen) in [12-28] weeks. Please call [Telephone/Fax (1) 1864] to make an appointment. Completed by:[2200-1-20]	[ "2851", "25000", "4019", "2720", "3051" ]
Admission Date: [2122-5-4] Discharge Date: [2122-5-9] Date of Birth: [2050-3-30] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Shortness of breath and fatigue Major Surgical or Invasive Procedure: [2122-5-4] - Ascending aorta replacement with a 29mm Gelweave graft and aortic valve replacement with a #23 [Company 1543] Mosaic tissue valve. History of Present Illness: This is a 72-year-old female with a 13-year known history of a bicuspid aortic valve. She was followed during this time with progression of the aortic stenosis and some dilation of the ascending aorta. During the most recent echocardiogram, it showed an aortic valve area of 0.5 with a peak gradient in the mid 30s and an ascending aneurysm that was approximately 4 cm in size. Based on these findings, the progression of the disease and the extreme small aortic valve area, it was decided to proceed with repair. The risks and benefits were explained to the patient and she agreed to proceed. The patient agreed to undergo aortic valve replacement with a tissue valve. Past Medical History: Aortic stenosis Bicuspid Aorti Valve Dilated Ascending Aorta Hyperlipidemia Osteoporosis Neuropathy Colon polyps Social History: Retired. Never smoked and drinks 4 alcoholic beverages per week. Lives with her husband. Family History: None Physical Exam: 82 SR 18 130/80 GEN: Well appearing 72 y/o female in NAD HEENT: Unremarkable LUNGS: CTA HEART: RRR, 4/5 SEM ABD: Soft, NT, ND, NABS EXT: warm, well perfused, 1+ LE Edema. Pulses [11-18]+. NEURO: Nonfocal Pertinent Results: [2122-5-4] - PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The ascending aorta is moderately dilated. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. The aortic valve is bicuspid. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). No aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine. 1. A well-seated bioprosthetic valve is seen in the aortic position with normal leaflet motion and gradients (mean gradient = 5 mmHg). No aortic regurgitation is seen. 2. An ascending aorta tube graft is also seen. 3. Biventricular function is preserved 4. Other findings are unchanged Brief Hospital Course: Mrs. [Known lastname 97516] was admitted to the [Hospital1 18] on [2122-5-4] for surgical management of her aorta and aortic valve disease. She was taken directly to the operating room where she underwent an aortic valve replacement with a 23mm tissue valve and replacement of her ascending aorta. Please see operative note for details. Postoperatively she was taken to the intensive care unit for monitoring. By postoperative day one she had awoke neurologically intact and was extubated. She was then transferred to the step down unit for further recovery. She was gently diuresed towards her preoperative weight. The physical therapy service was consulted for assistance with her postoperative strength and mobility. She had progressed well with her mobility, and is ready to be discharged home today. Medications on Admission: Aspirin 81mg QD Fosamax lipitor 20mg QD Vitamins/Minerals Discharge Medications: 1. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 10 days. Disp:20 Packet(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:40 Tablet(s) Refills:0 7. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:20 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Bicuspid Aortic Valve, Aortic Stenosis, Dilated Ascending Aorta - s/p AVR and Replacement of Ascending Aorta PMH: Hyperlipidemia, Neuropathy, Osteoporosis, Colon polyps Discharge Condition: Stable 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. Followup Instructions: Follow-up with Dr. [Last Name (STitle) 1290] in 1 month. ([Telephone/Fax (1) 1504] Follow-up with Dr. [Last Name (STitle) ] in 2 weeks. Follow-up with Dr. [First Name (STitle) 1313] in 2 weeks. ([Telephone/Fax (1) 97517] Please call all providers for appointments. Scheduled Appointments: Provider: [Name Initial (NameIs) 326] (B) BONE DENSITOMETRY [Name Initial (NameIs) 706] Phone:[Telephone/Fax (1) 1125] Date/Time:[2122-8-10] 11:00 Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 327] Date/Time:[2122-9-15] 2:00 Completed by:[2122-5-9]	[ "4241", "2724" ]
Admission Date: [2184-12-27] Discharge Date: [2184-12-31] Date of Birth: [2101-12-18] Sex: F Service: SURGERY Allergies: IV Dye, Iodine Containing Contrast Media / Labetalol / furosemide / amlodipine Attending:[First Name3 (LF) 3200] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [2184-12-28]: Incisional hernia repair, primary closure History of Present Illness: 83F with distant history of appendectomy and known asymptomatic ventral hernia for more than 20 years presents with a one day history of the hernia "being stuck, hard, and painful". Reports she woke up with the pain this morning and has not been able to reduce since. Has never had it incarcerate in the past. Has felt nauseated and vomited once this morning. Last bowel movement was yesterday and she does not recall passing flatus today. Denies fevers or chills. Past Medical History: HTN, HLD, osteoporosis, osteoarthritis, trigeminal neuralgia, infectious colitis (admitted to [Hospital1 18] [Date range (1) 69839]/[2184]) PSH: appendectomy @ age 17 for perforated appendicitis; cerebral aneurysm s/p clipping in mid [2162] @ [Hospital1 2025] Social History: High functioning, lives alone in [Name (NI) 3146], MA, son lives 30 minutes away and assists her when needed. Denies smoking, rare EtOH, no drug use. Family History: Brother with heart disesae. No known h/o inflammatory bowel disease, colon cancer, or other GI malignancies. Physical Exam: ON admission: Vitals 97.3 65 [Telephone/Fax (2) 91913]0%RA NAD, AAOx3 RRR, unlabored respirations abdomen soft, non-distended, 4 inch x 3 inch bulge in hypogastric region, tender, firm and with mild erythematous skin changes, irreducible DRE minimal stool in vault, normal tone, guaiac negative ext no edema = On discharge Vitals 97.1 83 138/70 16 94%RA Gen-NAD, AAOx3 Card- RRR Pulm- unlabored respirations, CTAB Abd- soft, non-distended, incision healing, no erythema Ext- no ededea Pertinent Results: [2184-12-27] 04:42PM BLOOD Glucose-108* UreaN-17 Creat-1.0 Na-131* K-5.7* Cl-97 HCO3-20* AnGap-20 [2184-12-27] 04:51PM BLOOD Lactate-1.2 K-4.6 [2184-12-27] 04:42PM BLOOD WBC-18.1# RBC-4.13 Hgb-12.8 Hct-36.8 MCV-89 MCH-30.9 MCHC-34.7 RDW-11.6 Plt Ct-308 CT abdomen/pelvis: 1. Large midline ventral hernia, now with new involvement of distended small bowel since [2184-11-23], with moderate neighboring [Name2 (NI) ] stranding, concerning for incarceration. Lack of IV contrast makes evaluation of bowel wall enhancement to evaluate for ischemia impossible. No free air or pneumatosis seen. 2. Right middle lobe opacities, minimally changed since [11-24], [2183], but not fully imaged/not fully evaluated, may represent chronic aspiration or inflammation vs chronic infection. Brief Hospital Course: Ms. [Known lastname 59975] was taken to the OR emergently on [2183-12-28] for incisional hernia repair for her incarcerated hernia. She was extubated in the OR and brought to the ICU in stable condition. She was noted to be hypertensive to 200/100 immediately postop and responded well to morphine and hydralazine. With improved pain control, her hypertension resolved. She was transferred to the floor on POD#1. Once transferred to the floor she continued to progress. Her NG output had diminished and was removed on POD# 2. Her diet was advanced slowly. Once able to tolerate a diet her Morphine PCA was stopped and she was started on oral pain medications; Ultram and Tylenol were added as well. During the remainder of her stay her blood pressures remained stable ranging in the 130's/70's. Physical therapy worked with her and deemed her safe for home. At time of discharge the patient was tolerating a regular diet, ambulating with a cane and minimal assistance, voiding without difficulty, and had minimal pain. The patient was discharged to rehab with follow up in [Hospital 2536] clinic. Medications on Admission: losartan 100', carbamazepine 200''', simvastatin 40', spironolactone 50'' Discharge Medications: 1. carbamazepine 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:30 Tablet(s) Refills:2 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 4. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. Disp:20 Tablet(s) Refills:0 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day: hold for diarrhea. 9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Extended Care Facility: Life Care Center at [Location (un) 2199] Discharge Diagnosis: Incarcerated incisional hernia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with an incarcerated ventral hernia requiring an operation to repair this. You have done well from your surgery are now being discharged to rehab. Bulb Suction Drain Care: Please look at the drain site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warmth, and fever). Maintain the bulb on suction. Record the color, consistency, and amount of fluid in the drain. Call the [Location (un) 5059], nurse practitioner, or VNA nurse if the amount increases significantly or changes in character. Empty the drain frequently. You may shower and wash the drain site gently with warm, soapy water. You may also wash with half strength hydrogen peroxide followed by saline rinse. Keep the insertion site clean and dry otherwise. Place a drain sponge for cleanliness. Avoid swimming, baths, and hot tubs. Do not submerge yourself in water. Attach the drain securely to your body to prevent pulling or dislocation. ACTIVITY: Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. You may climb stairs. You may go outside, but avoid traveling long distances until you see your [Location (un) 5059] at your next visit. Don't lift more than 15-20 lbs for 6 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. You may start some light exercise when you feel comfortable. You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. HOW YOU [Month (only) ] FEEL: You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. You may have a sore throat because of a tube that was in your throat during surgery. You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. You could have a poor appetite for a while. Food may seem unappealing. All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your [Month (only) 5059]. YOUR INCISION: Your incision may be slightly red around the stitches or staples. This is normal. You may gently wash away dried material around your incision. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay. It is normal to feel a firm ridge along the incision. This will go away. Avoid direct sun exposure to the incision area. Do not use any ointments on the incision unless you were told otherwise. You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your [Month (only) 5059]. You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. Ove the next 6-12 months, your incision will fade and become less prominent. YOUR BOWELS: Constipation is a common side effect of medicine such as Percocet or codeine. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. If you go 48 hours without a bowel movement, or have pain moving the bowels, call your [Month (only) 5059]. After some operations, diarrhea can occur. If you get diarrhea, don't take anti-diarrhea medicines. Drink plenty of fluids and see if it goes away. If it does not go away, or is severe and you feel ill, please call your [Month (only) 5059]. PAIN MANAGEMENT: It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your [Name2 (NI) 5059]. You will receive a prescription from your [Name2 (NI) 5059] for pain medicine to take by mouth. It is important to take this medicine as directied. Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. Your pain medicine will work better if you take it before your pain gets too severe. Talk with your [Name2 (NI) 5059] about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your [Name2 (NI) 5059] has said its okay. If you are experiencing no pain, it is okay to skip a dose of pain medicine. Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the folloiwng, please contact your [Name2 (NI) 5059]: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your [Name2 (NI) 5059]. DANGER SIGNS: Please call your [Name2 (NI) 5059] if you develop: - worsening abdominal pain - sharp or severe pain that lasts several hours - temperature of 101 degrees or higher - severe diarrhea - vomiting - redness around the incision that is spreading - increased swelling around the incision - excessive bruising around the incision - cloudy fluid coming from the wound - bright red blood or foul smelling discharge coming from the wound - an increase in drainage from the wound Followup Instructions: Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: TUESDAY [2185-1-18] at 2:15 PM With: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 853] ACUTE CARE CLINIC Phone: [Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "2724", "4019" ]
Admission Date: [2161-11-29] Discharge Date: [2161-12-10] Date of Birth: [2096-5-9] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2474] Chief Complaint: CC: shortness of breath Major Surgical or Invasive Procedure: Intubation, Arterial Blood Gases History of Present Illness: This is a 65 year old with mental retardation, severe COPD and recent admission with COPD exacerbation treated with intubation presents with SOB. The patient normal has oxygen sats in the high 80s on RA, however today he was noted to be 72% on RA. He uses 2L of oxygen at home at night. He complains of SOB. He has had cough with clear sputum production for the last 3 weeks. He denies chills or fevers. He restarted smoke 3 weeks ago. He was brought to the ED by EMS. . In the ED, initial vs were: T 99 P 80 BP 117/78 R 22 O2 sat 98% NRB. A CXR showed a questionable LLL PNA. Patient was given Albuterol and ipratropium nebs, Levofloxacin 750mg IV, Prednisone 60mg, and 1L NS. ABG showed respiratory acidosis with pCO2 of 88 (baseline 70s) and preserved oxygenation. The patient was clearly against intubation in the ED. CPAP was started in the ED prior to transfer. VS prior to transfer were 97, HR 75, 98/60, 50, 95%3L. PIV x 2 were placed in the ED. The patient received 15 min of BiPAP in the ED with improvement in mentation. . On the floor, patient [Last Name (un) ] tachypneic, with cynanotic lips but felt that his breathing is improved from the ED. . Past Medical History: 1) COPD: FEV1 23% predicted, home 1.5-2L O2 at night only 2) Secondary Pulmonary Hypertension (51-66 mm Hg on ECHO [2159-9-18]) 3) Schizophrenia 4) Hx GI bleeding 5) Mental Retardation 6) Pulmonary Hypertension 7) s/p tonsillectomy Social History: Lives in [Location ] with brother and brother-in-law. On disability since [2149] for mental health issues. Has home nurse visit every morning and evening. Reports ~50 pack-year smoking and has now cut down to 3 cigs/day. Denies any ETOH/drug use. Family History: Patient unable to provide. Physical Exam: Physical examination: - Gen: Well-appearing in NAD. - [Year (4 digits) 4459]: Conj/sclera/lids normal, PERRL, EOM full, and no nystagmus. Hearing grossly normal bilaterally. Sinuses non-tender. Nasal mucosa and turbinates normal. Oropharynx clear w/out lesions. - Neck: Supple with no thyromegaly or lymphadenopathy. - Chest: Normal respirations and breathing comfortably on room air. Lungs clear to auscultation bilaterally. - CV: PMI normal size and not displaced. Regular rhythm. Normal S1, S2. No murmurs or gallops. JVP <5 cm. 2+ carotids. No carotid bruits. - Abdomen: Normal bowel sounds. Soft, nontender, nondistended. Liver/spleen not enlarged. - Rectal: No external lesions. Normal tone, stool guaiac negative. - Extremities: No ankle edema. - MSK: Joints with no redness, swelling, warmth, tenderness. Normal ROM in all major joints. - Skin: No lesions, bruises, rashes. - Neuro: Alert, oriented x3. Good fund of knowledge. Able to discuss current events and memory is intact. CN 2-12 intact. Speech and language are normal. No involuntary movements or muscle atrophy. Normal tone in all extremities. Motor [6-10] in upper and lower extremities bilaterally. Gait normal. DTRs 2+ at brachioradialis and patella bilaterally. Plantar reflex down (neg Babinski). Finger-to-nose and heel-to-shin normal. Romberg and pronator drift negative. Sensation to light touch intact in upper and lower extremities bilaterally. - Psych: Appearance, behavior, and affect all normal. No suicidal or homicidal ideations. Pertinent Results: [2161-12-8] 06:03AM BLOOD WBC-9.3 RBC-4.13* Hgb-12.6* Hct-37.7* MCV-91 MCH-30.5 MCHC-33.3 RDW-13.5 Plt Ct-267 [2161-11-29] 09:40PM BLOOD WBC-11.4* RBC-4.16* Hgb-12.7* Hct-39.9* MCV-96 MCH-30.4 MCHC-31.7 RDW-14.0 Plt Ct-412# [2161-12-9] 06:05AM BLOOD Glucose-182* UreaN-17 Creat-0.7 Na-145 K-3.6 Cl-101 HCO3-40* AnGap-8 [2161-11-29] 09:40PM BLOOD Glucose-173* UreaN-19 Creat-1.0 Na-146* K-4.1 Cl-101 HCO3-40* AnGap-9 [2161-12-8] 06:03AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.9 [2161-11-30] 05:05AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.8 . Blood Gases [2161-12-8] 04:36PM BLOOD Type-ART pO2-60* pCO2-62* pH-7.43 calTCO2-43* Base [2161-12-8] 04:36PM BLOOD Type-ART pO2-60* pCO2-62* pH-7.43 calTCO2-43* Base XS-13 [2161-12-5] 04:42AM BLOOD Type-ART pO2-129* pCO2-60* pH-7.45 calTCO2-43* Base XS-15 [2161-12-2] 12:42PM BLOOD Type-ART Rates-16/ Tidal V-500 PEEP-8 FiO2-21 pO2-58* pCO2-45 pH-7.49* calTCO2-35* Base XS-9 -ASSIST/CON Intubat-INTUBATED [2161-12-2] 10:37AM BLOOD Type-ART Temp-36.3 Rates-16/ Tidal V-500 PEEP-8 FiO2-35 pO2-115* pCO2-66* pH-7.41 calTCO2-43* Base XS-14 -ASSIST/CON Intubat-INTUBATED Vent-IMV [2161-12-2] 09:27AM BLOOD Type-ART FiO2-35 pO2-94 pCO2-97* pH-7.28* calTCO2-48* Base XS-14 Intubat-NOT INTUBA . [2161-12-1] 12:41PM BLOOD Type-ART pO2-101 pCO2-89* pH-7.28* calTCO2-44* Base XS-11 Intubat-NOT INTUBA [2161-11-30] 12:31AM BLOOD Type-ART pO2-84* pCO2-88* pH-7.32* calTCO2-47* Base XS-14 [2161-12-6] 06:21PM BLOOD Lactate-0.9 K-4.2 [2161-12-6] 02:17PM BLOOD Lactate-1.0 K-3.5 [2161-12-1] 12:41PM BLOOD Glucose-202* Lactate-1.2 K-5.0 [2161-12-5] 01:34PM BLOOD freeCa-1.15 . [2161-11-29] CXR IMPRESSION: Findings suggestive of early left lower lobe pneumonia. . CXR [2161-12-8] IMPRESSION: AP chest compared to chest radiographs since [2159], most recently [12-6]: Aeration at the base of the right lung has improved, with remission of peribronchial opacification. The discrete flame-shaped lesion in the left mid lung whch appeared on [11-30] is smaller, probably atelectasis in a region of an acute infection or infarction. No indication of current pneumonia or cardiac decompensation. Heart size normal. Of note prior chest CT scans have findings suggesting a propensity to tracheobronchomalacia, as well as moderately severe emphysema. Left PIC catheter ends in the upper SVC. No pneumothorax or pleural effusion. Brief Hospital Course: 65 y/o with severe COPD, mild mental retardation presented with hypercarbic resp failure. . # Acute on Chronic Respiratory Failure: This patient has Co2 chronically in the high 80s and presented with worsening dyspnea consistent with a COPD exacerbation in the setting of Bronchitis, and resuming smoking was likely. This patient has been hospitalized with multiple prior intubations during the past year. After some respiratory distress on HD 3 he was put on BIPAP and did not tolerate it well with a high amount of respiratory secretions which could not be suctioned. He was transferred to intensive care unit where he remained tachypneic and in respiratory distress and therefore was intubated. He completed a complete 7 day course of levofloxacin for COPD exacerbation. He was diuresed 2.5 liters while in the intensive care unit. He was successfully extubated HD 8, and tolerated nasal cannula well. He was continued on prednisone 60mg and started a slow taper after transfer to the floor when he was clinically stable from a respiratory standpoint. He was continued on aggressive Albuterol and Atrovent nebulizer treatment. On the floor he had an episode of transient unresponsiveness and was found to be in hypoxic respiratory distress on arterial blood gas. He recovered quickly with a nebulizer treatment and was stable for the duration of his hospitalization. He was discharged on the remainder of his prednisone taper and on home 24 hour oxygen with nursing services and close primary care follow-up. . #Hypotension - While in the intensive care unit, the patient required Dopamine for few hours because of systolic pressures in the 70??????s. After administration of 2 liters of normal saline the patient was normotensive and blood pressures were stable throughout the remainder of his hospitalization. . # Schizophrenia: The patient was continued on Zyprexa. . # Glucose intolerance. The patient was placed on an insulin sliding scale due to elevated blood sugars in the setting of prednisone. The patient declined insulin on discharge stating he would not take it if prescribed, as he had not taken it in the past. He will have close follow-up with his primary care physician and will tolerated mildly elevated blood sugars given the temporary duration of prednisone therapy. . # Anemia: HCT at baseline, normocytic. Trended HCT Q daily Medications on Admission: Zyprexa 7.5 mg daily Advair Diskus 500 mcg-50 mcg inhaled twice daily Spiriva 1 capsule inhaled daily Aspirin 81 mg daily Nicotine 14 mg/24 hr daily Patch ProAir HFA 90 mcg/Actuation Aerosol Inhaler 2 puffs(s) inhaled twice a day and q 4 hours prn wheeze Multivitamin with Minerals daily Famotidine 20 mg twice daily Discharge Medications: 1. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every 4-6 hours as needed for wheeze/sob. Disp:30 units Refills:0 3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Transdermal once a day: Apply patch once a day for one month then switch to 7mg patch for one month then stop. (Continue as started on [11-17]). 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 6. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 1.5 Tablet, Rapid Dissolves PO DAILY (Daily). 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation twice a day: Additional 2 puffs as needed every 4 hours for SOB. 8. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) puff Inhalation twice a day. 9. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a day. 11. multivitamin Capsule Sig: One (1) Capsule PO once a day. 12. Home Oxygen 1- 2 liters nasal canula to keep O2 sat above 90%. Ambulatory Saturation on Room Air is 86%. Ambulatory Saturation on 1L NC is 88%. Please use nasal cannula during night and day to keep saturations above 90%. 13. prednisone 50 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: Start friday [2161-12-11]. Take for three days. Disp:3 Tablet(s) Refills:0 14. prednisone 10 mg Tablet Sig: as taper directs Tablet PO once a day: start after 50mg prednisone, take 4 tablets daily for three days, then take 3 tablets daily for 3 days, then take 2 tablets daily for 3 days then take 1 tablet daily for 3 days. Disp:40 Tablet(s) Refills:0 15. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. 16. Home Nebulyzer Machine Diagnosis: COPD Discharge Disposition: Home With Service Facility: [Hospital 7272] Health Systems Discharge Diagnosis: 1. COPD exacerbation 2. Secondary pulmonary hypertension, DM2, schizophrenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for management of a chronic obstructive pulmonary disease (COPD) exacerbation. Your ability to breathe on your own was compromised such that you were intubated for several days. You were treated with a complete antibiotic course during your admission and were given steroids treat the inflammation in your lungs. You required oxygen supplementation throughout the day in addition to your nightly requirement. In addition to your regular medications, Please continue the prednisone taper as directed. Please continue daytime home oxygen as directed until otherwise insructed by your primary care physician. Followup Instructions: Department: [Hospital3 249] When: TUESDAY [2161-12-15] at 9:40 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2477], M.D. [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2477] MD, [MD Number(3) 2478]	[ "486", "2760", "2762", "4168", "2859", "25000", "4019", "3051" ]
Admission Date: [2123-6-26] Discharge Date: [2123-7-19] Date of Birth: [2080-2-1] Sex: M Service: MEDICINE Allergies: Zemplar / Ampicillin Attending:[First Name3 (LF) 826] Chief Complaint: Bacteremia Major Surgical or Invasive Procedure: Transesophageal echocardiogram History of Present Illness: Patient is a 43 yo Thai speaking male with ESRD on HD, HTN presented to [Hospital1 18] on [6-26] after being notified that blood cultures drawn on [6-24] returned positive for GPC in [1-28] bottles. He arrived to HD on [6-24] with rigors and chills, but was afebrile to 99.1, and had blood cx's drawn. On arrival to the ED, he was afebrile to 96.8, with BP 92/38, and was admitted to medicine for further work-up. He was given 1g vanco x1, 1 g ceftaz x1, which were continued on the floor. ROS were negative for any fever, cough, SOB, dysuria, odynophagia or any other localizing symptoms. It was felt that his tunneled HD line was likely the source, and it was planned to have that line removed. Pt was dialyzed on [6-26] through his still maturing AVF in his L arm. On [6-27], pt became increasingly hypotensive, with BPs at 80/40. He was otherwise afebrile to 97.8, but Tmax 100.3, with HR 70s, RR 20s, and satting 100% on RA. He was given 1L NS bolus without improvement in his blood pressure. Pt was transferred to the ICU for closer monitoring. He was transferred to the floor after he was hemodynamically stable. Past Medical History: HTN ESRD ([1-28] HTN) AVF placed [2123-4-9] (awaiting maturation) Anemia (baseline hct 30) CHF EF 40% Uric acid elevation Social History: No smoking, no alcohol, no drug use. Family History: Father and mother died at age 40-50. Brothers with HTN. No family history of stroke or MI. Physical Exam: VS: T 98 BP80/34 HR72 RR o2sat: GEN: lying on bed, does not appear toxic. able to speak in full sentences without difficulty. HEENT: PERRL, EOMI, anicteric, MM dry. NECK: Supple, no elev JVP. CHEST: CTAB, no c/w/r. HEART: RRR, nl S1 and S2, no m/r/g ABD: Soft, NTND, NABS, no bruits, no HSM EXT: Warm, 2+ pulses bilaterally, 1+ pitting edema bilaterally Neuro: A&O x 3, no focal neurologic signs. Brief Hospital Course: Patient is a 43 yo male with history of ESRD [1-28] HTN presents with high-grade bacteremia with 2/2 bottles of pansensitive Enterococcus and Enterobacter and 4/4 bottles of GNR. 1. Enterococcal/Enterobacter bacteremia: Patient with polymicrobial bacteremia secondary to infected tunneled HD line; no other localizing symptoms on admission. Initially hypotensive with BPs in 80/40's consistent with sepsis. He was transferred to the MICU for closer management, no pressors were required. His tunneled HD Line was pulled and he was started on Vancomycin and Levaquin, as per ID. He also had been on Ceftaz, Meperidine, and Linezolid, all of which were stopped in the MICU. TTE was done and did not suggest any vegetations or abcesses. TEE was then done and showed a moderate sized aortic vegetation that was consistent with aortic regurgitation, which was auscultated on exam. Patient was seen by CT surgery and felt that he would require AVR after he had completed his 6 week course of antibiotics and suggested he undergo cardiac catheterization as part of the pre-op evaluation. Patient was also seen by cardiology was consulted Vancomycin was changed to Ampicillin, as per ID, who felt that Enterococcus was more sensitive to this drug. Two weeks later he became neutropenic, developed a diffuse erythematous rash, and started spiking temperatures. 2. ESRD: Patient on hemodialysis TTHSat d/t ESRD from HTN. s/p HD yest on [6-26], not due for HD until Tues. tunneled line pulled on [6-26], renal consulting, following, dialyzed through mature av fistula on [6-29]. 3. HTN - Hold antihypertensives given sepsis, restart on floor once stable 4. Anemia: At baseline Hct ~30. Continue Epo 6000units qhd. Medications on Admission: Meds at home: Metoprolol 75mg PO bid norvasc 10mg PO qday tums 500mg PO tid epo 6000 units qhd calajex 2mcg qhd Discharge Medications: 1. Vancomycin HCl 1250 mg IV QHD Please dose at hemodialysis 2. Gentamicin 60 mg IV QHD 3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 4. Lanthanum 250 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). Disp:180 Tablet, Chewable(s) Refills:2 5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours). Disp:15 Tablet(s) Refills:0 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: 1. Endocarditis 2. End stage renal disease on HD 3. Hypertension Discharge Condition: Stable Discharge Instructions: 1. You are being treated for a bacterial infection with 3 antibiotics for 6 weeks ([Date range (1) 67279]). Two of the antibiotics will be given at hemodialysis. The third antibiotic is Levaquin. You will take 1 tablet every 2 days until [2123-8-12]. 2. Recommended follow-up as listed below 3. If you experience any fevers, chills, chest pain, SOB or any other concerning symptoms please return to the ER> Followup Instructions: 1. You will getting hemodialysis on Tuesdays, Thursdays, and Saturdays at [Hospital1 18]. You will be informed about the time and place. 2. Please have labs done at hemodialysis. Weekly CBC, LFTs, vancomycin trough, and gentamycin peak/trough levels should be faxed to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 9404] at [Telephone/Fax (1) 1419]. 3. You are scheduled for an appointment with Cardiothoracic Surgery on [8-11] at 2:30pm. 4. You are scheduled to have an echocardiogram on Thursday, [8-5] at 8am in the [Hospital Ward Name 23] Building, [Location (un) 436]. Phone number [Telephone/Fax (1) 128]. 5. Dr. [Last Name (STitle) ] will be contacting you regarding your appointment for tooth extraction. 6. You are scheduled for an appointment with Infectious Disease clinic, DR. [First Name (STitle) ] [Doctor Last Name 9406] Phone:[Telephone/Fax (1) 457] Date/Time:[2123-8-17] 11:00	[ "40391", "42789" ]
Admission Date: [2171-10-25] Discharge Date: [2171-10-31] Service: CSU HISTORY OF PRESENT ILLNESS: This is an 81 year old gentleman who reports having chest discomfort for the past four years with recent increase in frequency. He had a stress test, which was positive and he was referred to [Hospital1 346] for cardiac catheterization and subsequently a coronary artery bypass grafting. PAST MEDICAL HISTORY: Hypertension. Demyelinating polyneuropathy. Sciatica. Decreased vision in his left eye due to retinal problems. Status post hernia repair. ALLERGIES: Inderal which causes claustrophobia and asthma. PREOPERATIVE MEDICATIONS: 1. Verapamil 240 mg p.o. q a.m. and 120 mg p.o. q p.m. 2. Hydrochlorothiazide 25 mg p.o. q. Day. 3. Trileptal 300 mg p.o. twice a day. 4. Ditropan XL 10 mg p.o. q. Day. 5. Lisinopril 10 mg p.o. twice a day. 6. Aspirin 162 mg p.o. twice a day. HOSPITAL COURSE: The patient was admitted to [Hospital1 346] on [11-3] for a cardiac catheterization. Cardiac catheterization showed an ejection fraction of 65 percent. A 70 to 90 percent left anterior descending lesion; 90 percent first diagonal lesion; 50 percent obtuse marginal one lesion and 80 percent right coronary artery lesion. The patient was referred to Dr. [Last Name (STitle) ] for coronary artery bypass grafting. The patient's cardiac catheterization was on [2171-10-14]. The patient was discharged to home after his cardiac catheterization and was readmitted on [10-25] for his surgery. He was taken to the operating room for coronary artery bypass grafting times four; left internal mammary artery to left anterior descending; saphenous vein graft to first diagonal; saphenous vein graft to second diagonal and saphenous vein graft to right coronary artery. Total cardiopulmonary bypass time was 87 minutes. Cross clamp time was 69 minutes. The patient was transferred to the Intensive Care Unit in stable condition on Neo-Synephrine and Propofol. The patient initially had moderate amount of tube drainage and was treated with packed red blood cells. He was weaned and extubated from mechanical ventilation on his first postoperative evening. On postoperative day number one, the patient intermittently required some Neo-Synephrine. He remained in the Intensive Care Unit for some pulmonary toilette as well as some hypotension. By the evening of postoperative day number one, the patient had been started on Lopressor and became hypertensive. The patient was started on Neo-Synephrine. The patient had some intermittent wheezing and congestive cough and required some pulmonary toilette and some Nebulizer treatment. On postoperative day number two, the patient's chest tubes and pacing wires and Foley catheter were removed without incident. On postoperative day number three, the patient was transferred from the Intensive Care Unit to the regular part of the hospital, where he began working with physical therapy. It was determined that the patient would benefit from a stay at short term rehabilitation. Over the next couple of days, the patient continued on diuretics and beta blockers. By postoperative day number five, the patient was cleared for discharge to rehabilitation. CONDITION ON DISCHARGE: Temperature 98.2; blood pressure 100/60; pulse 80 and regular. Oxygen saturation 95 percent on room air. The patient's weight was 100.3 kg; preoperatively, the patient weighed 94.8 kg. Neurologically, the patient was awake, alert, grossly intact, oriented times three. Respiratory: Breath sounds were decreased at bilateral bases. Heart is regular rate and rhythm. Abdomen is soft, nontender, nondistended. Extremities: Warm and well perfused. The patient has 1 plus pedal edema bilaterally. Sternal and leg incisions are clean, dry and intact without any erythema or drainage. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. twice a day times seven days. 2. Potassium chloride 20 mEq p.o. twice a day times seven days. 3. Colace 100 mg p.o. twice a day. 4. Zantac 150 mg p.o. twice a day. 5. Trileptal 300 mg p.o. twice a day. 6. Detrol XL 5 mg p.o. twice a day. 7. Lopressor 100 mg p.o. twice a day. DISCHARGE DIAGNOSES: Coronary artery disease. Hypertension. Demyelinating polyneuropathy. DISPOSITION: The patient is to be discharged to rehabilitation in stable condition. He is to follow up with Dr. [Last Name (STitle) ] in one to two weeks. He is to follow-up with Dr. [Last Name (STitle) ] in one to two weeks. He is to follow-up with Dr. [Last Name (STitle) ] in three to four weeks. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(2) 5897] Dictated By:[Last Name (NamePattern4) 8524] MEDQUIST36 D: [2171-10-30] 20:08:45 T: [2171-10-30] 20:45:32 Job#: [Job Number 45350]	[ "41401", "4019" ]
Admission Date: [2180-3-7] Discharge Date: [2180-3-15] Date of Birth: [2153-12-22] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5378] Chief Complaint: OSH transfer for AMS, seizures Major Surgical or Invasive Procedure: extubation, Lumbar puncture History of Present Illness: Per admitting resident: 26 year old RH man with an unremakable PMH who was last seen in his USOH in the early am (prior to going to work) and then at noon (normal conversation with his wife over the phone) p/w confusion and question of seizure. Today at around 13:00 he was found confused by his peers. The report says he could not maintain a conversation and was thrashing and moving his arms and legs bl and symmetrically. He did not have a facial droop. He was not bumping into objects per wife. [Name (NI) ] was not seen seizing. There was no documented LOC. While taken by EMS to OSH, there is the question of a seizure episode. Unfortunately, I see no documentation in this regard. EMS took the pt to [Hospital ] hospital. The pt was noted to have a fever 101.9F with 139/ 68 and 155 bpm and 24 RR with So2 100% in RA. Pt received a CT CNS w/o contrast that showed LEF Ttemporo-parietal hypodense wedge shaped lesion. No fractures or bleed. No hydrocephalus or herniation data. His Chem showed a normal Na and Ca. His Glu was 177. He did have an AG of 22. He was tapped: LP showed: Pr 58, glu 92 BRCs 50, 2 WBC (100% L) RBCs 48, 2 WBCs. (100% L) His EKG showed a sinus tachycardia w/o repol abnormalities. His C-spine scan was negative. He received ceftriaxone 2 g iv and vancomycin 1 g iv. He received 1 g PHT iv and was ETT'd at 14:45 after sedation with sucinylcholine and vecuronium and placed on a versed drip. Once at [Hospital1 18], he was started on propofol drip and bolussed with versed (agitated). He also received acyclovir 800 mg iv. ROS is negative otherwise. NO sick contacts. [Name (NI) ] ID symptoms. No headaches. NO seizure hx. NO aneurisms hx. Baseline: IADLS. Additional hx obtained from witness: Per discussion with witness, patient was working on a boat engine. Last seen normal at noon time. Owner heard back from him when calling his name at 1pm on another part of the boat. ~ 30 minutes later, owner heard loud banging, ran to see pt. and oted that him laying on floor, arms and legs stiffened, head shaking and banging on the back of the metal wall. This lasted nearly 1-2 minutes. Once banging stopped, patient appeared to be unconscious with heavy breathing. EMS arrived and by this time (10 mins) he "came to" crawled out of area on his own, could not say his name to EMS, did not know where he was, "glassy eyed" and dazed. Few minutes later had another episode: eyes opened wide, clenched his teath, foam coming out of his mouth, body straightened/rigid. This lasted 2 minutes and then became loose again and confused. Patient was at that time transported to OSH. Past Medical History: none Social History: Lives with wife and daughter Exercises (-) Tobacco occasional cigarrettes. ETOH two beers per night Drugs (-) He works as an electrician. Family History: Hx of early strokes (-) Seizures (-) CNS tumors (+) - granmother. Demyelinating conditions (-) Autoimmune conditions (-) Procoagulant conditions (-) CAD (-) Aneurysm (+) grandfather. Physical Exam: Exam on admission: 176/ 76, 136 bpm: agitated. When sedated: 130/ 80s. On vent, CMV mode breathing at 22 RR (overbreathing the vent). Sedated on Propofol at 50 mcg/ kg/ min which was stopped 15 minutes prior to my examination. Gen: Lying in bed, fighting the tube. 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: MS: He is responsive to noxious stimuli in all limbs. He does withdraw to pain symmetrically and localizes well. CN: Brain stem reflexes : preserved: Corneals + bl. Pupils 3.5 to 2.5 bl and symmetrically. resisting my pupillary exam. Closes his eyes symmetrically. No gaze deviation. No bobbing or Robbing. No nystagmus. No facial asymmetries. Gag +. Tone: normal. DTR: 2+. Toes : would not allow exam (withdraws and quicks) Labs: reviewed. U Tox and serum tox: negative, except for tylenol level (7.5: given at [Hospital1 18] and at OSH). Pertinent Results: Labs on admission: [2180-3-7] 07:25PM BLOOD WBC-16.1* RBC-4.77 Hgb-14.4 Hct-41.8 MCV-88 MCH-30.1 MCHC-34.3 RDW-12.4 Plt Ct-232 [2180-3-9] 03:17AM BLOOD WBC-8.8 RBC-4.45* Hgb-13.5* Hct-38.9* MCV-87 MCH-30.3 MCHC-34.6 RDW-12.7 Plt Ct-190 [2180-3-7] 07:25PM BLOOD Neuts-92.3* Lymphs-4.0* Monos-3.4 Eos-0.1 Baso-0.2 [2180-3-7] 07:25PM BLOOD PT-12.5 PTT-22.5 INR(PT)-1.1 [2180-3-7] 07:25PM BLOOD Glucose-148* UreaN-13 Creat-1.7* Na-139 K-3.8 Cl-106 HCO3-24 AnGap-13 [2180-3-8] 01:55PM BLOOD UreaN-11 Creat-1.6* Na-142 K-3.7 Cl-111* HCO3-25 AnGap-10 [2180-3-9] 12:36PM BLOOD Glucose-121* UreaN-7 Creat-1.3* Na-141 K-3.3 Cl-105 HCO3-28 AnGap-11 [2180-3-8] 12:02AM BLOOD ALT-61* AST-193* CK(CPK)-[Numeric Identifier 85885]* AlkPhos-43 TotBili-0.7 [2180-3-8] 01:55PM BLOOD CK(CPK)-[Numeric Identifier ]* [2180-3-8] 10:32PM BLOOD CK(CPK)-[Numeric Identifier 85886]* [2180-3-9] 03:17AM BLOOD ALT-141* AST-622* LD(LDH)-1687* CK(CPK)-[Numeric Identifier 85887]* AlkPhos-32* TotBili-0.4 DirBili-0.2 IndBili-0.2 [2180-3-9] 12:36PM BLOOD CK(CPK)-[Numeric Identifier 85888]* [2180-3-7] 07:25PM BLOOD Albumin-4.4 Calcium-8.3* Phos-2.9 Mg-2.8* [2180-3-8] 12:02AM BLOOD Triglyc-101 HDL-48 CHOL/HD-3.7 LDLcalc-108 [2180-3-8] 01:55PM BLOOD ANCA-NEGATIVE B [2180-3-7] 07:25PM BLOOD CRP-8.7* [2180-3-7] 07:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-7.6* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Labs during hospital stay CBC [2180-3-14] 04:20AM BLOOD WBC-5.9 RBC-4.67 Hgb-13.8* Hct-39.5* MCV-85 MCH-29.6 MCHC-35.0 RDW-12.4 Plt Ct-227 [2180-3-13] 05:15AM BLOOD WBC-5.3 RBC-4.31* Hgb-13.2* Hct-36.5* MCV-85 MCH-30.7 MCHC-36.2* RDW-12.3 Plt Ct-174 [2180-3-12] 05:50AM BLOOD WBC-4.1 RBC-4.09* Hgb-12.5* Hct-35.0* MCV-85 MCH-30.5 MCHC-35.7* RDW-12.2 Plt Ct-171 [2180-3-11] 04:17AM BLOOD WBC-5.6 RBC-4.06* Hgb-12.8* Hct-35.5* MCV-88 MCH-31.6 MCHC-36.1* RDW-12.1 Plt Ct-182 [2180-3-10] 03:17AM BLOOD WBC-6.8 RBC-4.39* Hgb-13.3* Hct-38.8* MCV-89 MCH-30.4 MCHC-34.4 RDW-12.2 Plt Ct-191 [2180-3-9] 03:17AM BLOOD WBC-8.8 RBC-4.45* Hgb-13.5* Hct-38.9* MCV-87 MCH-30.3 MCHC-34.6 RDW-12.7 Plt Ct-190 [2180-3-8] 01:55PM BLOOD Hct-36.8# [2180-3-8] 12:02AM BLOOD WBC-14.0 RBC-5.27 Hgb-16.0 Hct-47.0 MCV-89 MCH-30.4 MCHC-34.0 RDW-12.3 Plt Ct-262 [2180-3-13] 05:15AM BLOOD Neuts-66.0 Lymphs-29.4 Monos-3.1 Eos-1.1 Baso-0.3 [2180-3-9] 03:17AM BLOOD Neuts-80.4* Lymphs-14.2* Monos-4.8 Eos-0.2 Baso-0.4 [2180-3-14] 04:20AM BLOOD Plt Ct-227 [2180-3-13] 05:15AM BLOOD Plt Ct-174 [2180-3-12] 05:50AM BLOOD Plt Ct-171 [2180-3-11] 04:17AM BLOOD Plt Ct-182 [2180-3-10] 03:17AM BLOOD Plt Ct-191 [2180-3-9] 03:17AM BLOOD Plt Ct-190 [2180-3-8] 01:55PM BLOOD ESR-1 Chem 7 [2180-3-14] 04:20AM BLOOD Glucose-94 UreaN-15 Creat-1.0 Na-140 K-3.8 Cl-100 HCO3-30 AnGap-14 [2180-3-13] 05:35PM BLOOD Glucose-110* UreaN-13 Creat-1.0 Na-140 K-4.2 Cl-103 HCO3-30 AnGap-11 [2180-3-13] 05:15AM BLOOD Glucose-110* UreaN-11 Creat-1.2 Na-139 K-3.7 Cl-102 HCO3-30 AnGap-11 [2180-3-12] 03:22PM BLOOD Glucose-120* UreaN-10 Creat-1.0 Na-140 K-3.6 Cl-102 HCO3-30 AnGap-12 [2180-3-12] 05:50AM BLOOD Glucose-112* UreaN-9 Creat-1.1 Na-138 K-3.5 Cl-102 HCO3-30 AnGap-10 [2180-3-11] 03:24PM BLOOD Glucose-105* UreaN-8 Creat-1.2 Na-139 K-3.1* Cl-98 HCO3-35* AnGap-9 [2180-3-11] 04:17AM BLOOD Glucose-170* UreaN-7 Creat-1.1 Na-140 K-3.3 Cl-100 HCO3-34* AnGap-9 [2180-3-10] 02:37PM BLOOD Glucose-118* UreaN-6 Creat-1.1 Na-140 K-3.6 Cl-103 HCO3-34* AnGap-7* [2180-3-10] 03:17AM BLOOD Glucose-167* UreaN-5* Creat-1.1 Na-140 K-3.4 Cl-103 HCO3-33* AnGap-7* [2180-3-9] 07:50PM BLOOD Glucose-131* UreaN-6 Creat-1.3* Na-140 K-3.8 Cl-103 HCO3-32 AnGap-9 [2180-3-9] 12:36PM BLOOD Glucose-121* UreaN-7 Creat-1.3* Na-141 K-3.3 Cl-105 HCO3-28 AnGap-11 [2180-3-8] 01:55PM BLOOD UreaN-11 Creat-1.6* Na-142 K-3.7 Cl-111* HCO3-25 AnGap-10 Muscle enzymes [2180-3-14] 04:20AM BLOOD ALT-436* AST-448* LD(LDH)-484* CK(CPK)-[Numeric Identifier 85889]* [2180-3-13] 05:35PM BLOOD CK(CPK)-[Numeric Identifier 85890]* [2180-3-13] 05:15AM BLOOD ALT-487* AST-803* CK(CPK)-[Numeric Identifier 85891]* AlkPhos-57 TotBili-0.4 [2180-3-12] 05:50AM BLOOD ALT-377* AST-994* LD(LDH)-2039* CK(CPK)-[Numeric Identifier ]* AlkPhos-46 TotBili-0.4 [2180-3-11] 04:17AM BLOOD ALT-299* AST-1062* CK(CPK)-[Numeric Identifier 85892]* AlkPhos-34* TotBili-0.3 [2180-3-10] 02:37PM BLOOD CK(CPK)-[Numeric Identifier 85893]* [2180-3-10] 03:17AM BLOOD ALT-224* AST-890* LD(LDH)-3034* CK(CPK)-[Numeric Identifier 85894]* AlkPhos-29* TotBili-0.2 [2180-3-9] 07:50PM BLOOD CK(CPK)-[Numeric Identifier 85895]* [2180-3-9] 12:36PM BLOOD CK(CPK)-[Numeric Identifier 85888]* LFTs [2180-3-9] 03:17AM BLOOD ALT-141* AST-622* LD(LDH)-1687* CK(CPK)-[Numeric Identifier 85887]* AlkPhos-32* TotBili-0.4 DirBili-0.2 IndBili-0.2 [2180-3-8] 10:32PM BLOOD CK(CPK)-[Numeric Identifier 85886]* Ca/Mg/P [2180-3-14] 04:20AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.9 [2180-3-13] 05:35PM BLOOD Calcium-8.6 Phos-3.6 Mg-2.0 Iron-67 [2180-3-13] 05:15AM BLOOD Albumin-3.4* Calcium-8.7 Phos-2.7 Mg-1.8 [2180-3-12] 03:22PM BLOOD Calcium-7.9* Phos-2.4* Mg-1.8 [2180-3-12] 05:50AM BLOOD Albumin-3.2* Calcium-7.7* Phos-2.1* Mg-1.8 [2180-3-11] 03:24PM BLOOD Calcium-7.8* Phos-2.5* Mg-1.8 [2180-3-10] 02:37PM BLOOD Calcium-7.7* Phos-2.0* Mg-1.9 [2180-3-10] 03:17AM BLOOD Calcium-7.4* Phos-2.2* Mg-1.8 Other tests [2180-3-10] 03:17AM BLOOD TSH-1.8 [2180-3-8] 12:02AM BLOOD TSH-1.5 [2180-3-8] 01:55PM BLOOD ANCA-NEGATIVE B [2180-3-8] 01:55PM BLOOD [Doctor First Name ]-NEGATIVE [2180-3-10] 02:37PM BLOOD HIV Ab-NEGATIVE [2180-3-7] 07:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-7.6* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Urine [2180-3-11] 12:58PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.015 [2180-3-11] 12:58PM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-9.0* Leuks-NEG CSF [2180-3-9] 10:33AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-22* Polys-33 Lymphs-49 Monos-18 [2180-3-9] 10:33AM CEREBROSPINAL FLUID (CSF) WBC-5 RBC-125* Polys-13 Lymphs-80 Monos-7 [2180-3-9] 10:33AM CEREBROSPINAL FLUID (CSF) TotProt-24 Glucose-81 CSF other tests HSV, EBV, HHV 6, CMV - negative Lyme, MS profile- pending Microbiology HIV-1 Viral Load/Ultrasensitive (Final [2180-3-13]): HIV-1 RNA is not detected. Performed using the Cobas Ampliprep / Cobas Taqman HIV-1 Test. Detection range: 48 - 10,000,000 copies/ml. This test is approved for monitoring HIV-1 viral load in known HIV-positive patients. It is not approved for diagnosis of acute HIV infection. In symptomatic acute HIV infection (acute retroviral syndrome), the viral load is usually very high (>>1000 copies/mL). If acute HIV infection is clinically suspected and there is a detectable but low viral load, please contact the laboratory for interpretation. It is recommended that any NEW positive HIV-1 viral load result, in the absence of positive serology, be confirmed by submitting a new sample FOR HIV-1 PCR, in addition to serological testing. RAPID PLASMA REAGIN TEST (Final [2180-3-13]): NONREACTIVE. Reference Range: Non-Reactive. [Doctor Last Name ]-[Doctor Last Name ] VIRUS VCA-IgG AB (Final [2180-3-13]): POSITIVE BY EIA. [Doctor Last Name ]-[Doctor Last Name ] VIRUS EBNA IgG AB (Final [2180-3-13]): POSITIVE BY EIA. [Doctor Last Name ]-[Doctor Last Name ] VIRUS VCA-IgM AB (Final [2180-3-13]): NEGATIVE <1:10 BY IFA. INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION. In most populations, 90% of adults have been infected at sometime with EBV and will have measurable VCA IgG and EBNA antibodies. Antibodies to EBNA develop 6-8 weeks after primary infection and remain present for life. Presence of VCA IgM antibodies indicates recent primary infection. CMV IgG ANTIBODY (Final [2180-3-10]): POSITIVE FOR CMV IgG ANTIBODY BY EIA. 23 AU/ML. Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. CMV IgM ANTIBODY (Final [2180-3-10]): NEGATIVE FOR CMV IgM ANTIBODY BY EIA. INTERPRETATION: INFECTION AT UNDETERMINED TIME. A positive IgG result generally indicates past exposure. Infection with CMV once contracted remains latent and may reactivate when immunity is compromised. If current infection is suspected, submit follow-up serum in [2-16] weeks. Greatly elevated serum protein with IgG levels >[2170] mg/dl may cause interference with CMV IgM results. DIRECT INFLUENZA A ANTIGEN TEST (Final [2180-3-9]): Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final [2180-3-9]): Negative for Influenza B. TOXOPLASMA IgG ANTIBODY (Final [2180-3-10]): NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA. 0.0 IU/ML. Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml. LYME SEROLOGY (Final [2180-3-9]): NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA. Reference Range: No antibody detected. Negative results do not rule out B. burgdorferi infection. Patients in early stages of infection or on antibiotic therapy may not produce detectable levels of antibody. Patients with clinical history and/or symptoms suggestive of lyme disease should be retested in [2-16] weeks. ASO Screen (Final [2180-3-9]): POSITIVE by Latex Agglutination. Reference Range: < 200 IU/ml (Adults and children > 6 years old). ASO TITER (Final [2180-3-9]): POSITIVE 200-400 IU/ml. Performed by latex agglutination. Reference Range: < 200 IU/ml (Adults and children > 6 years old). TOXOPLASMA IgM ANTIBODY (Final [2180-3-10]): NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA. INTERPRETATION: NO ANTIBODY DETECTED. Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final [2180-3-12]): GRAM POSITIVE COCCI IN CLUSTERS. REPORTED BY PHONE TO [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 85896],RN 12:15PM [2180-3-12]. Blood Culture, Routine [3-8] (Final [2180-3-14]): NO GROWTH. [2180-3-7] 11:38 pm BLOOD CULTURE Source: Venipuncture. FINAL REPORT [2180-3-14] Blood Culture, Routine (Final [2180-3-14]): NO GROWTH. Imaging: MRI/A of head and neck: IMPRESSION: 1. FLAIR abnormality in the subcortical left occipital lobe with some focal overlying cortical involvement and no evidence of associated hemorrhage, restricted diffusion, or definitive enhancement. The differential diagnosis includes low-grade primary glial neoplasm and tumefactive demyelination. 2. Unremarkable MRA of the head and neck without evidence of tumor vascularity, shunting, or flow-limiting stenosis. 3. Sinus disease as described above, the activity of which is to be determined clinically. TTE: 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%). 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 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 regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The pulmonary artery systolic pressure could not be determined. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No echo evidence of endocarditis. Brief Hospital Course: 26 year old RH man with an unremakable PMH who was last seen in his USOH in the early am (prior to going to work) and then at noon (normal conversation with his wife over the phone) p/w two subsequent seizures with associated leukocytosis, fever, non-blanching erythematous rash, conj. hemorrhage, rhabdomyolisis, ARF, transaminitis with a L parietal lesion on MRI representative on edema w/o [Year/Month/Day ] enhancement. NEURO. Unclear what the unifying diagnosis is at time of presentation. DDx included an underlying primary CNS malignancy with edema, leading to seizure and subsequent rhabdomyolisis, ARF, though given fever and rash an infectious process (viral HSV, EBV, HHV-6) could not be definitively ruled out. In addition, a metastasis from a lymphoma in this patient was also considered. OSH LP negative and viral studies w/ cultures pending. Patient treated empirically with Acyclovir/CFTX/Vancomycin as per ID recommendation for possible coverage of HSV encephalitis (atypical presentation), possible meningitis and/or endocarditis with vancomycin. No stigmata of endocarditis were noted and TTE was negative. BCx were negative. Additionally, vasculitis etiology was considered, however ESR was 1 and ANCA was negative. He underwent a repeat LP for cytology which showed 5 cells, normal protein and gluocose. Opening pressure was 32. Viral studies inclusind HSV, VZV, EBV, HHV-6 were negative. Lyme serology and CSF were negative Olygoclonal bands were obtained with concern for atypical ADEM and were negative. Neuro-oncology was consulted who recommended outpatient follow up for biopsy of brain tumor after normalisation of high CK and improvement in general medical condition. EEG was obtained and showed spikes nearly Q1-2mins w/o NCSE, thus patient was continued on Dilantin with goal of > 10 corrected for albumin, which was later changed to keppra which was continued as outpatient. PULM. Pt. was extubated on HD1. No further respiratory issues were noted, after trasnfer to floor. HEME/RENAL. CK on arrival ~ 18K treated with moderate IVF rate, and rose to peak of 100 K. Pt. was treated with D5HCO3 and NS titrated to goal UOP of > 200cc/hr with aid of lasix. Cr peaked at 1.9 and microscopic analysis was notable for granular casts concerning for tubular renal injury. Cr at time of discharge was 4000s, with rapid downward trend. ID. Pt. w/ fever on presentation and recurrence on HD2. He was empirically treated with IV ABx for etiologies concerning above, however no clear source was identified. BCx, UCx were pending and CXR was negative for infection. There was opacification of sinuses, however patient did report URI sx prior to presentation. He was continued on oral antibiotics for total of 7 days for presumptiveaspiration pneumonia. Medications on Admission: none Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:2 2. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H (every 24 hours) for 3 days. Disp:9 Tablet(s) Refills:0 3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days. Disp:9 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Left parietal area wedge shaped brain lesion ? neoplastic Rhabdomyolyis- recovering aspiration pneumonia Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted for evaluation of seizure. You were initially admitted to ICU for monitering. You were found to have a wedge shaped lesion on left side of brain. You were seen by Neuro oncology team who suggested biopsy as an outpatient in next few weeks after the general condition permits. You had a condition called rhabdomyolysis which results from injury to muscles. You were evaluated by renal team, and treated with IV fluids with very good response. You were found to have aspiration pneumonia for which you recieved/will be recieving antibiotics for total duration of 1 week. You were started on a medicine called keppra for control of seizures which you will be taking even after discharge. Please take your medicines as directed. Please call 911 or your doctor if any questions or concerns. Followup Instructions: Please follow up with 1. Neuro oncology Provider: [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) 4861], MD Phone:[Telephone/Fax (1) 1844] Date/Time:[2180-3-27] 4:00 2. Renal Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 721] Date/Time:[2180-4-25] 2:30 3. Primary care Provider: [First Name8 (NamePattern2) 1112] [Last Name (NamePattern1) 18569], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2180-3-28] 1:45 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5379] MD, [MD Number(3) 5380]	[ "5070", "5849" ]
Name: [Known lastname 11946],[Known firstname 732] Unit No: [Numeric Identifier 11947] Admission Date: [2108-6-20] Discharge Date: [2108-7-3] Date of Birth: [2039-7-6] Sex: F Service: SURGERY Allergies: Bactrim / Cogentin Attending:[First Name3 (LF) 9036] Addendum: Patient discharged on [2108-6-29] to [Hospital 1238] rehab facility. Chief Complaint: s/p post colonic perforation w/ ileostomy Major Surgical or Invasive Procedure: [2108-6-21] Exploratory lap, Ileostomy take down w/ ileo-transverse colostomy History of Present Illness: 68 yo female with schizoaffective disorder and diabetes insipidus, probably from lithium use. She suffered a perforated colon approximately 6 months ago due to C- difficile colitis incidentally found at her operation for gross peritonitis was an ileal carcinoid which was resected and had positive nodal metastases. She has been intolerant of her ileostomy due to food and electrolyte issues and has been in the hospital for renal failure on two occasions on the medicine service despite trying her best to manage her fluid intake herself. She also has extensive skin excoriation and dermatitis problems due to her ileostomy. She is, therefore, electively brought in for ileostomy reversal. Past Medical History: carcinoid syndrome, ARF/CRF, hypoNa, hypoMag, hypothyroid, UTI ([5-31]), PNA ([3-31]), psoriasis, elevated transaminases (resolved), mental retardation, schizoaffective d/o, r elbow hemarthrosis PSHx: ileosotomy [11-29] Social History: Previously resided in group home Family History: Noncontributory Physical Exam: VS: Temp 99, HR 114, BP 130/86, Resp 18, SaO2, 98% on RA. Neuro: Pleasant, MR CVS: normal S1, S2, RRR Pulm: CTA b/l Abd: Soft, NT, ostomy intact, psoriasis Ext: good peripheral pulses, no edema Pertinent Results: [2108-6-20] 08:00PM GLUCOSE-128* UREA N-15 CREAT-1.7* SODIUM-140 POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-28 ANION GAP-14 [2108-6-20] 08:00PM CALCIUM-9.1 PHOSPHATE-5.1* MAGNESIUM-1.4* [2108-6-20] 08:00PM WBC-7.2 RBC-3.55# HGB-11.6# HCT-31.7* MCV-89 MCH-32.7* MCHC-36.6# RDW-15.8 [2108-6-20] 08:00PM PLT COUNT-377 [2108-6-20] 08:00PM PT-15.9* PTT-27.6 INR(PT)-1.4* CHEST (PRE-OP PA & LAT) Reason: S/P ILEOSTOMY; DIABETES INSIPIDIS; SCHIZO-AFFECTIVE DISORDER [Hospital 5] MEDICAL CONDITION: 68 year old woman here for reversal of ileostomy and ileocolic anastamosis REASON FOR THIS EXAMINATION: pre-op INDICATION: 68-year-old woman here for reversal of ileostomy and ileocolic anastomosis. Preop. COMPARISON: [2108-2-29]. FINDINGS: Since prior exam, the right PICC line has been removed. The cardiac silhouette, mediastinal and hilar contours are stable. The lungs are clear. No evidence of pneumothorax. The aorta is mildly tortuous. IMPRESSION: No evidence of acute cardiopulmonary process. Brief Hospital Course: She was admitted to the Surgical Service and taken to the operating room for exploratory lap, ileostomy takedown with ileo-transverse colostomy on [6-21]. There were no intraoperative complications. Postoperatively she has done fairly well, her diet was advanced slowly; she is having bowel movements. She was started on Imodium and Metamucil to help minimize frequent stools. Her ileostomy site is being packed with moist to dry dressing changes [Hospital1 ]; her staples will remain in place until next week when she follows up with Dr. [Last Name (STitle) ]. Her medications were changed from intravenous to oral, she is tolerating these without difficulty; appetite is good. Her fluids and electrolytes have been monitored closely and repleted accordingly. Her most recent sodium on [6-28] was 145. The wound ostomy nurse specialists were consulted because of dermatitis issues; Nystatin cream was recommended to these areas. Miconazole powder is being used to her perineal region. Medications on Admission: tincture of opium, mag oxide, oscal, medroline, vitD, levothyroxine, zyprexa, heparin, folate, tylenol, Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 2. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 3. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for breakthrough agitation. 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day): hold for HR <60; SBP <110. 7. Levothyroxine 125 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 11. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [12-27] Tablet, Delayed Release (E.C.)s PO twice a day as needed for constipation. 12. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 weeks. 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 14. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day). 15. Metamucil Powder Sig: One (1) TBSP PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital6 4356] - [Location (un) 164] Discharge Diagnosis: Ileostomy takedown Secondary diagnosis: Diabetes Insipidus Discharge Condition: Stable Discharge Instructions: Please call your primary care physician or go to the nearest ER if you experience any pain uncontrollable on your medications, blood in your stool, temperature greater than 101.5, increased diarrhea, nausea/vomiting, or any other symptoms that are concerning to you. Followup Instructions: Follow up with Dr. [Last Name (STitle) ] in Surgery Clinic in [12-27] weeks, call [Telephone/Fax (1) 11871] for an appointment. [First Name11 (Name Pattern1) 1332] [Last Name (NamePattern1) 9039] MD [MD Number(2) 9040] Completed by:[2108-6-29]	[ "2449" ]
Admission Date: [2145-4-27] Discharge Date: Date of Birth: [2067-11-11] Sex: F Service: [Hospital Unit Name 153] CHIEF COMPLAINT: Hypotension. HISTORY OF PRESENT ILLNESS: The patient is a 76 year old female with multiple medical problems including dysphagia, emphysema, congestive heart failure, coronary artery disease, who was recently discharged from the [Hospital6 649] on [2145-4-23], following treatment of Methicillin-resistant Staphylococcus aureus pneumonia and hypotension. The patient had previously been admitted to the Medicine Intensive Care Unit on the sepsis protocol, was hypotensive to the 60s without improvement following fluids and was also febrile to 102.8. In the Medicine Intensive Care Unit, hypotension was believed to be multifactorial (including hypovolemia in a preload dependent patient, bacterial versus viral infection and acute renal failure). Fluid resuscitated with improvement, briefly on pressors. Sputum growing Methicillin-sensitive resistant Staphylococcus aureus with chest x-ray showing left lower lobe infiltrate and the patient was started on a two week course of Vancomycin intravenously. Blood cultures showed no growth. She was ruled out for myocardial infarction with three sets of negative cardiac enzymes. She developed diarrhea which was improving at the time of discharge. Three sets of Clostridium difficile were negative. The patient had refused rehabilitation placement on previous admissions and was discharged with home services. Since discharge, the patient states that she had been eating and drinking well. On the day prior to admission she went to the grocery store and cooked a meal. Over the past day she noticed decreased urine output although continued to drink well (two to three glasses of water per day). The patient told the Emergency Room staff that she had been taking her Lasix since discharge. She told me upon admission she was not taking her Lasix. The patient was seen by her [Hospital6 407] on the day of admission and was concerned about the patient's condition. She went to see her primary care physician and was found to be hypotensive with systolic blood pressure in the 80s and unsteady on her feet. In the Emergency Department, she was still hypotensive with systolic blood pressure in the 80s although she appeared to be improving to the 100s with intravenous fluids. Her creatinine was elevated to 4.9 from a baseline of approximately 0.7. It is to note that the patient did suffer from acute renal failure in her Medicine Intensive Care Unit course earlier in [Month (only) 958], to a maximum creatinine of 2.3. PAST MEDICAL HISTORY: 1. Dysphagia, motility study in [2144-1-29] showed no esophageal contraction. 2. Prerenal, acute renal failure in [2144-3-28] secondary to poor p.o. intake and again in [2145-3-29] secondary to poor p.o. intake. 3. Obstructive sleep apnea on CPAP at 8 to 10 cm of water. 4. Emphysema on home oxygen 2 to 4 liters, nasal cannula. 5. Bronchiectasis. 6. Pulmonary hypertension. 7. Symptomatic bradycardia, status post VDD pacemaker in [2143-11-29]. 8. Gastroesophageal reflux disease. 9. History of Methicillin-resistant Staphylococcus aureus in her sputum following hernia repair and again in [2145-3-29] with documented pneumonia. 10. Status post hernia repair. 11. Right ventricular systolic function with echocardiogram from [2145-3-29] showing right ventricular dilation, borderline left ventricular dilation, ejection fraction greater than 55% and borderline normal right ventricular function, 1+ mitral regurgitation. 12. Coronary artery disease. 13. Hypertension. 14. Status post appendectomy. 15. Status post total abdominal hysterectomy. 16. Status post back surgery. 17. Status post right total hip. 18. Chronic lower back pain with questionable narcotic use recently. ALLERGIES: Penicillin, codeine and Bactrim. MEDICATIONS ON ADMISSION: 1. Colace 100 mg p.o. b.i.d. 2. Fluticasone 4 puffs inhaler b.i.d. 3. Salmeterol inhaler q. 12 hours. 4. Reglan 5 mg p.o. t.i.d., a.c. h.s. 5. Senna 8.6 b.i.d. 6. Levofloxacin 250 mg p.o. q. day to complete a two week course. 7. Valsartan 150 mg p.o. q. day 8. Atorvastatin 40 mg p.o. q.h.s. 9. Calcium carbonate 500 p.o. t.i.d. 10. Vitamin D 400 units p.o. q. day 11. Gabapentin 800 mg in the morning and 400 mg in the afternoon and 800 mg at night. 12. Vancomycin 1.5 gm intravenously q. 24 hours to complete a two week course. 13. Combivent 2 puffs inhaler b.i.d. SOCIAL HISTORY: History of tobacco use, rare alcohol use. Lives with her cousin. [Name (NI) ] refused rehabilitation in the past and has visiting nurses. FAMILY HISTORY: The patient has a father and brother with chronic obstructive pulmonary disease. A sister with breast cancer. PHYSICAL EXAMINATION: On admission vital signs with temperature 98.3, blood pressure 108/52, pulse 70, respirations 14, 95% on 2 liters oxygen by nasal cannula. General: Lethargic, overweight woman answering questions appropriately but answering slowly. Left upper extremity and left lower extremity appeared to be twitching intermittently in no acute distress, breathing comfortably. Head, eyes, ears, nose and throat: Sclera anicteric, eyelids dropping bilaterally. Mucous membranes moist. Chest, decreased breath sounds at the left lower base, greater than right lower base, no egophony, scattered expiratory and inspiratory wheezing. Cardiovascular, regular rate and rhythm, II/VI diastolic murmur best heard at the left upper sternal border. Abdomen: Soft, obese, nontender. Good bowel sounds, no rebound, no guarding. Extremities: 2+ lower extremity pitting edema, left greater than right. Positive asterixes. Neurologic: Lethargic but easily arousable. Oriented times three. Speech fluent. Pupils asymmetric from previous cardiac surgery but reactive to light, able to close eyes against resistance bilaterally. Sensation over face intact. Says saliva comes out of the right corner of her mouth but face and smile appears symmetric. Able to puff cheeks against resistance. Tongue midline. Grip [6-2] bilaterally. Sensation intact bilaterally. Reflexes, toes equivocal bilaterally, no clonus, positive asterixes. LABORATORY DATA: Laboratory data on admission revealed white blood count 13.3 with 76 polys, 15 lymphocytes, no bands, hematocrit 32.3, platelets 408. Chemistry was significant for a potassium of 5.8, bicarbonate 23. His creatinine was 4.9, BUN 38. Electrocardiogram showed sinus rhythm at 70 with questionable right bundle branch block, no peak T waves, left axis deviation. Chest x-ray showed unchanged cardiomegaly and position of left-sided pacemaker. NO evidence of congestive heart failure or focal pulmonary parenchymal consolidation. Unchanged bibasilar and interstitial markings. HOSPITAL COURSE: (By problem) 1. Acute renal failure - The patient's urine electrolytes were checked and her FENA was found to be 0.3 indicating likely a prerenal etiology. Urine was negative for eosinophils. The patient had a renal ultrasound which was negative for hydronephrosis or obstruction. The patient's creatinine continued to climb in the initial 24 hours of admission. Her maximum creatinine was 6.0. At this time, the patient was still making a small amount of urine. A renal consult was obtained and followed the patient closely during her hospitalization. It was thought the patient may have a mixture of prerenal etiology as well as acute tubular necrosis. It is unclear if the patient had any ingestions prior to her admission as she was a poor historian. She does suffer from chronic lower back pain and may have ingested some non-steroidal anti-inflammatory drugs. The patient was also on Vancomycin since her last admission with extremely high levels of 73.1 on the day after admission. The patient's levels trended downward and on the day of this dictation are 37.4. It was thought that this may also have been renal toxic. At the time of this dictation, the patient's etiology of her renal failure remains somewhat unclear. [Name2 (NI) ] [Last Name (un) ] medication was held as well as any diuresis. The patient was given a small fluid challenge in the Intensive Care Unit with 1 unit of packed cells and approximately 2 liters of intravenous fluids. The patient's creatinine did respond to this and began to trend downward. Her urine output greatly improved and on the day prior to transfer to the floor, the patient was making urine at greater than 50 cc/hr. Please see addendum to this dictation for further workup and treatment of the patient's acute renal failure. 2. Delta MS - On the day after admission, the patient was found with a depressed mental status. she was alert to voice but not very arousable. A blood gas at that time showed a pH of 7.18, pCO2 of 67 and pO2 of 81. Lactate was 0.7. The patient's hypercarbia was felt to be due to some respiratory depression of unclear etiology. There was a possibility that the patient had ingested some narcotics for lower back pain at home prior to admission. The patient was transferred to the Intensive Care Unit after initiation of BiPAP on the floor on [Hospital Ward Name 517]. Upon arrival to the Intensive Care Unit, the patient continued to have hypercarbia. It was thought that the patient might be progressing towards intubation. However, a trial of intravenous Narcan times two at 0.4 mg was given to the patient for the thought of recent narcotic use. The patient had instant and dramatic improvement in her mental status upon injection of Narcan. It was thought that with the patient's acute renal failure, recent narcotic use may not have cleared. The patient's mental status continued to improve and her blood gases began to look less hypercarbic. She was transitioned to a nasal cannula at 4 liters and did well over the next two days. The patient was continued on her BiPAP at 10/5 in the evening for her known obstructive sleep apnea. The patient maintained good saturations during her admission and oxygenation was not an issue. The patient's hypercarbia was likely contributing to poor mental status and once resolved, the patient's mental status was at her baseline. 3. Fevers - The patient has a questionable left lower lobe infiltrate on her x-ray with a recent confirmed Methicillin-resistant Staphylococcus aureus pneumonia. Her Vancomycin level remained very elevated during her admission and she would not redose Vancomycin during her [Hospital Unit Name 153] course. Upon transfer to the floor, she was on day #10 of Vancomycin. She was also treated empirically with Levaquin beginning on her last admission for presumed community acquired pneumonia. She is currently on day #10 of this, at renal dosing. The patient was pancultured with no growth to date on her cultures during this admission. 4. Hypotension - The patient's hypotension resolved after initial overnight stay on the regular medicine floor. The patient's blood pressure medications were held. She was given gentle fluid challenges during her stay in the Intensive Care Unit with good response. On day of transfer to the floor, the patient actually became hypertensive, it was thought that we should continue to hold her [Last Name (un) ] and now a trial of Nifedipine was started as this was thought to increase renal blood flow. 5. Obstructive sleep apnea - The patient was continued on her BiPAP at 10/5 during this admission. 6. Coronary artery disease - The patient had no acute chest pain during this admission, however, she did have a troponin leak with normal MB index. The patient's electrocardiogram was without any changes. It was thought that the patient may have had a troponin leak in the setting for initial hypotension and in the setting of acute renal failure, this was difficult to interpret. There was no workup for acute ischemia, and the patient's troponin began to trend down. She was continued on her Atorvastatin. She was not started on Aspirin in the setting of her acute renal failure. She is not on a beta blocker currently and we did not start one in her [Hospital Unit Name 153] course due to her chronic obstructive pulmonary disease, intermittent wheezing and oxygen requirement. 7. Fluids, electrolytes and nutrition - The patient was kept NPO for her stay in Intensive Care Unit until her mental status improved. Once her mental status improved she had a great appetite. She was started on PhosLo for a phosphorus of 7.7. 8. Prophylaxis - The patient was given subcutaneous heparin and intravenous Famotidine and was switched to p.o. Famotidine. 9. Contacts - The patient's brother [Name (NI) ] as well as her cousin were the patient's contacts. The patient's cousin and proxy was currently hospitalized at [Hospital6 1708]. The most contact with the patient's cousin was made through the patient's primary care physician, [Last Name (NamePattern4) ] .[Doctor Last Name ]. DISPOSITION: The patient was discharged to the floor on [2145-5-1] in stable condition. Please see addendum to this discharge summary for further discharge planning and medications as well as hospital course upon transfer to general medical service. DR. [First Name8 (NamePattern2) ] [Name (STitle) ], 17-AFO Dictated By:[Last Name (NamePattern1) 9244] MEDQUIST36 D: [2145-5-1] 18:08 T: [2145-5-1] 18:39 JOB#: [Job Number 30897]	[ "5845", "4280", "4019", "41401" ]
Admission Date: [2134-5-5] Discharge Date: [2134-5-11] Date of Birth: [2053-11-19] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 5790] Chief Complaint: T3 mid esophageal lesion and dysphagia Major Surgical or Invasive Procedure: [2134-5-7] Left Port-A-Cath via cephalic vein access and a PEG tube. [2134-5-7] Evacuation of left port-a-cath hematoma History of Present Illness: The patient is an 80-year-old gentleman with esophageal cancer who presents for feeding tube access and port for chemotherapy. Past Medical History: HTN Social History: The patient lives alone in [Hospital3 4634] near the Symphony. He has a son who is an anesthesiologist and practices locally. His son is married and has three children. The patient smoked 10 cigarettes per day, but quit in [2120]. He smoked for approximately 25 years. He came to the United States in [2120]. In [Country 651], he worked previously in importing business. The patient drinks alcohol rarely. Family History: NC Physical Exam: Discharge Vital Signs: T: 97.0 BP: 112/62 HR 65 SR RR 18 O2 sats:96% Discharge Physical Exam: Gen: pleasant in NAD, A & O x 3 Lungs: clear b/l CV: RRR S1, S2 no MRG Abd: soft, NT, ND, PEG intact without redness, purulence or drg Ext: warm without edema. L portacath with eccyhmosis near axilla without swelling,drg or redness near site, incision covered with dermabond. Pertinent Results: [2134-5-8] 07:20AM BLOOD WBC-6.2 RBC-4.10* Hgb-13.8* Hct-39.1* MCV-95 MCH-33.7* MCHC-35.4* RDW-13.7 Plt Ct-126* [2134-5-5] 04:05PM BLOOD WBC-4.8 RBC-4.47* Hgb-14.9 Hct-42.1 MCV-94 MCH-33.3* MCHC-35.4* RDW-13.9 Plt Ct-146* [2134-5-8] 07:20AM BLOOD Glucose-141* UreaN-10 Creat-1.0 Na-139 K-3.8 Cl-105 HCO3-26 AnGap-12 [2134-5-5] 04:05PM BLOOD Glucose-101* UreaN-18 Creat-0.9 Na-138 K-3.9 Cl-104 HCO3-26 AnGap-12 [2134-5-8] 07:20AM BLOOD Calcium-8.4 Phos-2.7 Mg-1.8 CXR [2134-5-7] REASON FOR EXAMINATION: Evaluation of the patient after Port-A-Cath placement. Portable AP chest radiograph was reviewed in comparison to CT torso from [2134-4-24]. The Port-A-Cath catheter was inserted through the left central venous approach. The tip is at the level of cavoatrial junction. There is no evidence of pneumothorax. The heart size and mediastinal silhouettes are stable. No interval development of focal consolidation or interstitial abnormalities were noted. Pulmonary nodules seen on the CT torso are below the resolution of chest radiograph. Brief Hospital Course: Mr. [Known lastname ] was admitted to Thoracic surgery service, ICU on [2134-5-4] after EUS for esophageal cancer, for complaints of dysphagia. Urgent endoscopy was done and food bolus was seen, on [2134-5-5]. The patient was stable after resolution of food bolus, and then transferred to the floor, NPO with IV fluids. Radiation and medical oncology teams were consulted and after discussion with the patient and his son, it was decided to go forth with chemotherapy and radiation therapy. A port-a-cath and feeding tube were requested, therefore Dr. [Last Name (STitle) ] took the patient down to the operating room late on [2134-5-7] for a left Port-A-Cath via cephalic vein access and a PEG tube. He went back that evening for evacuation of left hematoma of port-a-cath site. Below is a systems review of his hospital course: Pulm: Incentive spirometry and early mobilization were utilized. CV: The patient remained hemodynamically stable in NSR. GI: The patient was kept NPO and hydrated with IVF. Nutrition: Nutrition consulted and recommended Fibersource HN at 70ml/hour x 24 hours. POD 1 this was started and tolerated. On [5-10] this was switched to bolus feedings, of 7 cans a day. The patient returned repeat demonstration on bolus feedings through his PEG. Renal: The patient voided well throughout his stay. Proph: SQ heparin and SCD's were instituted to prevent VTE. ID: No active ID issues throughout this stay. Pain/Neuro: The patient remained neurologically intact throughout his stay, Mandarin interpretor was used. His pain was initially controlled with IV dilaudid then controlled with prn roxicet, with 1/10 pain on discharge without pain medication. DISPO: Physical Therapy saw the patient and felt he would be find for home with stabilization device, and gave him a cane. The patient lives alone, therefore VNA services established. Social worker, case management, and [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Cancer navigator all met with the patient and discussed home discharge with him and his son, given that the patient lives alone in [Hospital3 4634]. Community supports were initiated to assist the patient. Please see social work notes for full details. The patient was discharged home on [2134-5-11] with his son and tube feeds and supplies. Medications on Admission: HCTZ 25mg po daily Discharge Medications: 1. Tube feedings Formula: Fibersource Bolus feedings: 2 cans of fibersource through G-tube at breakfast, lunch and dinner. One can at 8pm. Water flush: Before and after each feeding flush G-tube with 50ml of water. Supply with 60ml syringe for bolus feeding. 2. shower chair as needed for safety while showering Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Esophageal cancer Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Call Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 2348] if you have: fevers greater than 101.5, chills, shakes, nausea, vomiting, diarrhea, abdominal pain, shortness of breath, cough of chest pains. Call if left port-a-cath site becomes swollen or incision becomes red, or drains. Call if your feeding tube becomes clogged or falls out. PEG tube site: [Month (only) 116] leave open to air. Activity: You may shower. Walk several times a day and use the incentive spirometer at home. Pain: You may get over the counter liquid acetaminophen if you have pain. Followup Instructions: Followup with Dr. [Last Name (STitle) ] of radiation oncology on [2134-5-13] at 10am Location: [Location (un) 442] treatment planning. The following appointments are located on [Hospital Ward Name ] [Location (un) ] [Hospital Ward Name 23] center: Provider: [First Name8 (NamePattern2) 251] [Name11 (NameIs) ], MD Phone:[0-0-] Date/Time:[2134-5-20] 9:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 12633], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2134-5-20] 9:00 Provider: [Name10 (NameIs) 8111] [Name11 (NameIs) 8112], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2134-5-20] 10:00 Dr. [Last Name (STitle) ] [2134-5-20] at 2:30pm [Hospital Ward Name 23] [Location (un) ] Completed by:[2134-5-12]	[ "4019", "V1582" ]
Admission Date: [2174-8-18] Discharge Date: [2174-8-19] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2485] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: 89 yo woman who is a nursing home resident with dementia here with increasing hypoxia, hypotension and rapid afib, this morning at rehab while being escorted to bathroom, just passed out, caught by support staff, she did not fall, but the could not get a BP or O2sat so called 911. [Name8 (MD) ] NP at [Hospital3 2558], she had had a pna 6 weeks ago that was not clearing with associated wheezing and so was started on steroids which have slowly been tapered. On [8-9] was noted to be more lethargic and had a positive UA and so was started on levofloxacin for 10 day course. Today as above episode of syncope and per EMS vitals Sat 95% on RA, P 149-160 and HR 100/60. In ED, HR 160 with BP initially 160/24, but then 105/65 and given diltiazem 10mg x 2 and then started on ditiazem gtt at 5mg/hr, also given 4L NS, ceftriaxone 1gm x1 and azithro 500mg x1, tylenol and then transferred to [Hospital Unit Name 153] for monitoring, given borderline BP's. On arrival here, pt appears comfortable off O2, b/c she pulled it off with sats 90-93%, HR 115 in fib and BP 74/56, after pt stablized, spontaneously converted to sinus rhythym with HR 69 and BP 74/56. Diltiazem stopped and given fluid bolus. Per sister here, pt has advanced dementia and does not recognize any of her family memebers and has not been any different recently, mostly non-communicative. Past Medical History: MR [Name13 (STitle) ] dementia atypical psychosis depressive d/o with hx of suicidal ideations elevated alk phos osteopenia weight loss Social History: Russian speaking lives at nsg home, had previously lived by self, but too much to care for by self and for 2yrs in Nsg home, only son died [2170] of pancreatic ca. Sister is visiting from chigcago, pt's granddaughter is HCP, [Name (NI) 62943] [Name (NI) 62944] [Telephone/Fax (1) 62945]. Family History: son died of pancreatic ca Physical Exam: VS: T 96.8ax P 118 (118--151) BP 150/126(91--160/58-126) R 24 Sat 88-93%on RA GEN awake, elderly woman, not responding to questions, moving all extremities HEENT PERRL, +tardive dyskinesia with lip smacking, flat JVP CHEST CTAb, poor resp air mvmt, possibly slightly decreased sounds at RLL CV irregularly, irregular, +3/6 SEM best heard at apex Abd soft NT/NS, +BS EXT no edema, slight area of erythema on left hip Pertinent Results: Labs on admission: [2174-8-18] 09:10AM BLOOD WBC-8.1 RBC-5.07 Hgb-14.2 Hct-42.8 MCV-84 MCH-28.0 MCHC-33.2 RDW-13.3 Plt Ct-335 [2174-8-18] 09:10AM BLOOD Neuts-62.7 Lymphs-27.2 Monos-4.6 Eos-5.3* Baso-0.1 [2174-8-18] 09:10AM BLOOD PT-13.0 PTT-26.8 INR(PT)-1.1 [2174-8-18] 09:10AM BLOOD Glucose-124* UreaN-13 Creat-0.9 Na-141 K-4.2 Cl-103 HCO3-23 AnGap-19 [2174-8-18] 09:10AM BLOOD CK(CPK)-43 [2174-8-18] 09:10AM BLOOD cTropnT-<0.01 [2174-8-19] 01:30AM BLOOD CK(CPK)-66 [2174-8-19] 01:30AM BLOOD CK-MB-5 cTropnT-0.02* [2174-8-19] 01:30AM BLOOD Calcium-8.0* Phos-1.9* Mg-1.7 [2174-8-18] 09:10AM BLOOD TSH-4.2 [2174-8-18] 10:54AM BLOOD Lactate-1.5 EKG: Afib with RVR rate 160bpm, ST depressions in II, aVF, v2, v3, v4 after converting, NSR at 69bpm, nl axis, no [Name Prefix (Prefixes) ] [Last Name (Prefixes) 62946] or LVH, borderline QT, Twave flattening inferiorly . CXR: prelim with RLL infiltrate, no effusions or cardiomegaly Brief Hospital Course: A/P: 89 yo nursing home pt here with RLL pna, new afib and hypotension in setting of Afib with RVR and likely hypovolemia. . Pna: with RML/RLL infiltrate, but no white count, fevers, likley aspiration pneumonitis especially given nursing home's hx of poor po's at baseline with dementia and is on a pureed diet at baseline. Initially started on ceftriazxone/azithro, for CAP and then flagyl added for possible aspiration, but as not signs of pna clinically. All abx were d/c'd and can possibly restart flagyl if needed. She had been started on prednisone at NSH [Name6 (MD) ] her NP for bronchospasm from persistent pna about 6 weeks ago and was on a slow taper, currently at 5mg, but as she did not need this and was at a physiologic dose, this was discontinued. Her CXr did have concern for obtuse angle of her carina for possible left atrial enlargement vs mass effect and elevated left hemi-diaphragm, as [Last Name (LF) 62947], [First Name3 (LF) ] just reccommend follow up CXR in a few weeks time to make sure stable. . UTI: positive UA at NSH and had completed 7days of levofloxacin and no further need as UA here without signs of infection. . Hypotension: likley hypovolemia and rate related. Improved with fluid boluses and rate control. Diltiazem was stopped after she spontaeously converted after arrival in [Hospital Unit Name 153]. She received a few fluid boluses, with good BP response and at time of d/c was off IVF and toelrating some po's. Hypotension not thhought to be related to sepsis, without leukocytosis, fevers, lactate or other signs of overwhelming septic infection. . syncope: witnessed event am of admission while walking, most likely related to decreased perfusion with hypotension from Afib with RVR and dehydration. She improved with rate control and volume rescusitation and no further events. . Afib: new, isolated afib, spontaneously converted after rate control. Ruled out, but most likley trigger was hypoxia or volume depletion. Her baseline BP is good and HR in sinus was in the 60's so no nodal agents were added and she has no need for anticoagulation given this was an isolated event. . dementia: stable at baseline, cont nsg home meds as needed. . FEN: IVf as needed, pureed diet . CODE: FULL, will need to discuss with her guardian, who has been newly appointed per PCP, [Name10 (NameIs) ] need discussion of goals, but were unable to reach during this hospital stay. Medications on Admission: lexapro 20mg qd prednisone 5mg qd mirtazapine 7.5qhs aricept 10mg qd risperidol 1mg qhs trazadone 25mg qhs MVI maalox 30 ml prn bisacodyl prn guiafenacin prn tylenol prn colace 50mg [Hospital1 ] levoquin 500mg qd started on [2174-8-10] Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: aspiration pneumonitis hypotension volume depletion atrial fibrillation with rapid ventricular rate alzheimer's dementia atypical psychosis Discharge Condition: good, breathing comfortably on room air sats around 95-97%, HR in 60's and SBP>100 Discharge Instructions: Please call or return if you become more short of breath, start coughing or have fevers. Please take all medications as prescribed. Followup Instructions: Please follow up with your PCP at your nursing home. Completed by:[2174-8-19]	[ "5070", "42731" ]
Admission Date: [2160-7-3] Discharge Date: [2160-7-23] Service: Medicine, [Hospital1 139] Firm HISTORY OF PRESENT ILLNESS: This is a 77-year-old male who was admitted on [2160-7-3], to the Medical Intensive Care Unit for hypotension. Mr. [Known lastname ] was sent to the Emergency Department after he was found by his primary medical doctor to be hypotensive to 70/30. For several days prior to this admission the patient reports increased weakness and lightheadedness, particularly upon standing. He also complains of weight loss of approximately 10 pounds. This patient was recently admitted to the [Hospital1 346] from [2160-6-15] to [2160-6-22]. During this admission he was found to be in atrial fibrillation, and in the setting of anticoagulation for this condition developed a gastrointestinal bleed. Endoscopy revealed peptic ulcer disease (duodenal ulcers), and the patient was also found to be H. pylori positive. After being hemodynamically stabilized the patient was discharged on amoxicillin, clarithromycin, and a proton pump inhibitor for treatment of his H. pylori infection. In the Medical Intensive Care Unit the patient was found to have a central venous pressure of 1.5. He was placed on dopamine which was quickly weaned off. The patient responded well to aggressive hydration. An echocardiogram was done which showed an [Year (4 digits) ] fraction of greater than 55%, mild aortic insufficiency, moderate-to-severe tricuspid regurgitation, and mild pulmonary hypertension. Cardiac enzymes were cycled, and the patient was ruled out for a myocardial infarction. His heart rate in the setting of atrial fibrillation was controlled with Lopressor. The patient also developed low-grade fevers during his Medical Intensive Care Unit stay of 100 to 100.7. Blood and urine cultures were all negative. Chest x-ray was normal. No source of infection was found during the [Hospital 228] Medical Intensive Care Unit stay. At the time of transfer to the Medical floor on [2160-7-5], the patient felt well. His only complaint was the development of a cough. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post myocardial infarction in [2139], 2-vessel coronary artery bypass graft in [2139], anterior myocardial infarction in [2156], and percutaneous transluminal coronary angioplasty and stenting of saphenous vein graft in [2156]. 2. History of congestive heart failure. 3. Atrial fibrillation since [2160-5-25]. 4. Hypertension. 5. High cholesterol. 6. Peptic ulcer disease, status post upper gastrointestinal bleed in [2160-5-25]. 7. Gastroesophageal reflux disease. 8. Diverticulosis. 9. Ventral hernia. 10. Questionable history of prostate cancer. 11. Type 2 diabetes mellitus times 20 years. 12. Peripheral vascular disease. 13. Status post appendectomy. MEDICATIONS ON ADMISSION: Medications on admission were glyburide 10 mg p.o. b.i.d., Diovan, insulin, Lipitor, allopurinol, Zantac, Cardura, Lopressor, multivitamin. ALLERGIES: MORPHINE causes gastrointestinal upset. SOCIAL HISTORY: The patient denies tobacco or alcohol use. PHYSICAL EXAMINATION ON ADMISSION: Temperature was 97.9, heart rate was 110 and irregular, blood pressure was 105/65, oxygen saturation was 97% on room air. In general, the patient was comfortable, alert and oriented. HEENT revealed anicteric sclerae. Extraocular muscles were intact. Pupils were equal, round, and reactive to light. Mucous membranes appeared dry. Neck examination revealed the patient had a large V-wave in the jugular venous pulse. Neck was supple. Cardiovascular examination was irregular, a 2/6 systolic murmur at the left lower sternal border. No gallops. Pulmonary examination showed increased expiratory phase and crackles at the right base. Abdominal examination revealed soft, nontender, and nondistended, positive bowel sounds. No masses. No hepatosplenomegaly. Rectal examination was heme-positive in the Emergency Department. Extremities revealed no edema. Right leg had diffuse purple bruising which the patient reported to be one week old. The patient stated that he had seen an orthopaedic surgeon for this and was told that he had a torn hamstring. LABORATORY DATA ON ADMISSION: White blood cell count of 6.3, hematocrit of 34.3, platelets of 121. Differential was 63 neutrophils, 2 bands, 2 nucleated red blood cells, 1 atypical cell, 1 meta cell, and 25 lymphocytes. Chem-7 revealed sodium of 135, potassium 4.5, chloride 101, bicarbonate 24, BUN 45, creatinine 1.9, and glucose of 60. RADIOLOGY/IMAGING: Chest x-ray was unremarkable. Electrocardiogram showed no changes from previous study on [2160-6-20]. HOSPITAL COURSE: (Since transfer to the medical floor). On transfer to the medical floor a workup for a source of the patient's fevers was continued. Because of the patient's complaint of cough, a chest x-ray was performed which showed right middle lobe infiltrated. On [2160-7-6], the patient was started on Levaquin to treat empirically for pneumonia. On [7-7], 1/2 bottles of the patient's blood cultures grew gram-positive cocci. However, since central line had been removed it was determined not to treat this, but to re-culture. All further blood cultures were negative. On [7-8], a CT of the abdomen was performed to evaluate for abdominal sources of infection which was unremarkable. A repeat chest x-ray showed right middle lobe and retrocardiac opacities. The patient continued to spike fevers and had intermittent episodes of hypotension to approximately 80/50. These episodes responded well to small fluid boluses. At this time the Infectious Disease Service was consulted. Many cultures and serologies suggested by Infectious Disease were performed. None yielded a source of infection for this patient. Levofloxacin was discontinued on [7-12] due to concern that the patient was still spiking fevers after seven days of treatment. Blood cultures and urine cultures were done while the patient was off antibiotics which also did not yield an organism. On approximately [2160-7-14], the patient's fever spikes subsided into a consistent low-grade temperature. Although there had been a mild improvement in clinical status, the patient did not appear to be continuing to improve. Therefore, on [7-16] a bronchoscopy was performed with bronchoalveolar lavage. The lavage showed gram-positive cocci on the Gram stain but no growth occurred on culture. Multiple studies for viral and other pathogens were also negative. The patient was subsequently placed back on levofloxacin for an expected 3-week course. The patient showed slow but consistent improvement over the next few days. On [2160-7-18], the patient was noted to have left lower extremity swelling, and Doppler studies were positive for deep venous thrombosis of the popliteal to common femoral veins. The patient was started on Lovenox. By the time of discharge, the patient's cough had markedly subsided. He had been afebrile for several days, and he had good oxygen saturations off of oxygen both at rest and with ambulation. MEDICATIONS ON DISCHARGE: 1. Protonix 40 mg p.o. b.i.d. 2. NPH 14 units subcutaneous q.a.m. and 10 units subcutaneous q.p.m. 3. Ferrous gluconate 300 mg p.o. t.i.d. 4. Lipitor 10 mg p.o. q.d. 5. Lopressor 50 mg p.o. b.i.d. 6. Cozaar 25 mg p.o. q.d. 7. Levaquin 500 mg p.o. q.d. (to be continued until [2160-8-6]). 8. Lovenox 60 mg subcutaneous b.i.d. 9. Tylenol 650 mg p.o. q.4-6h. p.r.n. 10. Serax 15 mg p.o. q.h.s. p.r.n. for insomnia. 11. Cepacol lozenges p.r.n. 12. Tessalon Perles 100 mg p.o. t.i.d. p.r.n. for cough. 13. Regular insulin sliding-scale. DISCHARGE STATUS: The patient was discharged to a rehabilitation facility. DISCHARGE FOLLOWUP: Followup by Dr. [First Name (STitle) 1313]. CONDITION AT DISCHARGE: The patient was stable for discharge to a rehabilitation facility. DISCHARGE DIAGNOSES: 1. Bilateral pneumonia. 2. Left lower extremity deep venous thrombosis. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 31943], M.D. [MD Number(1) 31944] Dictated By:[Last Name (NamePattern1) 15468] MEDQUIST36 D: [2160-7-22] 18:18 T: [2160-7-22] 17:46 JOB#: [Job Number ]	[ "42731", "42789", "41401", "53081", "4019" ]
