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Admission Date: [2107-10-14] Discharge Date: [2107-10-21] Date of Birth: [2036-4-3] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5893] Chief Complaint: Hypoxemia Major Surgical or Invasive Procedure: GJ tube placement, previous G tube removed History of Present Illness: 71 year old trached and PEG'd male w/ multiple medical problems including DM, COPD, afib, CAD s/p CABG and locally invasive laryngopharyngeal cancer on chemo and XRT who was admitted to [Hospital3 417] Hospital from [Hospital1 1872] rehab on [10-12] for shortness of breath, chest pain and atrial fibrillation with RVR. During the episode his O2 sat reportedly dropped to 87%. Prior to admission he developed neutropenic fever and was being treated with broad spectrum antibiotics. . While at OSH, continued to have AF with rapid ventricular response. ECG showed diffuse ST depressions during RVR (rate 138). Troponin I elevated at 65.48. For his AF he was treated with diltiazem drip and then converted to PO metoprolol day of transfer. He was not started on anticoagulation due to recent [Hospital1 18] admission for hemoptysis as well as thrombocytopenia. He did report some chest pain during these episodes of rapid HR. CXR revealed cardiomegaly and interstitial pulmonary changes indicative of CHF. . Other notable lab values include neutropenia (ANC 700) with an elevated BUN/Cr (57/2.2) - baseline Cr 0.9-1.0. CXR showed a right middle lobe pneumonia. . Patient was recently admitted here on [9-20] for hemoptysis which was felt due to tumor mass. He was given 1U PRBC. Past Medical History: Diabetes Hypertension Coronary Artery Disease, s/p CABG x 5 Permanent Pacemaker for sick sinus Peripheral Vascular Disease (AAA s/p repair) COPD Spontaneous Pneumothorax s/p chest tube Colon Cancer s/p resection and chemo (pt does not know details of therapy) in approximately [2102] Social History: Patient is single. He does not have any children. He reports he has been an alcoholic for the past 45 years and had been drinking 2 glasses wine per day up to hospitalization in [Month (only) ]. He has a 59 pack year smoking history. Family History: Aunt with breast cancer and uncle with throat cancer. Physical Exam: VITALS: 97.6, BP 117/99, HR97, RR 17, O2sat 100% on trach GEN: Cachectic male lying comfortably in bed, conversant HEENT: NC/AT, + temporal wasting, OP clear, PERRL NECK: trach in place, no JVD CARDIAC: Irregular rhythm, nl s1 s3, no discernible murmur. Heart sounds obscured by lung sounds LUNG: Diffuse rhonchi with some wheezing. ABDOMEN: scaphoid, PEG site erythematous, dry, healing EXT: decreased bulk and tone, no c/c/e NEURO: grossly intact SKIN: erythematous with some breakdown over anterior neck Pertinent Results: [2107-10-14] 09:49PM GLUCOSE-151* UREA N-81* CREAT-2.7* SODIUM-137 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16 [2107-10-14] 09:49PM ALT(SGPT)-1014* AST(SGOT)-408* LD(LDH)-736* CK(CPK)-80 ALK PHOS-97 TOT BILI-1.1 [2107-10-14] 09:49PM CK-MB-NotDone cTropnT-4.92* [2107-10-14] 09:49PM ALBUMIN-2.5* CALCIUM-8.1* PHOSPHATE-5.1* MAGNESIUM-2.2 [2107-10-14] 09:49PM WBC-2.5* RBC-3.27* HGB-10.0* HCT-29.1* MCV-89 MCH-30.4 MCHC-34.2 RDW-17.2* [2107-10-14] 09:49PM NEUTS-80.8* BANDS-0 LYMPHS-12.7* MONOS-5.5 EOS-0.4 BASOS-0.4 [2107-10-14] 09:49PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ BURR-1+ [2107-10-14] 09:49PM PLT COUNT-49* [2107-10-14] 09:49PM PT-19.7* PTT-32.8 INR(PT)-1.9* [2107-10-14] 09:49PM GRAN CT-[2090]* [2107-10-14] 09:48PM HBs Ab-NEGATIVE HBc Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [2107-10-14] 09:48PM ACETMNPHN-NEG [2107-10-14] 02:26PM GLUCOSE-203* UREA N-83* CREAT-2.7* SODIUM-137 POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-17 [2107-10-14] 02:26PM CK(CPK)-131 [2107-10-14] 02:26PM CK-MB-14* MB INDX-10.7* cTropnT-6.43* [2107-10-14] 02:26PM CALCIUM-8.0* PHOSPHATE-5.5* MAGNESIUM-2.3 [2107-10-14] 02:26PM PT-20.1* PTT-32.7 INR(PT)-1.9* [2107-10-14] 07:47AM URINE HOURS-RANDOM UREA N-623 CREAT-84 SODIUM-12 POTASSIUM-65 [2107-10-14] 04:21AM TYPE-ART TEMP-36.8 RATES-16/1 TIDAL VOL-500 PEEP-5 O2-40 PO2-88 PCO2-33* PH-7.50* TOTAL