Admission Date: [2194-12-7] Discharge Date: [2194-12-23] Date of Birth: [2118-3-21] Sex: M Service: CARDIOTHORACIC Allergies: Amiodarone Analogues Attending:[First Name3 (LF) 1505] Chief Complaint: severe aortic stenosis, coronary artery disease Major Surgical or Invasive Procedure: liver biopsy CABG x1 (LIMA->LAD), AVR (19mm CE magna) [12-18] History of Present Illness: Mr. [Known lastname 30842] is a 76-year-old male, with known severe critical aortic stenosis that has been followed and now reached a level of 0.5 cm2 by echocardiography, who [Known lastname 1834] cardiac catheterization that confirmed the presence of critical aortic stenosis and showed an 80-90% proximal left anterior descending stenosis, with a 70% stenosis of a small ramus branch. He is presenting for valve and coronary surgery. The ejection fraction is preserved. Past Medical History: idiopathic thrombocytopenic purpura hepatitis C x8-10years coronary artery disease aortic stenosis hypertension hyperlipidemia atrial fibrillation pulmonary fibrosis secondary to amiodarone squamous cell CA of the RLE PSH: TURP [2171] hernia repair [2171] Social History: quit smoking 13 years ago rare use of alcohol Family History: Father: diabetes, died at age 55yo from unknown causes Mother: died in 70s Physical Exam: T 98.6 HR 73 BP 129/72 RR 18 97%RA NAD RRR, incis: c/d/i CTAB s/nt/nd, +BS no c/c/e Pertinent Results: [12-8] Carotids FINDINGS: Duplex evaluation was performed of both carotid arteries. Minimal plaque was identified. On the right, peak systolic velocities are 62, 66, 66 in the ICA, CCA, ECA respectively. The ICA to CCA ratio is 0.9. This is consistent with no stenosis. On the left, peak systolic velocities are 59, 54, 73 in the ICA, CCA, ECA respectively. The ICA to CCA ratio is 1.1. This is consistent with no stenosis. There is antegrade flow in both vertebral arteries. [12-10] abdominal u/s: FINDINGS: The liver is normal in echotexture without focal lesions. Gallbladder contains several layering stones without signs of cholecystitis. Common bile duct is normal in diameter measuring 0.4 cm. The pancreas is unremarkable. The aorta is normal in diameter. The right kidney measures 10.1 cm in length. There is a caliceal diverticulum in the upper pole containing calcium with an additional 0.6 x 4.2 x 1.0 cm simple cyst. The spleen is normal in size measuring 10.2 cm. [2194-12-12] Liver needle biopsy: 1) Mild portal chronic, predominantly mononuclear cell, inflammation. 2) Focal, mild steatosis. 3) Trichrome stain: Focal mild portal fibrosis. 4) Iron stain: No stainable iron. [2194-12-7] 03:40PM BLOOD WBC-6.9 RBC-4.50* Hgb-14.6 Hct-43.3 MCV-96 MCH-32.4* MCHC-33.8 RDW-12.5 Plt Ct-74* [2194-12-18] 11:05AM BLOOD WBC-12.5* RBC-2.43# Hgb-8.3# Hct-24.3# MCV-100 MCH-34.2* MCHC-34.2 RDW-12.8 Plt Ct-63* [2194-12-18] 05:06PM BLOOD WBC-15.0* RBC-3.51# Hgb-11.4# Hct-32.5# MCV-92# MCH-32.4 MCHC-35.1* RDW-15.1 Plt Ct-148# [2194-12-23] 07:05AM BLOOD WBC-14.1 RBC-4.28* Hgb-13.8* Hct-39.9* MCV-93 MCH-32.1* MCHC-34.5 RDW-15.1 Plt Ct-54* [2194-12-21] 05:30AM BLOOD PT-14.4* INR(PT)-1.4 [2194-12-22] 07:30AM BLOOD PT-14.1* INR(PT)-1.4 [2194-12-10] 07:25AM BLOOD HCV Ab-POSITIVE Brief Hospital Course: Mr. [Known lastname 30842] was admitted to the Cardiac Surgery service under the care of Dr. [Last Name (STitle) ]. Given his low platelet counts (74) at [Hospital1 ] and at [Hospital1 18], a hematology consult was obtained for further evaluation. His thrombocytopenia had been previously documented and worked up by Dr. [Last Name (STitle) 30843]. An abdominal ultrasound showed no signs of splenomegaly and his heparin-dependent antibody assay was negative. In addition, the Hepatology team was asked to evaluate Mr. [Known lastname 30842] for his thrombocytopenia in the presence of HCV. On [12-12], Mr. [Known lastname 30842] [Last Name (Titles) 1834] an ultrasound-guided liver biopsy. The results were mild portal chronic, predominantly mononuclear cell, inflammation; and focal, mild steatosis. Mr. [Known lastname 30842] was cleared for surgery by the Hematology and Hepatology teams. His chronic thrombocytopenia was attributed to either ITP or HCV. He received platelet transfusions pre-operatively. On [12-18], he [Month/Year (2) 1834] his CABG x1 and AVR without complications. Please see Dr.[Name (NI) 5572] Operative Note for further detail. Post-operatively, he did well. He was extubated, his chest tubes removed, and transferred to the floor by POD #2. His platelet and hematocrit levels were closely followed. By the time of discharge on POD #5, his epicardial wires were removed, he was evaluated by physical therapy, had good pain control, and was tolerating a regular diet, although complained of poor appetite. His Coumadin was restarted on [12-20] for his atrial fibrillation. Medications on Admission: Coumadin 2.5mg PO daily Atacand 32mg PO daily Lopressor 100mg PO BID Insulin NPH 22 [Hospital1 ] Glucotrol 5' Digoxin 0.125' Lipitor 20' Celexa 20' Protonix 40' Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: titrate for INR between 1.5-2.5. 7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: for [Date range (1) 24295]. 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: to start [Date range (1) 30844]. 12. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Humulin N 100 unit/mL Suspension Sig: Eleven (11) units Subcutaneous twice a day. 15. Humalog 100 unit/mL Cartridge Sig: One (1) Units Subcutaneous four times a day as needed for hyperglycemia: insulin sliding scale. Discharge Disposition: Extended Care Facility: [Hospital1 ] - [Location (un) 47] Discharge Diagnosis: idiopathic thrombocytopenic purpura coronary artery disease aortic stenosis diabetes hyperlipidemia atrial fibrillation hepatitis C Discharge Condition: Good Discharge Instructions: If you have any chest pain, difficulty breathing, persistent nausea/vomiting, redness/oozing from your incision site, seek medical attention immediately. Followup Instructions: Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 6256] Follow-up appointment should be in 2 weeks Provider: [Last Name (Prefixes) 413],[First Name3 (LF) 412] [Telephone/Fax (1) 170] Follow-up appointment should be in 1 month Completed by:[2194-12-23]	[ "41401", "4241", "42731", "25000", "4019" ]
Admission Date: [2166-10-9] Discharge Date: [2166-10-14] Date of Birth: [2080-5-14] Sex: F Service: MEDICINE Allergies: Macrobid Attending:[First Name3 (LF) 1943] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: EAST HOSPITAL MEDICINE ATTENDING [Hospital ] TRANSFER TO FLOOR ACCEPT NOTE The patient is an 86 yo F with h/o orthostatic hypotension and recent SAH in [6-/2166] sustained following a mechanical fall who presented to the ED this evening with acutely altered mental status with incoherent speech. For the past week, she has been having b/l "body" tremors including UE and head. The episodes last about 10 mins and are low amplitude. Her daughter describes an episode where she begins to fall following the episode, but that she is speaking during the event and is not confused either during or after the episode. She also has been experiencing a [Hospital1 ]-temporal headache that began on Wednesday evening and was associated with decreased appetite, nausea and vomiting. The daughter's report that their mother described it as pressure like on both sides of her head. On the night prior to admission, she got up to use the bathroom and reported sustained a mechanical fall on to her left hip (not uncommon for her according to her daughter), following which she was "normal" and went back to sleep. She woke up in the morning, her home health associate noted that she "was not her self" and took her to see her PCP. [Initials (NamePattern4) ] [Last Name (NamePattern4) 91538] head CT (NCHCT) was done and reportedly negative. She also had left hip films which revealed fractures of the L superior and inferior pubic rami (subacute vs old) with minor degenerative changes. Her BP was recorded at 124/70. Of note, the patient sustained a hip fracture over the summer. Upon returning home, she slept from 2pm-5pm and upon wakening, she was acutely altered and confused with incoherent speech and was brought to the ED. In the ED, inital vitals were, 191/127, 94, 22, 98% on RA. A Code Stroke was called. She was electively intubated due to agitation so that she could undergo her imaging studies. A NCHCT preliminary showed no acute intracranial process. As per the neuro consult note, a CTA of the head and neck showed normal vasculature with no thrombi or dissections and a CT perfusion study did not reveal any perfusion deficits. She was not given tPA as she thought to be outside of the therapeutic window. Neurology reported her neuro exam was non localizing and that the etiology of her AMS was not entirely clear. They are concerned for PRES or a hypertensive encephalopathy given her dramatic swings in BP. Of note, during her ED course, she spiked a fever to 102 F and was also found to have a UA c/w UTI and was given ceftriaxone. She was then transfered to the ICU for further management. Vitals on transfer were, 103/79 98 RR 16 on vent, Vt 400, PEEP 5, FiO2 50%. She was hypertensive on arrival with a recorded SBP of 190. She was not given antihypertensives, however following sedation with propofol her SBP was in the 140s. She was switched from propofol to fent/versed just prior to transfer. Of note, she dropped her BP to 82/55 while being moved to the stretcher and required a 500cc bolus. Her BP then improved to 106/66. In the ICU, her UTI was treated with bactrim. She was subsequently extubated and her mental status was found to be at baseline. In the ICU, her UTI was treated with bactrim. She was transferred to the medicine floor for further management. On the medicine floor, she reports no problems. She endorses left hip pain only when she is moving around. She denies headache, chest pain, shortness of breath, diarrhea, fevers, chills, nausea, vomitting. Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies visual changes, headache, dizziness, sinus tenderness, neck stiffness, rhinorrhea, congestion, sore throat or dysphagia. Denies chest pain, palpitations, orthopnea, dyspnea on exertion. Denies shortness of breath, cough or wheezes. Denies nausea, vomiting, heartburn, diarrhea, constipation, BRBPR, melena, or abdominal pain. No dysuria, urinary frequency. Denies arthralgias or myalgias. Denies rashes. No increasing lower extremity swelling. No numbness/tingling or muscle weakness in extremities. No feelings of depression or anxiety. All other review of systems negative. Past Medical History: - Orthostatic hypotension, BP range on average 90-150 systolic. - SAH ([6-/2166]) following ?mechanical fall during which she also sustained a orbital fracture - Hyperlipidema - Urinary incontinence - Hip fracture, noted in [Month (only) 205]. Imaging studies not entirely clear, but daughter reported it is on the L and was incorrectly reported as R on CT. - Chronic LE edema - Chronic hearing Loss - Osteoporosis Social History: Lives by her self, has HHA but not 24 hrs, family attempts to fill gaps in supervision. Has frequent falls primarily [1-29] orthostatic hypotension sustaining injuries including SAH, hip fx, facial fx. Was in rehab following fall from a stair for 6 weeks in Summer [2165]. Family History: Not relevent to presentation of altered mental status and UTI in an 86 y/o F. Physical Exam: VS: 98.2 134/60 89 20 96%RA; 0/10 pain at rest; [7-6] left hip pain with movement GEN: No apparent distress, pleasant HEENT: No trauma, pupils round and reactive to light and accommodation, no LAD, oropharynx clear, no exudates CV: Regular rate and rhythm, no murmurs/gallops/rubs PULM: Clear to auscultation bilaterally, no rales/crackles/rhonchi GI: Soft, non-tender, non-distended; no guarding/rebound EXT: No clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV present; pneumoboots in place NEURO: Alert and oriented to person, place and situation; CN II-XII intact, [5-1] motor function globally DERM: Ecchymoses on left upper posterior thigh/butt Pertinent Results: [2166-10-9] 08:15PM BLOOD WBC-9.8 RBC-3.46* Hgb-11.3* Hct-32.9* MCV-95 MCH-32.6* MCHC-34.3 RDW-13.3 Plt Ct-290 [2166-10-9] 08:15PM BLOOD PT-12.7 PTT-19.8* INR(PT)-1.1 [2166-10-10] 04:30AM BLOOD Glucose-148* UreaN-16 Creat-1.0 Na-136 K-4.2 Cl-102 HCO3-27 AnGap-11 [2166-10-10] 04:30AM BLOOD ALT-6 AST-24 LD(LDH)-153 CK(CPK)-136 AlkPhos-21* TotBili-0.5 [2166-10-9] 08:15PM BLOOD cTropnT-<0.01 [2166-10-10] 04:30AM BLOOD Albumin-3.4* Calcium-8.4 Phos-4.0 Mg-1.6 [2166-10-10] 04:30AM BLOOD TSH-2.4 [2166-10-10] 04:30AM BLOOD VitB12-565 Folate-GREATER TH [2166-10-11] 04:27AM BLOOD Hapto-71 [2166-10-14] 07:05AM BLOOD Glucose-95 UreaN-10 Creat-0.7 Na-139 K-3.5 Cl-103 HCO3-26 AnGap-14 [2166-10-14] 07:05AM BLOOD WBC-8.2 RBC-2.88* Hgb-9.2* Hct-27.2* MCV-95 MCH-32.0 MCHC-33.8 RDW-15.3 Plt Ct-277 URINALYSIS: [2166-10-9] 10:30PM URINE Color-Straw Appear-Hazy Sp [Last Name (un) ]-1.046* [2166-10-9] 10:30PM URINE Blood-SM Nitrite-POS Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG [2166-10-9] 10:30PM URINE RBC-66* WBC-83* Bacteri-MANY Yeast-NONE Epi-0 [2166-10-9] 10:30PM URINE CastHy-2* [2166-10-9] 10:30 pm URINE Site: CATHETER FINAL REPORT [2166-10-12] URINE CULTURE (Final [2166-10-12]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- 8 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING: CTA Head ([2166-10-9]) IMPRESSION: 1. No evidence of infarction, or hemorrhage. 2. No evidence of stenosis, occlusion, or aneurysm . 3. Calcified plaque at the left distal common carotid artery causing approximately 25% stenosis. CXR ([2166-10-9]) IMPRESSION: Endotracheal tube in appropriate position. Trace right pleural effusion. MRI HEAD ([2166-10-10]) IMPRESSION: Limited study. With this limitation in mind, there is no large territorial infarct seen on diffusion-weighted imaging. CT Chest/Abd/Pelvis ([2166-10-11]) IMPRESSION: 1. Massive left gluteal/posterior thigh hematoma measuring 12.9 x 7.7 x 19.8 cm. Active extravasation cannot be assessed given the lack of intravenous contrast material. 2. Multiple old fractures involving the left scapula, left posterior ribs, and left pelvic bones, as described above. 3. Lingular pulmonary nodule measuring 2 mm requires no additional followup if this patient is a non-smoker and has no prior history of malignancy. Otherwise, followup with a chest CT in one year is recommended. Brief Hospital Course: 86 year-old woman with orthostatic hypotension and recent SAH in [6-/2166] following a mechanical fall presented to the ED this evening with acutely altered mental status with incoherent speech. #. Delirium from Metabolic Encephalopathy: The patient presented with an acute alteration in her mental status which was originally concerning for a neurologic origin. A Code Stroke was called and her initial imaging (NCHCT, CTA head, and CT perfusion imaging) did not reveal an acute neurologic cause. Neurology was consulted and recommened an MRI of the head to evaluate for other causes including PRES or hypertensive encephalopathy, and while the study was limited by motion artifact, it did not reveal any neurology abnormalities. Upon arrival, the patient was found to have a UA consistent with a UTI. She was originally treated with antibiotics as below, and her mental status greatly improved and it seems most likely that her AMS was a result of her infection. Upon transfer from the ICU, the patient was reportedly almost back at her baseline mental status which some residual confusion as per her daughter. She was alert and oriented to name and place, and was not oriented to year, but did know that it was [Month (only) 359]. On the floor she is alert and oriented to name, place, and date, but does still get confused sometimes. #. Orthostatic hypotension: Upon arrival to the ICU, the patients blood pressure was highly elevated. Following her intubation, her BP began to drop and fluctuated widely early in her admission. Her home medications for orthostatic hypotension were held and her sedation while intubated was limited to minimize swings in BP. Following extubation, her BP remained more stable and her home medications were restarted. The day of transfer from the MICU, her BP ranged from 123/55 to 166/77. - Continue home midodrine and fludrocortisone #. Urinary Tract Infection, E Coli: Patient's urinalysis was found to be consistent with UTI. She was started on ceftriaxone and her mental status improved as above. When cultures returned, she was transitioned to Bactrim in the ICU. Due to a concern for potential allergy to Bactrim per ICU and per Ucx sensitivities, her Bactrim was changed to ciprofloxacin. 5 total days of antibiotics were administered. #. Anemia: Stable. It was noted that the patients hematocrit had decreased from admission (34.9 to 24.0). Hemolysis labs were done and were unrevealing. A CT scan of the Chest/Abdomen/Pelvis was done which revealed a large hematoma surronding her left hip (consistent with the events surronding her fall prior to admission). She was closely monitored for compartment syndrome. She received a total of 4 units of PRBCs while in the ICU and her hematocrit stablized. #. Respiratory Status: Stable. The patient was electively intubated for airway protection in the setting of her acute agitation and need for emergent head imaging. She was extubated without event the following afternoon and was satting well on room air prior to and after her transfer to the general medical floor. #. Hip Fractures: At the time of her fall prior to admission, the patient also fell onto her L hip. Plain films done at her PCPs office revealed left sided fractures, which were known from a prior fall. As above, the patient also underwent a CT scan which revealed a large hematoma around her left hip. - Pain control with acetaminophen and lidocaine patch. Avoid narcotic pain medications if possible as they may worsen her confusion. #. Hyperlipidemia: The patient statin was initially held when she was intubated and restarted prior to her transfer to the general medical floor. Continue home simvastatin. #. Communication: Daughter: [First Name8 (NamePattern2) ] [Known lastname 16807]: [Telephone/Fax (1) 91539] #. CODE: Full code Medications on Admission: -Potassium Chloride 10 mEq Oral Tablet Extended Release Take 1 tablet twice daily or as otherwise directed -Midodrine 10 mg Oral Tablet take one tablet three times daily or as otherwise prescribed -Fludrocortisone (FLORINEF) 0.1 mg Oral Tablet take 1 tablet daily until otherwise instructed -Simvastatin 40 mg Oral Tablet 1 tablet every evening for cholesterol -CALCIUM ORAL -MULTIVITAMIN ORAL Discharge Medications: 1. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. potassium chloride 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day. 5. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO twice a day. 6. multivitamin Tablet Sig: One (1) Tablet PO once a day. 7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for left lower back. 8. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every [4-2] hours as needed for fever or pain. Discharge Disposition: Extended Care Facility: [Location (un) 582] at [Location (un) 620] Discharge Diagnosis: - Metabolic encephalopathy - Urinary tract infection - Anemia from acute blood loss - Left upper thigh hematoma - Orthostatic hypotension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - should not ambulate without assistance from another person to supervise. Discharge Instructions: You presented with delirium likely caused by Urinary Tract Infection. CT scan of the head did not reveal a stroke. You were also found to have a low blood count and were found to have bleeding into your upper left thigh. You received blood transfusions. Your confusion is improving, but you are not quite at your baseline yet. You will complete a course of antibiotics for your urinary tract infection. Your blood count was stable after the blood transfusions. Followup Instructions: After you are discharged from rehab, you should make an appointment for follow-up with your primary care physician: Name: [Last Name (LF) ],[First Name3 (LF) ] J Location: [Location (un) 2274]-[Location ] Address: 291 INDEPENDENCE DR, [Location ],[Numeric Identifier 1700] Phone: [Telephone/Fax (1) 28551]	[ "5990", "51881", "2851", "2724" ]
Admission Date: [2142-1-1] Discharge Date: [2142-1-3] Date of Birth: [2099-12-31] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 9871] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: intubation and mechanical ventilation History of Present Illness: 42 y/o F PMH Breast Cancer metastatic to lungs, cranium, spine (epidural T1/T4, cervical/upper thoracic spine) and bone (spine and sternum) and leptomeniges. According to recent Oncology notes current treatment is Doxorubicin (last treatment [2141-12-26]), steroids and s/p XRT for leptomenigeal disease. Patient currently intubated consequently history from OMR and family. . Patient presented to ED T 95.3, BP 129/95, HR 98, O2 Sat 100% (? oxygen) and triggered for respiratory distress. She was placed on NRB with O2 Sat 93%. Respiratory status worsened despite inhalers and patient became increasing somnelent and consequently was intubated. Patient was given levaquin for concern of PNA. . Per family patient had 1 week history of SOB with exertion. Breathing increasingly laboured over the past week at rest. Family reports several months of SOB but with exertion only. Denies associated fever, chills, cough, hemopytsis. Daughter has cold, but not severe and requires no antibiotics. No chest pain. Does report bloody nose last night and usually every other week. Mother reports patient more disoriented this afternoon and easily tired. Family not aware of lung metastasis. . Of note patient's most recent admission [2141-10-17] for headaches started on steroids/radiation therapy, dyspnea ruled out for PE felt to be secondary to metastasis. Recent Heme Onc notes notable for agitation/hallucinations felt to be related to steroids. Past Medical History: Past Oncologic History: - diagnosed in late [2135] with infiltrating ductal carcinomas of the right breast with positive sentinel node, ER positive, PR positive, and HER-2/neu negative - underwent dose-dense AC followed by dose-dense Taxol, then mastectomy and level 1 axillary node dissection with only one focus residual DCIS, then postoperative radiation therapy and hormonal therapy - developed bone metastases in [2139-5-31] and subsequently received multiple hormonal and chemotherapy regimens and radiation therapy to symptomatic sites - began Abraxane and Avastin on [2141-5-31], had 3 cycles (last one on [2141-7-28] - began complaining soon after of increased pain in bilateral ribs at the mid chest level. -MRI on [2141-6-9], showed further compression of the T4 and T6 vertebral bodies and new fusiform abnormalities in the posterior epidural space at T6-8 and T9-10 without evidence of spinal cord signal abnormality or significant compression. - C1D1 Gemzar [2141-8-18], has recieved 2 cycles (cycle 2 on [2141-9-8]) - Most recent regimen Doxil (Doxorubicin 10mg/m2 d1,d8,d15); following chemo zometa every 3 months - Whole brain irradiation from [Date range (3) 98116] Dr. [Last Name (STitle) 3929] . - Depression Social History: Lives with her daughter and her mother lives in the [Last Name (un) ] downstairs. - Tobacco: previously smoked 1ppd. Quit 2 months ago. - etOH: social drinker, last had a drink 2 months ago. - Illicits: smokes marijuana about every other week. Family History: Mother with cervical cancer. No family history of breast or ovarian cancer. Physical Exam: Admission Physical Exam: VS: BP: 111/58 HR: 74 RR: 27 O2sat: 99% vent GEN: intubated and sedated, not responsive to verbal stimuli HEENT: PERRL, anicteric, MMM, op without lesions RESP: CTA b/l with good air movement anterior CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters Pertinent Results: Admission Labs [2142-1-1]: -WBC-7.2 RBC-3.58* Hgb-10.7* Hct-32.0* MCV-89 MCH-29.9 MCHC-33.5 RDW-20.4* Plt Ct-17* -Neuts-59 Bands-4 Lymphs-13* Monos-12* Eos-3 Baso-0 Atyps-0 Metas-3* Myelos-4* Promyel-2* NRBC-19* -Hypochr-1+ Anisocy-3+ Poiklo-1+ Macrocy-1+ Microcy-1+ Polychr-1+ Schisto-1+ Tear Dr[Last Name (STitle) ]1+ Bite-1+ -PT-13.2 PTT-21.9* INR(PT)-1.1 -Fibrino-551* -Glucose-121* UreaN-24* Creat-0.8 Na-131* K-5.1 Cl-99 HCO3-23 AnGap-14 -ALT-62* AST-73* LD(LDH)-947* AlkPhos-148* TotBili-0.8 -proBNP-411* -Hapto-<5* -Type-ART Rates-/16 Tidal V-450 PEEP-5 FiO2-70 pO2-234* pCO2-40 pH-7.42 calTCO2-27 Base XS-1 Intubat-INTUBATED -Lactate-0.9 . [2142-1-3]: -Platlets 14* . Select Reports: -CTA: 1. No pulmonary embolus. 2. Progression of metastatic disease involving mediastinal and right hilar nodes. True extent of malignancy likely underestimated by low lung volumes and bibasilar consolidations, due to combination of aspiration and pneumonia. 3. Given septal thickening at least in part due to pulmonary edema, lymphangitic spread of carcinomatosis would be difficult to exclude. 4. Left breast nodule, though subcentimeter, is larger than in [2141-8-30]. . -TTE: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2140-9-29], probably no major change. . -CT Head: There is no evidence of hemorrhage, edema, mass effect, or infarction. The ventricles and sulci are normal in size and configuration. [Doctor Last Name ]-white matter differentiation is well preserved. Paranasal sinuses and mastoid air cells are clear and well aerated. Re-demonstrated is diffuse metastastic involvement of the calvarium and skull base. . -CXR on day of discharge [2142-1-3]: In comparison with the study of [1-2], there is increasing diffuse bilateral pulmonary opacifications. In view of the enlargement of the cardiac silhouette and blunting costophrenic angles, this could well represent pulmonary edema. However, the possibility of supervening pneumonia or even ARDS would have to be considered. Brief Hospital Course: A/P: 42 year old female PMH metastatic breast cancer (lung, spine and leptomeningeal) who presents with respiratory distress of 1 week duration requiring intubation on arrival to ED. No specific cause was found for her deterioration whcich was put down to disease progression following an unchanged TTE, negative CT-PA for PE, no evidence radiologically for DVTs and no culture data to suggest an infectious precipitant. . . # Respiratory Distress: Thsi was considered likely due to progression of knoen metastatic breast cancer. Her primary oncologist felt that she should not be intubated again. Mrs [Known lastname 98114] was celebrating birthday with family, unable to blow candles out. She then noted increasing sob, family called EMS. On NRB at presentation to the EW, sO2 91%. A&O at that time and stated she would like to be intubated, if needed. She then ecame tachypneic and lethargic and was intubated and commenced on propofol. She was transferred to the MICU for further care CXR showed no evidence of pneumonia. Sputum revealed respiratory commensal flora. Given progressive shortness of breath without symptoms of cough/fever concerning for PE especially in setting of known metastatic disease. She therefore had a CT-[MD Number(3) 24709] showed no evidence of PE but did show progression of metastatic disease involving mediastinal and right hilar nodes. In addition, teh report noted that given septal thickening at least in part due to pulmonary edema, lymphangitic spread of carcinomatosis was considered difficult to exclude. The Left breast nodule, was larger than in [2141-8-30]. LENIs were done and were negative for DVTs. Given possible pulmonary edema, she had a TTE which showed no significant change from prior. She had furosemide IV prior to extubation given above BNP 411 and she had a good diuresis to this. She was treated Levofloxacin and Vancomycin and thsi was stopped post extubation. She was successfully extubated on the evening of [1-2] and passed a SBT. She was saturating well on room air and transferred to teh oncology service and was discharged on [1-3]. . # Altered Mental Status: This was initially presnet at time of hospital admission and peri-intubation and resolved [1-2] post intubation. She had a CT-head which showed no acute process. She was at her baseline after this. . # Thrombocytopenia: Slowly trending down from [2141-11-10]. Last platelet count [2141-12-28] 23. Most likely chemotherapy side effect - received Doxorubicin [2141-12-26] - espeically in setting of diff with metas/myelos/nRBC. This was felt unlikely DIC as PT/PTT within normal limits, no schistocytes, fibrinogen elevated. This was trended and trended remaining around 15. There was no sign of active bleeding. # Hyponatremia: This was initially felt most likely hypovolemic or SIADH. Urine Na 49 and urine osmo 441 suggested SIADH. She has several possible causes for SIADH including metastatic disease, possible pneumonia or CNS involvement. This was trended and improved to 140 on discharge. . # Anemia: Above baseline 26-29. This was trended. . # Transaminitis: Slightly elevated from prior however labs hemolyzed. Prior CT A/P showed no metastatic disease within the abdomen and pelvis. This was trended and decreased by teh time of discharge. No further work-up was performed. . # Metastatic breast cancer: Overall poor prognosis due to metastasis to lung and bone. MR head [2141-12-20] near total resolution of the previously noted pachymeningeal and leptomeningeal disease compared to [2141-9-29] s/p XRT. Per ED, patient wished to be intubated and also discuss with mother. O/P oncologist felt that patient should not be intubated in future. We started dexamethasone 4mg [Hospital1 ]. - Confirm whether patient currently taking Dexamethasone 4 mg [Hospital1 ]. She was extubated on [1-2] and was saturating well on room air. Post extubation, we restarted her outpatient pain regimen of Fentanyl and Oxycodone. . # Depression/Anxiety: WE held Alprazolam while on midazolamd infusion adn post extubation on [1-2] we restarted he home regime of alprazolam, Setraline and Perphenazine. Medications on Admission: ALPRAZOLAM - 0.5 mg Tablet - one Tablet(s) by mouth tab po TID and one PRN for agitation DEXAMETHASONE - (Prescribed by Other Provider) - 4 mg Tablet - 1 Tablet(s) by mouth twice a day FENTANYL - 50 mcg/hour Patch 72 hr - TD q72H LIDOCAINE-PRILOCAINE - 2.5 %-2.5 % Cream - Apply topically to port one hour prior to chemotherapy - No Substitution OXYCODONE - 20 mg Tablet - 2 Tablet(s) by mouth every 4-6 hours as needed for pain. - No Substitution PERPHENAZINE - 2 mg Tablet - one Tablet(s) by mouth [2-1] times/day SCALP PROSTHESIS - - 174.9 SERTRALINE - 50 mg Tablet - one Tablet(s) by mouth daily Discharge Medications: 1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 6 days: to be finished on [2142-1-9]. Disp:6 Tablet(s) Refills:0 2. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO three times a day. 3. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for agitation. 4. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 5. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Transdermal q 72 hours: please resume prior schedule. 6. lidocaine-prilocaine 2.5-2.5 % Cream Sig: One (1) application Topical prior to chemotherapy: Apply topically to port one hour prior to chemotherapy - No Substitution . 7. oxycodone 20 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours as needed for pain. 8. perphenazine 2 mg Tablet Sig: One (1) Tablet PO 2 to 3 times per day. 9. scalp prosthesis Sig: as directed as needed. 10. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: pneumonia thrombocytopenia metastatic breast cancer respiratory distress pulmonary edema anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms [Known lastname 98114], You were recently admitted for management of shortness of breath. You were initially admitted to the Intensive Care Unit (ICU) where you had a machine helping you breathe. They provided you with antibiotics and medications to remove excess fluid and you improved. You were transferred to the floor. We are providing you with a prescription for an antibiotic to continue after discharge. . Your platelets were discovered to be very low during this admission. You will need to return for a follow up appointment tomorrow morning at 9 AM (detail below). You will need to have your platelets re-checked. Please be very careful that you do not fall, as injurying yourself could be very dangerous because with low platelets your blood does not clot appropriately. . We are making the following changes to your outpatient regimen: -Please START Levofloxacin 750 mg by mouth daily until [2142-1-9] Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [2142-1-9] at 10:00 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 73088], NP [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: NEUROLOGY When: THURSDAY [2142-1-18] at 1:30 PM With: [Doctor Last Name 640] [Doctor First Name 747] [Name8 (MD) ], M.D. [Telephone/Fax (1) 1844] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "486", "51881", "2761", "2875", "2859" ]
Admission Date: [2110-7-7] Discharge Date: [2110-7-10] Date of Birth: [2062-4-13] Sex: M Service: Cardiothoracic Surgery CHIEF COMPLAINT: Mitral regurgitation HISTORY OF PRESENT ILLNESS: Mr. [Known lastname 12750] is a 48 year old male with a history of mitral valve disease. Cardiac catheterization confirmed 4+ mitral regurgitation and normal coronary arteries. He presents for evaluation and treatment of his mitral regurgitation. PAST MEDICAL HISTORY: Tonsillectomy. MEDICATIONS ON ADMISSION: Zestril 20 mg q.d., Klonopin 0.5 mg b.i.d. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Heartrate 68, blood pressure 120/80. His heart is regular rate and rhythm, systolic murmur at the apex. His lungs are clear to auscultation bilaterally. His abdomen is soft, nontender, nondistended with normoactive bowel sounds. His extremities are without cyanosis, clubbing or edema. HOSPITAL COURSE: Mr. [Known lastname 12750] was taken to the Operating Room on [2110-7-7] for minimally invasive mitral valve repair. The procedure as performed without complication and Mr. [Known lastname 12750] was subsequently transferred to the Cardiac Surgical Intensive Care Unit. He was weaned off of drips, extubated and hemodynamically stabilized. Postoperative chest x-ray revealed an air leak and consequently Mr. [Known lastname 12750] was left with his chest tube on suction. Otherwise he had an uneventful stay in the Intensive Care Unit and was transferred to the floor on postoperative day #1. By postoperative day #2 his air leak had resolved. Chest x-ray revealed resolution of pneumothorax and subsequently the chest tube was discontinued. Mr. [Known lastname 12750] [Last Name (Titles) 8337] this well. He continued to improve on the floor. He was tolerating an oral diet and his pain was controlled with oral medications. He was switched from Percocet to Tylenol #3 and Motrin due to a feeling of over-sedation from the Percocet. Mr. [Known lastname 12750] was ambulating well with physical therapy completing a Level 5 performance test. On postoperative day #3 Mr. [Known lastname 12750] was felt stable for discharge home. Physical examination at discharge revealed temperature 99.6, pulse 67, blood pressure 130/60, respirations 18 and oxygen saturation 98% on room air. His heart was regular rate and rhythm. His lungs were clear to auscultation bilaterally. Incisions were clean, dry and intact. Abdomen was soft, nontender, nondistended with normoactive bowel sounds. Extremities were without cyanosis, clubbing or edema. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg q.d. 2. Lisinopril 15 mg q.d. 3. Clonazepam 0.5 mg b.i.d. 4. Docusate 100 mg b.i.d. prn 5. Amiodarone 400 mg q.d. 6. Ibuprofen 600 mg q. 6 hours prn 7. Tylenol #3 one to two tablets q. 4 hours prn FO[Last Name (STitle) 996]P: Mr. [Known lastname 12750] should follow up with Dr. [Last Name (STitle) 4127] in three to four weeks and Dr. [Last Name (Prefixes) ] in four weeks. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Mr. [Known lastname 12750] is to be discharged home. DISCHARGE DIAGNOSIS: Status post mitral valve repair. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Name8 (MD) 11235] MEDQUIST36 D: [2110-7-10] 09:50 T: [2110-7-10] 10:06 JOB#: [Job Number 12751]	[ "4240" ]
Admission Date: [2116-12-13] Discharge Date: [2116-12-18] Date of Birth: [2042-4-20] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1253] Chief Complaint: Lower extremity weakness Major Surgical or Invasive Procedure: Dobhoff placement and removal History of Present Illness: Mrs. [Known lastname ] is a 74 year old woman with history of metastatic pancreatic cancer and distant history of [First Name9 (NamePattern2) 7816] [Location (un) ] Syndrome who is now transferred from an outside hospital with lower extremity weakness. Patient is unable to provide any history at present. Chart review from the OSH and discussion with patient's husband provided history contained here. Per husband, the patient had her last chemotherapy about 10 days ago and was feeling well one day following. Was able to go shopping with a few friends for an hour or two. The following day the patient complained of generalized malaise, fatigue, then rigoring at home. EMS took her to [Hospital ] Hospital [2116-12-8] where she was noted to be febrile and she was treated with Ceftriaxone and Azithromicin for ? RLL pneumonia and UTI. The patient improved the following day and was ambulatory in the hospital, however the following day (Sat. [12-12]) the patient was very lethargic and slept most of the day. This continued to Sunday [12-13] and pt was noted to be unable to get out of bed on her own. She could sit at the edge of the bed but her "legs were like a rag doll's," and she was unable to stand. Her arms also seemed weak. The patient and her husband had a negative experience with a neurologist at [Hospital1 ], and they love their GI surgeon here at [Hospital1 18] and requested transfer for further evaluation. The patient underwent MRI of her T and L spine without note of cord compression at the OSH prior to transfer. Vitals at OSH T 98--Tm 99, BP 98-120/56-82, she was on 2L NC sat 91-93%, Prior to transfer NIF -30, Vital capacity 1 Liter. MRI T and L spine with no reported compression, ? bone metastsis in T 5, T6, T10. Pt was more drowsy than earlier due to ____ she got (for MRI sedation?). Also given 1g solumedrol earlier in the day. She was treated with ceftriaxone and azithromycine for RLL pneumonia and also treated for E. Coli UTI. In arrival to the Trauma ICU the patient was hypoxic at 89% and started on 40% facemask. Patient is unable to offer a full ROS. She denies any pain or discomfort at present. Past Medical History: 1) Metastatic Pancreatic Cancer- diagnosed with obstructive jaundice d/t pancreatic head mass, mets to liver and ? lung, tumor is inoperable. She is s/p biliary stent placement. Pt was undergoing chemotherapy, last dose ~10 days ago, her oncologist is Dr. [First Name4 (NamePattern1) 19948] [Last Name (NamePattern1) ] in [Hospital1 ], MA. 2) [First Name9 (NamePattern2) 79755] [Location (un) ] Syndrome- "GBS approximately 5 years ago a few weeks after receiving a flu shot. She describes being at work (at [Hospital1 3597] Witchcraft Elementary School) when a young boy asked her to help tie his shoe, when she reached to tie the shoe her hands completely passed their mark and she was concerned. She rapidly worsened with total body weakness prompting hospitalization at [Hospital ] Hospital where she was plasmapheresed x 5 days. She did have a few days of dyspnea but did not require ventilatory support. Residual pins and needles sensation in the hands and feet and residual BLE weakness. She thought she might have had a recurrence a few years ago (felt weak for 2 days), but these symptoms resolved on their own." 3) Hypertension 4) Hypothyroidism 5) Hyperlipidemia 6) Esopageal spasm 7) S/p CCK. Social History: Married with 2 children. Worked at [Hospital1 3597] Elemetary in kitchen; retired after GBS. Quit smoking 5 years ago, no recent ETOH. No illicits. Family History: Father died of MI Mother died of stroke No history of other neurologic disease or malignancy Physical Exam: Vitals: T 96.7, HR 105, BP 106/70, R 24, 94% on 40% FM Gen- ill appearing, drowsy but arouses briefly to voice, appears comfortable. HEENT- NCAT, pale, anicteric sclera, MMM, OP clear Neck- no carotid bruits. CV- tachycardic, no MRG Pulm- scattered crackles throughout. Abd- soft, nt, nd, BS+ Extrem- no CCE. Neurologic Exam: MS- place=[Hospital ] hospital, month=[Month (only) ], year=?. She is inattentive. able to name days of week forwards, but when asked to say them backwards she is unable to switch tasks. Her naming of "watch" is intact, but with other objects the patient is too inattentive to comply with further testing. She follows simple commands, but is perseverative "open your eyes" but difficulty with "show me two fingers on your left hand" CN- smell not tested, pupils 4mm-->3mm and sluggish to light bilaterally, EOM's are full, no nystagmus. blinks to threat bilaterally. Funduscopic exam could not be performed due pt uncooperativeness with exam (pulled eyes shut forcibly). face is symmetric with symmetric sensation to LT. no ptosis. hearing intact to FR bilat, unable to view palate with face mask for O2, tongue protrudes at midline. Motor- no adventitious movements, tone appears low throughout. She displays motor impersistence. Holds both arms antigravity for 2-3 seconds and they fall to her chest. She spontaneously holds her legs antigravity briefly. When asked to move her legs to command she is unable to do so. She briskly withdraws her legs to noxious stim. Sensory- intact to light touch in all extrem, intact to noxious in all extrem. unable to perform detailed sensory testing due to mental status. Reflexes: unable to elicit any DTR's in [Hospital1 ], tri, [Last Name (un) ], patell, ankles. Plantar response down on right, up on left. Gait- unable to test. Pertinent Results: CHEST RADIOGRAPH AP ([2116-12-13]): Mild cardiomegaly. No vascular engorgement. No lung consolidation or mass. No pleural effusion. Metallic stent projects over the right upper quadrant. CT HEAD WITHOUT CONTRAST ([2116-12-14]): 1. No evidence of infarction, hemorrhage, of mass effect. 2. MR [First Name (Titles) 151] [Last Name (Titles) ] is most sensitive for evaluation of intracranial metastatic disease. BILATERAL LOWER EXTREMITY DOPPLERS ([2116-12-15]): No DVT in the bilateral lower extremities. CHEST PA/LAT ([2116-12-16]): In comparison with the study of [12-14], the patient has taken a somewhat better inspiration and the atelectatic changes at the bases have decreased. Some costophrenic angle filling posteriorly suggests small pleural effusions. Dobbhoff tube remains in place. Specifically, no evidence of acute pneumonia. [2116-12-18] 06:30AM BLOOD WBC-7.9 RBC-2.87* Hgb-9.6* Hct-28.3* MCV-99* MCH-33.4* MCHC-33.9 RDW-17.4* Plt Ct-342 [2116-12-16] 07:55AM BLOOD Neuts-71.7* Lymphs-18.2 Monos-6.8 Eos-2.6 Baso-0.7 [2116-12-16] 07:55AM BLOOD PT-14.0* PTT-27.2 INR(PT)-1.2* [2116-12-18] 06:30AM BLOOD Glucose-108* UreaN-6 Creat-0.6 Na-143 K-4.3 Cl-105 HCO3-33* AnGap-9 [2116-12-16] 07:55AM BLOOD ALT-52* AST-88* LD(LDH)-358* AlkPhos-120* TotBili-0.2 [2116-12-16] 07:55AM BLOOD calTIBC-157* VitB12-767 Folate-17.4 Ferritn-334* TRF-121* [2116-12-13] 10:05PM BLOOD TSH-0.069* [2116-12-15] 01:17AM BLOOD Free T4-0.89* [2116-12-14] 12:13AM BLOOD Type-ART pO2-84* pCO2-37 pH-7.46* calTCO2-27 [2116-12-14] 12:13AM BLOOD Lactate-1.5 Brief Hospital Course: 74 year-old female with pancreatic cancer metastatic to her liver and possibly lung, GBS 5 years ago after a flu shot, hypertension, and hyperlipidemia who intially presented to an OSH with a fever after chemotherapy and was found to have pneumonia and E. coli UTI, and then was transferred to [Hospital1 18] for neurological evaluation for lower extremity weakness. Hospital course was as follows. NeuroICU course: Her neurologic examination on admission was notable for marked inattention, which further limited detailed motor and sensory testing; however, she was able to hold her legs antigravity. Neurologic exam the morning after her admission showed [3-2] strength in the IPs, [4-3] in the deltoids and quads, and 5-/5- in all other muscle groups. She was areflexic, but this was documented in previous neurology notes from [2116-8-31]. Her inattention was thought to be due to toxic metabolic encephalopathy, likely due to her underlying pneumonia and UTI. It was determined that GBS was not the cause of her symptoms, and her encephalopathy improved by the second day (oriented to person, place, and date). Head CT showed no evidence of infarction, hemorrhage, of mass effect. Ammonia 10, ALT 13/AST 31, LDH 489, AP 166, T bili 0.3, alb 2.5, INR 1.6, amylase 14/lipase 8, TSH 0.069, T4 6.0; free T4 0.89. She was continued on ASA 325 mg daily, Amlodipine 5 mg daily, and Levothyroxine 75 mcg daily. Her PNA and UTI were treated with CTX and azithromycin. The medicine team was consulted for her PNA and UTI, and the patient was called out to the medicine floor with neurology following. Medicine course: On arrival to medicine floor, patient appeared well. Her breathing felt improved over her baseline and she felt stronger than when she arrived initially. Her active issues included resolving mental status changes, ?RUL PNA (sat's 98% on 60%FM, apparently baseline O2 sat in low 90's), UTI, and climbing WBC (12) on antibiotics. As above, the patient's weakness was thought to be secondary toxic metabolic encephalopathy; she continued to improve on antibiotics for treatment of UTI and community acquired pneumonia. Patient completed a 5 day course of azithromycin and 7 day course of ceftriaxone. Blood cultures remained no growth to date of discharge, and patient was unable to provide sputum specimen. Leukcytosis resolved. Concurrently the patient's hypoxia also improved. Of note, patient has history of COPD with baseline sats in the low 90's. She was initially kept on standing albuterol and ipratropium nebulizer treatments. Patient worked with physical therapy as well. On day of discharge, patient was satting at baseline at rest but requiring oxygen (1 to 2 liters) with ambulation. Remained of care was as follows. - Hypertension: Continued antihypertensives per home regimen. - Hypothyroidism: TSH, FT4 low. Given acute illness, no changes to medication regimen were made. Patient will require recheck of TFTs as outpatient. - Anemia: Hematocrit slightly lower than baseline on admission. B12 and folate normal. Labs consistent with anemia of chronic disease. Continued folate, iron per home regimen. - GERD: Continued omeprazole per home regimen. - Hyperglycemia: Patient was started on metformin for persistently elevated blood glucose. Blood glucose should be checked at rehab facility and hypoglycemics titrated as needed. - Nutrition: Patient required Dobhoff for short duration in neuroICU. On medicine floor, she was evaluated by speech therapy and was found to be able to take regular food and thin liquids without problem. Code status: DNR/DNI Communication: [Name (NI) ] [Name (NI) ] (husband), ([Telephone/Fax (1) 79756] Medications on Admission: Medications on Transfer: Amlodipine 5mg daily ASA 325mg daily Azithromycin 500mg daily (day 1 is ??) Ceftriaxone 1gram IV daily (day 1 is ??) Carbamazepine 200mg [Hospital1 ] Folate 1mg daily Gabapentin 600mg TID Heparin 5000units SC TID Synthroid 0.075mg daily MVI Nortriptyline 50mg QHS Prilosec 20mg daily Potassium Chloride 20mg PO daily Albuterol 1puff INH Q6h Zofran 4mg IV q6h Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Calcium 500 With D 500 (1,250)-400 mg-unit Tablet Sig: One (1) Tablet PO once a day. 4. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 9. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:1 month supply Refills:2 14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:40 Tablet(s) Refills:0 15. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 16. Home oxygen 1-2L oxygen by nasal cannula, continuous. Goal is to maintain O2 sat greater than 90%. 17. Tegretol 200 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [Hospital ] Medical Center - [Hospital1 3597] Discharge Diagnosis: Primary: - Toxic metabolic encephalopathy secondary to urinary tract infection, community acquired pneumonia] - Hyperglycemia Secondary: - History of [Last Name (un) 4584] [Location (un) ] - Pancreatic cancer - Hypothyroidism Discharge Condition: Hemodynamically stable. Ambulatory. Discharge Instructions: You were transferred to [Hospital1 ] Hospital on [2116-12-13] for further care of your weakness. You were initially admitted by the neurology team, who felt that your weakness was due to an infection in your bladder or lungs. You were treated with antibiotics for both of these infections and your weakness improved. You also required a feeding tube placed temporarily. You worked with physical therapy and your strength and coordination improved, and you will be going to a rehabilitation facility for more physical therapy. On discharge, you are eating and drinking well. Your medication regimen has changed. We added a new medication, Metformin, for better control of your blood glucose. Other than this change, you may resume your home medications just as you were doing prior to this hospitalization. Please be sure to follow-up with your appointments as listed below. Please call your physician or return to the emergency department for any worsening weakness, shortness of breath, fevers, or for any other concerns. Followup Instructions: Someone from Dr.[Name (NI) 60764] office (neurology) will call you with an appointment time. If you do not hear from them by Monday, please give them a call at ([Telephone/Fax (1) 79757] on Tuesday. Someone from your primary care physician's office will call you early next week with an appointment date with Dr. [First Name (STitle) ]. If you do not hear from them on Monday, please call the office at ([Telephone/Fax (1) 79758]. Completed by:[2116-12-18]	[ "486", "5990", "4019", "2449", "2720", "53081", "2859", "V1582" ]
Admission Date: [2152-1-15] Discharge Date: [2152-1-21] Date of Birth: [2090-1-26] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[First Name3 (LF) 338] Chief Complaint: respiratory distress, transferred from OSH Major Surgical or Invasive Procedure: bronchoscopy History of Present Illness: This is a 61 y/o male with a PMH significant for HTN and ?history of pleurisy 20+ year ago, with symptoms of dyspnea, tachypnea, and pleuritic chest pain intermittently since [Month (only) 359] of this year, who presented with acute respiratory distress 1 day ago. History is obtained primarily from the patient's family due to patient's respiratory status and lack of records: . The patient is generally a healthy male with only HTN who began having pulmonary symptoms back in [Month (only) 359] of this year. Per his wife, the patient was having intermittent dyspnea with exertion and at rest with pleuritic chest pain. No orthopnea, PND. In addition, he has intermittent fevers with temps up to 101.4 with his symptoms - no night sweats. No cough, hemoptysis, URI symptoms. No recent known sick contacts. [Name (NI) ] saw his PCP for these symptoms and was tried on at least 2 course of antibiotics with minimal improvement. In addition, he saw a pulmonologist as well, and was told that his symptoms may be secondary to an "allergy" exposure. He has had several CXRs and CT scans which reportedly "did not show anything bad." He had a negative PPD 1 month ago and has had no exposures to TB or other agents that the family is aware of. Between his episodes of symptoms, he would feel well back to his baseline and was back to his baseline state of health for 3-4 weeks prior to this presentation. He recently traveled to [State 4260] for a business trip and returned late Wednesday night (3 days PTA) and was feeling well until yesterday (Friday) morning when he began having symptoms of dyspnea and pleuritic chest pain again. This occured while he was at work and he was noted to appear very ill by his secretary, who called EMS. The patient also reported symptoms of nausea and dizzness at the time of his respiratory distress. He was taken to [Hospital6 17032] by EMS. . At the OSH, initial VS were T 97.3, BP 97/50, HR 60, RR 28-30, SaO2 100%/2L. The patient was dyspneic but able to speak complete sentences per the family. He became progressively tachypneic into the 50's and diaphoretic, unable to complete full sentences. A CXR by report demonstrated "multiple opacities in the right lung field and RLL infiltrate." An initial ABG was 7.46/28/36 on 2 L NC. Per report, a CT (?CTA) of the chest showed bilateral infiltrates. He spiked to 101.6 around 9pm at the OSH. He received 750 mg IV levaquin, 2 gm IV Rocephin, and 60 mg IV solumedrol q6 hours. He also received IV morphine and ativan. During his ED course, he became progressively dyspneic and tachypneic, and was feeling more fatigued. A repeat CXR per report showed worsening bilateral infiltrates. The patient was intubated subsequently for hypoxic respiratory distress around 3 am [2152-1-15] on settings AC 500x14, FiO2 100%, PEEP 10 with PIP's 28-30. He was then transferred to [Hospital1 18] for further management. . Upon arrival to the MICU, the patient was intubated and sedated. A left IJ CVL was placed and a right A-line was placed. He was briefly on peripheral dopamine for hypotension (SBP 80's) in the setting of increased sedation while intubated. . ROS - No URI sx, cough, hemoptysis, chest pain (except for the pleuritic chest pain at the time of symptoms), n/v/abdominal pain, diarrhea, blood in stools, dysuria, hematuria, edema. +40-lb weight loss since Septemeber intentionally. No changes in appetite. No early satiety. No skin changes. +frequent travels to the East Coast and Midwest for business. Past Medical History: HTN ?pleurisy 20 years ago Social History: Lives at home with his wife in [Name (NI) 8117], [Name (NI) ] for 22 years, previously lived in [State 2690] 22 years ago for 12 years. Works as a salesman in a plastics plant, and travels frequently for business (3-4x/month) mainly in the midwest ([Location (un) ], [State ]) and east coast. No international travel. Was never incarcerated. Has no history of tobacco use. Occasional to rare EtOH only. No illicit drug use. Family History: Father (deceased) - HTN, colon CA, MI at age 80, renal CA Mother (deceased) - [Name (NI) 2481] Children healthy One sibling with asthma Physical Exam: VS: Tc 97.6, BP 89-104/50-54, HR 70, RR 20-21, AC 500x14, FiO2 60%, PEEP 10, SaO2 97% General: Intubated, sedated HEENT: NC/AT, PERRL. ETT in place. Neck: supple, + L IJ CVL; difficult to appreciate JVD Chest: minimal BS at the bases, no wheezes or crackles CV: distant heart sounds, RRR no m/g/r Abd: soft, obese, NT, NABS Ext: no c/c/e, wwp - ?deformity of left ankle Neuro: sedated, intubated. Not following commands Skin: no rashes noted Pertinent Results: [1-14] OSH: WBC 3.2, Hct 46.2, Plts 180, diff N44, B42, L11 BNP 69.6 Na 140, K 3.1, Cl 109, HCO3 25, BUN 21, Cr 1.0, Ca 8.6 TP 6.4, Albumin 3.6, Tbili 1.3, ASA 21, ALT 26, Alk P 53 CK 78, Trop <0.04 PT 13, PTT 25.5, INR 1.1 . IMAGING - OSH CT reviewed in detail with radiology: Diffuse airspace disease, with less involvement of the anterior segments; no PE appreciated; 1 calcified granuloma in the RUL; no emphysematous changes . [1-14] EKG at OSH - Sinus bradycardia at 58 bpm. Slightly prolonged PR interval. LAD. No ischemic ST or T wave changes noted. No prior for comparison. . [1-17] CT chest: Endotracheal tube terminates just above the thoracic inlet level, approximately 7 cm above the carina. Nasogastric tube terminates in the stomach, and a left internal jugular catheter terminates in the left brachiocephalic vein. Within the lungs, dependent areas of consolidation are present within both lower lobes, and a gradient of ground-glass attenuation is present in the remainder of the lungs, more prominent posteriorly with relative sparing of the most nondependent anterior portions of the lungs. Specifically, there are no areas of consolidation within the least dependent portions of the lungs. Central airways are remarkable for retained secretions within the right main, right upper lobe, and bronchus intermedius. Incidental note is made of a calcified granuloma in the right upper lobe with associated calcified lymph nodes in the right paratracheal and right hilar regions. Slightly prominent noncalcified lymph nodes are present within the subcarinal region. Heart size is normal. Coronary artery calcifications are present. No pericardial or substantial pleural effusions are identified. Examination was not specifically tailored to evaluate the subdiaphragmatic region, but adrenal glands are well visualized and normal in appearance. High attenuation is present within the gallbladder, possibly due to vicarious excretion if the patient has had recent intravenous contrast-enhanced study (no contrast given for this examination). Skeletal structures demonstrate no suspicious lytic or blastic skeletal lesions. IMPRESSION: 1. Lung parenchymal findings consistent with provided history of ARDS, but coexisting infection cannot be excluded by imaging alone. 2. Proximal position of endotracheal tube which has been advanced since the time of the CT scan (as documented on separate CXR). 3. High attenuation material within the gallbladder, possibly due to vicarious excretion of contrast if the patient has received recent contrast administration. In the absence of contrast administration, this may represent high attenuation sludge. Gallbladder ultrasound could be considered if warranted clinically. . Echo [1-17]: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial 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: 61 y/o male with HTN, recent symptoms of intermittent DOE and pleuritic chest pain x 2 months, now with acute respiratory failure. . # Respiratory distress - hypoxic in nature, acute on chronic distress with findings suggestive of ARDS. Intubated at OSH, changed to ARDSnet protocol. PaO2/FiO2 113 with bilateral ground glass opacities on CT chest from OSH. Patient does not appear volume overloaded and has a normal-sized heart on CT, BNP at OSH<100, so less likely to be from CHF. He received an ECHO during admission which confirmed normal cardiac function. Potential etiologies of ARDS include infection (bacterial, atypical, fungal, PCP [Name Initial (PRE) ] [Name10 (NameIs) ] no known immunocompromised state), alveolar hemorrhage, BOOP, idiopathic ARDS, hypersensitivity pneumonitis. He initially had ARF but resolved rapidly with IVFs so pulmonary renal syndrome was thought to be less likely. [Doctor First Name ], ANCA, and anti-GBM were negative. He received bronchoscopy and BAL which revealed PMNS and bands but only minimal eos and no organisms. He was continued on empiric levofloxacin and vancomycin with improvement in his leukocytosis. His CT chest also improved, suggesting potential infectious component. Cultures remained negative throughout admission. Atypical pneumonia antigens were sent. He was successfully extubated [2152-1-19] and has been on nasal cannula since. He is being continued on Vancomycin and Levofloxacin for a 7-day empiric source for nosocomial PNA, although no pathogens have been isolated. Other cultures, including blood and urine were negative to date. His atypical antigens were pending at the time of discharge. . It is unclear what the ARDS was a result from. Review of prior CT in [Month (only) 359] (at OSH), CT at OSH prior to admission here, and CT here all demonstrate ground-glass opacities, suggestive of ARDS. His outpatient pulmonologist, Dr. [Last Name (STitle) ], is aware of the admission, and the patient should follow-up with him as an outpatient. . # HTN - on home regimen . # PPx - PPI, heparin SC . # Code - full . # Communication - wife, [Name (NI) ] (h) [Telephone/Fax (1) 75528], (c) [Telephone/Fax (1) 75529]; son, [Name (NI) ] (c) [Telephone/Fax (1) 75530]; daughter, [Name (NI) ] (c) [Telephone/Fax (1) 75531] Medications on Admission: Norvasc 5 mg daily Atenolol 50 mg daily HCTZ 25 mg daily Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: showhegan vna Discharge Diagnosis: Primary - Hypoxic respiratory distress ARDS Secondary - HTN Discharge Condition: Stable, O2 sats mid 90s on room air and with ambulation Discharge Instructions: You were admitted with respiratory failure of unclear etiology. You were treated with antibiotics for 7 days and improved significantly. Please follow-up with your pulmonologist and PCP [Last Name (NamePattern4) ] [2-9] weeks for follow-up, as it is still not clear what caused your symptoms. You should have a repeat CT of the chest in [3-14] weeks to assess for changes. Please continue your home medications as prescribed. Followup Instructions: Please follow-up with your PCP and pulmonologist in [2-9] weeks.	[ "51881", "486", "5849", "4019" ]
Admission Date: [2198-3-29] Discharge Date: [2198-4-4] Date of Birth: [2143-8-13] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2817] Chief Complaint: Found unresponsive Major Surgical or Invasive Procedure: Mechanical ventilation Intubation History of Present Illness: Mr. [Known firstname 85836] [Known lastname 1005] is a 54 yo man with a history of DM, polysubstance abuse, HCV, liver cirrhosis, and gastric ulcer who was BIBA to [Hospital3 ] ED after being found unresponsive on his bed by his roommate with needles scattered around him. He had not been seen for 2 days. EMS was called and administered Narcan on arrival with with minimal improvement. At [Hospital3 ], the pt was febrile to 105.4, for which he received tylenol. He was again given narcan without improvement so was intubated. On AC with 400/20/5/100%, ABG was 7.29/27/463. WBC 18.4 (83%N), Hct 39.5. Na 150, K 5.6, Cl 117, HCO3 14, BUN 76, Cr 3.1, anion gap 27. AST 101, ALT 38, AP 112, TB 1.8. CK 2431, CK-MB 9.5, Trop 1.98 (nl <0.3). U/A with [10-27] WBC and RBC, 3+ bact, + epis, ketones, [1-12] hyaline casts. Tox screen was neg. EKG without peaked T waves, ST dep in lateral leads, old q waves in inferior leads. CT head neg but could not exclude mild cerebral edema due to motion artifact. CXR with question of RML infiltrate, and as there was concern for meningitis given his AMS, he was given vancomycin 1gm, ceftriaxone 2gm. He received a total of 4L NS IVF. In our ED, initial VS were: T 101, P 131, BP 119/65, R 48, O2 sat 100% on AC 760/?/5/100%. ABG 7.25/33/81/15. FSG 128. Pt was not sedated but was minimally responsive to painful stimuli. Pupils reactive. BS rhonchorous b/l. No e/o trauma. Noted to have melena; OG tube here without any hematemesis. Lactate 4.6. WBC 22.6. Bcx drawn. CXR without obvious infiltrate but question of R paratracheal stripe. An LP was not done because of INR 3. Patient was given tylenol 650mg pr and abx coverage broadened to metronidazole 500mg IV and cefepime for pseudomonal coverage. He received 1 L NS. On transfer to MICU, VS: T 101 (rectal), P 134, BP 112/70, RR 47, O2sat 100% on vent, CPAP 15/5, FiO2 100%. Review of OSH records shows that pt was admitted from [Date range (1) 85837] for LLE cellulitis and hematoma d/t trauma from fall; no acute fractures. During that hospital course, he did have a work-up for abdominal pain. CT abd ruled out pancreatitis with an abnormal duodenal finding; EGD showed severe duodenitis and small esophageal varices. He was started on pantoprazole 40mg [Hospital1 ]. There were concerns about drug-seeking behavior although pt was discharged with 30 tabs of oxycodone due to recent trauma. Review of systems: Unable to elicit Past Medical History: (Per OSH records; daughter confirms diabetes and "liver disease" as well as addictions to alcohol, heroin and possible meth) DM GERD Left leg cellulitits Left leg ecchymosis/hematoma Thrombocytopenia Hepatitis C Hepatic cirrhosis c/b encephalopathy, small gastric varices Polysubstance abuse H/o anasarca Stasis dermatitis Gastric ulcer (biopsy from EGD on [2198-3-23] negative for stain for H. pylori) Social History: Unable to elicit from patient. Has two adult daughters who live in [Name (NI) 74122], PA as well as a son in [Name2 (NI) ] who is in jail. Daughter [Name (NI) 50269] can be contact[Name (NI) ] at [Telephone/Fax (1) 85838] (home), [Telephone/Fax (1) 85839] (cell), or [Telephone/Fax (1) 85840] (cell) Lives with a roommate (contact info unknown). Not currently employed. Polysubstance abuse history including alcohol and heroin, possibly other drugs as well per daughter. Family History: Unknown Physical Exam: Vitals: T 99.7, P 133, BP 124/71, RR 48, O2sat 99 on PS 10/5 General: Obtunded, tachypneic, using accessory muscles of respiration HEENT: Sclera anicteric, intubated, +OG tube Neck: Supple, JVP not elevated, no LAD Lungs: Coarse rhonchi b/l CV: Tachycardic, regular rhythm, normal S1 + S2, unable to appreciate m/r/g Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: Warm, well perfused, 2+ pulses, venous Neuro: Pupils reactive b/l, unable to elicit corneal/gag reflexes or cough w/ suctioning, nl tone, no asterixis, small withdrawal to pain in all extremities except LUE, pronating response to DTR, toes equivocal (?upgoing on left) to Babinski. Pertinent Results: LABS ON ADMISSION: [2198-3-29] 01:25AM URINE EOS-NEGATIVE [2198-3-29] 01:25AM URINE RBC-[2-9]* WBC-[5-17]* BACTERIA-FEW YEAST-NONE EPI-0-2 TRANS EPI-0-2 [2198-3-29] 01:25AM URINE BLOOD-LG NITRITE-NEG PROTEIN-150 GLUCOSE-100 KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG [2198-3-29] 01:25AM URINE COLOR-Yellow APPEAR-Hazy SP [Last Name (un) 155]-1.017 [2198-3-29] 01:25AM FIBRINOGE-215 [2198-3-29] 01:25AM PT-30.3* PTT-50.1* INR(PT)-3.0* [2198-3-29] 01:25AM PLT COUNT-69* [2198-3-29] 01:25AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL BURR-1+ TEARDROP-OCCASIONAL BITE-OCCASIONAL [2198-3-29] 01:25AM NEUTS-92* BANDS-1 LYMPHS-3* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2198-3-29] 01:25AM WBC-22.6* RBC-3.53* HGB-10.7* HCT-32.8* MCV-93 MCH-30.5 MCHC-32.8 RDW-17.8* [2198-3-29] 01:25AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [2198-3-29] 01:25AM URINE GR HOLD-HOLD [2198-3-29] 01:25AM URINE OSMOLAL-460 [2198-3-29] 01:25AM URINE HOURS-RANDOM [2198-3-29] 01:25AM URINE HOURS-RANDOM UREA N-471 CREAT-108 SODIUM-19 PROT/CREA-2.0* [2198-3-29] 01:25AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2198-3-29] 01:25AM PEP-AWAITING F IgG-1430 IgA-728* IgM-151 [2198-3-29] 01:25AM TSH-0.57 [2198-3-29] 01:25AM OSMOLAL-346* [2198-3-29] 01:25AM calTIBC-224* VIT B12-GREATER TH FOLATE-GREATER TH HAPTOGLOB-<5* FERRITIN-585* TRF-172* [2198-3-29] 01:25AM TOT PROT-5.6* ALBUMIN-2.4* GLOBULIN-3.2 CALCIUM-7.5* PHOSPHATE-5.3* MAGNESIUM-1.8 IRON-53 [2198-3-29] 01:25AM CK-MB-17* MB INDX-0.6 cTropnT-0.26 [2198-3-29] 01:25AM LIPASE-47 [2198-3-29] 01:25AM ALT(SGPT)-55* AST(SGOT)-231* LD(LDH)-684* CK(CPK)-2749* ALK PHOS-95 TOT BILI-1.3 [2198-3-29] 01:25AM estGFR-Using this [2198-3-29] 01:25AM GLUCOSE-109* UREA N-77* CREAT-3.1* SODIUM-154* POTASSIUM-3.9 CHLORIDE-126* TOTAL CO2-11* ANION GAP-21* [2198-3-29] 01:34AM LACTATE-4.6* [2198-3-29] 01:34AM TYPE-ART TEMP-40.0 RATES-/50 TIDAL VOL-760 PEEP-5 O2-100 PO2-81* PCO2-33* PH-7.25* TOTAL CO2-15* BASE XS--11 AADO2-613 REQ O2-98 INTUBATED-INTUBATED VENT-SPONTANEOU [2198-3-29] 02:55AM RET MAN-4.2* [2198-3-29] 02:55AM FDP-40-80* [2198-3-29] 02:55AM HCT-32.0* [2198-3-29] 02:55AM AMMONIA-20 [2198-3-29] 03:47AM TYPE-ART TEMP-37.3 RATES-/47 TIDAL VOL-640 PEEP-5 O2-90 PO2-497* PCO2-22* PH-7.34* TOTAL CO2-12* BASE XS--11 AADO2-135 REQ O2-32 INTUBATED-INTUBATED VENT-SPONTANEOU [2198-3-29] 07:44AM PT-31.7* PTT-45.7* INR(PT)-3.2* [2198-3-29] 07:44AM PLT COUNT-45* [2198-3-29] 07:44AM WBC-15.7* RBC-3.16* HGB-9.9* HCT-29.7* MCV-94 MCH-31.2 MCHC-33.2 RDW-18.0* [2198-3-29] 07:44AM CALCIUM-7.8* PHOSPHATE-6.8* MAGNESIUM-1.7 [2198-3-29] 07:44AM CK-MB-26* MB INDX-1.0 cTropnT-0.20* [2198-3-29] 07:44AM CK(CPK)-2698* [2198-3-29] 07:44AM GLUCOSE-201* UREA N-85* CREAT-3.9* SODIUM-150* POTASSIUM-4.4 CHLORIDE-122* TOTAL CO2-9* ANION GAP-23* [2198-3-29] 08:00AM LACTATE-6.2* [2198-3-29] 08:00AM TYPE-[Last Name (un) ] COMMENTS-GREEN TOP [2198-3-29] 11:45AM PLT COUNT-50* [2198-3-29] 12:05PM LACTATE-6.0* [2198-3-29] 12:05PM TYPE-[Last Name (un) ] TEMP-38.1 PO2-263* PCO2-20* PH-7.34* TOTAL CO2-11* BASE XS--12 INTUBATED-INTUBATED VENT-CONTROLLED [2198-3-29] 02:34PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-476* POLYS-18 LYMPHS-35 MONOS-47 [2198-3-29] 04:41PM FIBRINOGE-184 [2198-3-29] 04:41PM PT-24.6* PTT-42.0* INR(PT)-2.4* [2198-3-29] 04:42PM PLT COUNT-42* [2198-3-29] 04:42PM HCT-24.4* [2198-3-29] 04:42PM CALCIUM-7.5* PHOSPHATE-4.8# MAGNESIUM-1.8 [2198-3-29] 04:42PM CK(CPK)-1838 [2198-3-29] 04:42PM GLUCOSE-368* UREA N-89* CREAT-4.1* SODIUM-144 POTASSIUM-3.1* CHLORIDE-116* TOTAL CO2-14* ANION GAP-17 [2198-3-29] 04:54PM O2 SAT-99 [2198-3-29] 04:54PM LACTATE-4.7* [2198-3-29] 04:54PM TYPE-ART PO2-141* PCO2-22* PH-7.51* TOTAL CO2-18* BASE XS--2 [2198-3-29] 08:15PM PT-26.2* PTT-40.8* INR(PT)-2.5* [2198-3-29] 08:15PM PLT COUNT-36* [2198-3-29] 08:15PM HCT-24.3* [2198-3-29] 08:15PM CALCIUM-7.4* PHOSPHATE-4.4 MAGNESIUM-1.8 [2198-3-29] 08:15PM CK(CPK)-1608* [2198-3-29] 08:15PM GLUCOSE-264* UREA N-89* CREAT-4.2* SODIUM-144 POTASSIUM-3.2* CHLORIDE-116* TOTAL CO2-17* ANION GAP-14 ======== MICROBIOLOGY: - [2198-3-29] Blood culture - PENDING - [2198-3-29] Blood culture - PENDING - [2198-3-29] Blood culture - PENDING - [2198-3-29] MRSA screen - no MRSA isolates - [2198-3-29] Urine culture - no growth - [2198-3-29] Urine legionella antigen - negative - [2198-3-29] RPR - non-reactive - [2198-3-29] CSF: gram stain - negative; culture - no growth; viral culture - PENDING - [2198-3-30] Sputum: > 25 PMNs, < 10 epithelial cells, 1+ GPC in pairs/chains; culture: ESCHERICHIA COLI - sensitivities: \| AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R - [2198-3-30] Bacterial stool studies (incl. Yersinia, E. coli) - negative - [2198-3-30] C. difficile toxin - negative - [2198-3-31] Urine culture - negative, final - [2198-3-31] Sputum: > 25 PMNs, < 10 epithelial cells, no microorganisms; culture - Gram negative rods, sparse - [2198-3-31] Blood culture - PENDING, no growth to date - [2198-3-31] Blood culture - PENDING, no growth to date ======== IMAGES/STUDIES: - [2198-3-29] ECG: Sinus tachycardia and respiratory variation in QRS complex suggesting dyspnea. No previous tracing available for comparison. - [2198-3-29] ECG: Sinus tachycardia. Compared to the previous tracing of [2198-3-29] no diagnostic interim change. - [2198-3-29] CXR portable: SINGLE FRONTAL PORTABLE CHEST RADIOGRAPH: The endotracheal tube terminates approximately 5.8 cm above the carina. The NG tube terminates in the first portion of the duodenum. There is appearance of widening of upper mediastinum, likely secondary to mediastinal lipomatosis. The lungs are clear. There is no pneumothorax or pleural effusions. The cardiac silhouette is normal. The hilar contour and pulmonary vasculature are within normal limits. The underlying osseous structures are normal. A rounded lucency in the right lateral lung is likely atelectasis. There is no radiographic evidence of acute displaced rib fracture. IMPRESSION: No pneumothorax or pleural effusion. No acute displaced rib fracture. Recommend follow-up with upright view to better assess the mediastinum when the patient can tolerate it. - [2198-3-29] Liver/GB ultrasound: FINDINGS: The liver is coarsened and echogenic, consistent with cirrhosis. There are no focal lesions and there is no biliary dilatation. The common duct measures 5.5 mm at the porta hepatis. The gallbladder is unremarkable, without shadowing stones or sludge. The main portal vein is patent, with normal direction of flow. The pancreas is not visualized due to overlying bowel gas. The spleen is enlarged, measuring 17.1 cm. The right kidney measures 12.0 cm, and the left kidney measures 13.1 cm. The kidneys are unremarkable bilaterally, without focal lesion or hydronephrosis. There is no ascites. The visualized abdominal aorta and IVC are unremarkable. There is loculated fluid in the anterior right pleural space. IMPRESSION: 1. Cirrhosis, without focal lesion. 2. Splenomegaly. 3. Loculated fluid in the anterior right pleural cavity. - [2198-3-30] TTE: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is a trivial/physiologic pericardial effusion. No vegetation seen (cannot definitively exclude). - [2198-3-30] ECG: Normal sinus rhythm. Diffuse T wave flattening throughout the tracing. Compared to the previous tracing of [2198-3-29] patient's rhythm has changed from sinus tachycardia at a rate of 132 to normal sinus rhythm at a rate of 72. Diffuse T wave flattening is more prominent on this tracing. Consider electrolyte abnormality. - [2198-3-30] CXR portable: SINGLE PORTABLE CHEST RADIOGRAPH: Retrocardiac opacity, new since one day prior, most likely represents atelectasis and less likely pneumonia. Also new is a small left pleural effusion. The right lung is clear. Mild cardiomegaly is unchanged. Fullness of central vascular markings is suggestive of mild volume overload or cardiac decompensation. There is no pneumothorax. Tubes and lines are in stable positions since one day prior. IMPRESSION: 1. New left lower lobe atelectasis, less likely pneumonia. 2. New small left pleural effusion. 3. Mild volume overload versus cardiac decompensation. - [2198-3-31] EEG: Report PENDING - [2198-3-31] CXR portable:FINDINGS: As compared to the previous radiograph, there is minimal improvement with partial resolution of the pre-existing left retrocardiac atelectasis. Overall, the ventilation of the lung parenchyma has slightly improved. Unchanged size of the cardiac silhouette. No focal parenchymal opacity suggesting pneumonia. No larger pleural effusions. No pneumothorax. The size of the cardiac silhouette is at the upper range of normal. - [2198-4-1] EEG: Report PENDING - [2198-4-1] CXR portable: FINDINGS: As compared to the previous radiograph, the three monitoring and support devices are in unchanged position. Unchanged borderline size of the cardiac silhouette without evidence of pulmonary edema. The pre-existing retrocardiac atelectasis has mostly resolved. No evidence of newly appeared focal parenchymal opacities suggesting pneumonia. No pleural effusions. - [2198-4-2] EEG: Report PENDING - [2198-4-2] CXR portable: As compared to the previous radiograph, there is no relevant change. The monitoring and support devices are in unchanged position. Unchanged size of the cardiac silhouette, unchanged absence of focal parenchymal opacities suggesting pneumonia. No visualization of pleural effusions. - [2198-4-3]: FINDINGS: In comparison with the study of [4-2], the monitoring and support devices remain in place. Some indistinctness of pulmonary vessels raises the possibility of elevated pulmonary venous pressure. No evidence of acute focal pneumonia or pleural effusion. -MRI ([4-2]): IMPRESSION: 1. Diffuse bilateral subacute ischemic changes consistent with a global anoxic brain injury. 2. Sinus and mastoid disease as described above, the activity of which is to be determined clinically. 3. Old left frontal lobe infarction. ------ Brief Hospital Course: 51 yo man with a h/o diabetes mellitus II, polysubstance abuse (alcohol and heroin), HCV, cirrhosis, small esophageal varices, duodenitis/gastritis presenting with unresponsiveness. # Unresponsiveness, most likely from anoxic brain injury: The patient was found unresponsive, intubated at OSH ED for airway protection. There was concern for intoxication given finding of needles but tox screens negative. Pt also recently discharged with short course oxycodone despite concerns of drug seeking behavior; pupils noted to be pinpoint by EMS but minimal response to Narcan. Given IV drug use, concern that pt may have endocarditis with embolic showering, though TTE negative and no acute intracranial event seen on OSH CT head. The patient was started on Vancomycin and cefepime for treatment of possible meningitis, though lumbar puncture was not indicative of a CNS infection. Metabolic reasons for unresponsiveness included hepatic encephalopathy, hypernatremia, hyperglycemia, and low-grade uremia which were all treated. B12, TSH and RPR were normal. Neurology consulted on the patient and diagnosed him with anoxic brain injury likely due to hypotension and later confirmed through a MRI. Prior to extubation, the patient seemed more responsive. He was extubated and able to understand commands with limited verbalization. His speech sounded dysarthric. # Respiratory failure: The patient required intubation and mechanical ventilation for inability to protect his airway secondary to his unresponsiveness. He was continued on pressure support ventilation and was extubated without difficulty. # Seizure disorder: The patient was found to have a subclinical seizure disorder on EEG, most likely secondary to his anoxic brain injury. The patient was started on Keppra and uptitrated to 1000 mg [Hospital1 ]. He was also loaded with fosphenytoin per neurology recommendations. He will continue on Keppra and has neurology followup. Final EEG [Location (un) 1131] was pending on discharge. # E. coli pneumonia: The patient presented with fever and was initially broadly covered with vancomycin, cefepime, acyclovir and flagyl. Sputum culture revealed E.coli and antibiotics were narrowed with a course of 7 days for IV cefepime. # E. coli urinary tract infection: The patient was found to have a E. coli UTI which was treated with 7 days of IV cefepime. # Acute renal failure: The patient presented with a Cr to 4.9 (baseline unknown). Nephrology felt that it was most likely due to acute tubular necrosis (secondary to pre-renal from hypoperfusion). Rhado (CKs elevated on admission) might have also played a role. With time, the patient's creatinine contined to improve and he continued to produce adequate urine output. # Upper GI bleed: The patient was noted to have black tarry, guaiac positive stools. His EGD report from OSH was obtained which showed small esophageal varices and gastritis/duodenitis. Per his OG tube, he did not have active hematemesis. He was initially started on PPI and octreotide drips. He required 4 units of pRBCs. Since he did not have any evidence of blood per OG tube, it was concluded that he did not have a brisk bleed and his initial bleed was likely due to his gastritis/duodenitis. His hematocrit remained stable over the last couple days of his hospitalization and did not need any transfusions. He will continue on PPI. Baseline Hct unknown. # Hypernatremia: The patient presented with hypernatremia, likely due to decreased PO intake. The patient was started on free water to treat his deficit. He was continued on maintainence fluids of D5 [12-9] normal saline for poor PO intake. # Type II Diabetes mellitus: The patient has a history of diabetes mellitus. His home glipizide was held and he was started on an insulin drip with tubefeeds due to hyperglycemia. His insulin regimen was later switched to 18 units of humalog [Hospital1 ] with a sliding scale. He will likely need further titration based on nutritional requirements. # Anion gap metabolic acidosis: The patient presented with an anion gap metabolic acidosis with elevated lactate. Toxic ingestion on differential but serum tox negative and renal consult felt that the AG metabolic acidosis was unlikely. With IV hydration, improved renal function and treatment of underlying issues, his anion gap metabolic acidosis improved. # Polysubstance abuse: The patient has a history of narcotics and alcohol abuse. It remains unclear on how his addictions played into his clinical presentation and course. He did not receive any benzodiazepine doses for alcohol withdrawal and he is out of the window for any withdrawal symptoms. # Coronary artery disease with demand ischemia: At OSH, CK, CK-MB, and trop all elevated; EKG with ST depressions. Here, CK remains elevated but trop improving with resolution of ST depressions. [Month (only) 116] represent demand in setting of tachycardia, exacerbated by renal failure. Possible that CK elevation may also reflect muscle breakdown as may have been nonresponsive for up to 2 days before being found. Echo without any wall motion abnormalities and normal left ventricular EF>55%. # Cirrhosis: The patient has hepatic cirrhosis complicated by encephalopathy and small gastric varices. The etiology of his cirrhosis is presumably hepatitis C and alcohol. Initially his transaminases were elevated, likely due to liver hypoperfusion, but continued to trend downward. His total bilirubin was 2.7 on discharge. He has evidence of synthetic dynsfunction, though not compensated. Further details pertaining to his liver disease were not available during this hospitalization. # Coagulopathy: The patient was noted to have an INR elevated to 3.0. He received Vitamin K with improvement. His continued elevated INR is likely due to his underlying cirrhosis. # Thrombocytopenia: Pt w/ history thrombocytopenia per OSH records. Pt also with anemia but DIC unlikely with nl fibrinogen. Probably splenic sequestration in setting of cirrhosis. # Hepatitis C: No current issues. # Nutrition/fluids: Pureed diet. Fluids of D51/2 normal saline at 75 cc/hr for maintainence while low PO intake # Prophylaxis: DVT: pneumoboots, GI: PPI . # Access: Right internal jugular. Will need a PICC line for access since IV nurse unable to find peripheral IV. Medications on Admission: Doxazosin 2mg qhs Tiotropium 1 cap daily Omeprazole 20mg daily Lasix 40mg [Hospital1 ] Ipratropium/albuterol 1 puff qid Glipizide ER 10mg [Hospital1 ] MVI daily Oxycodone 15mg q6h Discharge Medications: 1. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [12-9] Puffs Inhalation Q6H (every 6 hours) as needed for wheezing. 2. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 3. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 4. Levetiracetam 500 mg/5 mL Solution Sig: 1000 (1000) mg Intravenous [Hospital1 ] (2 times a day). 5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for goal 3 BM daily. 6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 9. Humalog 100 unit/mL Cartridge Sig: Eighteen (18) units Subcutaneous twice a day: Hold dose when NPO. 10. Humalog 100 unit/mL Cartridge Sig: see comment Subcutaneous at meals and bedtime: per attached sliding scale. 11. D5 %-0.45 % Sodium Chloride Parenteral Solution Sig: Seventy Five (75) cc/hr Intravenous continuous. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: -respiratory failure -anoxic brain injury -acute renal failure . Secondary: -upper gastrointestinal bleed -seizure disorder not otherwise specified -liver cirrhosis -hepatic encephalopathy -esophageal varices -gastritis, duodenitis -diabetes mellitus Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were admitted because you were found unresponsive. You required mechanical ventilation to help you breath. You were found to have injuries to your brain from low oxygen and subsequent sub-clinical seizures. You also had a problem with your kidneys called renal failure, which started to recover at the end of your hospitalization. You also had a pneumonia and urinary tract infection which were treated with antibiotics. . Your medications have changed: -start pantoprazole -stop omeprazole -stop oxycodone -stop lasix -stop doxazosin -stop glipizide -start humalog insulin Followup Instructions: You have the following appointments scheduled: . Physician: [Name10 (NameIs) ],[Name11 (NameIs) 4739] MD, neurology Date/Time: [2198-5-9] at 1:30 pm Location: [Hospital Ward Name 23] Building, [Location (un) ] neurology, [Hospital1 771], [Location (un) 830], [Location (un) 86], [Numeric Identifier 718] Phone: ([Telephone/Fax (1) 2528**]	[ "25000", "2875", "2859", "42789", "51881", "5845", "2762", "2760", "5990" ]
Admission Date: [2131-6-7] Discharge Date: [2131-6-15] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5827] Chief Complaint: Bright red blood in bowel movement Major Surgical or Invasive Procedure: none History of Present Illness: This is an 83yo female with a past medical history of CAD/CVA, DM2, hypertension, hypercholesterolemia, chronic pain on hospice for pain control, with abd pain x 2 days, BRBPR x 1. Initially constipated for 1 day, then took dulcolax and now with brbpr in stool on the day of admission. She apparently fainted while having bm, no fall, and then vomited x 1. Denied f/c/sob. . In ED, + BRBPR in vault, + TTP LLQ/RLQ. CT abd performed with results suggestive of proctocolitis, differential including ischemic bowel vs. less likely, infectious etiology. Surgery was consulted for possible bowel ischemia, who recommended IVF, Hct trending and possible OR if abdominal exams worsen. . Past Medical History: - CAD: s/p CABG '[15] (reportedly had 2 vein grafts, but unclear anatomy) and cath at [Name (NI) 336] in [3-22] revealed severe triple vessel disease, patent SVG to RCA, SVG to OM, SVG to D1, SVG to D2, SVG to OM1. - h/o multiple CVA's: residual L sided weakness. Severely limited activity at home, with daughter providing help with all [Name (NI) 5669]. - h/o seizures (last sz reportedly 1 yr ago, on keppra at home) - DM2 x 20 yrs - HTN - hyperlipidemia - hypothyroidism (on synthroid) - arthritis - spinal stenosis w/ chronic leg and hand pain Social History: Lives at home with elderly partner. Daughter helps with most ADL. No tobacco, EtOH or illicit drugs. Retired professional singer Family History: Mother died of stomach CA. Brother and sister with "heart problems." Physical Exam: PHYSICAL EXAM: Vitals: Tm 99.0 P 64 BP 154/72 R [12-7] 100%ra I/O- 1.6/1.5 General: Anxious appearing, but NAD HEENT: AT/NC, PERRL, EOMI, anicteric. OP clear, MM dry. Neck: no LAD. JVP at 5cm. Neck supple. EJ in place, c/d/i Lungs: CTAB no w/r/r Heart: RRR no m/r/g +S3 Abd: soft, ND, mild ttp LLQ, no rebound/guarding Ext: no e/c/c. warm and well perfused. 2+ DP pulses. Neuro: CN II-XII in tact bilaterally. Mild [3-22] LUE weakness, hip flexors LLE [3-22], plantarflexion on L [4-21]. Right [4-21]. Pertinent Results: Pt. had a spike in WBC to 17.9 with a left shift on [6-7] which subsequently decreased to 12.0 on discharge with resolution of L shift. . Upon admission ([6-6]), BUN/Creat were elevated to 31/1.5 which subsequently decreased with treatment to normal limits (9/0.7). Potassium on [6-6] was 8.5 and decreased to normal limits by discharge. . Troponin-T ranged from 0.17 to 0.10. . Stool studies showed WBCs, but was negative for all of the following: C.dif, O+P, Salmonella and Shigella. . Urine cx showed no growth, blood cx: **** . EKG ([6-13])Atrial fibrillation, average ventricular response 116. Since [2131-6-11] atrial fibrillation is now seen. The inferior T wave inversions are less prominent. The Q-T interval is shortened. Increased ST-T wave abnormalities are noted . CXR: ([6-6])IMPRESSION: No acute cardiopulmonary process. . CTA Head ([6-12]): IMPRESSION: 1) Occlusion of the entire visualized superior left internal carotid artery and left middle cerebral artery. The left anterior cerebral artery is supplied from the right via the ACOM. Obscuration of the left putamen consistent with evolving left MCA infarction. No evidence of acute intracranial hemorrhage or hemorrhagic transformation. Findings discussed immediately with the neurology team, and an MRA with Gadolinium of the neck was suggested to evaluate the more proximal carotid system. 2) Short segment stenosis of the left posterior cerebral artery. 3) Scattered chronic small vessel ischemic disease in the white matter and chronic right thalamic lacune. . MRA/MRI Head/Neck ([6-12]): IMPRESSION: 1) Evolving infarction involving the left putamen, caudate body, corona radiata, and medial aspect of the left temporal lobe. 2) Occlusion of the distal left cervical ICA, with two probable areas of high-grade stenosis in the proximal left cervical ICA, though the latter would be far better assessed with a gadolinium enhanced study, and if the patient is able to tolerate such, a repeat study with gadolinium is recommended. . Echocardiogram ([6-14]):Conclusions: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with basal inferior and inferolateral hypokinesis. There is normal systolic function of the remaining segments. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Mild regional left ventricular systolic dysfunction. Moderate-to-severe mitral regurgitation. Moderate pulmonary hypertension. . Compared with the prior study (images reviewed) of [2130-12-12], mitral regurgitation severity has increased and pulmonary pressures are higher. The other findings are similar. . CT Abdomen/Pelvis: IMPRESSION: 1. Uniform, circumferential bowel wall thickening involving the descending colon, sigmoid and rectum, concerning for an inflammatory or infectious etiology. Rectal involvement make ischemic etiology less likely. 2. Multiple hypodensities within the kidneys, too small to characterize. Brief Hospital Course: The patient was initially admitted to the MICU for monitoring of BRBPR. Her HCT fell from 42.8-- 34-- 29 over 20 hours (baseline 28-32). The patient was evaluated by GI and felt to have an ischemic vs. infectious proctocolitis. She was given levo/flagyl, IV ppi, 2L LR. Kayexelate was held as the patient was having diarrhea and no peaked t's. She remained stable throughout her MICU course, she was given 1 unit of blood, she remained afebrile with stable vitals and was transferred out to the floor the following day. . On the floor her GI sx shortly resolved with levo/flagyl, and her pain was adequately controlled. She had a run of atrial fibrillation with RVR that responded to IV Diltizem and returned to sinus. This recurred once again during her stay and again converted to sinus after IV Dilt. and was maintained on po metoprolol. . On the morning of [6-12] she was found to have a new right sided facial droop and R sided hemiparesis as well as aphasia. A stroke alert was called, the patient was given aspirin and underwent urgent CT/CTA of the head which showed a L sided carotid occlusion and evolving area of infarction in the L internal capsule. There was no bleed. MRI/MRA confirmed these findings. Due to the unclear time of onset of symptoms, thrombolysis was not performed. In addition, due to the patient's history of bleeding and risk of hemorrhagic transformation of the infarction, heparin was not given. Coumadin was started on [6-14] due to discovery of paroxysmal Afib to prevent future embolic events. . The patient remained stable throughout the remainder of the hospital course. Speech/swallow eval determined that she was in fact globally aphasic, and recommended pureed foods and nectars. On the days of discharge she was afebrile, displaying normal vital signs (sinus rhythm) and tolerating po with assistance. Medications on Admission: Colace sodium 100 mg 1 cap(s) [Hospital1 ] Synthroid 75 mcg (0.075 mg) 1 tab(s) once a day atenolol 25 mg 1 tab(s) once a day aspirin 325 mg 1 tab(s) qd roxanol 20 mg/mL .25 ml Q4H benadryl 25 mg 1 tab(s) TID Sarna 0.5%-0.5% as directed TID Claritin 10 mg 1 tab(s) once a day lactulose 10 g/15 mL 15 mL [Hospital1 ] Protonix 40 mg 1 tab(s) once a day metformin 500 mg 1 tab(s) [Hospital1 ] Zetia 10 mg 1 tab(s) once a day Aspirin Low Strength 81 mg 1 tab(s) once a day Keppra 250 mg 2 tab(s) [Hospital1 ] simvastatin 40 mg 1 tab(s) once a day (at bedtime) lisinopril 10 mg 1 tab(s) once a day Morphine IR 15 mg 1 tab(s) q 12 hrs morphine 5 mg sl q2hrs . Medications on transfer: 1. DiphenhydrAMINE 25 mg PO Q6H:PRN 2. Insulin SC (per Insulin Flowsheet) 3. Levofloxacin 750 mg IV Q48H 4. Levothyroxine Sodium 75 mcg PO DAILY 5. Levetiracetam 500 mg PO BID 6. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 7. Morphine Sulfate 2-4 mg IV Q6H:PRN pain in abd, legs 8. Pantoprazole 40 mg IV Q24H 9. Simvastatin 40 mg PO DAILY 10. Vancomycin 1000 mg IV Q24H Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for prn pain. 4. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 5. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale Injection ASDIR (AS DIRECTED). 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: One (1) infusion Intravenous Q8H (every 8 hours) for 7 days. 13. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Levofloxacin in D5W 750 mg/150 mL Piggyback Sig: One (1) infusion Intravenous once a day for 7 days. 15. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea. 16. Morphine 2 mg/mL Syringe Sig: Two (2) mg Injection Q4H (every 4 hours) as needed for pain legs/abd/chest. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: 1. Infectious colitis 2. L-sided CVA (Stroke) 2. DMII 3. Chronic pain Discharge Condition: fair Discharge Instructions: You were admitted with an infection of your intestines and placed on antibiotics. While you were in the hospital you suffered a stroke that resulted in weakness of the right side of your face and body. Continue full course of antibiotics and take all other medications as prescribed. If your condition worsens, such as severe abdominal pain, vomiting, bloody diarrhea contact your physician. [Name10 (NameIs) ] if you have any new weakness, chest pain, difficulty breathing or palpitations seek medical care. Continue to keep all health care appointments. Followup Instructions: Please follow up with your primary care physician [Last Name (NamePattern4) ]. [Last Name (STitle) 1789**] in one week of discharge from your rehab facility. Follow-up with your physician for blood work to check INR and adjust Coumadin dose as necessary	[ "5849", "2767", "4240", "42731", "2449", "25000", "4168", "V4581", "2720", "4019" ]