CO2-27 BASE XS-2 -ASSIST/CON INTUBATED-INTUBATED [2107-10-14] 02:50AM GLUCOSE-105 UREA N-77* CREAT-2.7# SODIUM-142 POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-23 ANION GAP-23 [2107-10-14] 02:50AM estGFR-Using this [2107-10-14] 02:50AM ALT(SGPT)-2522* AST(SGOT)-1552* LD(LDH)-1182* CK(CPK)-318* ALK PHOS-111 AMYLASE-26 TOT BILI-1.5 [2107-10-14] 02:50AM LIPASE-27 [2107-10-14] 02:50AM CK-MB-28* MB INDX-8.8* cTropnT-10.43* [2107-10-14] 02:50AM ALBUMIN-2.8* CALCIUM-8.9 PHOSPHATE-5.6# MAGNESIUM-2.3 IRON-190 [2107-10-14] 02:50AM calTIBC-185* VIT B12-GREATER TH FOLATE-GREATER TH FERRITIN-GREATER TH TRF-142* [2107-10-14] 02:50AM WBC-2.3* RBC-3.59* HGB-10.7* HCT-30.9* MCV-86 MCH-29.8 MCHC-34.6 RDW-16.8* [2107-10-14] 02:50AM PLT COUNT-46# [2107-10-14] 02:50AM PT-20.4 PTT-31.2 INR(PT)-2.0* [2107-10-14] 02:50AM GRAN CT-1640* Brief Hospital Course: 71M with head and neck cancer, trach/[Hospital 73098] transferred from an outside hospital with atrial fibrillation with RVR, NSTEMI, acute oliguric renal failure, and acute ischemic hepatitis. . # NSTEMI: Patient has a history of CABG, and had very elevated cardiac enzymes on admission (Trop T 65.48, CKMB 72.1). TTE during this admission shows acute changes, EF from 55-60% on [7-26] to 25-30%, severely depressed LV systolic function, severe LV global HK in inf, post, lat walls, depressed RV systolic function, 3+MR, 2+TR. EKG shows 2 mm STD V3-V5 which is 0.[Street Address(2) 73099] depression laterally from his old EKGs. CXR shows unchanged pleural effusions and atelectasis. He was maintained on aspirin and metoprolol. He was not started on a statin since he was admitted with acute ischemic hepatitis, and LFTs were still decreasing to normal levels. . # AFIB with rapid ventricular rate: He was in AFIB with rapid ventricular rate, with a pacer for sick sinus/tachy-brady, HR 100-140s, controlled on Metoprolol and Diltiazem. He was not anticoagulated since he has head and neck cancer and had pancytopenia from chemo and radiation. . # Hypoxemic respiratory failure: Likely associated with bilateral pleural effusions, cardiac stunning, and COPD. Patient has a trach and was kept on trach mask for most of the day, with intermittent transition to AC and PS ventilatory support during the night or with decreasing O2 saturation. Patient was diuresed here with lasix gtt, 5-10 mg per hour for pleural effusions, but he was not total body fluid overloaded. Patient has COPD and was placed on albuterol inhalers, spiriva, and advair during admission to be continued. . As a note, the patient's lasix regimen was added during this admission, and should be titrated up as appropriate to diurese for his bilateral pleural effusions. Currently at the standing dose, he is running even in his fluid goals daily. . # Acute oliguric renal failure: Patient's acute renal failure was prerenal in etiology and associated with a depressed EF and/or post-ischemic ATN, not responsive to fluid boluses. Renal US showed atrophic L kidney unchanged since [7-14], no stone, no hydro, no mass. Ulytes consistent with prerenal etiology. Renal failure gradually resolved over admission. . # Acute ischemic hepatitis: Patient had LFTs in the thousands, associated with hepatic congestion from NSTEMI. He showed no signs of cholestasis or obstruction. Tylenol tox screen was negative, hepatitis panel was negative. . # Febrile neutropenia/pancytopenia/L piriform sinus SCC: Patient has head and neck cancer, s/p carboplatin/taxol and XRT, last XRT and chemo [10-7]. He was neutropenic for only the first day of admission, and was afebrile throughout admission. He is followed as an outpatient by Hem/Onc: [First Name8 (NamePattern2) 7306] [Last Name (NamePattern1) ], Dr. [Last Name (STitle) ]. He completed a Ceftazidime/Vanco for a 7 day course for neutropenia and coverage in case of pneumonia. He was on neupogen until he was no longer neutropenic. All blood, urine, sputum cultures were negative. His goal Hct was maintained at >28, goal platelets were >30, and these goals were met throughout admission. . # Hypertension: Was unremarkable throughout admission, controlled on Metoprolol