Admission Date: [2130-9-11] Discharge Date: [2130-9-25] Service:HEPATOBILIARY SURGERY SERVICE DISCHARGE DIAGNOSIS 1. Adenocarcinoma of the gallbladder. 2. Hypertension. 3. Aortic stenosis. 4. Cataracts. CHIEF COMPLAINT: Painless jaundice. HISTORY OF PRESENT ILLNESS: This 79-year-old female presents on [2130-9-11] with painless jaundice for ten days. The patient had felt weak with a decrease in appetite for the past three to four weeks and had a five pound weight loss. The patient denied any abdominal pain, no nausea, vomiting, history of ulcer disease. The patient had an endoscopic retrograde cholangiopancreatography on [2130-9-6]. Study showed obstruction in portions above the cystic duct. The patient also had entry of the cystic duct that was irregular consistent with tumor brush biopsies and a 17 French stent was placed. The patient had no diarrhea since barium for CT scan. Denied feeling febrile or having chills. No nausea or vomiting, some constipation, no chest pain, short of breath, dysuria, normal bowel habits. PAST MEDICAL HISTORY: Significant for hypertension, heart murmur, bilateral cataracts, early menopause, right wrist fracture in [2096] and aortic stenosis. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Potassium chloride 20 mEq q day. 2. Hydrochlorothiazide 25 mg q day. 3. Lipitor 10 mg q day. 4. Toprol 50 mg q day. 5. Aspirin 81 mg q day. SOCIAL HISTORY: The patient had a history of smoking 20 pack years, quit 29 years ago, one drink per day. FAMILY HISTORY: No history of cancer. Mother had a stroke. Father had a heart attack. LABORATORY: At [Hospital3 ] Hospital showed a total bilirubin of 40, sodium 129, potassium 2.4, chloride 95, bicarbonate 20, the albumin was 3.6, white count 9.8, CA-199 was 26,000. The patient had an ultrasound done also at [Hospital3 ] Hospital which showed positive gallstone obstruction, intrahepatic ducts without dilated or distended common bile duct or dilated pancreatic duct. The patient had CT which showed calcified gallstones in the gallbladder, dilated intra-hepatic bile ducts, no gross masses. Chest x-ray showed chronic interstitial and chronic obstructive pulmonary disease, bibasilar linear densities consistent with fibrosis. An echocardiogram showed ejection fraction of 65% Mild aortic regurg, Doppler evidence of left ventricular diastolic dysfunction. Moderate severe calcified aortic stenosis. PHYSICAL EXAMINATION: The patient was afebrile with normal vital signs. The patient was alert and oriented. Had icteric sclera and was very jaundice. Regular rate and rhythm with a 3/6 systolic ejection murmur. Lungs were clear to auscultation bilaterally. Her abdomen was soft, nontender, nondistended. There was no edema. Her neurological exam showed cranial nerves 2 through 12 were grossly intact and normal. She had grossly intact sensory and motor function. The patient was admitted as a 79-year-old female with a questionable mass, was scheduled for percutaneous transhepatic tubes to be placed in the morning, was made NPO, put on intravenous fluid maintenance at 100, started on Ampicillin and Gentamicin for on-call for the percutaneous transluminal coronary angioplasty. The patient was scheduled to be seen by Cardiology for cardiac workup. Cardiology consult on the patient and recommended close hemodynamic monitoring if surgery was needed with a Swann, no further workup needed and to continue beta-blockade during admission. On hospital day two, the patient was afebrile, vital signs were stable, the patient was brought for PTC performed with bilateral PTC drains placed. However PTC wad cancelled on hospital day two because prior to patient being called she spiked a temperature to 101.7. On hospital day three the patient was brought and PTC stents were placed. The patient tolerated the procedure well and was transferred back to the floor, however, the patient had a T-max of 101.2, was afebrile immediately following the procedure. The patient was subsequently transferred to the Intensive Care Unit for a low blood pressure and elevated temperature, the patient's white count was 21.0 and required a Neo drip to maintain adequate blood pressures. The patient had a significant fluid requirement in addition however, the patient did well. Arterial line and left subclavian line were placed to better monitor the patient's hemodynamic status and better facilitate resuscitation. The patient continued to be weaned from a Neo drip in the Intensive Care Unit, blood pressures responding well, continued to receive intravenous fluids. White count trended down on hospital day five, post procedure day two, the patient is on intravenous Vancomycin and Zosyn. Her white count at this time was 7.6. On hospital day seven the patient was transferred from Intensive Care Unit to the floor. The patient had been weaned from her drips and was continued to do well. The patient continued to have a low white count, was afebrile, continued to be jaundiced and have hypokalemia and an elevated bilirubin but was overall hemodynamically stable. The patient was transfused with one unit of packed red blood cells on hospital day eight for anemia. The Vancomycin was removed. The patient was continued on Zosyn. On hospital day eight, Anesthesia was consulted for the possibility of an operative candidacy for removal of possible mass. The patient was seen by Anesthesia and was deemed to be moderate to severe risk. The patient was continued on intravenous antibiotics. On hospital day nine, in addition to having hyperkalemia was found to have low albumin and TPN was started for nutritional supplement. The patient was started on a soft diet. The patient's bilirubin continued to be elevated at 14.4. On hospital day ten the patient went for cholangiogram. Cholangiogram showed stenosis in both biliary trees. The patient had a transient jump in temperature to 100.4 after cholangiogram and a slight jump in her white count from 7 to 11.2. The patient however continued to remain stable. Bilirubin also jumped from 14 to 16.7. The patient was continued on TPN, regular diet and transitioned to oral pain medicines. The patient was begun on calorie counts, it was found that the patient was receiving approximately 773 calories, it was felt that she can continue with her TPN and calorie counting. At this time pathology brushings were returned and it was found that the patient had adenocarcinoma. This was discussed with the patient and the patient's family and a family meeting was arranged. Palliative care was also available. The patient was met with husband and children and discussed goals of care. The patient had understood at this time that she had a surgically unresectable tumor and her prognosis was three the four months. She was agreeable to continuing with Hospice care and VNA outside the hospital. On hospital day two, the patient was continued on TPN and pain management as needed. The patient was begun planning for hospice care on hospital day 15. The patient continued to be afebrile, vital signs were stable. The patient's laboratory showed an elevated bilirubin to 13, however, white count was stable. The patient was comfortable in no acute distress. The patient had explored hospice options and plan was to discharge patient with home hospice care. The patient will be discharged on her medicines, Atorvastatin 10 mg p.o. q day, Percocet 1 to 2 tablets p.o. every 4 to 6 hours as needed for pain, Actigall 300 mg tablets, one tablet by mouth three times a day, Metoprolol 50 mg tablets half tablet by mouth twice a day, Hydrochlorothiazide 25 mg one tablet by mouth per day, Protonix 40 mg one tablet by mouth per day and Ciprofloxacin 500 mg tablets, one tablet by mouth twice a day for 14 days. The patient will follow-up with her primary care physician and will [Name9 (PRE) 702] with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] in one to two weeks. The patient will have VNA to keep drain tubes kept and to keep dressings around drains dry and intact. The patient will keep a regular diet, will not have any TPN but may supplement her diet with nutritional shakes. The patient's post discharge services will be with Hospice care. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], M.D.,Ph.D. 02-366 Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2130-9-25] 13:43 T: [2130-9-25] 15:33 JOB#: [Job Number 50276]	[ "4241", "2859", "4019" ]
Admission Date: [2103-8-15] Discharge Date: [2103-9-1] Date of Birth: [2028-4-2] Sex: M Service: NEUROLOGIC CONTINUATION: MEDICATIONS: Allopurinol 200 mg po q.d., Synthroid 75 micrograms q.d., HCTZ 25 mg q.d., Theophylline 200 mg po b.i.d., multivitamin one po q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Mr. [Known lastname 724] lives with his wife and son. [Name (NI) ] smoked one pack per day for forty years, but quit forty years ago. He drinks alcohol socially. FAMILY HISTORY: Stroke in brother in his 50s. No seizures. PHYSICAL EXAMINATION: Temperature 98.7. Blood pressure 100/60. Respiratory rate 15. Heart rate 100. SPO2 98% on room air. General, elderly man who is arousable. Head and neck normocephalic, atraumatic. Neck is supple. No bruits. Cardiovascular regular rate and rhythm. Pulmonary clear to auscultation bilaterally. Abdomen positive bowel sounds, soft, nontender. Neurological arousable minimally. Opens eyes to voice. Pupils are equal, round and reactive to light. Extraocular movements are full to excursion. Fundi appear normal bilaterally. The face is symmetric except for a hint of right facial droop on primary position. Motor bulk is normal. Tone in the right arm is decreased, but increased in the right and left legs. Reflexes 1+ on the right arm and right leg. Brisk on the left patellar. No ankle jerk appreciated. Toes are downgoing on the left and equivocal on the right. Reflexes, withdraws to noxious stimuli on all four extremities. Note that this examination is as noted by the author and is worse then the examination noted by Dr. [Last Name (STitle) 102587] and [Doctor Last Name 1004] previously where they show that the patient was more alert and responsive and able to follow commands more readily with right sided hemiparesis, but mild. LABORATORY: White blood cell count 13, hematocrit 38.8, platelets 307, INR 1.3, sodium 137, potassium 2.7, chloride 95, bicarb 27, BUN 9, creatinine 0.8, glucose 123, CK 104, 103, MB 1 and 3, troponin less then 0.3 times two. MR IMAGING: Increased diffusion weighted signal on the left parietal occipital region with a left ICA and an MCA with severely diminished flow. Perfusion study revealed a defect t hat extende that seen on diffusion. HOSPITAL COURSE: Mr. [Known lastname 724] was admitted to the Neurological Intensive Care Unit for an acute stroke management. Given the mismatch in the perfusion and diffusion imaging sequences we f elt that Mr. [Known lastname 724] likely has ischemic and stunned neuronal tissue that may be salvaged if a perfusion can be maintained with hig h pressures. Therefore he underwent central line placement along with arterial line placement for continuous blood pressure monitoring. He was initially started on neo-synephrine to maintain his systolic blood pressure between 160 and 190. However, escalating doses of neo-synephrine was ineffective in maintaining his blood pressure and therefore he was switched to Levophed with good results. He appeared to be clinically better and more responsive on the hypertensive therapy. He was able to open his eyes and repeat one, two, three in Chinese only one day after high perfusion pressure treatment. Cardiac echocardiogram revealed a normal left ventricular systolic function with an ejection fraction greater then 55% without significant wall motion abnormalities. Carotid duplex revealed significant plaque in the cervical left ICA and minimal disease in the right carotids. The right peak systolic velocities suggest less then 40% stenosis. The left velocity in the ICA was diminished with a systolic/diastolic of 32/0. This is concerning for high grade distal stenosis or occlusion of the ICA on the left. Therefore further studies with an angiogram was done and Dr. [Last Name (STitle) 1132] performed this procedure, which revealed a proximal left MCA occlusion. The left A1 was also occluded. The left bifurcation was 85% stenotic. The left petrous ICA was 50% stenotic. The right ICA supplies the right and left ACA. There are no posterior communicating arteries. In summary, there was a 85% stenotic lesion at the proximal left ICA and a 50% stenotic lesion in t he petrous ICA on the left with a complete occlusion of the MCA on the left. No intervention was done at this time. Mr. [Known lastname 724] was subsequently weaned off pressor support with blood pressures maintained at adequate levels. Clinically he remained stable. Given the significant extracranial vascular disease the stroke attending recommended that Mr. [Known lastname 724] be started on aspirin and Plavix for prevention of further ischemic events. While in the Intensive Care Unit Mr. [Known lastname 724] was found to have a urinary tract infection with cultures growing enterococcus species and staph coag negative species. He was started on Levofloxacin for this urinary tract infection. We note, however, that the staph species was resistant to Levofloxacin. Sputum cultures also revealed staph aureus, which was felt to be colonization and therefore Mr. [Known lastname 724] was not started on antibiotics. However, on the day of this dictation Mr. [Known lastname 724] had a temperature of 101.8. Blood, urine and sputum cultures were resent and I recommended starting Vancomycin to cover for staph aureus. From a gastrointestinal perspective Mr. [Known lastname ] hematocrit has been trending down from about 35 to 32 today. We will continue to monitor the hematocrit given his recent history of coffee ground emesis in the Emergency Room on admission. We intend to continue Pantoprazole prophylaxis. He is currently not alert enough to take po, however, we anticipate that with treatment of his acute infectious process that he will likely be able to take po fluids and medications. In the meantime, it is not unreasonable to consider tube feeding. Finally, regarding long term management of his cerebrovascular disease we would favor initiating a statin drug. We realize that his cholesterol may not be high in the usual sense, however, a low dose statin at for example of 10 mg of Lipitor q day is favored by the Stroke Intensive Care Unit Service. At this time Mr. [Known lastname 724] is clinically stable and appropriate for transfer to the floor under the care of the Neurological Service. MEDICATIONS ON TRANSFER: 1. Aspirin 300 mg pr q.d. 2. Vancomycin 1000 mg intravenous q 12. 3. Levofloxacin 500 mg intravenous q 24 hours. 4. Levothyroxine 50 micrograms intravenous q day. 5. Pantoprazole 40 mg po intravenous q 24 hours. 6. Heparin 5000 units subQ q 12. 7. Albuterol and Atrovent nebulizers q 4 hours prn. 8. Insulin sliding scale per flow sheet. 9. Beclomethasone depro two puffs t.i.d. 10. Plavix 75 mg po q day when taking po. DISCHARGE DIAGNOSES: 1. Left hemispheric infarction, evidence of left MCA occlusion and severely stenotic left ICA. 2. Hypertension. 3. Chronic obstructive pulmonary disease. 4. Gout. 5. Urinary tract infection. 6. Question of pneumonia. The on service neurology house staff will complete this dictation upon Mr. [Known lastname ] discharge from this hospital. Thank you very much for the opportunity to participate in the care of this very pleasant man. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(1) 12114] Dictated By:[Last Name (NamePattern4) 25132] MEDQUIST36 D: [2103-8-20] 23:27 T: [2103-8-21] 07:29 JOB#: [Job Number 102588]	[ "5990", "486", "2449" ]
Admission Date: [2194-2-6] Discharge Date: [2194-3-12] Date of Birth: [2123-4-12] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 668] Chief Complaint: jaundice Major Surgical or Invasive Procedure: Liver transplant Intracranial bolt Tunneled dialysis line Post pyloric feeding tube placement ERCP Liver Biopsy x 2 History of Present Illness: Mr [Known lastname ] is a pleasant 70 yo previously healthy gentleman with no significant PMH who presented to liver clinic for the first time today on referral from his PCP for jaundice, dark urine and [Male First Name (un) 1658] colored stool x 2wks. PT states that since [10/2193] he has generally been feeling unwell, with decreased energy, night sweats, decreased exercise tolerance and SOB with walking short distances. He states that he initially attributed this to old age however became more concerned on [2194-1-20] when he developed dark urine, pale stools. This progressed to decreased appetite on [1-25] and jaundice on [1-26]. He postponed calling his PCP because of the holidays, however was then advised to go to the hospital on [2194-1-28] when he was able to reach his PCP. [Name10 (NameIs) ] presented to [Hospital3 ] where he was found to have bili >10 and ast/alt >900. He was admitted and CT of the abdomen was performed and per, report, showed gallbladder thickening. CXR was WNL. Pt was offered further inpatient w/u however elected to f/u with his PCP who [Name Initial (PRE) ]/u with hepatitis serologies (negative) and advised ERCP which was performed on [1-31], and was normal other than a large peri-ampullar diverticulum. At that time, labs were notable for a bili of 20, ALT/AST> 900 and elevated ap to 196. INR was 1.4. He was scheduled to f/u with Dr. [First Name (STitle) ] in clinic today. . In clinic today, labs BP was low at 90/60 and the pt appeared dry. Labs were sent and were pending on admission to the floor. Pt was admitted for further w/u of his liver failure. . On arrival to the floor pt confirms the above history and denies any new complaints. He denies fevers (took temp at home and no greater than 100), N/V/D, abd pain. He states that he has no hx of drug/EtOH abuse or tatoos. He has not traveled outside the the country in 15 yrs, denies new food exposures (including wild mushrooms) and has not been around children or in daycare centers recently. He has no fam hx of liver disease. He has not ever used tylenol and has not recently started any medications. Past Medical History: Tubulovillous adenoma Rotator cuff syndrome, s/p repair x2 Inguinal hernia repair [2158], [2188] Osteoarthritis Hypertension Social History: Small amount of chemical exposure as a worker in an instrumention lab Smoking: Former Smoker (quit [2185-4-15]) 1 ppd, 55 pack-years Alcohol: social Family History: Father Deceased CAD/PVD Mother Deceased CAD/PVD Sisters: Diabetes - Type II; MS, Stroke Denies family history of liver disease Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 114/76 76 18 wt 101.4 kgs GENERAL: Well appearing 70 yo M who appears stated age. Comfortable, appropriate and in good humor. Diffusely Jaundiced HEENT: Sclera icteric. PERRL, EOMI. NECK: Supple with nl JVP, no LAD CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, S1 S2 clear and of good quality without murmurs, rubs or gallops. No S3 or S4 appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, moving air well and symmetrically. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Mildly distended but soft, non-tender to palpation except over the liver edge where there is mild TTP. No fluid wave or shifting dulness. Liver edge palpable 2 cm below the costal margin, no splenomegaly. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. mild [Location (un) ] bilaterally to knees. 2+ DP/PT pulses NEURO: aao x3, CNs [3-9] intact, strength and sensation grossly intact. Pertinent Results: On Admission: [2194-2-6] WBC-11.4# RBC-3.06# Hgb-10.6# Hct-25.0# MCV-76# MCH-34.6# MCHC-45.8# RDW-19.9 Plt Ct-343# PT-15.6* INR(PT)-1.5* Glucose-141* UreaN-38* Creat-1.7* Na-135 K-4.3 Cl-101 HCO3-20* AnGap-18 ALT-1293* AST-858* AlkPhos-165* TotBili-60.5* Albumin-3.2* Iron-224* Calcium-9.0 Phos-4.8* Mg-2.1 HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE AMA-NEGATIVE Smooth-POSITIVE A HIV Ab-NEGATIVE . [2194-2-10] 08:31AM BLOOD ALT-208* AST-178* LD(LDH)-2680* AlkPhos-67 TotBili-82.2* Transplant [2194-2-11] At Discharge [2194-3-12] WBC-6.6 RBC-3.08* Hgb-10.0* Hct-30.2* MCV-98 MCH-32.4* MCHC-33.0 RDW-17.8* Plt Ct-248 PT-9.4 PTT-27.4 INR(PT)-0.9 Glucose-126* UreaN-86* Creat-6.0# Na-137 K-5.5 Cl-96 HCO3-29 AnGap-18 ALT-32 AST-23 AlkPhos-183* TotBili-1.4 Albumin-2.6* Calcium-8.5 Phos-5.2* Mg-2.5 tacroFK-5.8 Brief Hospital Course: 70 yo Male admitted with jaundice with abnormal LFTs. Etiology unknown and extensive workup undertaken. Liver biopsy was done to evaluate for autoimmune vs malignant etiology. Steroid treatment with prednisone was initiated [2-7] pending diagnosis. On [2-8], the patient rapidly decompensated and was in fulminant liver failure. Tbili rose to 70, Hct dropped to 18, and INR rose to 9. He was emergently treated with FFP, pRBCs, and steroids. He was transferred to the SICU for management Transvenous biopsy was done. WBC was 31.4 on [2-8], elevated from 16.6. He was afebrile with no clear etiology. Empiric treatment with Ceftriaxone was started. Mental status worsened. On [2194-2-9], Dr. [Last Name (STitle) ] placed a Right-sided high frontal intracranial pressure bolt placement. Renal function declined and CVVHD was started for worsening renal function. Liver biopsy was notable for histologic features in keeping with an acute, fulminant hepatitis with a clinical differential of acute viral or immune-mediated injury (either primary autoimmune hepatitis or immune-mediated drug reaction). No infiltrative neoplasm was identified. A transplant work up was completed and he was listed for liver transplant. On [2194-2-11], a liver donor offer became available and was accepted. He was taken to the OR with Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. He received an Orthotopic deceased donor liver transplant (piggyback), portal vein-portal vein anastomosis, common bile duct to common bile duct anastomosis without a T-tube, and celiac patch of the donor to the common hepatic artery of the recipient. Of note, his native liver was reported as firm but without evidence of cirrhosis. He tolerated the procedure without complication and was transferred to the SICU in stable condition. In the post operative period, his recovery was very slow, and he remained intubated through POD 10. His mental status had initially been very slow to improve. Additionally, the patient had elevated WBC into the mid 20's. Although he was not febrile, Infectious disease was consulted and Culture data was closely followed. On POD 3 a BAL was performed which yielded yeast and Haemophilus influenzae. Prior to transplant had been on Vanco and Zosyn due to his rapid decompensation, however once the culture data was retuned he was started on meropenem. All antibiotics have been off since POD10, WBC has returned to [Location 213] and he has remained afebrile. Prior to transplant, the patient was in acute kidney failure, and was started on CVVHD while in the ICU prior to the transplant. There has yet to be return of kidney function. CVVH was done until POD 11, and then he was started on intermittent HD, with the first HD treatment done in the ICU with good tolerance of fluid removal. However, he was transferred to [Hospital Ward Name 121] 10, and his first attempt at intermittent HD outside of the ICU caused hypotension, and he was returned to the SICU, and CVVH was once again resumed. Once he was more stable, intermittent HD was tried again, and since that time he has continued on intermittent HD every Monday, Wednesday, Friday with typical fluid removal from 1-2 Liters as tolerated. Urine output has been zero until about POD 27 when he has started to make about 100 to 200 cc's daily. His weight has decreased from a maximum 112 kg around POD 3 to about 95 kg at discharge. The patient had transferred out of the ICU on POD 15, returned to the ICU with hypotension on dialysis, spent another 8 days in the ICU and has been on [Hospital Ward Name 121] 10, with routine surgical care since POD 24. The patient has been receiving tube feeds via a post pyloric feeding tube with good tolerance. His appetite is poor at this time. The patient underwent routine induction immunosuppression at time of transplant to include solumedrol with taper, cellcept, prednisone taper per protocol once solumedrol was completed, and prograf which was started on the evening of POD 1. Levels have been monitored daily with adjustments per level. Total bilirubin was 75.6 on day of transplant, and has decreased over the course of the hospitalization to 1.4 on day of discharge. AST and ALT are WNL. Alk phos was 65 on day of transplant, and although initially was trending down, by POD 11 was noted to be trending back up and was 397 on POD 14. On [2-25] he underwent liver biopsy which showed cholestasis and bile duct proliferation, so on [2194-2-27] he underwent an ERCP which showed a mis-match in the diameter of the donor and native duct. [Donor duct was 8 mm in diameter and native duct was 4 mm in diameter]. No strictures were noted. The anastomosis was patent. No resistance to flow of contrast or passage of 5 mm balloon was noted. No extravasation was contrast was noted. Both right and left hepatic ducts filled normally. The alk phos has started to trend back towards normal and was 183 on day of discharge. The patient has been evaluated by physical therapy and will require extensive rehab. He receives hemodialysis via right tunneled HD line every Monday, Weds, Friday, is taking tube feeds via PPFT, and has poor appetite, appears to be tolerating the tube feeds, and has had normalization of bowel function. Medications on Admission: -Metoprolol Succinate 25 mg Oral Tablet Extended Release 24 hr Take 1 tablet daily Pt dc'd the following medications 2 days PTA out of concern for AEs in the setting of new jaundice: -Omeprazole 20 mg Oral Capsule, Delayed Release(E.C.) Take 1 capsule 30 minutes before first meal of day -Naproxen Sodium 220 mg Oral Tablet 2 tabs po bid prn -Aspirin 81 mg Oral Tablet -Vitamin Discharge Medications: 1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 2. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 3. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 4. sodium chloride 0.65 % Aerosol, Spray Sig: [1-27] Sprays Nasal QID (4 times a day) as needed for dry nose. 5. midodrine 5 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). 6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. dextrose 50% in water (D50W) Syringe Sig: One (1) Intravenous PRN (as needed) as needed for hypoglycemia protocol. 10. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea/vomiting. 11. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK (TU,FR). 12. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): for [3-12] and [3-13] then decrease to every other day for 1 week then stop on [3-20]. 15. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (TU) for 4 weeks. 16. prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): follow taper. 17. insulin lispro 100 unit/mL Solution Sig: follow sliding scale units Subcutaneous four times a day. 18. NPH insulin human recomb 100 unit/mL Suspension Sig: Fifteen (15) units Subcutaneous once a day: AM dose. 19. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty (20) units Subcutaneous once a day: Suppertime dose. 20. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day: Check trough level friday [3-14]. Discharge Disposition: Extended Care Facility: [Hospital3 ]-[Location (un) ] Discharge Diagnosis: fuliminant hepatic failure of unknown etiology malnutrition 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: For this week only, please draw labs on Friday [3-14]. CBC, Chem 10, AST, ALT, T bili, Alk Phos, Trough Prograf, fax results to [Telephone/Fax (1) 697], then resume Monday/Thursday labs You will be transferring to [Hospital ] Rehab in [Location (un) 53637] You will continue to receive Hemodialysis 3 times per week Labs will be drawn every Monday and Thursday starting week of [3-17] Tube feeds will continue until you are able to take in sufficient calories to meet your body's needs Followup Instructions: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2194-3-19] 1:20 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 707], MD, PHD[MD Number(3) 708]:[Telephone/Fax (1) 673] Date/Time:[2194-3-26] 9:40 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 14254], [Name12 (NameIs) 1046] Phone:[Telephone/Fax (1) 673] Date/Time:[2194-3-26] 10:30 Completed by:[2194-3-12]	[ "5845", "51881", "5070", "78552", "0389", "99592", "2762", "4019", "V1582" ]
Admission Date: [2197-11-14] Discharge Date: [2197-11-19] Service: MEDICINE Allergies: Morphine / Shellfish Attending:[First Name3 (LF) 1148] Chief Complaint: hypoglycemia and hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 87 year old female with ESRD on HD Tu/Th/Sat, CAD s/p PCI LAD, OM1 '[91], NSTEMI [7-18], DM2, RAS who presented to OSH from nursing home with confusion and diaphoresis. Glucose noted to be in the 30's and given D50 with improvement in mental status. At OSH she had abdominal pain and a CT Abd/Pelvis without contrast was performed which showed no evidence of obstruction, free air, or AAA but had significant bandemia. She was given Ceftriaxone and flagyl and transferred to [Hospital1 18]. . On transfer to [Hospital1 18] ED, SBP in 60's, hypoglycemic to 40's with abdominal pain. She was guaiac (+) with dark flecks of material on rectal. An NG lavage was done with bilious material which cleared with 700cc NS (no blood). Surgery was consulted, reviewed her CT scans from OSH and felt there was no acute surgical issue. She was given Vanco x1. U/A was positive, and patient was given 2 L NS with SBP into 120s and HR 60's. Blood sugars improved to 140's with 1 amp D50. Blood and urine cultures drawn. Patient was due for dialysis on the day of admission. Renal was contact[Name (NI) ] about missing her HD but felt no acute need for HD. On admission, patient was unable to recall preceding events. Does not remember why she was sent in from NH. Denied fevers, chills, nausea, vomiting, diarrhea. Did complain of some left-sided abdominal pain. Past Medical History: CAD PCI LAD, OM1 '[91] NSTEMI [8-11] ESRD Chronic HD DM2 HTN Dyslipidemia Hypothyroidism RAS Dementia Depression RBBB/LAFB/Bradycardia Staph Epidermis infection dialysis catheter [7-18] OA Social History: Widowed. Lives at Pine Manor Nursing Center. STM loss. Has 2 grown sons. [Name (NI) ], [Name (NI) 122] is power of attorney and health care proxy for patient. Nonsmoker. Denies alcohol use. Family History: NC Physical Exam: PHYSICAL EXAM: VS: T: 98.0; HR: 70; BP: 130/87; RR 18; O2 95% RA GEN: awake, alert, oriented to self and year. Thought she was @ [Hospital1 112]. HEENT: EOMI. MMM. OP clear. 3 cm diameter soft, mobile, nontender mass over R occiput (?lipoma). Pt states has been present for x4mos. NECK: supple, no JVD. CV: RRR. Nl S1, S2. [3-20] sys murmur at LUSB. PULM: bibasilar crackles. ABD: (+) BS. soft, ND. Minimal epigastic tenderness. No rebound or guarding. BACK: No CVA tenderness EXT: Lower extremities warm, well-perfused. 1+ DP pules bilat. No edema. Pertinent Results: [2197-11-14] 02:50PM PT-15.4* PTT-68.3* INR(PT)-1.4* [2197-11-14] 02:50PM PLT SMR-NORMAL PLT COUNT-163 [2197-11-14] 02:50PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL BURR-1+ [2197-11-14] 02:50PM NEUTS-78.0* BANDS-0 LYMPHS-16.9* MONOS-3.9 EOS-1.1 BASOS-0.1 [2197-11-14] 02:50PM WBC-4.9# RBC-3.20* HGB-11.0* HCT-33.6* MCV-105* MCH-34.4* MCHC-32.8 RDW-18.0* [2197-11-14] 02:50PM CALCIUM-6.7* PHOSPHATE-7.1# MAGNESIUM-1.4 [2197-11-14] 02:50PM CK-MB-NotDone cTropnT-0.03* [2197-11-14] 02:50PM LIPASE-12 [2197-11-14] 02:50PM ALT(SGPT)-18 AST(SGOT)-22 CK(CPK)-23* ALK PHOS-91 TOT BILI-0.2 [2197-11-14] 02:50PM GLUCOSE-42* UREA N-60* CREAT-5.3# SODIUM-139 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-19 ANION GAP-24* [2197-11-14] 09:30PM CK-MB-NotDone cTropnT-0.05* [2197-11-17] 06:55AM BLOOD CK-MB-NotDone cTropnT-0.21* [2197-11-17] 07:19PM BLOOD CK-MB-NotDone cTropnT-0.31* [2197-11-19] 06:55AM BLOOD CK-MB-NotDone cTropnT-0.16* [2197-11-19] 06:55AM BLOOD WBC-5.1 RBC-3.76* Hgb-12.7 Hct-39.4 MCV-105* MCH-33.9* MCHC-32.3 RDW-17.5* Plt Ct-219 [2197-11-19] 06:55AM BLOOD Plt Ct-219 [2197-11-19] 06:55AM BLOOD Glucose-73 UreaN-26* Creat-5.1# Na-140 K-3.9 Cl-100 HCO3-28 AnGap-16 [2197-11-19] 06:55AM BLOOD CK(CPK)-38 [2197-11-19] 06:55AM BLOOD CK-MB-NotDone cTropnT-0.16 [2197-11-19] 06:55AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.3 KUB: IMPRESSION: Nonspecific bowel gas pattern without evidence of obstruction. Brief Hospital Course: 87 year old female with ESRD on HD, CAD s/p MI and PCI, DM2, RAS presented from OSH with hypoglycemia, hypotension, abdominal pain, UTI, now normotensive with new epigastic pain and persistent intermittent hypoglycemia. --In the MICU, patient treated for UTI and question of urosepsis with Cipro. Pyelonephritis was considered possible source of abdominal pain. Urine cultures came back positive for pansensitive E. coli and patient was continued on Cipro. There was no growth in blood cultures. She was ruled out for MI with mild troponin elevation in the setting of renal failure but flat CKs. Patient was restarted on HD the day following admission. Her labetolol, norvasc, clonidine, and isosorbide were held. She had no further hypotension following initial volume recessitation. However, she continued to be hypoglycemic at times, thought most likely secondary to persistent blood levels of glipizide in the setting of renal insufficiency as well as poor po intake. Patient's po intake began to improve and prior to transfer to the floor, BGs had improved to 70-140 [11-16]. MICU stay also complicated by epigastric abdominal pain and emesis, bilious and non-bloody. Pancreatic enzymes and LFTs were normal. PTT and INR elevated in MICU. Heparin sc stopped. Both trended down on repeat checks. . The morning after transfer, the patient was found to have increasing nausea and vomiting that was poorly responsive to anti-nausea meds. As there was concern for cardiac ischemia, an EKG was done that showed new T-wave inversions in the lateral leads. Pt had significan troponin elevation and cardiology was consulted. Though the patient was likely having mild episode of cardiac ischemia, given the patient's significant comorbidities and resolvation of symptoms as well as no hemodynamic compromise, the patient was treated medically with aspirin, plavix, beta blocker and oxygen. The patient was asymptomatic and had downtrending troponins. For the remainder of the hospital, the patient has stable vital signs and no other complaints of chest pressure. . # UTI: Urine culture positive for pansensitive E coli. Was initially treated with cipro, but with the patient's nausea and vomiting, it was changed to levofloxacin QHD. Pt now on day 6 of appropriate abx. Currently afebrile. CVA tenderness noted on admission now resolved. Pyelonephritis possible cause of initial abdominal pain but no clear evidence of that on CT abdomen from OSH. . # ESRD on HD (Tues/Thurs/Sat) Pt now on MWF schedule, nephrology following. - next session due [11-20] - monitor electrolytes - continue nephrocaps . # EPIGASTRIC TENDERNESS/VOMITING: minimal epigastric tenderness on exam, +N/V. Unclear etiology. LFTs, pancreatic enzymes normal. [Month (only) 116] be [3-16] to gastroparesis given h/o DM and patient reports chronic N/V prior to admission. Now asymptomatic, if persists, nay need gastric emptying study. . # DMII: patient p/w hypoglycemia, now resolved. Was likely [3-16] oral hypoglycemics in setting of worsened renal function due to infection. Stable finger sticks on day of discharge, pt on insulin sliding scale - monitor QID finger sticks - cont to hold glyburide as was hypoglycemic - RISS if needed . # HTN: Labetalol, clonidine, and norvasc held on admission to MICU given hypotension. Restarted prior to discharge. . # CAD: stable, denies CP. slight troponin elevation likely [3-16] renal failure, but slight elevation likely due to mild ischemic event, managed medically as pt has multiple comorbities. CK/MB negative. - continue ASA, Plavix, statin . # Right hip pain- pt given history of falling prior to admission. X ray on admission showed no signs of occult fracture though small linear lucency on x ray. Pt with large hematoma on hip that precludes anticoagulation. . # HYPOTHYROIDISM: continue levothyroxine . # DEPRESSION: continue sertraline . # CODE: DNR/DNI confirmed with patient at the time of transfer Medications on Admission: ASA 325 Plavix Labetalol 200 [Hospital1 ] clonidine 0.3mg po bid sucralfate 1g qid nephrocaps FeSO4 325 qday glyburide 5mg qday isosorbide Mononitrate 60 qday levothyroxine 100 qday lipitor 80 norvasc 10 qday sertraline 50 qday colace/senna/dulcolax protonix 40 qday razadyne 4mg qhs ativan 0.5mg qday prn prochlorperazine 25 mg pr prn nausea tylenol/benadryl prn sl NTG prn percocetq4 prn pain 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). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 14. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: Two Hundred Fifty (250) mg Intravenous Q48H (every 48 hours): please give at dialysis. 15. Imdur 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 16. Razadyne 4 mg Tablet Sig: One (1) Tablet PO at bedtime. 17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain, fever. 18. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 19. Labetalol 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 20. Insulin Regular Human 100 unit/mL Solution Sig: see sliding scale Injection ASDIR (AS DIRECTED): Check glucose QID, if < 70 give [2-13] amp D 50 and [Name8 (MD) 138] MD, if 70-150 no insulin, if 151-200 give 2 U, if 201-250 give 4 U, if 300-350 give 6 U, if 351-400 give 8 U, if >400, give 10 U and [Name8 (MD) 138] MD. Discharge Disposition: Extended Care Facility: [Hospital 25499] Manor - [Location (un) 47] Discharge Diagnosis: Urinary tract infection, hypoglycemia Discharge Condition: Stable; tolerating PO intake and afebrile Discharge Instructions: Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Please take your medications as directed Please keep your follow-up appointments Followup Instructions: Please make an appointment with [Last Name (LF) ],[First Name3 (LF) ] [Telephone/Fax (1) 69239] for the next 7-10 days. Please return to your normal hemodialysis schedule	[ "5990", "40391", "311", "2449" ]
Admission Date: [2104-12-14] Discharge Date: [2104-12-22] Service: CARDIOTHORACIC Allergies: Methotrexate / Sulfa (Sulfonamides) / Quinine Attending:[First Name3 (LF) 922] Chief Complaint: presyncope & DOE Major Surgical or Invasive Procedure: cardiac catheterization AVR(#21CE Magna pericardial)PFO closure [12-19] History of Present Illness: EVENTS / HISTORY OF PRESENTING ILLNESS: Ms. [Known lastname 33681] is an 87 yo female with severe AS, HTN, PVD, s/p CVAx2 who presents for pre-operative catheterization and aortic valve replacement. Ms. [Known lastname 33681] reports that she has had shortness of breath for more than six months and has had increasing pre-syncope over the past few months. She reports intermittent leg swelling, but none at present. She reports orthopnea, but no PND. She is unable to walk more than one block due to both claudication and shortness of breath. . At present she denies shortess of breath, chest pain, fevers, chills, nausea, vomiting, diarrhea. . Past Medical History: PAST MEDICAL HISTORY: severe Aortic Stenosis with AI Hypertenion Peripheral [Known lastname 1106] disease with severe claudication Transient ischemic attack B/l Carotid stenosis CRI (Cr 1.5-1.9) Rheumatoid arthritis COPD Osteoporosis s/p CVA x 2 (occipital, cerebellar) Social History: Social history is significant for the absence of current tobacco use, though patient has a 25 PY smoking history and quit 10 years ago. There is no history of alcohol abuse but has one drink per day. There is no family history of premature coronary artery disease or sudden death. Family History: Family history is significant for son with diabetes and sister with stroke. Physical Exam: PHYSICAL EXAMINATION: VS - T 98.4, BP 150/50, HR 68, RR 18, 02 Sat 98% on RA Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: no JVP. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 2/6 Systolic ejection murmur. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, wheezes or rhonchi. Crackles at bases bilaterally. 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. . Pulses: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Brief Hospital Course: Ms. [Known lastname 33681] was admitted for preoperative cardiac cath which she underwent on [12-15]. She was maintained on IV heparin after cath due to her history of CVA and coumadin use. She was seen by renal. She was cleared for surgery by dental. She had a UTI for which she was treated with cipro and her surgery was postponed. She was taken to the operating room on [12-19] where she underwent an AVR (tissue) and PFO closure. She was transferred to the ICU in critical but stable condition. She was treated with prophylactic vancomycin perioperatively because she was in house preoperatively. She was given stress dose steroids. She remained intubated overnight. Initially, She had complete heart block and was paced, however her rhythm recovered to NSR. She was extubated on POD #1. She was transferred to the floor on POD #2. She did well postoperatively and was ready for discharge to rehab on POD #3. She was restarted on coumadin. She is being treated for a UTI, her foley could be discontinued on [12-23]. Medications on Admission: CURRENT MEDICATIONS: Actonel 35 mg PO once a week Prednisone 5 mg Tablet dialy Toprol XL 50 mg daily Pantoprazole 40 mg PO Q12H Atorvastatin 10 mg PO DAILY Warfarin 2 mg Tablet QHS (Last dose Friday) Aspirin 325 mg Tablet PO once a day Citracal 2 tabs [Hospital1 ] Centrum silver daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Capsule(s) 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Tablet, Delayed Release (E.C.)(s) 6. PredniSONE 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Risedronate 35 mg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). 8. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days. 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Check INR [12-24]. 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: sev AS w/AI, PFO now s/p AVR/PFO closure HTN,PVD w/claudication,TIA,B/L Carotid Stenosis, COPD, Osteoporosis,CVAx2(occipital/cerebellar),CRI(1.5-1.9) Discharge Condition: GOod. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: Dr. [Last Name (STitle) ] 2 weeks Dr. [Last Name (STitle) 914] 4 weeks Dr. [Last Name (STitle) ] 2 weeks Already scheduled appointments: Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. Phone:[Telephone/Fax (1) 285] Date/Time:[2105-2-25] 3:40 Provider: [First Name11 (Name Pattern1) 1037] [Last Name (NamePattern1) 13280], MD Phone:[Telephone/Fax (1) 2309] Date/Time:[2105-4-13] 2:45 Provider: [Name10 (NameIs) ] LAB Phone:[Telephone/Fax (1) 1237] Date/Time:[2105-4-21] 3:00 Completed by:[2104-12-22]	[ "4241", "5990", "496", "41401", "40390" ]