and Diltiazem. . # Diabetes mellitus: He was maintained on Lantus 16 qhs and sliding scale. Medications on Admission: MEDICATIONS AT HOME: Imipenem 500mg q8H Vancomycin 1g q12h Zofran 4mg IV PRN Nexium 40mg PO daily Metoclopramide 10mg QACHS Lopressor 50mg q8H PO RISS Albuterol nebs Atrovent nebulizer q6H . MEDICATIONS ON TRANSFER: Ondansetron 4mg q8H PRN Aspirin 325mg daily Metoprolol 50mg TID RISS Lantus 16U qhs Ambien 5mg qhs Colace 100mg [Hospital1 ] Lorazepam 0.5mg q8h PRN Metoclopramide 5mg QACHS Esomeprazole 40mg daily Heparin subq Imipenem 250mg q8H Ceftazidime 1000mg q24H Vancomycin 500mg x1 Filgrastim 480mcg x1 Furosemide 20mg x1 Albuterol nebs Ipratroprium nebs Discharge Medications: 1. Aspirin 325 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 2. Insulin Glargine 100 unit/mL Cartridge [Hospital1 ]: Sixteen (16) units Subcutaneous at bedtime. 3. Insulin Regular Human 100 unit/mL Cartridge [Hospital1 ]: One (1) dose Injection QACHS and bedtime: Please give according to standard insulin sliding scale. 4. Zolpidem 5 mg Tablet [Hospital1 ]: One (1) Tablet PO HS (at bedtime). 5. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: One Hundred (100) mg PO BID (2 times a day). 6. Metoclopramide 10 mg Tablet [Hospital1 ]: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 7. Heparin (Porcine) 5,000 unit/mL Solution [Hospital1 ]: 5000 (5000) units Injection TID (3 times a day). 8. Albuterol 90 mcg/Actuation Aerosol [Hospital1 ]: 4-6 Puffs Inhalation Q4H (every 4 hours) as needed for when on vent. 9. Ipratropium Bromide 17 mcg/Actuation Aerosol [Hospital1 ]: 4-6 Puffs Inhalation Q4H (every 4 hours) as needed for when on vent. 10. Senna 8.6 mg Tablet [Hospital1 ]: 8.6 mg Tablets PO BID (2 times a day). 11. Diltiazem HCl 30 mg Tablet [Hospital1 ]: Three (3) Tablet PO QID (4 times a day). 12. Metoprolol Tartrate 25 mg Tablet [Hospital1 ]: One (1) Tablet PO TID (3 times a day). 13. Furosemide 40 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 15. Ondansetron 4 mg IV Q8H:PRN Discharge Disposition: Extended Care Facility: [Hospital1 700] - [Location (un) 701] Discharge Diagnosis: Primary diagnosis: NSTEMI Secondary diagnosis: Head and neck cancer, AFIB, COPD, Trach, PEG Discharge Condition: VSS, on trach mask, comfortable and asymptomatic. Discharge Instructions: 1. Take all medications as prescribed. 2. Return to the ER if you experience increasing shortness of breath, difficulty of breathing, or chest pain. Followup Instructions: Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2108-4-2] 2:30 Completed by:[2107-10-21**]	[ "41071", "42731", "496", "51881", "5849", "486", "V4581", "25000" ]
Admission Date: [2169-3-29] Discharge Date: [2169-3-31] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1384] Chief Complaint: infected left AV graft Major Surgical or Invasive Procedure: excision of infected left AV graft [2169-3-29] History of Present Illness: 89 yo male who presented with chills at dialysis. He was noted to have a fever to 102 at that time. While at dialysis, he was noted to have a ulceration over his left AV graft site with bleeding. He was transferred to [Hospital1 18] for further evaluation and work-up of a likely infected left AV graft. Past Medical History: CKD-- stage IV disease, baseline ~3.8 in [3-/2168]; patient has one kidney, per the family; lost to f/u with nephrology after discharge from [Hospital1 18] in [3-/2168] for similar symptoms; family and family refused dialysis at that time 2o hyperparathyroidism 2o anemia HTN Hyperlipidemia Gout Hernias s/p repair Social History: Greek-only speaking Lives with daughter-in-law and son in JP Substance abuse history unknown Family History: His parents lived to their 90s; no known cancer history. Physical Exam: Vitals: 102 110 220/110 19 96%RA Gen: A+Ox3, mild distress HEENT: NC/AT, no LAD, no bruits CV: tachycardic, -MRG Chest: CTAB Abd: soft/NT/ND Ext: bleeding from ulceration over left AV graft site with likely associated infection, no edema Pertinent Results: [2169-3-31] 02:30AM BLOOD WBC-8.0# RBC-3.32* Hgb-10.6* Hct-32.2* MCV-97 MCH-32.0 MCHC-33.1 RDW-15.1 Plt Ct-162 [2169-3-30] 02:41AM BLOOD WBC-16.2# RBC-3.42 Hgb-10.9* Hct-32.8* MCV-96 MCH-31.7 MCHC-33.1 RDW-15.3 Plt Ct-183 [2169-3-29] 06:30PM BLOOD WBC-9.4 RBC-3.96* Hgb-12.7* Hct-37.8* MCV-96 MCH-32.1* MCHC-33.6 RDW-15.1 Plt Ct-208 [2169-3-29] 06:30PM BLOOD Neuts-90.2* Lymphs-5.5* Monos-3.2 Eos-0.8 Baso-0.3 [2169-3-29] 06:30PM BLOOD PT-13.9* PTT-150* INR(PT)-1.2* [2169-3-31] 02:30AM BLOOD Glucose-93 UreaN-57* Creat-6.8# Na-138 K-4.9 Cl-104 HCO3-20 AnGap-19 [2169-3-30] 02:41AM BLOOD Glucose-110* UreaN-42* Creat-5.5* Na-138 K-4.7 Cl-104 HCO3-20* AnGap-19 [2169-3-29] 06:30PM BLOOD Glucose-257* UreaN-36* Creat-4.9* Na-140 K-4.5 Cl-100 HCO3-23 AnGap-22* [2169-3-30] 02:41AM BLOOD Vanco-5.5* [2169-3-30] 02:58AM BLOOD Type-ART pO2-281* pCO2-28* pH-7.52* calTCO2-24 Base XS-1 [2169-3-29] 10:22PM BLOOD Type-ART pO2-58* pCO2-45 pH-7.32* calTCO2-24 Base XS--3 Brief Hospital Course: After presentation the patient was taken to the operating room where he underwent excision of his infected left AV graft. Post-operatively he was taken to the ICU because of difficulty weaning off the vent after the procedure. He was given vancomycin and levofloxacin as well at that time. The following day he was extubated without difficulty. His wound cultures grew coag + staph aureus from the OR. The following day he was given hemodialysis through his right sided tunnelled line. He was transferred to the floor following dialysis and his foley was discontinued. He was able to void after this was removed. Wet to dry dressing changes were used over his infected wound site. He was discharged home to continue dialysis with vancomycin for 6 weeks and with VNA for continued wet to dry dressing changes. He was discharged in good/stable condition. Medications on Admission: 1. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Pantoprazole 40 mg PO QD 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Pantoprazole 40 mg PO QD 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 4. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous with dialysis for 6 weeks. Disp:18 grams Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: infected left AV graft Discharge Condition: good/stable Discharge Instructions: Please continue on all of your medications that you were on prior to coming to the hospital and please take any new medications as prescribed. Please continue on your regular dialysis schedule at [Location (un) ] dialysis ([Telephone/Fax (1) 673]). You will be given vancomycin 1g IV (an antibiotic) with your dialysis for your left arm wound for 6 weeks after discharge. A home nurse will help you with your wet to dry dressing changes on your left arm. Please follow-up as scheduled. If you develop fevers, chills, nausea, vomitting, diarrhea, shortness of breath, or chest pain please contact a physician [Name Initial (PRE) 2227]. If you have any questions or concerns regarding your dialysis access please call [Telephone/Fax (1) 673]. Followup Instructions: Provider: [First Name11 (Name Pattern1) 819] [Last Name (NamePattern4) 820], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2169-4-6] 8:00	[ "40391", "2720" ]
Admission Date: [2101-8-9] Discharge Date: [2101-8-14] Date of Birth: [2047-3-1] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [2101-8-10] Coronary Artery Bypass Graft x 2 (LIMA to LAD, SVG to Ramus) History of Present Illness: 54 y/o male with h/o hypertension who presented to OSH with unstable angina. Cardiac cath demonstrated an ostial 95% lesions of the LAD. He was then referred for surgical revascularization. Past Medical History: Hypertension, s/p Tonsillectomy, s/p RLE varicose vein stripping Social History: Former smoker and drinks [3-17] glasses of wine/day. Family History: Father with sudden cardiac arrest at 80. Physical Exam: VS: 72 15 160/87 6'5" 250lbs Gen: well-appearing male in NAD Skin: W/D intact HEENT: EOMI, PERRL NC/AT Neck: Supple, FROM -JVD, -carotid bruit Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, well-perfused -edema, -varicosities Neuro: A&O x 3, MAE, non-focal Pertinent Results: [8-10] Echo: PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. POST-BYPASS: 1. Preserved biventricular function. 