Admission Date: [2170-3-23] Discharge Date: [2170-4-21] Service: MEDICINE Allergies: Sulfonamides Attending:[First Name3 (LF) 9598] Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 85 yo woman with h/o lymphoma who presents s/p fall at home. The patient has reportedly experienced a low grade fever and increased fatigue over the past three days and unsteadiness on her feet. Last night, she attempted to sit on the toilet and only recalls coming to lying on back with her head resting on a pipe. She pressed the emergency button and EMS arrived on scene. The event was unwitnessed, she does not recall feeling light headed, having any chest pain or palpitations or blurry vision,hitting her head, any seizure activity, aura or post ictal state or loss of bowel or bladder control. She does have prior history of falls, most recent five years ago.On one occaision she had suffered a SAH following a mechanical fall. She is unable to give clear hx regarding her other falls but does state that she had fallen on a hot day. She has a hx of EBV driven B and T cell proliferation-probably angio-immunoblastic lymphoma and is s/p 6 cycles CHOP completed [10-16] currently in remission. She had presented with LAD in neck in [2165] with CT showing multiple lymph nodes and biopsy cervical lymph node showing an atypical lymphoproliferative disorder, highly suggestive of evolving T-cell lymphoma. Subsequent inguinal biopsy in [5-16] was interpreted as either EBV expressing large B cell NHL or angio-immunoblastic lymphoma with an EBV expressing malignant B cell clone. She underwent 6 cycles of R-chop completed in [10-16]. PET/CT on [2169-11-14] showed no evidence of disease. In the ED, the patient's VS were T 99.3, BP 105/35, P 91, O2 96% on RA. She had a CT Head and Neck, which did not show any evidence of ICH or fracture. She had a CXR, which was negative for PNA, CHF, with trace fluid in R fissure, no pleural effusion. She was initially placed in ED Obs, where she was seen by PT and found to be orthostatic (SBP 140 to 80s). She received 1L IVF. She was admitted to medicine for further workup and evaluation. On floor, patient had a low grade temp to 99.4 and rigoring. Past Medical History: PAST MEDICAL HISTORY: Notable for status post cholecystectomy, status post subarachnoid hemorrhage [4-/2167] with no residua, status post appendectomy, hypertension Gerd Hypothyroidism Lymphoma Social History: The patient lives in a retirement community and continues to be active in all facets of her life. Family History: Non-contributory Physical Exam: On admission: VS - Temp 99.4 HR: 91 BP: 127/70 RR: 18 02 SAT: 100% RA GENERAL -comfortable, pleasant, shivering. HEENT - mucous membranes dry, OPC, unable to visualize tympanic membranes [1-9] wax, no ear pain with exam, no erythema, swelling externally. NECK - neck veins flat, no carotid bruit, no LAD LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, II/VI holosystolic murmur heard best at apex. ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [4-11] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, gait exam deferred. SKIN: 1cm erythematous plaque left lower lip. Pertinent Results: Admission Labs [2170-3-23] 09:10AM BLOOD WBC-8.3 RBC-3.19* Hgb-9.8* Hct-29.0* MCV-91 MCH-30.8 MCHC-33.8 RDW-16.0* Plt Ct-138* [2170-3-23] 09:10AM BLOOD Neuts-80.2* Lymphs-6.9* Monos-4.3 Eos-8.4* Baso-0.3 [2170-3-23] 09:10AM BLOOD Glucose-143* UreaN-22* Creat-0.9 Na-133 K-4.5 Cl-103 HCO3-23 AnGap-12 [2170-3-23] 09:20PM BLOOD CK(CPK)-24* [2170-3-23] 09:10AM BLOOD cTropnT-<0.01 Other Labs [2170-3-24] 06:30AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.1 [2170-3-27] 09:00AM BLOOD FDP-0-10 [2170-3-27] 09:00AM BLOOD Fibrino-283# [2170-3-30] 01:00PM BLOOD Ret Aut-1.8 [2170-4-3] 06:00AM BLOOD VitB12-462 Folate-18.6 [2170-3-30] 01:00PM BLOOD Hapto-109 [2170-3-27] 09:00AM BLOOD D-Dimer-1013* [2170-3-27] 09:00AM BLOOD Hapto-159 [2170-3-24] 06:30AM BLOOD TSH-2.6 [2170-3-24] 06:30AM BLOOD Cortsol-37.7* [2170-3-30] 08:00AM BLOOD HIV Ab-NEGATIVE [2170-4-6] 07:19PM BLOOD Vanco-13.7 CXR ([3-23]) - IMPRESSION: Apparent enlargement of the left atrium for which clinical correlation is advised. Mild interstitial coarsening which could be related to interstitial disease or may be exaggerated due to technique. CT Head ([3-23]) - IMPRESSION: 1. No acute intracranial process. No displaced fracture. 2. Stable age-related involutional change, small vessel ischemic disease. 3. Mild paranasal sinus disease. CT C-Spine ([3-23]) - IMPRESSION: 1. No acute fracture within the cervical spine. 2. Mild multilevel degenerative disease. Stable minimal C7 on T1 anterolisthesis. MRI Head ([3-25]) - CONCLUSION: No evidence of intracranial lymphoma. Two small foci of old hemorrhage in the right frontal and temporal lobes. CT C/A/P ([3-25]) - IMPRESSION: 1. Numerous new mediastinal, hilar, axillary, retroperitoneal, intraabdominal, mesenteric, pelvic, and inguinal enlarged abnormal lymph nodes are consistent with recurrent lymphoma. Mildly increased size of the spleen. 2. Wall thickening with surrounding fat stranding of the ascending colon, hepatic flexure, and proximal transverse colon, consistent with colitis. Etiologies include infectious, inflammatory, and ischemic. Clinical correlation is recommended. 3. Small bilateral pleural effusions with adjacent atelectasis. Small intra-abdominal and pelvic ascites, new since prior exam. [Month/Year (2) ] ([3-27]) - The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is no ventricular septal defect. 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. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior report (images unavailable for review) of [2169-7-7], the mitral regurgitation may be somewhat reduced. Bone Marrow Bx ([3-28]) - SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY: DIAGNOSIS: - HYPERCELLULAR MARROW WITH ATYPICAL T-CELL DOMINANT LYMPHOID AGGREGATES, SUSPICIOUS FOR BONE MARROW INVOLVEMENT BY T-CELL LYMPHOPROLIFERATIVE PROCESS (SEE NOTE) Bone Marrow Bx Cytogenetics ([3-28]) - INTERPRETATION: No clonal cytogenetic aberrations were identified in 20 metaphases analyzed from this unstimulated specimen. This normal result does not exclude a neoplastic proliferation. Mosaicism and small chromosome anomalies may not be detectable using the standard methods employed. [4-1] CT Head: No acute intracranial process as clinically questioned. If there is concern for lymphoma, an MRI of the brain may be obtained for further characterization. [2170-4-4] CXR: 1. Worsening moderate pulmonary edema. 2. Increased pleural effusions, large on the right and small on the left. [2170-4-5] ECG: Atrial fibrillation with a controlled ventricular response. Left axis deviation. Non-specific ST-T wave changes. Compared to the previous tracing the rate is slower. [2170-4-9] CXR: In comparison with the study of [4-7], the cardiomediastinal contours are unchanged. Bilateral pleural effusions persist. Indistinctness of pulmonary vessels. This suggests some underlying elevation of pulmonary venous pressure. Retrocardiac opacification is consistent with left basilar atelectasis. Monitoring and support devices remain in place. [2170-4-11] RUE Ultrasound: No evidence of DVT Brief Hospital Course: This is an 85 year old female with hx HTN, lymphoma s/p R-CHOP, SAH in setting of mechanical fall, admitted following unwittnessed non-mechanical fall and found to have recurrent lymphoma. #. Syncope: Pt presented s/p fall with loss of consciousness. 0f note she was orthostatic in ER and has had prior episodes which sound vasovagal in nature and it is likely that her vasovagal syncope and orthostasis was secondary to hypovolemia. Patient noted to have moderate MR [First Name (Titles) ] [Last Name (Titles) ] '[67]. Pt had mild peripheral edema, with MR [First Name (Titles) 21782] [Last Name (Titles) 34106] to poor forward flow and syncope, however repeat [Last Name (Titles) 113] showed no concerning features to suggest this. Pt has also had low grade fevers, rigors and fatigue for several days, suggesting possible infection although exam non focal without elevated white count Her urine cultures showed staph UTI. She received IVF, tylenol and demerol as needed. #. Lymphoma: She has a history of EBV driven B and T cell proliferation-probably angio-immunoblastic lymphoma and is s/p 6 cycles R-CHOP concluding [10-16] with PET in [11-15] showing no evidence active disease. Her presentation was discussed with her hematologist/oncologist who concluded that her rigors, fevers and fatigue was also strongly suggestive of B sypmtoms due to lymphoma recurrence. Patient also had cervical, inguinal, and axillary lymphadenopathy. She was transferred to the OMED service for further evaluation. A bone marrow biopsy was performed which showed lymphoma recurrence. Originally there were plans to start her on Rituxan, Doxil, and Velcade. However, she developed altered mental status and severe hyponatremia and chemotherapy was ultimately deferred due to her poor functional status. #. Thrombocytopenia: Patient noted to have platelets trending down. Initial concern was HIT as patient had a pre-test probability that was intermediate based on her 4T score. She was empirically started on argatroban. A HIT antibody was sent with a mildly positive result (Optic Density of 0.44) This was repeated and was negative. Given the high negative predictive value of this test, it was concluded that the patient did not have HIT. Her argatroban was discontinued. A bone marrow biopsy showed involvement of lymphoma in her bone marrow and it was ultimately felt that she had bone marrow suppression and thrombocytopenia from lymphoma. #. Atrial Fibrillation: New onset during this hospitalization with rates in the 140s. Patient was started on metoprolol tartrate and uptitrated as patient could tolerate. During her ICU stay hypotension was limiting use of metoprolol, therefore she was loaded with amiodarone. She was monitored on telemetry and was noted to be in and out of atrial fibrillation. Patient remained asymptomatic. CHADS2 score at least 2. She was continued on ASA 81 mg but was not further anticoagulated due to thrombocytopenia. Her dose of amiodarone should be tapered to 200mg po daily after discharge (should switch to this dose on [4-23]) #. Hyponatremia: While on the oncology service, the patient developed mental status changes with associated hyponatremia. Her sodium trended down, and renal was consulted. She was started on fluid restriction and given lasix because she was felt to be volume overloaded; however, her sodium continued to trend down and she became more somnolent and confused. She was transferred to the ICU for hypertonic saline administration. Her sodium improved with hypertonic saline. Ultimately, her hypertonic saline was stopped and she was started on lasix, NaCL tabs, tubefeeds, and 1L fluid restriction per renal recommendations. She had hypotension, however, and was therefore unable to tolerate the lasix. She was given some saline boluses with improvement in her sodium. Urine sodium decreased, suggesting improvement of her underlying SIADH. SIADH may be [1-9] oncologic process or respiratory infection. She was then weaned off salt tabs and her sodium remained stable on only a 1L fluid restriction. #. Delirium: Onset of delirium occurred with hyponatremia. Her delirium improved with hypertonic saline administration in the ICU but she remained mild delirious, felt to be due to resolving ICU delirium, UTI effect, bronchitis effect, or hyponatremia effect. #. Bronchitis: While in the ICU she developed a cough. Sputum cultures failed to reveal a bacteria and she remained afebrile. She was empirically started and completed on a 7 day course of levofloxacin. Her cough improved. #. HTN: She remained normotensive however given concern for infection and potential to decompensate to septic physiology, her diovan was initially held. While in the ICU, after being started on [Hospital1 ] lasix, the patient had some problems with hypotension. For this, she was given NS boluses with improvment in BP. She remained normotensive after discontinuation of all BP medications. #. Anemia: She had a normocytic anemia likely secondary to disease progression in her marrow and anemia of chronic disease. Hct was trended daily and remained stable and stools were guaiac negative. She did get intermittent blood transfusions during her stay. #. Hypothyroid: Continued home levothyroxine dosage. TSH 2.6 on [3-24]. #. UTIs: Initially found to have a Klebsiella UTI, for which she completed a 5 day course of ciprofloxacin. She was later found to have an MRSA UTI, for which she completed a 7 day course of vancomycin. Medications on Admission: Acetaminophen 650 mg PO/NG Q6H:PRN fever Aspirin 81 mg PO/NG DAILY Calcium Carbonate 500 mg PO/NG TID Ciprofloxacin HCl 500 mg PO/NG Q12H Docusate Sodium (Liquid) 100 mg PO/NG [Hospital1 ] Levothyroxine Sodium 100 mcg PO/NG DAILY Multivitamins 1 TAB PO/NG DAILY Oxybutynin 5 mg PO BID Pantoprazole 40 mg PO Q24H Vitamin D 400 UNIT PO/NG DAILY Diovan 160 daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Continue 200mg po bid until [4-22], then change to 200mg po daily. 7. Potassium & Sodium Phosphates 280-160-250 mg Powder in Packet Sig: One (1) Powder in Packet PO TID (3 times a day). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 9. Morphine 15 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 10. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). Discharge Disposition: Extended Care Facility: [Last Name (un) 100913] House Discharge Diagnosis: Primary Diagnosis: Non-Hodgkin's Lymphoma Secondary Diagnoses: Hyponatremia Altered Mental Status due to Urinary Tract Infection Urinary Tract Infection Bronchitis Hypothyroidism Hypertension Discharge Condition: Activity Status: Out of Bed with assistance to chair or wheelchair. Level of Consciousness: Alert and interactive. Mental Status: Confused - sometimes. Discharge Instructions: You were admitted to the hospital because you had fallen and we needed to evaluate why you fell. You were also spiking fevers and were found to have recurrence of your lymphoma. You were transferred to the oncology service where you were going to receive chemotherapy. However, you developed altered mental status and low sodium. You were transferred to the ICU temporarily due to your low sodium level. You were given IV fluids with extra sodium and your sodium improved. Your mental status has also slowly improved. You were seen by Dr. [Last Name (STitle) ] while you were in the hospital and it was decided not to give you any chemotherapy. You are being discharged back to the facility where you came from with hospice. The following changes were made to your medications: ADDED amiodarone 200mg by mouth twice daily through [4-22]. On [4-23], you should start taking amiodarone 200mg by mouth daily. Followup Instructions: You have the following appointments scheduled: Department: HEMATOLOGY/ONCOLOGY When: MONDAY [2170-6-25] at 1 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4286], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Dr. [Last Name (STitle) ] and Dr. [Last Name (STitle) ] will also be involved in your care while you are at your facility with hospice. [Name6 (MD) ] [Last Name (NamePattern4) 9601] MD, [MD Number(3) 9602]	[ "5990", "4019", "53081", "2449", "42731" ]
Admission Date: [2166-7-31] Discharge Date: [2166-8-8] Date of Birth: [2122-11-1] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: This 43-year-old female had a known history significant for coronary artery disease. She had a non-ST elevation myocardial infarction in [2166-5-13] with stenting of her LAD and circumflex. She returned two weeks after that with angina and a positive exercise tolerance test. Had a stent placed to the RCA at that time. A stress test on [8-4] depressions with partially reversible defect to the lateral wall, which was new since the study in [2166-5-13]. She reported ongoing angina mostly at rest relieved with sublingual nitroglycerin and shortness of breath with exertion. She had a cardiac catheterization done on [2166-5-31], which showed patent prior stents and a 70 percent left main stenosis. PAST MEDICAL HISTORY: Coronary artery disease with stents to the LAD, circumflex, and RCA as above. Hypertension. Hypercholesterolemia. Status post tonsillectomy. Status post tubal ligation. History of D and C status post stillborn birth. ALLERGIES: Codeine which caused vomiting. MEDS PRIOR TO CATH: 1. Aspirin 325 mg daily. 2. Lisinopril 5 mg p.o. daily. 3. Toprol XL 100 mg p.o. daily. 4. Lipitor 80 mg p.o. daily. 5. Plavix 150 mg p.o. daily. 6. Paxil 10 mg p.o. daily. 7. Ambien 5 mg p.o. q.h.s. SOCIAL HISTORY: The patient lives in [Location ] with family, her husband and two children ages 17 and 20. She quit smoking in [2166-5-13] with a 30 plus pack year history. She admits to one alcoholic drink per week. FAMILY HISTORY: Her family history was positive. Her mother had coronary artery disease at 47 years of age. Is still living. Her father had a myocardial infarction in his 60's. REVIEW OF SYSTEMS: Weight is stable. She was sleeping well with the Ambien with no difficulty with her appetite at this time. She was negative for psoriasis, pruritus, or sores. She had positive history of rare migraines, but negative for cataracts, glaucoma, sinusitis, rhinorrhea, or epistaxis. She had no history of asthma, pneumonia, bronchitis, TB; other than a remote episode of pneumonia more than 20 years ago. Her cardiovascular systems review is positive for palpitations and angina and myocardial infarction, but negative for CHF, PND, orthopnea, or edema. She also had a history of claudication. She had no history of nausea, vomiting, diarrhea, or constipation, problems with [Name2 (NI) ] or hemorrhoids as well as negative for dysuria, frequency, or burning. Her musculoskeletal system was negative for arthritis, fractures, or dislocations. Neurologically: She was intact with no neurologic history. Negative for CVA, seizures, syncope, and TIAs. She had no history of bleeding problems or bruising, and was on Paxil for her smoking cessation with no history of depression or anxiety. PHYSICAL EXAMINATION: On exam, she is 5'3" tall, 153 pounds with a heart rate of 47. Blood pressure 102/98. Saturating 98 percent on room air. She was lying in bed in no apparent distress. She was alert and oriented times three, appropriate, and neurologically grossly intact. Her lungs were clear bilaterally. Heart had good tones at S1, S2, regular rate and rhythm, bradycardic with no murmurs, rubs, or gallops. Her abdomen was soft, obese, nontender, and nondistended and had positive bowel sounds. Her extremities were warm and well perfused with no varicosities or edema. She had 2 plus bilateral radial, DP and PT pulses. PREOPERATIVE LABS: White count 9.3, hematocrit 33.7, platelet count 320,000. Sodium 138, K 4.1, chloride 104, CO2 21, BUN 13, creatinine 0.9 with a blood sugar of 162. PT 14.3, PTT 131.8 on Heparin, INR 1.3. ALT 23, AST 20, alkaline phosphatase 122, amylase 32, total bilirubin is 0.3, and albumin 4.2. HOSPITAL COURSE: The patient was referred to Dr. [First Name (STitle) ] [Name (STitle) ] of Cardiothoracic Surgery for coronary artery bypass grafting. Of note on prior cardiac catheterization in [2166-5-13], the patient had complication of left superficial femoral artery occlusion in the Cath Lab. In addition, echocardiogram performed preoperatively showed ejection fraction of approximately 50-55 percent and on [2166-8-1], the patient underwent coronary artery bypass grafting x2 with a LIMA to the LAD and a vein graft to the OM by Dr. [Last Name (STitle) ]. The patient was taken to the Cardiothoracic ICU in stable condition on an Epinephrine drip at 0.02 mcg/kg/minute, nitroglycerin drip at 0.3 mcg/kg/day, and a Neo-Synephrine drip at 1.5 mcg/kg/minute. Approximately 1-2 hours after arrival on the Cardiothoracic ICU, the patient displayed a depressed cardiac index with very high normal filling pressures. Echocardiogram was performed, which showed the distal [1-14] of the LV to be severely hypokinetic at the apex, which appeared to be akinetic and ejection fraction of approximately 25 percent. The RV size was normal. RV systolic function was mild-to- moderately depressed. There was trace MR, no AI, mild tricuspid regurgitation, no PR, no ASD, PFO by 2-D color Doppler. Decision was made to take the patient emergently back to the Cardiac Catheterization Laboratory fearing the patient had suffered an acute MI approximately two hours after bypass surgery. The hemodynamics in the Cath Lab were consistent with cardiogenic shock and a depressed cardiac index. Aortogram did show diffuse aortoiliac disease with a minimum diameter of 2 mm in bilateral common femoral arteries which was too small for any intra-aortic balloon pump to be safely placed. Cardiac catheterization showed that the vein graft to the OM had 100 percent proximal occlusion with thrombus and the LIMA to LAD was widely patent with 40 percent anastomotic lesion and diffuse spasm in the LAD beyond the touchdown. In the Cath Lab, the distal RCA was stented with a Cypher stent and dilatation in the area of spasm. Left main was also stented with a Cypher stent and the distal OM occlusion was crossed, dilated, and intracoronary nitroglycerin was given via balloon to relieve spasm. Please refer to the final cardiac catheterization report from [8-1]. The patient was then transported back to the Cardiothoracic ICU. On postoperative day one, the patient remained on a Neo- Synephrine drip at 1.5 mcg/kg/minute and milrinone drip at 0.375 mcg/kg/minute, insulin drip at 10, lidocaine drip at 2.0, propofol drip at 20, nitroglycerin drip at 0.05. She was A-paced with a blood pressure of 131/72 and heart rate of 90, most A-paced. Her cardiac index was 2.4. She remained intubated and sedated. Postoperative laboratory work revealed a white count of 11.6, hematocrit of 27.4, platelet count of 207,000. BUN 10, creatinine 0.8. She had decreased breath sounds bilaterally and decreased bowel sounds and 2 plus edema in her extremities. She began IV Lasix for diuresis. Her INR was 2.9. On postoperative day two, she remained on propofol drip, Neo- Synephrine drip, milrinone at 2.5, and nitroglycerin at 0.5, as well as a lidocaine drip at 1 mg/minute. She remained on pressure support and SIMV. Her white count rose slightly to 15 and her laboratories remained relatively stable. Her lungs had coarse breath sounds bilaterally. Heart was regular rate and rhythm. She continued on her perioperative Vancomycin with monitoring to try and wean some drips. On postoperative day three, she remained on insulin drip, milrinone at 0.25. Neo-Synephrine was turned off. A nitroglycerin drip at 0.8. Precedex at 0.4. She continued with her Plavix at 75 mg p.o. daily and was receiving Lasix also intravenously. Her white count came down to 9.8 with a hematocrit of 29.6. K of 3.6, BUN 12, creatinine 0.6. Blood pressure 115/60 in sinus rhythm in the 90s. She had no crackles, but decreased breath sounds bilaterally. Heart was regular rate and rhythm and the plan was to wean and extubate her. She continued on her Lasix diuresis. On postoperative day four, she was in sinus rhythm in the morning with some previous ectopy on amiodarone overnight, which continued. She was saturating 90 percent on 2 liters nasal cannula, continued on an insulin drip, and milrinone drip at 0.125, and nitroglycerin drip at 0.2. Amiodarone drip at 1. Her laboratory work was stable. She had crackles bilaterally. Her sternum was stable. Her incisions were clean, dry, and intact. She had 2 plus peripheral edema, significant amount of fluid on board, and continued her Lasix diuresis. She was screened by the Clinical Nutrition team and evaluated by Physical Therapy. Also on postoperative day five, she remained on amiodarone orally now. Captopril was started at 6.25 mg p.o. t.i.d. as well as diltiazem 30 mg p.o. q.d. to help prevent spasm. She also continued on her Plavix for her stents. She had a blood pressure of 111/88. Her creatinine rose slightly to 1.0. She was hemodynamically stable and was transferred out to the floor. She was evaluated again by Physical Therapy while she was out there. Pulmonary toilet was begun as well as ambulation. On postoperative day six, she had some pain only when she was coughing. Was hemodynamically stable with good blood pressure. She had decreased breath sounds bilaterally and 2 plus peripheral edema, but otherwise her examination was unremarkable. She was encouraged to have aggressive physical therapy as well as chest physical therapy and work with her incentive spirometer. She was also seen by the Case Management team to evaluate her ability to go home with VNA or to go to the facility in [Hospital1 41677]. On postoperative day seven, she was awake and alert with a T max of 97.9, blood pressure of 120/76, a heart rate of 74 in sinus rhythm with a respiratory rate of 20. Her lungs were clear. Her heart sounds were normal. Incisions were clean, dry, and intact. Sternum was stable. Patient was doing very well. Repeat echocardiogram revealed an ejection fraction of 50 percent with a plan for the patient to go home that day. She was ambulating well. Was taking p.o. Dilaudid for pain relief an to be followed by [Hospital2 ] [Hospital3 ] VNA. She was discharged on [8-8] in stable condition. DISCHARGE DIAGNOSES: Status post coronary artery bypass grafting times two. Status post emergent cardiac catheterization with placement of coronary stents. Hypertension. Hypercholesterolemia. Status post tonsillectomy. Status post tubal ligation. History of dilatation and curettage for status post stillborn birth. Status post stent placements in [2166-5-13]. DISCHARGE MEDICATIONS: 1. Lasix 20 mg p.o. twice a day x7 days. 2. Potassium chloride 20 mEq p.o. twice a day for seven days. 3. Docusate sodium 100 mg p.o. twice a day. 4. Enteric coated aspirin 325 mg p.o. once a day. 5. Isosorbide mononitrate 30 mg sustained release p.o. once a day. 6. Amiodarone 400 mg p.o. twice a day x7 days, then amiodarone 400 mg p.o. once a day x7 days, then amiodarone 200 mg p.o. once a day x2 weeks. 7. Lipitor 80 mg p.o. once a day. 8. Paxil 10 mg p.o. once a day. 9. Captopril 12.5 mg p.o. 3x a day. 10. Hydromorphone/hydrochloride 2 mg 1-2 tablets p.o. prn q.4-6h for pain. 11. Plavix 150 mg p.o. once a day. 12. Diltiazem 120 mg p.o. once a day. FOLLOW-UP INSTRUCTIONS: The patient was instructed to make a follow-up appointment with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3357], her primary care physician and cardiologist in approximately 1-2 weeks after discharge and to followup with Dr. [Last Name (STitle) ] for her postoperative surgical visit in the office in approximately four weeks post discharge. CONDITION ON DISCHARGE AND DISPOSITION: Patient was discharged in stable condition to a home with VNA services on [2166-8-8]. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(2) 5897] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2166-8-26] 11:02:44 T: [2166-8-26] 11:40:50 Job#: [Job Number 55808]	[ "41401", "41071", "9971", "4019", "25000" ]
Admission Date: [2114-6-26] Discharge Date: [2114-7-3] Date of Birth: [2067-10-16] Sex: M Service: MED Allergies: Lisinopril Attending:[First Name3 (LF) 689] Chief Complaint: nausea, vomiting, SOB Major Surgical or Invasive Procedure: N/A History of Present Illness: This is a 46 year old diabetic male who was hospitalized for hypertensive emergency, NSTEMI, and DKA. Briefly, patient was admitted to hospital [2114-6-25] with 3 days of nausea, vomiting, and headache. He vomited every morning for three days prior to admission. He had throat discomfort and a pressure in his chest. He did not have arm/shoulder/jaw pain. He did not have SOB/Diaphoresis, palp, edema, lightheadedness. In the ED he was found to be in DKA with glucose of 430. Insulin drip was started. BP was 218/110 with HR 62. TN 0.69 and MBI 10%. ECG with ST/T changes consistent with baseline ECG. He was started on ASA, BB, IIb/IIIa, heparin. Admitted to he MICU Past Medical History: Addison??????s Disease- [2099] on Hydrocort 25, 12.5 DM- dx in [2099], insulin-requiring. + triopathy CRI (baseline 3.5) Anemia Peripheral Neuropathy Peripheral Edema ?CAD: ETT MIBI (-) at RPP of 18,000 in [4-20] s/p right retinal hemorrhage repair Social History: Lives alone. On disability for one year. Not married, no kids. No smoking or drug use. Drinks EtOH rarely. Family History: Father died at 50 of an unknown cancer and mother at 60 of breast cancer. Of four brothers, one died in [2108] with diabetes. One living brother with diabetes. Physical Exam: 97.4 62, 218/110, 17, 98%RA Gen: Pleasant , NAD, A/O x3 HEENT: PEARLA, Anicteric, OP clear. MM dry CV:RR, No M/R/C/G Pulm: CTA b/l ABD:S/NT/ND Ext:3+ LE edema Neuro: CNII-XII GI. Motor [3-21]. Sensation GI Pertinent Results: [2114-6-25] 02:00PM WBC-7.8 RBC-4.33* HGB-13.0* HCT-36.7* MCV-85 MCH-30.0 MCHC-35.4* RDW-13.9 [2114-6-25] 02:00PM PLT COUNT-246 [2114-6-25] 02:00PM CK-MB-10 MB INDX-9.3* cTropnT-0.69* [2114-6-25] 02:00PM CK(CPK)-107 [2114-6-25] 02:00PM GLUCOSE-422* UREA N-84* CREAT-5.0# SODIUM-131 POTASSIUM-3.9 CHLORIDE-91* TOTAL CO2-21* ANION GAP-23* [2114-6-25] 08:15PM CK-MB-11* MB INDX-9.8* [2114-6-25] 08:15PM cTropnT-0.59* [2114-6-25] 08:15PM CK(CPK)-112 [2114-6-26] 06:00AM CK-MB-12* MB INDX-10.2* [2114-6-26] 06:00AM cTropnT-0.56* [2114-6-26] 06:00AM CK(CPK)-118 [2114-6-26] 03:50PM CORTISOL-33.4* [2114-6-26] 08:10PM GLUCOSE-326* UREA N-77* CREAT-5.1* SODIUM-132* POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-18* ANION GAP-18 Brief Hospital Course: 1. Non ST-segment myocardial infarction- The patient was admitted CCU after ruling in for a NSTEMI. The etiology is unclear, but it occurred in the setting of SBP > 200. Patient's nausea, vomiting, and throat pain were likely anginal equivalents. He was treated with aspirin, beta-blocker, IIb/IIIa, heparin and lipitor. Tight glucose control was obtained with an insulin drip. Given patient's high risk TIMI score, cardiology suggested that patient proceed with catherization. Given his creatinine of 5.0, nephrology was consulted. Nephrology concluded that there was a significant risk that the patient may require life-long dialysis if he proceeded with catheterization. The patient decided to defer the catherization procedure to an outpatient procedure. Patient wanted time to discuss treatment options with his nephrologist, Dr. [Known firstname ]. The patient continued to be treated medically with goal of normalizing blood pressures and glucose levels. After the patient was stablized on the medical floor, a pharmacologic stress test was performed which showed no angina or EKG changes at peak exertion. The perfusion scan was w/o focal abnormalities but with the non-specific finding of dilation with stress (? 3 vessel disease). Given that the patient was free of sx, he chose to defer catheterization. 2. DM- On admission, patient was found to be in DKA. He was placed on on an insulin drip, with resolution of anion gap metabolic acidosis. The patient was followed by [Initials (NamePattern4) ] [Last Name (NamePattern4) ] Diabetes Center endocrinologist. He was transitioned to insulin sliding scale. He was eventually restarted on his outpatient dose of NPH with the ISS. Blood sugars were high intermittently, but urine remained neg for ketones and gap was normal. Glucose control was well-controlled on discharged on NPH (16, 18). He was advised to follow-up at the [Hospital ] clinic as an outpatient. 3. Hypertension- On admission, blood pressures were over 200. During the course of his hospitalization, Labetolol was increased to 800 mg tid. Losartan 30 mg was added to blood pressure regimen. Patient's PMD was consulted, and acknowledged that pressures have also been difficult to treat as an outpatient. At time of discharge BP was 120/70 on Labetolol 800 tid, hydralazine 50 qid and nifedipine 90. He was instructed to follow up with his PMD. 4. Renal Failure- Patient's renal failure was thought to be pre-renal and a result of both, vomiting and dehydration. During hospitalization Cr decreased from 5.1 to 4.5. He was also discharged on epo injections. 5. Peripheral Edema- patient was gently diuresed on last two days of hospitalization. He was discharged on Lasix 20 mg [Hospital1 ]. 6. Addison's: He was maintained on fludrocortisone 0.1 and hydrocort 20 qAM, 5 qPM Medications on Admission: Labetalol 200 mg 3 tabs [Hospital1 ]. Nifedipine XL 90 mg qd. Hydralazine 50 mg qid. Procrit 5000 units injection weekly. Hydrocortisone 20 mg tablets 1 tablet am, tablet pm. Levothyroxine 50 mcg qd. Metolazone 2.5 mg qd. Lorazepam 0.5 mg prn Protonix 40 mg qd. Fludrocortisone Acetate 0.1 mg 3 tabs qd. Lasix 80 mg qd. Aspirin 325 mg qd. Insulin- 16 q AM, 17 qPM Lipitor 10 mg qd. Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. 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 3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QD (once a day). Disp:30 Tablet Sustained Release(s) Refills:2 4. Fludrocortisone Acetate 0.1 mg Tablet Sig: Three (3) Tablet PO QD (once a day). Disp:75 Tablet(s) Refills:2 5. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:30 Tablet(s) Refills:0 7. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 8. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 9. Hydralazine HCl 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:30 Tablet(s) Refills:2 10. Labetalol HCl 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:360 Tablet(s) Refills:2 11. Losartan Potassium 25 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:30 Tablet(s) Refills:2 12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:14 Tablet(s) Refills:0 13. Hydrocortisone 5 mg Tablet Sig: 2.5 Tablets PO at bedtime. Disp:90 Tablet(s) Refills:2 14. Hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO qAM. Disp:30 Tablet(s) Refills:2 15. Hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO qAM: total of 25 qAM. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Non ST-segment Elevation Myocardial Infarction Insulin Dependent Diabetes Chronic Renal Insufficiency Addison's Disease Anemia Peripheral Neuropathy Peripheral Edema Discharge Condition: Stable Discharge Instructions: Your persantine MIBI (cardiac stress test) demonstrated no regional reversible defects but did demonstrate enlargement of the heart with stress. As we discussed there is a risk that you have coronary artery disease and should go to the ER or call 911 with any symptoms of chest discomfort, shortness of breath, lightheadedness, fatigue or any other symptoms with exertion. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs. Adhere to renal diet (see handout) Fluid Restriction: 1500 ml Please call Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 1144] with any quesitions or concerns. Followup Instructions: You have an appointment w/ Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] on [2114-7-5] at 10:00 AM. Please call your kidney doctor, Dr. [First Name8 (NamePattern2) ] [Known firstname 805] ([Telephone/Fax (1) 817] to be seen within 1 week. Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) 542] Where: PA [Location (un) 5259] BUILDING ([Hospital Ward Name ] COMPLEX) Date/Time:[2114-7-11] 1:20 Provider: [Name10 (NameIs) 475] [Initials (NamePattern4) ] [Last Name (NamePattern4) 474], M.D. Where: [Hospital6 29] CARDIAC SERVICES. Please schedule an appointment with Dr. [Last Name (STitle) ] over the next month. [Last Name (un) ] Appts: Thursday, [7-5] at 3:30 pm with [First Name4 (NamePattern1) 16883] [Last Name (NamePattern1) 52672], RN Tuesday, [7-10] at 11am with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1968]-Ossure Completed by:[2114-9-23]	[ "41071", "5849", "40391", "2449" ]
Admission Date: [2145-1-13] Discharge Date: [2145-2-10] Date of Birth: [2068-9-1] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 3984] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: endotracheal intubation tracheostomy PEG placement History of Present Illness: 76 yo male with a history of end-stage pulmonary sarcoidosis who presents with increased shortness of breath over last 24hrs, tachycardia, general fatigue x 1 week. Similar prior presentations, felt to be related to sarcoidosis. Denies any increase in cough or sputum production, fevers, chills or sweats. No abdominal pain, nausea, vomting or diarrhea. Past Medical History: 1. Pulmonary sarcoidosis with pumonary fibrosis, dx [2128], s/p lung bx 2. BPH 3. Hypercholesterolemia 4. Orthostatic hypotension 5. L eye ptosis since birth 6. Glucose intolerance 7. Chronic Encephalomalacia secondary to head trauma while playing ice hockey in [2106] 8. h/o "tummy tuck" remotely Social History: Retired from import/export business in plumbing. Ran his own business. Only out of country travel was to Bermuda years ago. Smoking hx 1-1/2 ppd x 15 yrs, quit [2117]. No etoh or drugs. Lives alone. Brother and his familiy live in [Name (NI) 3146]. Family History: mother died at [Age over 90 ] y.o. hx [Name (NI) 11964], Father died at 75 yo, stroke/cerebral hemorrhage. Patient has 2 brothers, healthy. [Name2 (NI) 4084] married, no children Physical Exam: PE on admission: GEN: tachypnic appearing male HEENT: [Name (NI) 2994], ptosis on left, anicteric, dry mucous membranes, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: rhonchorous diffusely, poor air movement, using accessory muscles of neck and abdomen to assist with ventilation CV: tachycardic, no murmurs ABD: nd, +b/s, soft though muscles contracted EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. . Exam on Discharge Gen: awake and alert w/trach in place, sitting up in bed, thin frail-appearing man HEENT: PERRLA. EOMI. CV: rrr, no m/g/r Lungs: diffuse coarse inspiratory and expiratory sounds. Expiratory wheezing more prominent on right lung fields. [Last Name (un) ]: soft nondistended and nontender Ext: no edema, + peripheral pulses bilaterally Neuro: grossly intact, writing notes to communicate Pertinent Results: Admission Labs [2145-1-13] 11:30AM BLOOD WBC-13.6# RBC-4.83# Hgb-15.2# Hct-45.7# MCV-95 MCH-31.5 MCHC-33.3 RDW-13.0 Plt Ct-247 [2145-1-13] 11:30AM BLOOD Neuts-91.1 Lymphs-5.6* Monos-2.7 Eos-0.3 Baso-0.4 [2145-1-13] 11:30AM BLOOD Glucose-107* UreaN-15 Creat-0.8 Na-143 K-3.8 Cl-101 HCO3-31 AnGap-15 [2145-1-13] 11:30AM BLOOD cTropnT-<0.01 [2145-1-13] 07:56PM BLOOD CK-MB-3 cTropnT-<0.01 [2145-1-14] 06:19AM BLOOD CK-MB-3 [2145-1-13] 07:56PM BLOOD Calcium-7.1* Phos-2.6* Mg-1.4* [2145-1-13] 07:56PM BLOOD Cortsol-29.8* [2145-1-13] 11:33AM BLOOD Lactate-2.1* K-3.7 . Pertinent Labs [2145-1-17] 04:42AM BLOOD WBC-7.0 RBC-3.36* Hgb-10.5* Hct-31.6* MCV-94 MCH-31.2 MCHC-33.2 RDW-13.1 Plt Ct-196 [2145-1-22] 03:02AM BLOOD WBC-9.1 RBC-3.56* Hgb-10.8* Hct-32.5* MCV-91 MCH-30.4 MCHC-33.3 RDW-12.7 Plt Ct-341 [2145-1-26] 02:44AM BLOOD WBC-9.3 RBC-3.08* Hgb-9.5* Hct-28.4* MCV-92 MCH-30.9 MCHC-33.5 RDW-13.3 Plt Ct-399 [2145-2-7] 04:20AM BLOOD WBC-9.5 RBC-3.81* Hgb-11.9* Hct-35.9* MCV-94 MCH-31.3 MCHC-33.2 RDW-13.8 Plt Ct-449* [2145-1-21] 04:06AM BLOOD Plt Ct-323 [2145-1-26] 02:44AM BLOOD Plt Ct-399 [2145-2-6] 06:07AM BLOOD PT-12.7 PTT-24.9 INR(PT)-1.1 [2145-2-7] 04:20AM BLOOD PT-12.7 PTT-24.9 INR(PT)-1.1 [2145-1-22] 04:23PM BLOOD Glucose-86 UreaN-18 Creat-0.4* Na-139 K-3.5 Cl-94* HCO3-39* AnGap-10 [2145-1-25] 03:01AM BLOOD Glucose-87 UreaN-21* Creat-0.4* Na-146* K-3.7 Cl-106 HCO3-38* AnGap-6* [2145-2-4] 04:07AM BLOOD Glucose-78 UreaN-19 Creat-0.4* Na-145 K-3.8 Cl-98 HCO3-40* AnGap-11 [2145-2-7] 04:20AM BLOOD Glucose-101* UreaN-16 Creat-0.5 Na-148* K-3.9 Cl-100 HCO3-43* AnGap-9 [2145-1-25] 03:01AM BLOOD ALT-33 AST-24 LD(LDH)-162 AlkPhos-98 TotBili-0.2 [2145-1-15] 03:44AM BLOOD Type-ART Temp-36.8 Rates-/25 PEEP-5 FiO2-40 pO2-163* pCO2-59* pH-7.33* calTCO2-33* Base XS-3 Intubat-INTUBATED Vent-SPONTANEOU [2145-1-22] 04:34PM BLOOD Type-[Last Name (un) ] Temp-37.5 Rates-/12 Tidal V-320 PEEP-5 FiO2-30 pO2-48* pCO2-66* pH-7.43 calTCO2-45* Base XS-15 Intubat-INTUBATED Vent-SPONTANEOU [2145-1-27] 03:36AM BLOOD Type-[Last Name (un) ] Temp-38.2 Rates-/28 Tidal V-400 PEEP-5 FiO2-30 pO2-32* pCO2-59* pH-7.41 calTCO2-39* Base XS-8 Intubat-INTUBATED Vent-SPONTANEOU [2145-2-4] 12:07AM BLOOD Type-ART pO2-127* pCO2-73* pH-7.39 calTCO2-46* Base XS-15 Intubat-INTUBATED . Microbiology [2145-1-13] 12:00PM URINE Blood-MOD Nitrite-NEG Protein-150 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [2145-1-18] 03:34PM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [2145-2-6] 02:12PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM . Blood cultures ([2145-1-13]): No growth Urine culture ([2145-1-13]): No growth Sputum ([2145-1-13]): GRAM STAIN (Final [2145-1-13]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [2145-1-15]): SPARSE GROWTH Commensal Respiratory Flora. DIRECT INFLUENZA A ANTIGEN TEST (Final [2145-1-14]): Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final [2145-1-14]): Negative for Influenza B. Blood cultures ([2145-1-15]): No growth Blood cultures ([2145-1-18]): No growth Blood cultures ([2145-1-27]): No growth CXR ([2145-1-13]): Aside from slightly lower lung volumes, there is no significant interval change in the appearance of the end-stage sarcoidosis as previously documented. . CXR ([2145-1-24]): Comparison with the previous study done [2145-1-20]. There are extensive parenchymal and pleural changes consistent with end-stage sarcoidosis as before. An endotracheal tube and nasogastric tube remain in place. Allowing for differences in technique, there is no significant change. No significant interval change. . CXR ([2145-2-3]): Previously questioned retrocardiac nodular infection has cleared, presumably representing secretions resolved from a region of cystic lung. In all other respects the radiographic appearance of these severely scarred and bronchiectatic lungs, as well as bilateral pleural abnormalities are unchanged over the long-term. There are no findings to suggest acute pneumonia or pulmonary edema. Brief Hospital Course: 76 yo male with end stage sarcoidosis presenting with dyspnea. . # HYPERCARBIC RESPIRATORY FAILURE: Pt presented to the ER with increased shortness of breath over 24hrs, tachycardia, and generalized fatigue. Similar prior presentations were felt to be related to sarcoid flares. CXR showed end stage pulmonary fibrosis but no other abnormalities. It was felt his sx likely represented pneumonia in setting of severe underlying fibrotic lung disease. Pt was unable to sustain high minute ventilatory rate, evidenced by a rising pCO2 and thus required emergent intubation shortly after arrival to ICU. The patient was treated for presumed pneumonia with levofloxacin and meropenem given leukocytosis and dyspnea. Infectious work-up including multiple blood cultures and viral cultures were negative. The patient was not given steroids since it was felt that his sx were related to an infectious process rather than a flair of his sarcoid lung disease. The patient was made DNR after talking with the son. IP consult was sought for trach placement given the patient's inability to wean off the ventilator with subsequent placement of tracheostomy and PEG on [1-26] and [1-27] respectively. Pt tolerated trach mask well. He was transferred to the floor on [2-3]. Later that afternoon he was noted to desat into the 50's with increased work of breathing and was requiring high levels of nursing care. He was transferred back to the MICU where he again experienced agitation and increased work of breathing. He was placed back on the vent on PS overnight and tolerated this well and eventually was able to transition to trach mask throughtout the day and night. Clinical decompensation attributed to mucus plugging. # CHRONIC ORTHOSTATIC HYPOTENSION: Pt normotensive on admission to ICU. His home medications of midodrine and fludricortisone were continued while admitted. # Agitation: The patient had issues with agitation especially at night. Geriatrics was consulted and a regimen of Seroquel was initiated as well as efforts to limit lines and to orient him frequently. His mental status waxed and waned and he fell out of bed twice but sustained no injuries. By [2-1] his delirium had improved on a regimen of seroquel to 12.5 mg [Hospital1 ], seroquel 25 mg QHS and Seroquel 25mg prn. Upon readmission to the MICU, however, he again became significantly agitated and required IV haldol in addition to his scheduled seroquel. EKG the following morning did not show any eveidence of prolonged QT. Per geriatric recommendations the pt's seroquel was increased to 50mg qhs and his sundowning improved. QTc was noted to 419 on discharge dose of seroquel. . The patient was on SubQ heparin for DVT prophylaxis and PPI for stress ulcer prophylaxis. Communication was with the patient and his [Last Name (LF) 802], [Name (NI) ] [Name (NI) 2013] ([Name (NI) 802]) [Telephone/Fax (1) 97950]. Code status was DNR/DNI, confirmed with HCP. . # Malnutrition: He failed swallowing test twice with concern for aspiration. PEG tube was placed and his tube feeds were advanced to goal rate of 35 cc/hr. Medium chain trigylcerides were added for coloric help. . Follow up at Rehab 1. Sundowning: [Month (only) 116] increase his schedule dose of seroquel [Hospital1 ] and qhs. His QTc on current dose is only 419. Please check EKG after increasing his dose to ensure there is no significant QTc prolongation. Medications on Admission: 1. Fludrocortisone 0.1 mg DAILY 2. Tamsulosin 0.4 mg HS 3. Docusate Sodium 100 mg [Hospital1 ] as needed for constipation 4. Midodrine 1.25 mg PO BID 5. Acetaminophen 1000 mg PO Q6H as needed for pain Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution [Hospital1 ]: One (1) Injection TID (3 times a day). 2. docusate sodium 50 mg/5 mL Liquid [Hospital1 ]: One (1) PO BID (2 times a day). 3. senna 8.8 mg/5 mL Syrup [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 5. midodrine 2.5 mg Tablet [Hospital1 ]: 0.5 Tablet PO BID (2 times a day). 6. beclomethasone dipropionate 80 mcg/Actuation Aerosol [Hospital1 ]: One (1) Inhalation [Hospital1 ] (2 times a day). 7. fludrocortisone 0.1 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 8. quetiapine 25 mg Tablet [Hospital1 ]: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 9. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 10. quetiapine 25 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO BID (2 times a day). 11. nystatin 100,000 unit/mL Suspension [Last Name (STitle) ]: Five (5) ML PO QID (4 times a day) as needed for thrush. 12. acetylcysteine 20 % (200 mg/mL) Solution [Last Name (STitle) ]: One (1) ML Miscellaneous Q4H (every 4 hours). 13. oxycodone-acetaminophen 5-325 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 14. ipratropium-albuterol 18-103 mcg/Actuation Aerosol [Last Name (STitle) ]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 15. quetiapine 25 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO QHS (once a day (at bedtime)). 16. acetaminophen 500 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO Q8H (every 8 hours). 17. medium chain triglycerides 7.7 kcal/mL Oil [Last Name (STitle) ]: One (1) ML PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 1121] - [Location (un) 1456] Discharge Diagnosis: Primary Diagnosis 1. Hypercarbic respiratory failure 2. Pneumonia 3. Sarcoidosis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted because you had shortness of breath which was thought to be due to a pneumonia in setting of your underlying sarcoidosis. You were treated with antibiotics called MEROPENEM and VANCOMCYIN. You needed help with mechanical ventilation to breathe. A tracheostomy was performed as you required prolong ventilatory support. You were removed off of mechanical ventilation and were breathing on trach collar mask prior to transfer to [Hospital ] rehab. . Followup Instructions: Department: PULMONARY FUNCTION LAB When: WEDNESDAY [2145-3-10] at 3:40 PM With: PULMONARY FUNCTION LAB [Telephone/Fax (1) 609] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: MEDICAL SPECIALTIES When: WEDNESDAY [2145-3-10] at 4:00 PM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [Telephone/Fax (1) 612] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: PFT When: WEDNESDAY [2145-3-10] at 4:00 PM [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438]	[ "486", "2720", "V1582" ]