2. Aortic contours are intact. 3. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. Brief Hospital Course: As mentioned in the HPI, Mr. [Known lastname 4048] was transferred to [Hospital1 18] for surgical revascularization of his coronary disease. He underwent usual pre-operative work-up on day of admission. On [8-10] he was brought to the operating room where he underwent a coronary artery bypass graft x 2. Please see operative report for surgical details. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. Later on op day he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on beta blockers and diuretics and gently diuresed towards his pre-op weight. His chest tubes were removed and later on this day he was transferred to the SDU for further care. Epicardial pacing wires were removed per protocol. He continued to work with physical therapy for strength and mobility. He recovered well without post-op complications. On post-op day 4 he was discharged home with VNA services and the appropriate follow-up appointments. Medications on Admission: Cozaar 100mg qd Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:1 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:1 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:40 Tablet(s) Refills:0 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:1 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. Disp:28 Tablet(s) Refills:0 7. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours). Disp:60 Packet(s) Refills:2 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Doctor Last Name 74630], NH Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2 PMH: Hypertension, s/p Tonsillectomy, s/p RLE varicose vein stripping Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increasing pain. Please contact surgeon ([Telephone/Fax (1) 4044] with all wound issues. 2) Please shower daily. You may wash incision and gently pat dry. You may have steri-strips on incisions which should fall off on their own. If still intact after 3 weeks, you mat remove them. No lotions, creams or powders to incision until it has healed. No swimming until wound has healed. Use sunscreen on incision when out in sun after it has healed. 3) No lifting greater then 10 pounds for 10 weeks from the date of surgery. 4) No driving for 1 month. 5) Report any fever greater then 100.5. 6) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 7) Call with any questions or concerns. Followup Instructions: Dr. [Last Name (STitle) 28946] in 4 weeks Dr. [Last Name (STitle) 3302] in [1-15] weeks Dr. [Last Name (STitle) 32978] in [12-14] weeks Completed by:[2101-8-16]	[ "41401", "4019", "V1582" ]
Admission Date: [2137-6-26] Discharge Date: [2137-7-3] Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 710] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: ET intubation. R IJ central line. History of Present Illness: Ms. [Known lastname 72969] is a [Age over 90 ] year old woman with a history of CHF and moderate AS/MR who presented to the ED with vague complaints of shortness of breath, abdominal pain, and "just not feeling right". She hit her life line button, and was found by EMS to be bradycardic and "cyanotic". Her HR was in the 40s, and her BP was 60/palp. The patient was given atropine, and HR came up to the 80s. In the emergency department the patient was found to be in a junctional rhythm, for which the cardiology fellow was called to evaluate, and felt that it was a separate issue. Cardiac enzymes were negative. The patient's blood pressure intermittently dropped to systolic of 80s from 110s. A RIJ was placed, the patient was volume resuscitated and started on dobutamine in the setting of bradycardia. No CVP's were available secondary to agitation. The patient was found to have a lactic acidosis, hyponatremia, a LLL PNA, and a UTI. The patient was treated with ceftriaxone and azithromycin for presumed UTI and CAP. Given her vague abdominal symptoms, diarrhea, elevated lactate, and guaiac positive stools; the ED wanted to rule out an intra-abdominal source for her sepsis picture. She was unable to tolerate a CT secondary to movement, and was intubated