Admission Date: [2123-12-16] Discharge Date: [2123-12-18] Date of Birth: [2044-1-3] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 898] Chief Complaint: fever, hematuria Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: 79 y/o M w/CAD, CHF, CVA, C diff, B urolithiasis causing ARF requiring R ureteral stent and L perc nephrostomy tube, who presented to the ED tonight with one day of fever, nausea/vomiting. Per NH notes, he became increasingly lethargic and had an O2 sat of 85% on 2L so was sent to the ED for further eval. His only complaint is that he was having hematuria. He was seen in the ED on [12-13] for hematuria, had a negative renal u/s and was seen by urology who recommended d/c home with f/u. . In the ED, his vitals were T 102.8, BP: 106/56, P: 122, RR: 28, 98% on 4L (90%RA). His bp dropped as low as 80s/50s but was mostly 90s-110s/60s-70s. He received 6L NS. He was noted to have a UTI on his UA and was given levofloxacin, and also was given flagyl as he has a hx of c.diff. Central line was attempted but the wire was unable to be threaded. Past Medical History: CVA - [2117] with residual right-sided weakness OSA - on 2L NC during day and night; refused home CPAP CAD - s/p MI 3 yrs ago CHF - diastolic dysfunction Anemia - [8-24] EGD with gastritis, colonoscopy with diverticulosis, with GI bleeding C diff colitis [8-25], [11-24] Depression s/p right shoulder surgery s/p knee replacement h/o right ureteral stent placement and left nephrostomy tube placement for obstructive nephrolithiasis - removed [7-25] right subcapsular perinephric hematoma Social History: Married, currently at [Hospital ] rehab. H/o tobacco, 30 pack-years, quit about 20 years ago. Drinks 2 drinks/week. No IVDU Family History: Noncontributory Physical Exam: T: 95.8 BP: 111/67 P: 113 R: 29 O2 sat: 98% on 4L Gen: sleeping, arouses to voice, answers ?'s appropriately but quickly falls back to sleep HEENT: NC, AT, MM dry Neck: supple, neck veins flat Lungs: CTA anteriorly, pt unable to sit forward for posterior exam CV: regular, tachycardic, no murmur Abd: soft, nt/nd, +bs Ext: warm/dry, no edema, 2+ dp bilaterally Neuro: arouses to voice, R pupil reactive, L pupil surgical, intermittently following commands Pertinent Results: [2123-12-16] 08:22PM GLUCOSE-125* POTASSIUM-4.1 [2123-12-16] 08:22PM CALCIUM-8.0* MAGNESIUM-2.3 [2123-12-16] 08:22PM HCT-24.5* [2123-12-16] 05:39PM FIBRINOGE-391 D-DIMER-9675* [2123-12-16] 04:41PM HCT-26.1* [2123-12-16] 04:41PM FDP-80-160* [2123-12-16] 03:53AM GLUCOSE-117* UREA N-27* CREAT-1.4* SODIUM-140 POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-22 ANION GAP-12 [2123-12-16] 03:53AM ALT(SGPT)-9 AST(SGOT)-20 ALK PHOS-49 TOT BILI-0.6 [2123-12-16] 03:53AM CALCIUM-7.5* PHOSPHATE-3.4 MAGNESIUM-1.5* [2123-12-16] 03:53AM WBC-13.7# RBC-3.06 HGB-9.2* HCT-27.0* MCV-88 MCH-30.1 MCHC-34.0 RDW-16.9* [2123-12-16] 03:53AM NEUTS-79* BANDS-9* LYMPHS-3* MONOS-7 EOS-2 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2123-12-16] 03:53AM HYPOCHROM-OCCASIONAL ANISOCYT-OCCASIONAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL [2123-12-16] 03:53AM PLT COUNT-71* [2123-12-16] 03:53AM PT-15.6* PTT-30.5 INR(PT)-1.4* [2123-12-16] 12:15AM GLUCOSE-101 UREA N-27* CREAT-1.5* SODIUM-140 POTASSIUM-3.6 CHLORIDE-109* TOTAL CO2-19* ANION GAP-16 [2123-12-16] 12:15AM CALCIUM-7.7* PHOSPHATE-2.2* MAGNESIUM-1.3* [2123-12-15] 09:43PM URINE COLOR-DkAmb APPEAR-Cloudy SP [Last Name (un) 155]-1.013 [2123-12-15] 09:43PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM [2123-12-15] 09:43PM URINE RBC->50 WBC-[5-29]* BACTERIA-OCC YEAST-NONE EPI-0 [2123-12-15] 09:24PM LACTATE-2.0 [2123-12-15] 09:15PM GLUCOSE-131* UREA N-33* CREAT-1.7* SODIUM-136 POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-23 ANION GAP-16 [2123-12-15] 09:15PM CK(CPK)-29* [2123-12-15] 09:15PM CK-MB-NotDone cTropnT-0.05* [2123-12-15] 09:15PM CALCIUM-9.1 PHOSPHATE-1.8# MAGNESIUM-1.5 [2123-12-15] 09:15PM WBC-7.3 RBC-3.69* HGB-10.9* HCT-31.8* MCV-86 MCH-29.5 MCHC-34.2 RDW-17.0* [2123-12-15] 09:15PM NEUTS-84* BANDS-12* LYMPHS-3* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2123-12-15] 09:15PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2123-12-15] 09:15PM PLT SMR-VERY LOW PLT COUNT-79* [2123-12-15] 09:15PM PT-13.3* PTT-25.0 INR(PT)-1.2* . Microbiology: CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2123-12-16]): FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. . Blood culture: [12-15] KLEBSIELLA PNEUMONIAE CEFTAZIDIME----------- S CEFTRIAXONE----------- S CIPROFLOXACIN--------- R GENTAMICIN------------ S LEVOFLOXACIN---------- R MEROPENEM------------- S TOBRAMYCIN------------ S . Urine culture: [12-15] >100,000 KLEBSIELLA PNEUMONIAE AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 32 R CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 8 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 256 R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . Imaging: [12-16]: CTU Abdomen/Pelvis IMPRESSION: 1. Inappropriately placed Foley catheter, with the balloon inflated in the bulbous portion of the urethra, causing obstructive uropathy with a distended urinary bladder, prominent ureters, and full collecting systems bilaterally. 2. Improvement in the right kidney subcapsular fluid collection since the prior study. Nonspecific bilateral perinephric stranding. 3. Punctate nonobstructing right kidney stones. 4. Multiple bilateral hypodensities in both kidneys are incompletely evaluated. Some of these are high density, and further workup with ultrasound or MR, if not already completed, should be considered. 5. Multiple small hypodensities in the liver are likely cysts but are too small to characterize. 6. Diverticulosis without diverticulitis. 7. Pleural calcifications bilaterally consistent with prior asbestos exposure. Bibasilar atelectasis and small bilateral pleural effusions. . [12-17]: Bladder US IMPRESSION: Limited study that demonstrates Foley catheter balloon in decompressed urinary bladder Brief Hospital Course: This is a 79 y/o M w/ CAD, CHF, CVA, hx C.diff, B urolithiasis with ARF and R ureteral stent and left percutaneous nephrostomy tube, who came to ED on [12-16] with fever, nausea, vomiting and hematuria, likely with urosepsis, initially hypotensive on arrival to the MICU, stabilized, developed volume overload and oxygen requirment, then transferred to medical floor. . 1. Urosepsis: Originally came in with fever to 103, hypotension (80s/50s), resolved with the administration of 6L of NS in the ED as well as IV antibiotics (Levo/Flagyl). Originally, he was admitted to the MICU and treated for gram negative rod sepsis with meropenem (start date: [12-16]) given history of EBSL in urine. He did not require any pressors during his period of hypotension. Lactate was not elevated and he did not have any evidence of end-organ hypoperfusion. On the floor, he was continued on meropenem, gram negative rods speciated to Klebsiella pneumoniae. Sensitivities showed sensitivity to ceftriaxone, so spectrum was narrowed, and he was discharged on ceftriaxone 1g q24. This should be continued until [2123-12-30]. PICC line was placed for antibiotic administration. . 2. Hematuria: Urology following patient while in house. ? If hematuria was secondary to traumatic foley placement as evidenced on CTU, but thrombocytopenia may have played a role. Foley was placed on [12-16] (confirmed by ultrasound), and should remain in place for a total of two weeks until he follows up with Dr. [Last Name (STitle) 4229]. He should have his foley flushed every 8 hours. Thrombocytopenia was resolving at discharge with discontinuation of PPI (which was thought to be the cause). . 3. Congestive Heart Failure: TTE [5-25] with preserved EF, however, volume overloaded on exam after receiving 6L with initial hypotension. He was given IV Lasix prn for diuresis and responded well. He was weaned down to 1L of oxygen prior to discharge. . 4. Clostridium difficile: C.diff was checked given that he had it in [8-25] as a possible cause of his sepsis, although he did not have any symptoms of diarrhea. It came back positive and he was started on flagyl on [12-16]. This should be continued for a total of two weeks until [2122-12-30]. Patient not symptomatic with diarrhea, leukocytosis is resolving. . 5. Thrombocytopenia: ? cause as platelets were normal previously as an outpatient. PPI was discontinued in MICU for question of cause of thrombocytopenia. No heparin products administered during stay. Platelets continued to trend up with discontinuation of PPI. He should likely be kept off this medication unless he is being monitored closels. . 6. Chronic Renal Insufficiency: Creatinine at baseline. CKD likely due to hydronephrosis from renal stones. Trended creatinine, which remained stable. . 7. CAD: No signs or symptoms of ischemia; troponin checked in ED was mildly elevated at 0.05 but unclear significance of this. Aspirin has been on hold at NH, ? if due to thrombocytopenia. Initially held metoprolol given sepsis, but restarted due to hypertension [12-17]. LDL < 100, not on statin. . 8. Anemia: Hct above baseline, no indications for transfusion or clinical signs of bleeding. He was continued on his outpt iron regimen. . 9. FEN: He was on a cardiac/heart healthy diet, lytes were repleted prn . 10. Code: Full . 11. Communication: With patient . 12. Dispo: Back to rehab center Medications on Admission: multivitamin prilosec spiriva lopressor 25 [Hospital1 ] aspirin 81 (on hold) tylenol lidoderm patch oxycodone iron 325 mg tid ultram 25 mg [Hospital1 ] colace senna dulcolax compazine prn Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 11 days. 5. CeftriaXONE 1 gm IV Q24H Day 1: [12-16] 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. Famotidine 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. 13. Compazine 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 14. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day as needed for constipation. 15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital ] [Hospital ] Nursing Home - [Location (un) ] Discharge Diagnosis: Primary diagnosis: C. diff colitis Urosepsis with klebsiella pneumonia CHF . Secondary diagnosis: CAD OSA CVA with residual right-sided weakness Depression Pseudogout Discharge Condition: Good Discharge Instructions: You were admitted with urosepsis and C. diff colitis. You are being treated with ceftriaxone and metronidazole, which should be continued for a total of 2 weeks ([2123-12-30]). . Please call your doctor if you have fevers, chills, chest pain, shortness of breath, abdominal pain, hematuria, diarrhea. Followup Instructions: You have the following appointment already scheduled with Dr. [Last Name (STitle) 4229]. You should reschedule it for [2123-12-30] or close to it to have your foley catheter removed. You can reach his office at: Phone:[Telephone/Fax (1) 10941] Your appointment is for: Date/Time:[2123-12-21] 11:30 . Please make an appointment to see your primary care doctor, Dr. [Last Name (STitle) ] after discharged from rehab. You can reach his office at: [Telephone/Fax (1) 1579]	[ "2875", "5859", "2859", "41401", "32723" ]
Admission Date: [2157-1-27] Discharge Date: [2157-2-4] Date of Birth: [2108-11-30] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1406] Chief Complaint: Unstable angina Major Surgical or Invasive Procedure: Coronary artery bypass grafting times two (LIMA->LAD, SVG->OM) [2157-1-31] History of Present Illness: Mr. [Known lastname 84091] is ESRD on HD since '[46] who developed angina about 3 years ago. Cardiac cath at that time showed CAD and PCI was not successful. Patient was not interested in surgery at that time. Since [2154], patient has become wheelchair bound, had significant decrease in appetite, and significant weight loss. Patient has had increasing frequency of angina, sometimes taking up to 12 SL NTG/day. He was given prescriptions for plavix, but was unable to afford it. He is now willing to consider surgery. He underwent cardiac cath today which showed EF 25% and severe 3vd. Past Medical History: ESRD on HD since [2146] d/t polycyctic kidney disease HTN hyperlipidemia RBBB CAD depression restless leg syndrome s/p bilateral hip fractures-s/p surgical repair s/p ankle fracture-s/p repair osteoporosis hyperparathyroidism secondary to renal disease-unable to afford medication hyperkalemia remote h/o AF s/p repair of bilat hipfracture s/p repair of ankle fracture s/p multiple L AV fistulas and revisions Social History: Lives with:wife Occupation:disabled driver Tobacco:remote-quit [2130] ETOH:denies Family History: unremarkable Physical Exam: Pulse:76 Resp:15 O2 sat: 96 on RA B/P Right:170/90 Left: unable d/t fistula Height: Weight:54kg General:cachetic 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 [] Murmur3/6 diastolic murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x], distal LE w/loss of hair and ruborous color Neuro: Grossly intact Pulses: Femoral Right: 2+-cath site without hemaotma Left:2+ DP Right:2+ Left:2+ PT [Name (NI) 167]: 2+ Left:2+ Radial Right: 2+ Left:2+ Carotid Bruit Right:none Left:none Pertinent Results: [2157-2-3] 12:00PM BLOOD WBC-7.5 RBC-3.15* Hgb-9.6* Hct-29.7* MCV-95 MCH-30.5 MCHC-32.3 RDW-15.6* Plt Ct-239 [2157-1-31] 06:50PM BLOOD PT-14.1* PTT-36.8* INR(PT)-1.2* [2157-2-3] 12:00PM BLOOD Glucose-109* UreaN-64* Creat-5.7# Na-132 K-4.9 Cl-93* HCO3-27 AnGap-17 [Known lastname ],[Known firstname ] A [Age over 90 84092] M 48 [2108-11-30] Radiology Report CHEST PORT. LINE PLACEMENT Study Date of [2157-1-31] 9:45 PM [Last Name (LF) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5204] CSRU [2157-1-31] 9:45 PM CHEST PORT. LINE PLACEMENT Clip # [Clip Number (Radiology) 84093] Reason: ptx [Hospital 93] MEDICAL CONDITION: 48 year old man with s/p CABG - please [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 84094] with results if there is concern with findings REASON FOR THIS EXAMINATION: ptx Final Report CXR PORTABLE FILM HISTORY: Status post CABG. FINDINGS: Bilateral lower lobe opacities/atelectases noted. Sternotomy. Small left apical pneumothorax. ET tube tip lies 5 cm above the carina and is satisfactory. Swan-Ganz catheter tip lies in the main pulmonary artery outflow. CONCLUSION: Postop changes. Small left apical pneumothorax. Left chest tube is in place. DR. [First Name (STitle) 3934] [Name (STitle) 3935] Approved: [First Name8 (NamePattern2) ] [2157-2-1] 11:47 AM [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname ], [Known firstname ] [Hospital1 18] [Numeric Identifier 84095] (Complete) Done [2157-1-31] at 3:09:41 PM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 18] - Department of Cardiac S [Last Name (NamePattern1) 439], 2A [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2108-11-30] Age (years): 48 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: CABG ICD-9 Codes: 786.05, 786.51, 424.0 Test Information Date/Time: [2157-1-31] at 15:09 Interpret MD: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3318], MD Test Type: TEE (Complete) Son[Name (NI) 930]: [Initials (NamePattern4) ] [Last Name (NamePattern4) 3318], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW1-: Machine: aw5 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 45% to 50% >= 55% Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Mildly depressed LVEF. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Normal ascending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: 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. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is mildly depressed (LVEF= 45 - 50 %), with mild global free wall hypokinesis. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: There is preserved biventricular systolic fxn. No AI, no MR. Aorta intact. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3318], MD, Interpreting physician [Last Name (NamePattern4) ] [2157-2-2] 17:45 Brief Hospital Course: The patient was transferred from [Hospital6 1109] on [2157-1-27]. He continued to have daily chest pain and was on IV NTG. He had HD and on [2157-1-31] he underwent coronary artery bypass grafting times two with LIMA->LAD and SVG->OM. He tolerated the procedure well and was transferred to the CVICU on neo and propofol in stable condition. The cross clamp time was 38 minutes and the total bypass time was 49 minutes. He was extubated on the post op night and was transferred to the floor on POD#2. He was dialyzed on POD#1. His chest tubes were discontinued on POD#1. His epicardial pacing wires were discontinued on POD#3. He continued to progress and was discharged to rehab in stable condition on POD#4. Medications on Admission: toprol xl 100mg by mouth twice daily univasc 15mg by mouth twice daily asprin 162 mg by mouth twice daily renvalia 2-3 tabs w/meals SL NTG Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q6H (every 6 hours) as needed for pain. 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 8. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H (every 4 hours) as needed for anxiety. 12. Univasc 7.5 mg Tablet Sig: One (1) Tablet PO twice a day: home dose 15mg [Hospital1 ]- titrate as [Last Name (un) 1815]. Discharge Disposition: Extended Care Facility: [Location (un) 5176] Pines Extended Care - Facility (Spec) Discharge Diagnosis: ESRD on HD polycystic kidney disease hypertension coronary artery disease hyperlipidemia depression restless leg syndrome s/p bilateral hip fractures osteoporosis hyperparathyroidism atrial fibrillation in past s/p multiple AV fistula revisions 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] Followup Instructions: Recommended Follow-up:Please call to schedule appointments Surgeon Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] Primary Care Dr. [First Name (STitle) ] ([Telephone/Fax (1) 84096]) in [1-22] weeks Cardiologist Dr. [Last Name (STitle) 20222] ([Telephone/Fax (1) ]) in [1-22] weeks Wound check appointment - [Hospital Ward Name 121] 6 ([Telephone/Fax (1) 3071]) - your nurse will schedule Completed by:[2157-2-4]	[ "41401", "40391", "2724", "311" ]
Admission Date: [2179-2-1] Discharge Date: [2179-2-8] Date of Birth: [2114-2-8] Sex: M Service: MEDICINE Allergies: Doxepin / Levofloxacin / Oxycontin Attending:[Last Name (NamePattern4) 290] Chief Complaint: chest pain Major Surgical or Invasive Procedure: stenting of SVC History of Present Illness: 64 yo man with h/o lung CA s/p R pneumonectomy, severe COPD, with prolonged respiratory failure requiring prolonged trach (2 months ago) wean presents from rehab with increased bilateral upper extremety edema (present since [10-31] admission) and left sided chest pain for 2 days(continuous for about 20hrs). Patient denies any fevers, chills, cough, radiation, diaphoeris, no similar pain in past, no pleuritic nature, n/v/diaphoresis. No associated triggers or change with positions, no pain currently. He had been doing well at rehab this past week after ativan and valium were stopped and started on haldol with good relief. Past Medical History: 1. Squamous cell lung carcinoma, status post right pneumonectomy in [2174]. 2. Prostate cancer, status post radical prostatectomy. 3. Perioperative pulmonary embolus [2174]. 4. Type 2 diabetes mellitus. 5. Chronic obstructive pulmonary disease. 6. Atrial fibrillation. 7. Transient ischemic attack in [2165]. 8. Gout. 9. Atypical chest pain since [2164]. 10. Gastroesophageal reflux disease. 11. Obstructive sleep apnea. unable to tolerate BiPAP. 12. Hypertension. 13. Colonic polyps. 14. Hypercholesterolemia. 15. Basal cell carcinoma on his back. 16. Anxiety. 17. Sciatica. 18. History of herpes zoster. 19. multiple admissions for pneumonia (including pseudomonas) and bronchitis, last in [10-31] resulting in ventilator dependence, trach and [Date Range 282] placement 20. vitamin B12 deficiency. 21. Diastolic heart failure. Echo [7-31]: LVEF>55% 21. Cataracts 22. bradycardia on amiodarone Social History: Recently discharged to [Hospital ] rehab s/p trach and [Hospital 282]. He has a 3-pack-per-day tobacco history but quit in [2174] and an overall 160-pack-per-year history. No recent history of alcohol use. Family History: Mother with coronary artery disease. Physical Exam: VS: T 99.2 P 72-91 BP 129/75 R19 Sat 100% on AC 500/20/5/40% GEN aao, nad, able to mouth responses to questions HEENT PERRL, MMM, +trach in place CHEST CTAB with diffuse expiratory wheezes bilaterally posteriorly CV RRR- no murmurs ABD soft, +[Year (4 digits) 282] in place, +BS, nontender EXT no edema BLE, +edema BUE with scabs and excoriations Pertinent Results: [2179-2-1] 05:00PM CK(CPK)-54 CK-MB-NotDone cTropnT-0.09* [2179-2-2] 12:00AM CK(CPK)-55 CK-MB-NotDone cTropnT-0.12* [2179-2-2] 05:25AM BLOOD CK(CPK)-56 CK-MB-NotDone cTropnT-0.14* [2179-2-2] 01:10PM BLOOD CK-MB-NotDone cTropnT-0.12* [2179-2-2] 08:12PM BLOOD CK-MB-NotDone cTropnT-0.11* [2179-2-3] 03:59AM BLOOD CK-MB-NotDone cTropnT-0.12* . [2179-2-1] 05:00PM GLUCOSE-77 UREA N-18 CREAT-0.6 SODIUM-137 POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-43* ANION GAP-3* [2179-2-1] 05:00PM WBC-9.1 RBC-3.36* HGB-9.3* HCT-30.4* MCV-91 MCH-27.8 MCHC-30.7* RDW-13.9 [2179-2-1] 05:00PM NEUTS-87.3* LYMPHS-7.4* MONOS-3.7 EOS-1.2 BASOS-0.3 [2179-2-1] 05:00PM PLT COUNT-358 [2179-2-1] 05:00PM PT-18.0* PTT-31.0 INR(PT)-2.0 . CTA 1. No CT evidence of pulmonary embolism. 2. Stable right pneumonectomy changes. 3. Stable left upper lobe pulmonary nodule. 4. Small mediastinal lymph nodes, none of which meet criteria for pathologic enlargement. 5. Stable appearance of the superior vena cava which is patent throughout, but compressed proximally to a slit-like lumen. 5. Chronic occlusion of the left subclavian artery and vein with numerous vascular collaterals demonstrated within the anterior chest wall. . Brief Hospital Course: A/P: 64 yo man s/p lung ca s/p pneumonectomy and severe COPD here after prolonged admission for respiratory failure requiring tracheostomy placement here with new left sided chest pain. . 1. Chest pain: Multiple sets of cardiac enzymes were cycled and CK/MB remained flat while troponin increased slightly and then remained stable at 0.12. Repeat EKGs showed no changes. Cardiology was consulted and agreed that there was no evidence of an acute ischemic event. Pt was continued on ASA. The pt's chest pain may be related to his chronic SVC syndrome. . 2. Respiratory Failure: Pt on a prolonged ventilator wean secondary to COPD, pneumonectomy, lung cancer and hx of recurrent pneumonias. Pt was continued on AC at night and pressure support during the day. He will continued to wean at rehab. . 3. Bilateral upper extremety swelling: This has been chronic since last admission w/o evidence of DVT. Pt had another CTA in the ER that showed no PE but did show a narrowing of the SVC. Interventional radiology placed a stent in the SVC and over the next several days, the pt's upper ext swelling improved. . 4. Atrial fibrillation: Pt remained in normal sinus rhythm for most of the hospital stay except for a brief episode of a fib with rapid ventricular rate which resolved on its own. Pt was continued on his coumadin. . 5. Anxiety: Pt has a long history of anxiety controlled on fentanyl, morphine prn, haldol. AVOID benzos as pt has paradoxical response. * 6. Anemia: Likely secondary to chronic disease- baseline around 28. Iron studies were sent and revealed a low iron with normal TIBC, ferritin. He was transfused once to [Last Name (un) 291] hct>30. . 7. DM type 2: Pt's glucose was controlled with glargine and an insulin sliding scale. . 8. Access: A PICC line was placed by IR when pt was having his SVC stented. If this line is not needed, it should be pulled to decrease infection risk. It was placed on [2179-2-4]. Medications on Admission: haldol 2mg at q800/1400 and 5mg qhs and 1mg prn tid bacitracin, clotrimazole/betamethasone, albuterol neb q4hrs, budesonide 0.5mg neb q12hrs, ipratropium neb q4hrs, casec powder wafarin 7mg qd, colace 100mg [Hospital1 ], glargine 14units qam, glycerin suppository daily, MVI qd, magnes hydroxide 30ml qd lactulose 20gm tid, acetaminaphen 650mg q4hr prn, SSI, ambien 10mg qhs prn, ascorbic acid 500mg [Hospital1 ], zinc sulfate 220mg qd, sodium bicarbonate 10cc qd, lansoprazole 30mg qd, fentanyl 75mcg patch q72hrs, morphine 2-4mg IV prn Discharge Medications: 1. Haloperidol 5 mg Tablet [Hospital1 ]: One (1) Tablet PO HS (at bedtime). 2. Haloperidol 2 mg Tablet [Hospital1 ]: One (1) Tablet PO Q8AM/2PM (). 3. Haloperidol 1 mg Tablet [Hospital1 ]: One (1) Tablet PO TID (3 times a day) as needed for agitation. 4. Docusate Sodium 150 mg/15 mL Liquid [Hospital1 ]: Fifteen (15) mL PO BID (2 times a day). 5. Zolpidem Tartrate 5 mg Tablet [Hospital1 ]: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 6. Lactulose 10 g/15 mL Syrup [Hospital1 ]: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) [Hospital1 ]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Fentanyl 75 mcg/hr Patch 72HR [Hospital1 ]: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 9. Aspirin 325 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 10. Nitroglycerin 0.3 mg Tablet, Sublingual [Hospital1 ]: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 11. Multivitamin Capsule [Hospital1 ]: One (1) Cap PO DAILY (Daily). 12. Ascorbic Acid 100 mg/mL Drops [Hospital1 ]: One (1) mL PO BID (2 times a day). 13. Zinc Sulfate 220 mg Capsule [Hospital1 ]: One (1) Capsule PO DAILY (Daily). 14. Clotrimazole 1 % Cream [Hospital1 ]: One (1) Appl Topical [Hospital1 ] (2 times a day). 15. Betamethasone Dipropionate 0.05 % Cream [Hospital1 ]: One (1) Appl Topical [Hospital1 ] (2 times a day). 16. Bacitracin Zinc 500 unit/g Ointment [Hospital1 ]: One (1) Appl Topical [Hospital1 ] (2 times a day). 17. Warfarin Sodium 5 mg Tablet [Hospital1 ]: 1.5 Tablets PO HS (at bedtime): goal INR [12-31]. 18. Albuterol 90 mcg/Actuation Aerosol [Month/Day (3) ]: Four (4) Puff Inhalation Q4H (every 4 hours). 19. Ipratropium Bromide 18 mcg/Actuation Aerosol [Month/Day (3) ]: Two (2) Puff Inhalation QID (4 times a day). 20. Fluticasone Propionate 110 mcg/Actuation Aerosol [Month/Day (3) ]: Two (2) Puff Inhalation [Hospital1 ] (2 times a day). 21. Insulin Glargine 100 unit/mL Solution [Hospital1 ]: Fourteen (14) units Subcutaneous at bedtime. 22. Bisacodyl 10 mg Suppository [Hospital1 ]: One (1) Suppository Rectal DAILY (Daily) as needed. 23. Senna 8.8 mg/5 mL Syrup [Hospital1 ]: Five (5) mL) PO BID (2 times a day) as needed. 24. Morphine Sulfate 2 mg/mL Syringe [Hospital1 ]: [11-29] mL [Month/Day (2) ] Q4H (every 4 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary Diagnosis: 1. SVC syndrome 2. Angina Secondary Diagnosis: 1. Respiratory Failure s/p trach 2. Anxiety Discharge Condition: good Discharge Instructions: take all medications as prescribed and go to all follow-up appointments Followup Instructions: Follow-up with your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ], as needed [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "496", "4280", "2720", "53081", "42731", "25000", "V5861" ]
Admission Date: [2119-7-1] Discharge Date: [2119-7-6] Date of Birth: [2050-12-3] Sex: F Service: MEDICINE Allergies: fentanyl Attending:[Last Name (NamePattern4) 290] Chief Complaint: Obtunded Major Surgical or Invasive Procedure: Central Venous Catheter Placement History of Present Illness: 68-year-old female with chronic neck/back pain on high dose narcotics who presents with altered mental status. Her mental status has been poor for the past two days and her family suspects she took too many narcotics. No known nausea/vomiting or fever/chills. Family called EMS today where she was found sitting on the couch slumped over to her right. She was "out of it like this since Thursday (2 days prior to admission)." EMS found patient to be moaning with minimal movement and pupils were 3mm and sluggishly reactive. 1L NS was given and 1mg narcan was given. EMS reported after narcan "patient opens her eyes and responds verbally to EMS questioning, some words are understandable and correct in their response, while others are incomprehensible." She was given another 1mg narcan en route to OSH, however there was no documented response after this dose. At the OSH, AST/ALT were elevated in the thousands, APAP level negative. CT head showed no acute intracranial process. CXR showed minimal right basilar atelectasis. She was intubated for airway protection. . Upon arrival to the [Hospital1 18] ED, vitals: were afebrile SBP 70-80s, minimally responsive. Subclavian CVL placed and norepinephrine started. BP improved to 120/60. Received 2 doses of NAC. Vancomycin and zosyn given. She recieved 5L NS with minimal urine output. ECG showed sinus rhythm at 74bpm, RAD with ST depressions v3-v6. Labs notable for AST 617 ALT 750 CK 3800, Cr 4.1, BUN 50, HCO3 20, K 3.1, lactate 1.5, WBC 11.7, HCT 33, INR 4.4. Urine tox positive for benzodiazepines and opiates. Serum tox negative for ASA, ETOH, APAP, TCA, benzo, barbs. UA with 56 WBC moderate leukesterase and few bacteria and hyaline casts. Seen by toxicology who recommended evaluation of gap, continuing NAC. Vitals prior to transfer: 36.7C, HR 65 RR 22 100% 126/53. . On arrival to the MICU, she awoke and nearly pulled out her ET tube. She opens her eyes to voice and follows simple commands. She was breathing comfortably. Past Medical History: Fibromylagia anxiety depression COPD HTN hyperchol breast cancer s/p left breast lumpectomy s/p b/l CEA s/p bladder suspension bilateral hip fractures Social History: unable to obtain Family History: unable to obtain Physical Exam: ADMISSION EXAM: Vitals: 98.5, 70, 110/44, 100% on vent General: Intubated, not sedated, awakes to voice and follows simple commands HEENT: sclera anicteric, MMM, oropharynx clear Neck: supple 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, mildly distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no edema, unstagable coccyx ulcers Neuro: PERRL, moving all 4 extremities, responding to simple commands . DISCHARGE EXAM: Vitals: 97.9, 176/73, 77, 20, 99% on 2L NC General: No acute distress. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple 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, mildly distended, bowel sounds present, no organomegaly GU: Foley in place Ext: Warm, well perfused, 2+ pulses, no edema, unstageable coccyx ulcers Neuro: Knows name and where she is. Able to state month and year. Moves all 4 extremities on command. Pertinent Results: ADMISSION LABS: [2119-7-1] 09:20PM BLOOD WBC-11.7* RBC-3.59* Hgb-10.2* Hct-33.2* MCV-93 MCH-28.5 MCHC-30.8* RDW-15.4 Plt Ct-340 [2119-7-1] 09:20PM BLOOD Neuts-90.1* Lymphs-7.3* Monos-2.1 Eos-0.4 Baso-0.1 [2119-7-1] 09:20PM BLOOD PT-44.7* PTT-58.8* INR(PT)-4.4* [2119-7-1] 09:20PM BLOOD Glucose-156* UreaN-50* Creat-4.1* Na-136 K-3.1* Cl-99 HCO3-20* AnGap-20 [2119-7-1] 09:20PM BLOOD ALT-617* AST-750* CK(CPK)-3800* AlkPhos-102 TotBili-0.3 [2119-7-1] 09:20PM BLOOD Lipase-37 [2119-7-1] 09:20PM BLOOD Albumin-2.7* Calcium-6.9* Phos-5.8* Mg-1.7 [2119-7-1] 09:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2119-7-1] 09:30PM BLOOD Lactate-1.5 . PERTINENT LABS: [2119-7-1] 09:20PM BLOOD cTropnT-0.18* [2119-7-2] 04:01AM BLOOD CK-MB-13* MB Indx-0.5 cTropnT-0.17* [2119-7-2] 04:30PM BLOOD CK-MB-10 MB Indx-0.6 cTropnT-0.14* [2119-7-3] 01:56AM BLOOD CK-MB-8 cTropnT-0.11* [2119-7-3] 04:25AM BLOOD CK-MB-12* MB Indx-0.4 cTropnT-0.16* . [2119-7-1] 08:35PM URINE Color-YELLOW Appear-Cloudy Sp [Last Name (un) ]-1.014 [2119-7-1] 08:35PM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-TR Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [2119-7-1] 08:35PM URINE RBC-3* WBC-56* Bacteri-FEW Yeast-NONE Epi-3 [2119-7-2] 09:30AM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.014 [2119-7-2] 09:30AM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-TR Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [2119-7-2] 09:30AM URINE RBC-<1 WBC-3 Bacteri-NONE Yeast-NONE Epi-0 . DISCHARGE LABS: [2119-7-5] 03:23AM BLOOD WBC-6.0 RBC-3.07* Hgb-8.8* Hct-28.4* MCV-92 MCH-28.6 MCHC-31.0 RDW-16.5* Plt Ct-316 [2119-7-4] 04:17AM BLOOD PT-13.7* PTT-27.9 INR(PT)-1.3* [2119-7-5] 03:23AM BLOOD Glucose-88 UreaN-17 Creat-0.8 Na-144 K-3.8 Cl-109* HCO3-27 AnGap-12 [2119-7-5] 03:23AM BLOOD ALT-170* AST-50* LD(LDH)-216 AlkPhos-76 TotBili-0.5 [2119-7-5] 03:23AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.0 . MICROBIOLOGY: [2119-7-1] Blood cultrue: no growth to date [2119-7-2] Urine culture: no growth . IMAGING: [2119-7-1] CXR: Single portable view of the chest. No prior. Endotracheal tube is seen with tip approximately 4.5 cm from the carina. Endotracheal tube is seen coiled in the stomach with tip at the gastric fundus. The lungs are clear of large confluent consolidation or effusion. Cardiac silhouette is within normal limits. There is no evidence of pulmonary vascular engorgement. Osseous and soft tissue structures are unremarkable. IMPRESSION: No acute cardiopulmonary process. ET and enteric tubes as above. . [2119-7-3] CT Head w/o con: There is no hemorrhage, edema, mass effect, or territorial infarction. The ventricles and sulci are prominent, consistent with generalized atrophy. Periventricular white matter hypodensities are consistent with chronic small vessel ischemic disease. The basal cisterns are patent and [Doctor Last Name 352]-white matter differentiation is preserved. There is no fracture. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: No acute intracranial process. . [2119-7-4] CXR: As compared to the previous radiograph, patient has received a new endotracheal tube with the tip projects 5 cm above the carina. The other monitoring and support devices are constant. Unchanged lung volumes. Unchanged size of the cardiac silhouette. The right hilus appears a little more prominent, likely because of patient rotation. No new parenchymal opacities, pleural effusion or other lung parenchymal abnormalities. Brief Hospital Course: 68-year-old female with chronic neck/back pain on high dose narcotics who presented with altered mental status and shock. . # Altered mental status: Likely secondary to narcotic overdose given high home doses of oxycodone/oxycontin and reported improvement with narcan by EMS. Narcotics were initially held with continued improvement in mental status. CT head negative for bleed, stroke, or other acute process. Tox screen negative and no metabolic abnormalities. EEG negative for seizure activity. Patient was treated empirically with vanc/zosyn which were discontinued when there were no signs of infection (UA negative, CXR negative, blood cultures no growth to date). We restarted Oxycodone liquid 5mg Q8h prn pain, but are holding the oxycontin and gabapentin. Could consider restarting as needed if her mental status continues to improve. Social work evaluated the patient and this does not appear to have been an intentional overdose. The patient is currently alert and oriented to self and place and can state the month and year, however she is not back at her baseline mental status. Suspect that there is a component of hypoxic brain injury. . # Shock: Likely hypovolemic shock in the setting of narcotic overdose and poor PO intake for several days. Patient was initially on pressors and was empirically on vanc/zosyn which were later discontinued after all cultures and CXR were negative for infectious process. Patient was given IVF, narcotics were held, and her BP improved and she was weaned off the pressors. . # Acute kidney injury: Admission creatinine was 4.1 which was felt to be secondary to poor renal perfusion in the setting of hypovolemic shock. She was fluid resuscitated and her cratinine improved to 0.8 upon discharge. . # Acute liver failure: Admission ALT and AST were elevated, likely secondary to shock liver. They downtrended throughout this admission and are currently ALT 170, AST 50. Would continue to trend. . # Hypertension: Medications were initially held given shock, however her home dose of lasix 40mg daily was later restarted. . # Hypercholesterolemia: Continued simvastatin 40mg daily. . # COPD: Continued Combivent prn. . # Depression/anxiety: Continued Abilify. Medications on Admission: 1. Lasix 40 mg once a day 2. Simvastatin 40 mg once a day 3. K dur 10 once a day 4. Combivent 90-18 2 inh QID PRN 5. Famotidine 20 mg once a day 6. Gabapentin 600 mg (? 4x/day) 7. Oxycontin 40 mg(? TID) 8. Oxycodone 5 mg (? TID) 9. Abilify 10 mg once a day Discharge Medications: 1. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day. 4. Combivent 18-103 mcg/actuation Aerosol Sig: Two (2) inhalations Inhalation four times a day as needed for shortness of breath or wheezing. 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO Q8H (every 8 hours) as needed for pain. 7. Abilify 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: Oaks Long Term Care Facility - [Location (un) 5503] Discharge Diagnosis: Altered mental status secondary to narcotic overdose Hypovolemic shock Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were brought to the hospital because you were very sleepy. This is likely because you took too many of the pain medications. Please be careful in the future and only take the medications as prescribed. You initially had low blood pressures and required medications for this. Your blood pressures improved after we held your pain medications and gave you fluids. Followup Instructions: To be managed by rehab physicians [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "51881", "5849", "496", "2720", "4019", "311" ]
Admission Date: [2192-3-3] Discharge Date: [2192-3-25] Date of Birth: [2137-1-5] Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [Known lastname ] is a 55 year old man who was transferred in from an outside hospital on [2192-3-3]. The patient two days prior to seeking medical attention at the outside hospital complained of a headache. This headache seemed to get worse over a few days. He actually did have a head computerized tomography scan approximately on either [2-29] or [3-1] which did not show any abnormal findings. He represented to [Hospital3 38285] on [3-2] complaining of headache. Over night the patient became more lethargic and unresponsive. A head computerized tomography scan was obtained that showed hydrocephalus as well as a small amount of dependent intraventricular hemorrhage that had settled at the bottom of the occipital [Doctor Last Name 534]. The patient was then transferred to [Hospital6 1760] for further evaluation. In transit the patient received 2 units of FFP. PAST MEDICAL HISTORY: Coronary artery disease, status post ventricular fibrillation and cardiac arrest in [2191-6-25] requiring defibrillation, hypercholesterolemia. MEDICATIONS ON ADMISSION: The patient is on Aspirin 325 q. day, Coumadin for his coronary artery disease as well as severe peripheral vascular disease and Lopressor. PHYSICAL EXAMINATION: On transfer the patient's initial physical examination revealed temperature 99 degrees, heartrate 80, blood pressure 147/81. The patient was intubated. The patient withdraws to upper extremity pain, more on the right than on the left. Initial INR on transfer was 2.9. HOSPITAL COURSE: The patient was transfused with FFP as fast as possible. Once the patient's INR had come down to an acceptable range a ventricular catheter was placed in the right frontal area, in the right frontal [Doctor Last Name 534] of the lateral ventricle. The patient began to wake up after placement of his drain. The patient remained in the Intensive Care Unit for monitoring with q. one hour neurological checks, monitored for neurological decline. His blood pressure was below 140 to prevent rebleed and for ventricular catheter drainage management. The patient was then taken to the Angiography Suite by Dr. [Last Name (STitle) 1132] on [3-7] to rule out any underlying lesion that may have caused ventricular hemorrhage. There was no evidence of any type of aneurysm. There was a right M1 fenestration but this was felt to be an incidental finding. It was assumed that the patient had a small bleed secondary to being on Coumadin. The patient stayed in the Intensive Care Unit for several days. He was moving all extremities well. The patient was oriented to name, however, he has always had a difficult time and was never truly oriented to time and would occasionally be oriented to hospital. We attempted to wean the patient's ventricular drain over several days. On [3-18], the patient's ventricular drain was taken out. The patient, however, continued to have leakage of cerebrospinal fluid from the site where the ventricular catheter had been taken out of. The patient was kept on antibiotics. Because the patient continued to have a cerebrospinal leak it was felt that the patient most likely needed a ventriculoperitoneal shunt, however, the patient had become febrile, so we wanted to make sure that the patient had cerebrospinal fluid cultures negative before placing the ventriculoperitoneal shunt. Thus, at this time we replaced the ventricular drain on the right in a new twist drill hole to avoid infection. This was placed on [3-20] and the patient was then taken to the Operating Room on [3-22] after all the patient's cerebrospinal fluid cultures had been negative for greater than 48 hours. His ventriculoperitoneal shunt was placed on [3-22] into the left vertical [Doctor Last Name 534] without difficulty and the right frontoventricular catheter was removed. The patient did well, was neurologically stable and ready for discharge to rehabilitation as of [3-26]. DISCHARGE DIAGNOSIS: Hydrocephalus status post intraventricular hemorrhage and status post placement of ventriculoperitoneal shunt on [2192-3-22]. DISCHARGE MEDICATIONS: 1. Lisinopril 20 mg p.o. q. day, hold for systolic blood pressure less than 110. 2. Colace 100 mg p.o. b.i.d. 3. Metoprolol 12.5 mg p.o. t.i.d., hold for systolic blood pressure less than 110, heartrate less than 50 4. Zantac 150 mg p.o. b.i.d. 5. Simvastatin 20 mg p.o. q. day 6. Tylenol 325 to 650 mg p.o. q. 4-6 hours prn 7. Sliding scale regular insulin subcutaneously FOLLOW UP: The patient is to follow up with Dr. [First Name (STitle) ] of Neurosurgery in one month with noncontrast head computerized tomography scan at that time. The patient should also follow up with his primary care physician in two to three weeks to discuss management of his lower extremity vascular disease. We continue to recommend that the patient not be put back on Coumadin if at all possible. [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 342], M.D. [MD Number(1) 343] Dictated By:[Dictator Info ] MEDQUIST36 D: [2192-3-25] 14:56 T: [2192-3-25] 15:04 JOB#: [Job Number 46042]	[ "2761", "V5861", "41401", "2720" ]