for the study. She was transferred to the MICU for further evaluation and management. Past Medical History: Thyroid CA s/p thyroidectomy Moderate aortic stenosis Moderate mitral regurgitation Chronic diastolic dysfunction -EF >55% on [2135] echo with normal wall motion Moderate pulmonary hypertension Osteoporosis Hypertension Cataracts Social History: She lived most of her life in [Last Name (LF) 614], [First Name3 (LF) 12000]. She has two siblings, one older and one younger, who were still alive. She had a brother who died this last 1/[2135]. After her brother died, she moved to [Name (NI) 86] to live near her daughter. She has another daughter who lives in [Name (NI) 4565]. She currently lives in senior independent housing. Her daughter [Name (NI) ] [Name (NI) 1104] is a radiation oncologist at [Hospital1 ] and is very involved with her care (doctor's appt, grocery shopping, frequent meals, walking to temple) Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T=96.1 BP 70-120/30-50 HR=105 RR=18 O2= 99% on pressure support [4-8] FiO2 40% GENERAL: Intubated, sedated HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. CARDIAC: JVD to her ears, Regular rhythm, normal rate. [2-7] Systolic murmur at RUSB and apex LUNGS: coarse ventilated breath sounds ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: Cool, with 1+ distal pulses SKIN: No rashes/lesions, ecchymoses. RECTAL: Guaiac positive Pertinent Results: ADMISSION LABS: [2137-6-26] 06:43AM PT-16.6* PTT-32.6 INR(PT)-1.5* [2137-6-26] 06:12AM TYPE-MIX PO2-31* PCO2-41 PH-7.33* TOTAL CO2-23 BASE XS--5 [2137-6-26] 06:00AM ALT(SGPT)-269* AST(SGOT)-175* LD(LDH)-323* ALK PHOS-146* AMYLASE-49 TOT BILI-0.6 [2137-6-26] 06:00AM proBNP-8117* [2137-6-26] 03:56AM LACTATE-2.2* [2137-6-26] 03:45AM GLUCOSE-162* UREA N-23* CREAT-0.8 SODIUM-129* POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-20* ANION GAP-16 [2137-6-26] 03:45AM WBC-12.7* RBC-3.68* HGB-10.4* HCT-32.1* MCV-87 MCH-28.3 MCHC-32.4 RDW-15.3 [2137-6-25] 08:51PM CK-MB-NotDone cTropnT-<0.01 [2137-6-25] 08:51PM DIGOXIN-<0.2* [2137-6-25] 08:45PM GLUCOSE-188* LACTATE-5.9* NA+-126* K+-5.0 CL--95* TCO2-18* COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2137-7-3] 06:10AM 10.6 4.14* 11.8* 35.8* 86 28.6 33.0 15.4 389 [2137-7-2] 06:05AM 9.6 4.47 12.5 38.8 87 27.9 32.1 15.2 403 [2137-7-1] 06:10AM 8.7 4.03* 11.5* 35.0* 87 28.4 32.8 15.4 366 [2137-6-30] 05:17AM 8.8 3.68* 10.8* 32.0* 87 29.3 33.6 15.6* 302 Source: Line-RIJ [2137-6-29] 05:11AM 12.5* 3.79* 10.9* 33.2* 88 28.8 32.9 15.7* 310 Source: Line-R IJ [2137-6-28] 03:56AM 11.4* 3.63* 10.6* 31.5* 87 29.2 33.6 16.1* 263 Source: Line-ctl [2137-6-27] 04:20AM 12.5* 3.65* 10.6* 31.6* 87 29.1 33.6 15.9* 272 Source: Line-ctl [2137-6-26] 03:45AM 12.7* 3.68* 10.4* 32.1* 87 28.3 32.4 15.3 237 Source: Line-R IJ multi lumen [2137-6-25] 08:51PM 12.1* 3.78* 11.3* 33.4* 88 29.9 33.8 15.6* 265 Imaging: CXR [2137-6-25] (admission): 1. Cardiomegaly with mild pulmonary edema, which was also noted on the prior exam.2. Focal left basilar consolidation could be consistent with pneumonia in the appropriate clinical setting. 3. Additional consolidation/opacity in the right upper lung, possibly infectious in etiology as well. CT of the chest, however, is recommended to exclude underlying mass. CT Abdomen/Pelvis [2137-6-26]: 1. Moderate bilateral pleural effusions with right upper and bilateral lower lobe consolidations could reflect multifocal pneumonia. 2. No evidence of pulmonary embolism or acute aortic syndrome. 3. Markedly thickened gallbladder wall with edema, cholelithiasis, indicating acute cholecystitis 4. Large periportal soft tissue density mass with mass effect on portal vein, measures similar to liver attenuation however not definitely arising from liver, could be mesenchymal or stromal in origin. Characterize with MR once patient is stable. 5. Possible right heart failure with enlarged right atrium and distended IVC. Liver/gallbladder ultrasound [2137-6-26]: 1. Acute cholecystitis. 