Admission Date: [2108-7-1] Discharge Date: [2108-7-19] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4071] Chief Complaint: pulseless left hand Major Surgical or Invasive Procedure: [2108-7-1] Left axillary to brachial artery bypass with reversed right greater saphenous vein. [2108-7-1] Open reduction left proximal humerus fracture with manipulation. [2108-7-16] Pacemaker placement History of Present Illness: 87F s/p unwitnessed fall in driveway this morning. Her neighbors found her and called EMS who arrived at 9:40am. On the scene she was complaining of left arm pain and per EMS report she had a palpable pulse with good capillary refill. She was taken to [Hospital1 18] [Location (un) 620] where she was found to have a left humeral neck fracture. She was transferred to [Hospital1 18] for further management. Upon arrival she was noted to have a cool left hand with no radial pulse, no motor function, and decreased sensation in the radial distribution. In the ED at [Hospital1 18], orthopedics attempted to reduce left arm and left hand became a bit warmer yet pulses were still intermittent. Past Medical History: PMH: Alzheimers dementia, falls, anxiety, hyperlipidemia, ?htn, depression, DJD, thrombocytopenia, Anemia, ?afib Past Surgical History: s/p TAH/BSO Social History: Son is HCP [Name (NI) 21976] [Telephone/Fax (1) 82944], who lives in [State 531]. Lives with husband in [Name (NI) 620], has one son. -Tobacco history: smoked as teen x 4 years [12-16] PPD -ETOH: wine on holidays -Illicit drugs: none Family History: Noncontributory Physical Exam: On admission [2108-7-1] PE: 72, 184/71, 22, 99% on NRB HEENT: PERLA, EOMI, bilateral ecchymoses, forhead laceration Chest: RRR, lungs clear Abdomen: soft, nontender, nondistended, well healed infraumbilical midline incision Ext: bilateral LE edema Right arm: 2+ radial pulse, motor and sensation intact Left arm: dopplerable pulse, hand cool, insensate in radial distribution, no motor function Pulses: palpable femoral and DP bilaterally, palpable right radial, dopplerable left radial Pertinent Results: LABORATORIES: [2108-7-15] 06:45AM BLOOD WBC-9.2 RBC-3.24* Hgb-9.9* Hct-31.9* MCV-99* MCH-30.6 MCHC-31.0 RDW-21.8* Plt Ct-245 [2108-7-5] 04:25AM BLOOD WBC-11.3* RBC-3.13* Hgb-9.5* Hct-28.3* MCV-90 MCH-30.5 MCHC-33.7 RDW-20.6* Plt Ct-244 [2108-7-1] 04:00PM BLOOD WBC-24.5* RBC-3.67* Hgb-12.5 Hct-36.0 MCV-98 MCH-34.1* MCHC-34.8 RDW-21.1* Plt Ct-263 [2108-7-5] 04:25AM BLOOD Plt Ct-244 [2108-7-1] 04:00PM BLOOD Plt Ct-263 [2108-7-15] 06:45AM BLOOD Glucose-84 UreaN-18 Creat-0.7 Na-138 K-4.3 Cl-102 HCO3-27 AnGap-13 [2108-7-5] 04:25AM BLOOD Glucose-114* UreaN-17 Creat-0.6 Na-139 K-3.8 Cl-106 HCO3-25 AnGap-12 [2108-7-1] 02:38PM BLOOD Glucose-160* UreaN-18 Creat-0.6 Na-140 K-3.5 Cl-107 HCO3-21* AnGap-16 [2108-7-11] 06:55AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.1 [2108-7-5] 04:25AM BLOOD Calcium-8.1* Phos-1.4* Mg-2.3 [2108-7-1] 09:45PM BLOOD Calcium-7.9* Phos-3.5 Mg-1.9 [2108-7-12] 07:00AM BLOOD CK(CPK)-23* [2108-7-12] 07:00AM BLOOD CK-MB-3 cTropnT-<0.01 [2108-7-2] 12:49AM BLOOD CK(CPK)-231* [2108-7-1] 02:38PM BLOOD CK(CPK)-116 ========================= [2108-7-3] Shoulder X-Ray: FINDINGS: Again seen are comminuted fractures of the left humeral head and neck with medial displacement of the humeral diaphysis. Alignment is not significantly changed since the previous radiograph. The acromioclavicular joint is intact. There has been placement of staples overlying the anterolateral left chest. IMPRESSION: Comminuted fractures of the proximal left humerus, not significantly changed. . [2108-7-1] Shoulder X-ray: LEFT HUMERUS, PORTABLE FRONTAL VIEW: The severely comminuted fracture of the humeral head and neck, with marked medial displacement of the humeral shaft is unchanged. IMPRESSION: Comminuted fracture of the left humeral head and neck. Please refer to subsequent CT for additional details. . [2108-7-1] CTA OF THE LEFT SHOULDER AND PROXIMAL HUMERUS: Comparison is made with a left humeral radiograph from earlier the same day. FINDINGS: There is a comminuted fracture of the left humeral head and neck with dislocation of the left humeral head fragments from the glenoid fossa. The distal shaft of the humerus is medially and posteriorly displaced. There is extensive surrounding hematoma. The left AC joint appears well aligned. No additional fractures are seen. In the included portion of the left lung, hypoventilatory changes are noted without frank consolidation or effusion. The heart is enlarged, though incompletely imaged. There is no pneumothorax or rib fracture. The scapula appears intact. CTA: The subclavian artery and proximal segment of the left axillary artery appear widely patent and normal in course and caliber. There is a truncated appearance of the distal aspect of the left axillary artery at the level just distal to the origin of the posterior circumflex humeral artery. Distal to this point, the left brachial artery is thrombosed. There is a small collateral vessel along the medial left humerus, which is contrast-filled and this likely represents the ulnar collateral artery. There is no extravascular pooling of contrast to indicate active extravasation. IMPRESSION: 1. Thrombosis of the left brachial artery at the level just distal to the origin of the posterior circumflex humeral artery. 2. Comminuted fracture of the left humeral head with associated dislocation. . [2108-7-5] CHEST (PORTABLE AP) The right subclavian line tip is at the right atrium and should be pulled back for about 2 cm to secure its position at the cavoatrial junction or low SVC. Cardiomediastinal silhouette is unchanged. There are no areas of consolidation worrisome for interval development of pneumonia. Minimal opacity at the left lung base is unchanged and most likely representing area of atelectasis. There is no appreciable pleural effusion or peumothorax. The patient is after recent surgery of the left arm, most likely related to left humerus fracture. Enchondroma of the right humeral head is noted. IMPRESSION: The right subclavian line tip is in the proximal right atrium and should be pulled back for about 2 cm. Known left humerus fracture. Enchondroma of the right humerus. . [2108-7-17] CXR: As compared to the previous radiograph, the image quality is improved. There is no evidence of right-sided pneumothorax after pacemaker implantation. No evidence of overhydration, no pleural effusions. Unremarkable course of the pacemaker leads. Normal size of the cardiac silhouette. Known bilateral shoulder pathologies. ======================== TTE [2108-7-6]: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal(LVEF >55%). Right ventricular chamber size and free wall motion are normal. The 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. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: No structural cardiac cause of syncope identified. Normal global and regional biventricular systolic function. Mild pulmonary hypertension. Brief Hospital Course: 87yo woman was admitted after fall with humerus fracture. . # L Humeral Fracture: Patient was Transfered from [Hospital1 18] [Location (un) 620] after unwitnessed fall. She underwent Left axillary to brachial artery bypass with reversed right greater saphenous vein by vascular surgery and open reduction left proximal humerus fracture with manipulation by orthopedics. The patient has almost no motor function of the left hand and arm below the biceps and very limited sensation post-fall and post-operatively, though the hand is now well perfused with a good pulse. Patient's pain was very well controlled with standing tylenol 1000mg TID. Mrs. [Known lastname 82945] needs to keep her followup appointments with the Orthopedic and Vascular surgeons. She will also be followed by occupational therapy at acute rehab. . # Tachy-Brady Syndrome: Patient was found to be in afib on arrival to ED and preop. Because of persistent afib, patient was transferred to cardiology service on [7-5] for better management of her arrythmia. Metoprolol and ASA were started. Electrolytes repleted and pain controlled prior to transfer. Upon transfer, she was given separate trials of PO diltiazem and metoprolol for rate control, which were both unsuccessful. Her rate initially had to be controlled on a diltiazem drip; when the diltiazem drip was used in combination with oral nodal agents, there were apparent attempts to self-cardiovert with conversion pauses of 2 to 3 seconds and brief episodes of sinus bradycardia in the 30s. After consultation with the Electrophysiology service, amiodarone was started; once loaded, the amiodarone appeared to significantly help control rhythm. During the first couple of days, she had conversion pauses lasting up to 4.7 seconds; however, the patient was soon mostly controlled in sinus bradycardia with rate in the 50s with frequent PACs and PVCs. She did have multiple brief episodes of atrial fibrillation into the 120s-140s, but these were easily controlled with 5mg IV metoprolol; the IV metoprolol would slow her rate down enough to allow it to convert itself back to sinus bradycardia. Due to the lability of the patient's rate and rhythm, a pacemaker was placed on [7-16]. The pacemaker was not placed until the urinary tract infection had completely cleared. Since the pacemaker was placed, patient continued to go into afib episodically, so PO metoprolol dose was gradually increased. On discharge to acute rehab, patient's PO metoprolol was at 50mg TID with good blood pressure. In the discharge instruction, the rehab was informed that the dose can be increased to 75mg TID if blood pressure tolerates the higher dose. . # Urinary Tract Infection: Mrs. [Known lastname 82945] was found to have a positive urine analysis and treated accordingly with cephalosporins. Sulfa drugs were avoided due to a reported allergy; fluoroquinolones were avoided because the patient had a prolonged QT initially. She was treated for 14 days for a complicated UTI; the pacemaker was placed after finishing a full 10 days of antibiotics. The urinary tract infection was likely largely contributing to the altered mental status of the patient on admission and post-operatively. . # Bright Red Blood Per Rectum: The patient had 1 episode of [12-16] teaspoons of bright red blood per rectum, likely from hemorrhoids. Her hematocrit remained stable throughout the rest of her hospitalization, though she was typed and screened as a precaution. The patient appears to have a problem with constipation, so she was given an escalated bowel regimen. Her colonoscopy history was unclear, and she may need a colonoscopy as an outpatient to rule out other sources of GI bleed. . # Hyperlipidemia: Home statin was continued. . # Dementia: Patient had significant sundowning and delirium/agitation. She was confused about where she was most of the time, and required frequent reorientation. She was out in [Female First Name (un) ] chair at the Nursing Station frequently when she was more agitated which seemed to help. . # Anemia: Hct was stable at 28-30, baseline not known. . # Anxiety/Depression: Patient was put on sertraline which appeared to help. . # FEN: Patient was put on cardiac diet, she tolerated POs well. . Patient was on subcutaneous heparin for DVT ppx. She received bowel regimen. She was continued on ranitidine given that it is home med, though no clear h/o GERD. Her code was full (confirmed with son). Her contact is son [Name (NI) 21976] (HCP): [Telephone/Fax (5) 82946] (aware of transfer to medicine); husband [Name (NI) ]: [Telephone/Fax (1) 82947]. Medications on Admission: Ranitidine 150mg daily Lorazepam 0.5mg daily Lipitor 5mg daily B12 1000mcg daily MVI daily Calcium and Vitamin D Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 0.5 ml Injection TID (3 times a day). 4. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): hold for SBP<90 or HR<50. 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold if loose stools. 12. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 13. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO Q6H (every 6 hours) as needed for constipation. 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 15. Sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day. 16. B-12 DOTS 500 mcg Tablet Sig: Two (2) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: Primary Diagnoses: - s/p fall - left humeral neck fracture c/b traumatic injury to left axillary artery - s/p Left axillary to brachial artery bypass with reversed right greater saphenous vein and open reduction left proximal humerus fracture with manipulation - Atrial Fibrillation s/p Pacemaker placement - Urinary Tract Infection - Delirium Secondary diagnoses: - Hyperlidipemia - Dementia--has poor short term memory but is verbal and interactive - Anemia (baseline not known) - Possible Myelodysplastic syndrome - Anxiety/Depression - Osteoarthritis Discharge Condition: Stable, afebrile, A-V paced. Patient occasionally goes into afib with HR in the 150s. Patient is asymptomatic when this happens. If this does occur, please consider giving patient 25mg PO metoprolol. Discharge Instructions: It was a pleasure to be involved in your care, Mrs. [Known lastname 82945]. You were admitted to [Hospital1 1170] after having fallen. You had orthopedic and vascular surgery to fix your Left arm. You have been having some trouble moving your left arm since the fall, but an occupational therapist will help you rehabilitate your arm in the extended care facility. While you were in the hospital recovering from surgery, you were found to have an irregular heart rhythm called Atrial Fibrillation. This rhythm was going very fast, and we had some difficulty controlling it; with medicines, it would go too slow, so you underwent a procedure to get a pacemaker. You were also found to have a Urinary Tract Infecton, for which you were treated with antibiotics. The following changes were made to your medications: Lorazepam was discontinued We added the following medications: Aspirin 325 mg PO DAILY Metoprolol Tartrate 50 mg PO TID Amiodarone 200mg PO DAILY Tylenol 1000mg TID Sertraline 25 mg PO DAILY Heparin 5000 units SubQ TID TraMADOL (Ultram) 50 mg PO Q6H:PRN pain Ibuprofen 400 mg PO Q8H:PRN pain Please follow the following instructions from the Vascular Surgeons: Division of Vascular and Endovascular Surgery Upper Extremity Bypass Surgery Discharge Instructions 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 ?????? 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 arm you were operated on: ?????? Elevate your leg above the level of your heart (use [1-17] 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 arm: ?????? 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) 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 (from [7-6]) 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 arm or the ability to feel your arm ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Please be sure to keep all of your followup appointments. Please seek medical attention if you begin to have dizziness, chest pain, shortness of breath, palpitations, fevers, or if experience anything other symptoms that concern you. Followup Instructions: Please keep the following appointments that have been scheduled for you: Orthopedic Surgery: You have a visit scheduled with Dr. [Last Name (STitle) ] on Thursday, [2108-7-26] at 9:00pm on the [Location (un) ] of the [Hospital Ward Name 23] Building at [Hospital1 18] in [Location (un) 86]. Office number: [Telephone/Fax (1) 1228]. Please arrive at 8:40am to get x-ray done. If Dr. [Last Name (STitle) ] needs to change the date of your appointment, he will call you directly. You have a visit scheduled with Dr.[Name (NI) 7446] office on Date/Time: [2108-7-26] 11:45. [Telephone/Fax (1) 2625]. [Hospital Ward Name ] Office Building, [Doctor First Name ] 5B [Location (un) 86], [Numeric Identifier 718] You have a visit scheduled in the Device clinic for your pacemaker check on [2108-8-6] at 3pm. [Location (un) 8661] building, [Location (un) 436], at [Hospital1 18]. Cardiologist: You have a visit scheduled with Dr. [Last Name (STitle) 29111] [Name (STitle) 11302]. ([Telephone/Fax (1) 69986] Wed, [2108-8-1]. 11:00am [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 4074]	[ "5990", "42731", "2859" ]
Admission Date: [2164-4-29] Discharge Date: [2164-5-10] Date of Birth: [2083-6-2] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 1505] Chief Complaint: shortness of breath; chest pain with radiation to left arm Major Surgical or Invasive Procedure: Redo Sternotomy, Aortic Valve Replacement (21mm Biocore Epic) [2164-5-1] History of Present Illness: This patient is an 80 year old female with severe aortic stenosis and history significant of CAD s/p CABG, atrial fibrillation on Coumadin, pulmonary hypertension, hyperlipidemia, sleep apnea, and worsening renal insufficiency stage III. The patient was seen by Dr [Last Name (STitle) 51681] for follow up of her worsening dyspnea, now having to sit after walking as little as 3 steps. This is a marked decrease to what she could do 3-6 months ago. She fatigues more easily and has cut back on her activities wanting to sleep all the time. She also notes LUE pain that starts in the left arm and radiates upward to the heart happens when she is short of breath. She also does have some chest pain that is exertional. She sits down and it gets better rather quickly. The patient is unable to perform pulmonary function tests because of her difficulty with performing the test. An echocardiogram on [2164-1-25] revealed severe aortic stenosis with peak transalvular velocity of 4.44 m/sec, peak/mean pressure gradiesnt of 79/45 mmHg, and calculated [Location (un) 109] by continuity equation of 0.5-0.6 cm2. LVEF was 50-55%. Cardiac catheterization revealed mild-moderate coronary artery disease which will be managed medically. She presents pre-operatively for heparin prior to redo sternotomy. Past Medical History: Aortic Stenosis, s/p Aortic Valve Replacement PMH: CAD: s/p CABG [2155] at [Hospital3 8834] Atrial fibrillation, on Coumadin Pulmonary HTN Hypertension Hyperlipidemia Sleep apnea, unable to tolerate CPAP Stage III renal insufficiency Hypothyroid Cancer-skin of face Difficulty swallowing Anxiety Depression Mild dementia Rhinitis Tinnitus Spinal stenosis S/P gallstone GERD Past Surgical History: S/P C-section x4 Right Knee replacement Social History: Lives with son and daughter-in-law. Retired clerical worker at unemployment office in [Location (un) ]. Discharge contact: [Name (NI) 16883] [Name (NI) 18199], daughter. C: [Telephone/Fax (1) 101696] [Name2 (NI) ] Care Services: Housekeeper once per week. Companion [2-10] Tobacco: Never ETOH: None Recreational drug use: Denies Family History: Mother had CAD in her 70's Physical Exam: Pulse: 62 Resp: 20 O2 sat: 99%RA B/P Right: Left: 115/55 Height: 5'3" Weight: 170lb General: NAD, pleasant, forgetful, poor historian Skin: Dry [x] intact [x] well healed sternotomy HEENT: PERRLA [x] EOMI [x] tympanic membranes in tact bilaterally without evidence of erythema or fluid Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur [x] grade __3/6__ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] trace (wearing compression stockings), well healed incisions of endoscopic vein harvest of LLE, with incision of open harvest in thigh. well-healed incision of right TKA Varicosities: None [] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left:2+ DP Right: 1+ Left:1+ PT [Name (NI) 167]: Left: Radial Right: Left: Carotid Bruit Right: Left: bruits vs. radiation of cardiac murmur Pertinent Results: [2164-5-1] ECHO PREBYPASS A patent foramen ovale is present. There is a bidirectional shunt across the interatrial septum at rest. Left ventricular wall thicknesses are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Moderate (2+) aortic regurgitation is seen. There is a minimally increased gradient consistent with trivial mitral stenosis. Mild (1+) mitral regurgitation is seen. The main pulmonary artery is dilated. Dr. [Last Name (STitle) ] was notified in person of the results on [2164-5-1] at 930 am. POSTBYPASS Patient is AV paced and receiving an infusion of phenylephrine. Biventricular systolic function is unchanged. Bioprosthetic valve seen in the aortic position. It appears to be well seated. There is mild aortic insufficiency noted at the junction of the native non and right coronary cusps. 1- 2+ mitral regurgitation present. Aorta is intact post decannulation. Rest of the examination is unchanged. Very poor transgastric views. Brief Hospital Course: The patient was brought to the operating Room on [2164-5-1] where she underwent redo sternotomy, and aortic valve replacement by Dr. [Last Name (STitle) ]. Please see operative note for details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition. She was left intubated and sedated overnight. She required packed red blood cells for a postoperative anemia. On postoperative day one, she awoke neurologically intact and was extubated without incident. She initially experienced intermittent hypertension which responded well to Nicardipine drip. Warfarin was resumed for atrial fibrillation but held after one dose due to supratherapeutic INR. Over several days, beta blockade and Diltiazem were titrated accordingly with much improved blood pressure and rate control. However required titration down due to bradycardia. She responded well to Lasix, and dose adjusted for diuresis. INR gradually improved, and low dose Warfarin was resumed. She continued to progress and physical therapy worked with her on strength and mobility. On post-op day number 7, her INR was 2.5, the coumadin dose was help on [2164-5-8]. On post-op day 9, the patient's INR is stable at 2.6. She will be advised to take Coumadin 0.5mg on [2164-5-10], and INR will be followed every other day until a steady therapeutic INR is achieved. It is now felt that the patient is safe to be discharged to rehabilitation center on post-op day #9. Medications on Admission: Allopurinol 100mg daily, aricept 2.5mg am, 5mg pm, aspirin 81mg daily, calcium 500mg tid, centrum mvi daily, cranberry caps [Hospital1 ], crestor 5mg daily, digoxin 0.125 QOD (LD [4-27]), diltiazem cd 180 daily, enablex 7.5mg daily, fluoxeetine 40mg daily, fluticasone nasal spray daily, folic acid 1mg daily, furosemide 40mg daily, levothyroxine 100mcg daily, losartan 25mg daily, metoprolol 25mg [Hospital1 ], nicobid 250mg daily, ntg prn, omeprazole 20mg daily,k vitamin d 400 u daily, warfarin 3mg daily (LD [2164-4-25]), claritin Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. warfarin 1 mg Tablet Sig: 0.5 mg PO DAILY (Daily): please draw INR on [2164-5-11]. 7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever. 9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [1-9] Inhalation Q6H (every 6 hours) as needed for dypsnea. 12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for dyspnea. 13. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:60 Tablet(s) Refills:0 14. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily). 15. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. donepezil 5 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in the morning)). 17. donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 18. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 19. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 22. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days: Then after 7 days, decrease Lasix to 40mg by mouth daily. 23. potassium chloride 20 mEq Packet Sig: One (1) PO twice a day for 7 days: after 7 days, decrease KCL to 20mEq by mouth daily. 24. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Location (un) 14468] Nursing & Rehabilitation Center - [Location (un) 1456] Discharge Diagnosis: Aortic Stenosis, s/p Aortic Valve Replacement PMH: CAD: s/p CABG [2155] at [Hospital3 8834] Atrial fibrillation, on Coumadin Pulmonary HTN Hypertension Hyperlipidemia Sleep apnea, unable to tolerate CPAP Stage III renal insufficiency Hypothyroid Cancer-skin of face Difficulty swallowing Anxiety Depression Mild dementia Rhinitis Tinnitus Spinal stenosis S/P gallstone GERD Past Surgical History: S/P C-section x4 Right Knee replacement Discharge Condition: Alert and oriented x *** nonfocal Ambulating, deconditioned Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Surgeon: Dr. [Last Name (STitle) ] [2164-6-6] at 1:30pm [Telephone/Fax (1) 170] Cardiologist Dr. [Last Name (STitle) ] [2164-5-23] at 11:00am Please call to schedule the following: Primary Care Dr. [Last Name (STitle) ],[First Name3 (LF) ] E. [Telephone/Fax (1) 101697] in [4-12] 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 Coumadin for atrial fibrillation Goal INR 2.0 - 2.5 First draw day after discharge Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by Dr. [Last Name (STitle) 24307] to phone fax Completed by:[2164-5-10**]	[ "4241", "4168", "5119", "40390", "4280", "V4581", "42731", "2449", "2724", "32723", "V5861", "2859", "42789" ]
Admission Date: [2141-10-16] Discharge Date: [2141-10-23] Date of Birth: Sex: M Service: [Hospital Unit Name 196] HISTORY OF PRESENT ILLNESS: The patient is a 78 year-old male with a past medical history of coronary artery disease status post coronary artery bypass graft, congestive heart failure, diabetes, and chronic renal insufficiency who is admitted for asymptomatic right carotid stenosis now here for stenting. As an outpatient the patient underwent ultrasound on [2141-9-22], which showed a 40 to 60% stenosis and his right carotid artery and a 20 to 40% stenosis in his left carotid artery. The patient reports no associated symptoms with this and denies any weakness or neurological defects. He did have a left CEA in [2131]. He also reports a previous MRI that showed "old tiny strokes," but otherwise has no neurological history. The patient was admitted for an elective stenting of his right carotid artery. The patient underwent stenting of his right coronary artery without any complications. He was then admitted to the Coronary Care Unit for close monitoring following this procedure. At the time of his admission to the Coronary Care Unit the patient denies any concurrent complaints and confirms the above history. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft in [2131] four vessel disease. Cardiac catheterization in [2141-7-11]. 2. Congestive heart failure. 3. Diabetes mellitus type 2. 4. Peripheral neuropathy. 5. Chronic renal insufficiency. 6. Hypertension. 7. Hypercholesterolemia. 8. History of basal cell carcinoma status post resection. 9. History of diverticulosis. HOME MEDICATIONS: 1. NPH insulin b.i.d. 2. Lasix. 3. Atenolol. 4. Altace. 5. Lipitor. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He lives at home with wife. [Name (NI) ] tobacco or alcohol use. Retired accountant. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON ADMISSION: Vital signs temperature 96.5. Blood pressure 158/58. Pulse 67. Respirations 18. Satting 100% on room air. Physical examination older gentleman in no acute distress, conversant. Alert and oriented times three. HEENT bilateral surgical pupils. Extraocular movements intact. Oropharynx is clear. Neck no JVD. Cardiovascular regular rate. 2 out of 6 systolic murmur at the apex. Lungs clear to auscultation bilaterally. Abdomen positive bowel sounds, soft and nontender. Extremities no edema or cyanosis. Pulses intact in extremities times four. Cranial nerves II through XII intact. Strength and sensation grossly intact. LABORATORIES ON ADMISSION: White blood cell count 8.4, hematocrit 31, platelets 160, BUN 39, creatinine 2.8. Chest x-ray cardiomegaly, large pericardial fat pad, no acute infiltrates. Electrocardiogram sinus rhythm at a rate of 68, PR interval .256, right bundle, no acute ST changes. HOSPITAL COURSE: 1. Right ICA stent: The patient was admitted for elective stenting of his right ICA. This was following a carotid duplex in [Month (only) ], which showed significant occlusion in his right ICA with moderate to severe disease with 40 to 60% stenosis on the right. The patient did undergo a right ICA stent without any intraoperative complications. He was subsequently started on aspirin. Initially Plavix was held given plans for mitral valve replacement in the near future, however, later in the hospitalization following discussion with CT surgery staff he was started on Plavix. The patient was closely monitored after the surgery and remained neurologically intact. Initially his systolic blood pressures were kept elevated to ensure cerebral perfusion several days postop. These were slowly lowered as he was restarted on his outpatient antihypertensive medications. 2. Cardiovascular: Coronary artery disease, the patient with a history of coronary artery disease status post coronary artery bypass graft. He had a recent cardiac catheterization prior to admission at an outside hospital, however, this was a technically complicated procedure and his grafts were thought to not be well visualized during this catheterization. Additionally the patient had no symptoms of ischemia at admission. Several days into his hospitalization he did develop acute angina and had minor electrocardiogram changes, which did resolve with nitroglycerin. Given the patient's new unstable angina and his recent catheterization, which showed poor visualization of his grafts the patient did undergo coronary catheterization. The catheterization revealed three vessel coronary artery disease. His LMCA was without any significant stenosis. His proximal left anterior descending coronary artery was 50% stenosed and was totally occluded in the mid left anterior descending coronary artery. His left circumflex had a 50% stenosis at the origin, 70% stenosis proximally and 80% stenosis in the portion supplying collaterals to his right coronary artery. He was already known to have total occlusion of his right coronary artery graft and this was not further explored. His left internal mammary coronary artery left anterior descending coronary artery graft was widely patent. His saphenous vein grafts were already known to be occluded and were not further explored. The patient underwent percutaneous transluminal coronary angioplasty in the AV groove branch of the LCX and also in the proximal LCX. Subsequent repeat angiography showed these vessels to now be patent. The patient was maintained on a regimen of aspirin, Plavix, statin and beta blocker. He did have occasional pauses on telemetry, thus his beta blocker was unable to be titrated up. The patient was briefly on heparin prior to catheterization given his unstable angina. Following the catheterization with successful angioplasty he was taken off his heparin. Pump, the patient admitted with diagnosis of congestive heart failure. He had no echocardiogram reports on file, but reportedly had an EF of approximately 30%. The patient had no active symptoms of heart failure throughout the hospitalization. He was maintained on ace inhibitor for after load reduction as per his outpatient regimen. Valve, the patient with known mitral valve disease who was thought to need a mitral valve repair in the future. This surgery had been delayed until his right ICA could be stented. The patient was maintained on an ace inhibitor for after load reduction. He had no acute symptoms related to his mitral disease. The patient was to follow up with CT surgery following discharge to formulate plans for mitral valve repair. Rhythm, the patient maintained on telemetry throughout the hospitalization. He did have brief sinus pauses on telemetry, but related to nodal blockade. His beta blocker was titrated down and these symptoms resolved. The patient had no acute symptoms related to this and remained hemodynamically stable throughout the hospitalization. 2. Renal: Patient with chronic renal insufficiency with a baseline creatinine of approximately 2.1. He did have a mild bump in his creatinine at this admission thought to be due to dye nephropathy. He received intravenous fluids and Mucomyst with his catheterization and his creatinine stabilized and returned to his baseline prior to discharge. 3. FEN: The patient maintained on cardiac diet. His electrolytes were followed and his potassium and magnesium were maintained. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: To home with services. DISCHARGE DIAGNOSES: 1. Right ICA stenosis status post stent placement. 2. Coronary artery disease status post catheterization with percutaneous transluminal coronary angioplasty to his left circumflex. 3. Urinary tract infection. DISCHARGE MEDICATIONS: 1. Multivitamin q day. 2. Atorvastatin 20 q day. 3. Loperamide 2 mg q.i.d. prn. 4. Aspirin 325 mg q.d. 5. Ramipril 10 mg q.d. 6. Plavix 75 mg q day. 7. Metoprolol 37.5 mg b.i.d. 8. Epo injections two times per week. 9. NPH insulin 10 units b.i.d. 10. Sliding scale regular insulin as directed per sliding scale. 11. Ciprofloxacin 250 mg q day times seven days. DI[Last Name (STitle) 408]E FOLLOW UP: 1. Follow up with CT surgery Dr. [Last Name (Prefixes) ] on [11-2] at 1:30 p.m. with plans for MVR in approximately one month as per Dr. [Last Name (STitle) ] [Last Name (Prefixes) 2546] evaluations. 2. Follow up with Dr. [First Name (STitle) ] on [11-10] at 9:00 a.m. 3. Follow up with Dr. [First Name (STitle) ] in approximately three months with a carotid ultrasound at this point. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3184], M.D. [MD Number(1) 5211] Dictated By:[Last Name (NamePattern1) 5212] MEDQUIST36 D: [2142-1-18] 08:41 T: [2142-1-19] 10:07 JOB#: [Job Number 50578]	[ "4280", "4240", "41401", "4019", "2720" ]
Admission Date: [2103-3-27] Discharge Date: [2103-4-3] Date of Birth: [2053-3-20] Sex: M Service: SURGERY Allergies: Aspirin Attending:[First Name3 (LF) 1234] Chief Complaint: Sent from home by VNA for blood pressure control Major Surgical or Invasive Procedure: none History of Present Illness: Type B dissection aorta. History Present Illness: 50 year old male known type B aortic dissection, diagnosed in [2103-1-15] at [Hospital6 ]; transferred here per patient request. Was in house for a few days for control of blood pressure. He was seen by VNA today found to have a BP of of 160s so was sent to the ED. He had no complaints of abdominal or chest pain, No SOB. Past Medical History: Hypertension Chronic Renal Insufficiency Sickle Cell Trait Social History: Currently not working. He currently lives his mother. [Name (NI) ] alcohol. No tobacco. He is single with no children. Family History: No premature coronary disease. Hypertension; Brother Diabetic. Physical Exam: Vitals: 98.3 61 143/79 18 100%RA Gen: A&Ox3, NAD CV: RRR Lungs: CTA-B Abd: Soft, NTND, no palpable anurysm ext: good distal pulses, no edema Pertinent Results: [2103-3-29] 06:05PM BLOOD Glucose-145* UreaN-25* Creat-1.6* Na-136 K-4.0 Cl-100 HCO3-25 AnGap-15 Brief Hospital Course: Mr [Known lastname ] was admitted on [2103-3-27] for management of his blood pressure. Initially he was started on a nitro drip to control his blood pressure and was observed in the ICU. On HD3 the patient was weaned completely off drips and transferred to the floor. While in house his blood pressure was controlled with several anti-hypertensives which were quickly titrated up due to the inability to lower his blood pressure. While in house the patient remained hemodynamically stable. He tolerated a regular diet and ambulated daily. He was kept on subcutaneous heparin for DVT prophylaxis. He should follow-up with his primary care doctor 1-2 weeks for continued blood pressure management. At the time of discharge his blood pressure was ranging in the mid 130s. He is being discharged in stable condition Medications on Admission: Amlodpine 10mg, Clonidine 0.2mg TID, Labetolol 900mg TID, Lisinopril 40mg, Hydralazine 100mg TID Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 3. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 tabs Refills:2 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Hydralazine 25 mg Tablet Sig: Four (4) Tablet PO Q6H (every 6 hours). Discharge Disposition: Home Discharge Diagnosis: descending aortic dissection Discharge Condition: stable, ambulating and mentating normal Discharge Instructions: You were seen and evaluated for your elevated blood pressure. The most important thing for you to do when you get home is check your blood pressure and record it twice a day. You should bring these recordings to your primary care doctor at your next appointment. Your primary care doctor will be responsible for managing your blood pressure Please follow the general discharge instructions below: Activity: no strenuous activity or heavy lifting Diet: please limit the salt in your diet, this will help your blood pressure. Medications: Some of your medications have changed while in the hospital. Please only take the medications that have been prescribed to you while in the hospital. Followup Instructions: You should follow-up with Dr. [Last Name (STitle) ] in [2-15] weeks. Please call his office for that appointment. ([Telephone/Fax (1) 2867] You should schedule an appointment with your primary care doctor for management of your blood pressure medications. Please make arrangements to see them in the next 1-2 weeks (Dr. [First Name (STitle) ] [Telephone/Fax (1) 250])	[ "5859", "2859" ]
Admission Date: [2117-6-11] Discharge Date: [2117-6-15] Service: CCU HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old female with a history of hypertension who presented to an outside hospital on [2117-6-10] with a complaint of central chest pain lasting 30 minutes. The pain was [10-15] in intensity, did not have any radiation, and was not associated with any shortness of breath, diaphoresis, or palpitations. The patient was treated in the Emergency Department with aspirin and nitroglycerin which did not relieve the pain. Electrocardiogram demonstrated ST elevations of 2 mm to 4 mm in leads V1 through V5, a right bundle-branch block, and Q waves in leads V1 through V3. She was started on heparin, an nitroglycerin drip, and then treated with TNK 30 mg intravenously for thrombolysis. A repeat electrocardiogram one hour later demonstrated persistent ST elevations, and the patient continued to have pain rating [3-15] in intensity. The nitroglycerin drip was increased to 90 mcg per minute prior to transfer to [Hospital1 1444] for intervention, and she was then pain free. PAST MEDICAL HISTORY: 1. Hypertension (on multiple medications). 2. Bilateral cataracts. 3. Status post cholecystectomy. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Aspirin. 2. Atenolol 75 mg p.o. once per day. 3. Diovan 80 mg p.o. once per day. 4. Clonidine 0.1 mg p.o. once per day. 5. Norvasc 5 mg p.o. once per day. 6. Isosorbide dinitrate 20 mg p.o. two to three times per day. 7. Amitriptyline 10 mg p.o. q.h.s. SOCIAL HISTORY: The patient denies any tobacco history. She lives at home alone. FAMILY HISTORY: Family history was noncontributory. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, the patient was afebrile with a temperature of 98.2, heart rate was 77, blood pressure was 150/70, respiratory rate was 16, and oxygen saturation was 94% on 2 liters by nasal cannula. In general, the patient was pleasant and in no apparent distress. Head and neck examination revealed mucous membranes were dry. The oropharynx was clear. No carotid bruits. The lungs were clear to auscultation bilaterally. Cardiovascular examination revealed a regular rate and rhythm with a systolic murmur and positive third heart sound. The abdomen was benign. Extremities had trace edema bilaterally. Neurologic examination revealed cranial nerves II through XII were grossly intact and the patient had 5/5 strength. PERTINENT LABORATORY VALUES ON PRESENTATION: Outside hospital laboratories demonstrated white blood cell count was 13.1, hematocrit was 39.7, and platelets were 353. A Chemistry-7 panel was significant for a blood urea nitrogen of 40 and a creatinine of 1.7. Initial creatine kinase levels at the outside hospital were negative. PERTINENT RADIOLOGY/IMAGING: A chest x-ray demonstrated no acute process. Upon left heart catheterization, the patient's left main coronary artery was found to be normal. The left anterior descending artery had diffuse disease with a focal proximal 80% lesion. The left circumflex had minimal irregularities. The right coronary artery had a 60% to 70% mid lesion. The left anterior descending artery lesion was stented successfully. Right heart catheterization demonstrated right atrial pressures of 10, right ventricular of 40/70, pulmonary artery pressures of 38/19, and a pulmonary capillary wedge pressure of 22. Cardiac output and index were 3.06 and 1.99; respectively. HOSPITAL COURSE BY ISSUE/SYSTEM: 1. CORONARY ARTERY DISEASE: The patient's repeat electrocardiogram demonstrated resolution of the ST elevations and large Q waves in leads V1 through V5. She was treated with aspirin, Plavix, and a statin was started. Her creatine kinase peaked at 7400, and the MB peak was 1075. A repeat echocardiogram demonstrated an ejection fraction of 30% to 35%, and the patient experienced some mild heart failure. She was diuresed with Lasix and maintained good oxygen saturations. She was also started on her beta blocker and ACE inhibitor as well as long-acting nitrates. Due to her depressed ejection fraction and large anterior wall myocardial infarction, the patient was at risk for sudden cardiac death from arrhythmias. The option of an internal defibrillator was discussed with the patient, and she wished to defer at this time. Her right coronary artery lesion may be addressed within six months. Further monitoring on telemetry demonstrated no progressive dysrhythmias. 2. RENAL ISSUES: Repeat laboratories demonstrated a normal creatinine of 1. She did not require any fluids for rehydration, nor did she have any renal failure during her hospitalization. 3. HYPERTENSION ISSUES: The patient's blood pressure was maintained well with beta blocker, ACE inhibitor, and continued calcium channel blocker. Her clonidine was discontinued. CONDITION AT DISCHARGE: The patient's condition on discharge was stable. DISCHARGE STATUS: The patient was to be discharged to rehabilitation. DISCHARGE DIAGNOSES: 1. Anterior myocardial infarction. 2. Hypertension. 3. Congestive heart failure (with an ejection fraction of 35%). MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg p.o. once per day. 2. Plavix 75 mg p.o. once per day (times nine months). 3. Atenolol 75 mg p.o. once per day. 4. Lisinopril 10 mg p.o. once per day. 5. Norvasc 5 mg p.o. once per day. 6. Imdur 30 mg p.o. once per day. 7. Lipitor 10 mg p.o. once per day. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with her primary care provider in one to two weeks. 2. The patient was to follow up with her cardiologist in several months and consider addressing her right coronary artery lesion as well as placement of an automatic internal cardioverter-defibrillator if she wishes. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [MD Number(1) 1009] Dictated By:[Last Name (NamePattern1) 6916] MEDQUIST36 D: [2117-6-15] 12:46 T: [2117-6-15] 13:01 JOB#: [Job Number 48060]	[ "4280", "41401", "4019" ]
Admission Date: [2171-9-15] Discharge Date: [2171-9-19] Date of Birth: [2111-2-14] Sex: M Service: MEDICINE Allergies: Cephalosporins Attending:[First Name3 (LF) 1257] Chief Complaint: 60 year old male complaining of lightheadedness and weakness. Major Surgical or Invasive Procedure: Packed red blood cell transfusion Endoscopy History of Present Illness: Mr. [Known lastname 12056] is a 60 yo M with history of HTN, DM II, aortic valve endocarditis s/p replacement with a mechanical valve and atrial fibrillation who presented to the ED because of lightheadedness and low BP (at home) for 4 days. Patient reports that he was in his usual state of health until last Thursday when he noticed he was becoming lightheaded upon standing and he was getting short of breath with minimal acitvity and sometimes at rest, and his physical therapist took his blood pressure and it was ~90/50. He called his cardiologist who told him to stop his lasix which he did. He had persistent symptoms throughout the weekend. He reports having ~3 black, loose stools/day for one week but he attributes this to eating more fruit. . In the ED, initial vs were: T 99.4, HR 70, BP 118/53, RR 17, 100% O2 sat. Patient was found to have a Hct of 19.4, be guaiac (+) brown stools and an NG lavage showed coffee grounds that cleared after 500 mL. He was given 1L NS, IV pantoprazole 80 mg x2 and transfused 1 unit PRBC's. He was seen by GI in the ED. . On the floor, the patient states he is feeling better but persistently weak. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, rhinorrhea or congestion. Denies cough, or wheezing. Denies chest pain, chest pressure. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. . Past Medical History: Hypertension Diabetes Mellitus Type II Anxiety Peripheral Neuropathy Aortic Valve Replacement ([First Name8 (NamePattern2) ] [Male First Name (un) 923]) secondary to endocarditis Atrial fibrillation Diastolic CHF EF - 55% Anxiety Social History: Mechanical engineer, [Location (un) 67351], MA, Married, EtOH "3 beers a day" but has trouble cutting back. Remote history of tobacco, currently smokes cigars, denies illicits. Family History: Mother pancreatic CA, deceased Father alcoholism, deceased Brother with CABG, CVA. Physical Exam: Physical Exam: Vitals: T: 96.4 BP: 123/69 P: 70 R: 18 O2: 96% on RA FS: 171 6 am, 274 noon, 261 6 pm, 214 midnight General: Obese, man laying propped up in bed, alert, oriented, no acute distress HEENT: Sclera anicteric, DMM, oropharynx clear Neck: supple, JVP not appreciable, no LAD, no carotid bruit Lungs: Bilateral inspiratory crackles [2-3] way up, no wheezes or ronchi CV: Regular rate and rhythm, normal S1, pronounced mechanical S2, flow systolic murmur loudest at USB, no rubs, gallops Abdomen: Obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, palpable liver edge 2 in below liver, palpable spleen GU: no foley Ext: warm, well perfused, 2+ pulses, trace edema to ankles, no clubbing, cyanosis Psych: Mood "tired," affect sad Pertinent Results: [2171-9-15] 06:15PM WBC-4.6 RBC-2.71# HGB-6.4# HCT-19.7# MCV-73# MCH-23.8* MCHC-32.8 RDW-20.2* [2171-9-15] 06:30PM PT-23.7* PTT-25.9 INR(PT)-2.3* [2171-9-15] 06:15PM cTropnT-< 0.01 [2171-9-15] 06:15PM proBNP-1270* . Labs on Callout: . [2171-9-16] 06:07AM BLOOD Hct-24.5* [2171-9-16] 06:07AM BLOOD PT-21.1* PTT-24.7 INR(PT)-2.0* . Labs on Discharge: [2171-9-19] 06:50AM BLOOD Hct-30.7* MCV-80* MCH-25.6* MCHC-31.9 RDW-19.0* Plt Ct-110* [2171-9-19] 06:50AM BLOOD PT-22.4* PTT-25.6 INR(PT)-2.1* . Imaging: RUQ US [2171-9-16]: 1. Echogenic liver consistent with fatty infiltration. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. 2. Splenomegaly. . Studies: EGD: Findings: Esophagus: Mucosa: Area of linear erythema without bleeding noted at GE junction potentially related to NG tube trauma. of the mucosa was noted throughout the esophagus. Protruding Lesions 1 cords of grade I varices were seen in the lower third of the esophagus and gastroesophageal junction. The varices were not bleeding. Stomach: Protruding Lesions What appeared to be large gastric varices were seen in the cardia without stigmata of recent bleeding. Duodenum: Normal duodenum. Impression: Gastric varices Area of linear erythema without bleeding noted at GE junction potentially related to NG tube trauma. in the esophagus Varices at the lower third of the esophagus and gastroesophageal junction Otherwise normal EGD to second part of the duodenum Recommendations: Given computer difficulty images not retained. Area of erythema at GE junction likely from NG trauma though unclear. [Name2 (NI) ] active bleeding.What appeared to be a grade 1 varix distal esophagus without cherry red spot. What appeared to be gastric varices at the fundus without active bleeding. No hx of cirrhosis or portal hypertension in the past. Recommend imaging of abdomen, assessment of portal and splenic vasculature. LFTS, albumin. Heparin gtt. If active bleeding, liver team for potential injection of varices. Brief Hospital Course: # Acute blood loss: Presented with symptomatic acute blood loss and signs/history consistent with upper GI etiology. EGD demonstrated gastric varices (not actively bleeding) and grade 1 esophageal varices. Hct on admission was 19.7 from 30 @ baseline and lactate was 3.3. Lactate normalized to 1.1 after 3 units of pRBCs, but Hct showed an incomplete response to 24.5, prompting an additional unit, after which Hct remained stable for the duration, at ~27 on call-out from ICU, which then increased to 30 upon discharge. - Though not actively bleeding at time of EGD source felt to be gastric varices but to rule out lower etiology patient was recommended to follow-up with pcp for colonoscopy [Name9 (PRE) 13511]. # Gastric Varices / Portal HTN work-up / lower GI bleed work-up: Varices found on EGD prompted an RUQ US, which showed fatty liver and splenomegaly. Cirrhosis work-up included negative Hep serologies, GGT, AFP, and Fe studies. Further outpatient work-up with hepatology will include alpha-1 antitrypsin and US with doppler. Pt was prescribed low dose nadolol 20 mg to help reduce splanchnic blood flow and reduce risk of variceal bleed. - Patient should receive Hepatitis B and A vaccine - Patient scheduled with liver for follow-up and further work-up # Mechanical valve: Coumadin was held in the setting of an acute bleed while pRBCs were transfused until Hct stabilized HD2. It was re-initated at dose of 10 mg daily and pt's INR was monitored up to discharge at 2.1. Pt was counseled that therapeutic range of INR for him is 2.5 to 3. # A-Fib / [Last Name (LF) 9215], [First Name3 (LF) ] 55%: Coumadin was held as described above until Hct stabilized on HD2 and restarted HD3. Showed signs of left heart failure with wet adventitial sounds on exam; diuresed with IV Lasix, titrated to -1L daily and clinically improved. Remained hemodynamically stable without RVR and without signs of R heart failure; discharged in hemodynamically stable condition and normalized volume status. Restarted on home [Hospital1 ] 80 Lasix PO. Discharged on dronedarone and metoprolol per home meds. Will to continue to follow with cardiology as an outpatient. # Alcohol abuse: Patient declined intervention offered by social work. Consoled on risk of alcohol use especially with new diagnosis of liver disease. Medications on Admission: Januvia 100mg daily Metformin 500mg [Hospital1 ] Metoprolol Succinate 100mg daily Furosemide 80mg [Hospital1 ] Warfarin 10mg daily Lisinopril 40mg daily Cymbalta 30mg daily Lantus 100u HS Humalog ISS Aspirin 81mg daily Dronedarone 400mg [Hospital1 ] Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. Dronedarone 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lantus 100 unit/mL Cartridge Sig: One (1) 100 Subcutaneous at bedtime. 6. Humalog KwikPen Subcutaneous 7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 9. Warfarin 10 mg Tablet Sig: One (1) Tablet PO once a day. 10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 11. Cymbalta 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Gastric varices Acute blood loss Steatohepatitis/cirrhosis Alcohol dependence Secondary diagnoses: Diastolic congestive heart failure Mechanical aortic valve Atrial fibrillation Type II Diabetes Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for lighteadeness and weakness which we think was due to a significant drop in your hematocrit and loss of blood in your stool. The endoscopy found varices (swollen veins) in your stomach which probably were bleeding into your stomach. We transfused you by giving you back red blood cells which stabilized your hematocrit. We are discharging you on a new medication called Nadolol to control the varices. You will need to discuss with your primary care doctor having a colonoscopy. Please monitor your stool, and if you see black-colored stool, call your primary care doctor. Please continue the metoprolol and the dronedarone, as well as the lasix, as prescribed by Dr [Last Name (STitle) 911], and weigh yourself every morning. Please [Name8 (MD) 138] MD if your weight goes up more than 3 lbs or if you get very dizzy or lightheaded. We encourage you to avoid drinking alcohol in order to stop the damage of your liver and reduce your chances of having a major bleed in your stomach. We offered help to quit alcohol from our social worker. In terms of medications we STOPPED your Metformin. We have HELD your Januvia please discuss re-starting with your doctor that controls your diabetes due to your liver disease. We are continuing your warfarin. It is very important to follow your INR with your primary care doctor to ensure goal INR 2.5-3.5. We ADDED nadolol to help prevent the chance of a bleed in your stomach. Otherwise we made no changes to your medication. Followup Instructions: You have the following appointments for follow-up with your primary care doctor, the liver specialists, and the gastrointestinal doctors. Department: [State ] SQ When: TUESDAY [2171-10-8] at 1:15 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8428], MD [Telephone/Fax (1) 2205] Building: [State ] ([Location (un) ], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: On Street Parking You need to discuss having a colonoscopy with your primary care doctor. Department: LIVER CENTER When: TUESDAY [2171-10-15] at 10:00 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 We have adjusted your diabetes medications. We STOPPED Metformin and HELD your Januvia. Please schedule an appointment with your diabetic doctor to discuss your management. Completed by:[2171-9-21]	[ "2851", "2762", "4019", "25000", "V5861", "42731", "4280" ]

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