2. Rounded 5 cm heterogeneous mass inferior to the liver could represent bowel loop however real-time peristalsis was not seen. It is unclear if this corresponds to the periportal mass seen on CT. As suggested in concurrently obtained CT, correlation with MR when the patient is stable recommended. ECHO [2137-6-27]: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Moderate calcific aortic stenosis. Mild aortic regurgitation. Mild calcific mitral stenosis. Mitral valve prolapse with partial leaflet flail and moderate to severe mitral regurgitation. Moderate tricuspid regurgitation. Severe pulmonary hypertension. Compared with the prior study (images reviewed) of [2136-7-3], mitral regurgitation severity and aortic stenosis severity have slightly increased, and pulmonary pressures are higher. The other findings are largely similar. CXR [2137-6-27]: Significant interval improvement in parenchymal consolidation suggesting resolution of edema and/or aspiration with still present residual atelectasis. No evidence of failure on the current study. The right internal jugular line tip is in the cavoatrial junction. Brief Hospital Course: Ms. [Known lastname 72969] is a [Age over 90 ] y/o F with a chronic diastolic CHF, AS and MR, and severe pulmonary HTN admitted to the MICU on [2137-6-26] for pneumonia and septic shock. She was transferred to the medical floor on [2137-6-28] and discharged to her daughter's home with physical therapy services on [2137-7-3]. . #.Septic shock: The patient was treated with mechanical ventilation, large volume resuscitation and vasopressors (discontinued on [6-27]). She is completing a 7 day course of levofloxacin ending [7-3]. Urinary legionella antigen and urine and blood cultures were negative. . #.Respiratory status: Intubated for agitation in the ED so that CT torso could be performed. Extubated successfully on [6-27]. She briefly required BIPAP on [6-27] for volume overload, and was subsequently transitioned to 2L NC after a 5+ liter diuresis. On the floor she was diuresised with goal -0.5 to -1L and was weaned off oxygen. Patient was discharged on room air with O2 sats in the upper 90's. . #. Chronic diastolic heart failure: Volume overloaded following aggressive volume resuscitation for shock. ECHO was performed on [2137-6-27] which compared with the prior study of [2136-7-3], mitral regurgitation severity and aortic stenosis severity were slightly increased, and pulmonary pressures were higher. She was diuresed and on the floor was given po lasix for goal negative -0.5 to -1L. She was discharged on lasix 40 mg QD. Patient will follow up with her outpatient cardiologist Dr. [Last Name (STitle) ]. She was changed from metoprolol 12.5 mg [Hospital1 ] to home dose carvedilol 3.125 mg [Hospital1 ] prior to discharge. She was also discharged on aspirin 81 mg. #. Cholecystitis: Evidenced on RUQ ultrasound. Surgery was consulted and the patient was felt not to be a candidate for a laparascopic cholecystectomy, as this was an unlikely source of her sepsis. She was taken off Flagyl on [6-28]. LFTs WNL, and clinically, no [Doctor Last Name ] sign during admission. # Transaminitis: Thought to be from hypotension/shock liver on presentation. Decreased steadily during admission. WNL upon discharge. . #. Abdominal mass: Periportal mass noted on abdominal CT and U/S. She will need a dedicated MRI to further evaluate as an outpatient. #.Hypothyroidism: continued home regimen of levothyroxine #.HTN: held home flomax during admission due to hypotension initially and low-normal blood pressures subsequently; may be restarted by outpatient provider at their discretion #.Osteoporosis: alendronate/Vitamin D will be restarted upon discharge . #.Prophylaxis: Given SQH for DVT ppx. . # Nutrition - Given a low salt, heart-healthy diet PENDING ISSUES FOR FOLLOW-UP: (1) Question of periportal mass noted on abdominal imaging (see reports in OMR for further details). Needs a dedicated MRI as outpatient to evaluate further. (2) Flomax was held upon discharge due to the risk of orthostatic hypotension. [Month (only) 116] be restarted at the discretion of an outpatient provider. (3) Patient's daughter expressed concern regarding interval worsening of pulmonary hypertension on TTE between [6-10] (PASP 54) and [6-11] (PASP 66), although the clinical significance of and therapeutic options for this remain unclear. [Name2 (NI) 116] require repeat TTE as an outpatient as the [6-11] exam was performed while the patient was receiving treatment for septic shock in the ICU. Medications on Admission: ALENDRONATE-VITAMIN D3 [FOSAMAX PLUS D] - 70 mg-5,600 unit weekly CARVEDILOL 3.125 mg [Hospital1 ] LEVOTHYROXINE 75 mcg daily TAMSULOSIN 0.4 mg daily ASPIRIN 81 mg daily FERROUS SULFATE 325 mg daily OMEPRAZOLE 20mg daily SENNA [Hospital1 ] Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO once a day. 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Alendronate-Vitamin D3 70-5,600 mg-unit Tablet Sig: One (1) Tablet PO once a week. 5. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a day: Please hold if SBP<100, HR<55. 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Primary: Septic Shock Pneumonia Secondary: Diastolic Heart Failure Hypertension Primary: Septic Shock Pneumonia Secondary: Chronic Diastolic Heart Failure Hypertension Osteoporosis Discharge Condition: Good. Discharge Instructions: You were admitted to the hospital for pneumonia and low blood pressure. You were treated for a short time in the intensive care unit with mechanical ventilation and medicine to raise your blood pressure. You were then tranferred to the regular hospital floor where your antibiotics were continued. You do not need to take any additional antibiotics. Please refrain from taking tamsulosin (flomax) due to concerns about low blood pressure. One of your outpatient care providers may decide to restart this medication at a later date. Please continue taking your other medications as directed. Please call your doctor if you experience any difficulty breathing, fever, chills, or any other concerning symptoms. Please return to the emergency department if you cannot reach your doctor or if you feel severely short of breath or have chest pain. Followup Instructions: Please follow up at your primary care doctor's office with nurse practitioner [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 715] on Tuesday, [2137-7-9], at noon. The office phone number is [Telephone/Fax (1) 719]. Please follow-up with your cardiologist Dr. [Last Name (STitle) ] on Monday, [2137-8-26], at 2:00 pm. The office phone number is [Telephone/Fax (1) 62]. Completed by:[2137-7-3]	[ "0389", "486", "2762", "5990", "2761", "78552", "4280", "4168", "4019", "99592" ]
Admission Date: [2155-5-1] Discharge Date: [2155-5-5] Date of Birth: [2109-7-15] Sex: F Service: CARDIOTHORACIC SERVICE HISTORY OF PRESENT ILLNESS: This is a 45-year-old woman with unstable angina times two months. She described the pain as similar to indigestion which responds at times to antiacid; however, this has recently been getting worse, including symptoms of chest pain at rest. She has had no nocturnal episodes. She can walk about [Age over 90 ] yds and then becomes symptomatic with chest pain. She was admitted to [Hospital ] Hospital for work-up status post chest pain and heaviness on [4-29]. At that time, she had a positive ETT and underwent cardiac catheterization which showed 80% left main disease. She was begun on a Heparin drip and transferred to [Hospital6 256] for coronary artery bypass grafting. PAST MEDICAL HISTORY: Unstable angina. Alcohol and cocaine abuse. Lumpectomy. MEDICATIONS ON ADMISSION: Enteric coated Aspirin 325 q.d., sublingual Nitroglycerin. ALLERGIES: SOMA WHICH SHE STATES CAUSED A CARDIAC ARREST IN THE PAST, AS RECENTLY AS [2153-1-25]. NO DETAILS KNOWN OTHER THAN SHE BELIEVES THAT HER CARDIAC ARREST AT AN OUTSIDE HOSPITAL WAS RELATED TO SOMA USE. SHE WAS INTUBATED AT THAT TIME. STUDIES: Catheterization done at the outside hospital showed 78-80% left main, 20% left anterior descending, 20% right coronary artery, wedge pulmonary pressures within normal limits. PHYSICAL EXAMINATION: Vital signs: At the time of admission temperature was 98.2??????, heart rate 90, blood pressure 100/60, respirations 18. General: The patient was alert and oriented times three. Neck: Supple. No bruits. Lungs: Clear to auscultation. Heart: Regular, rate and rhythm. No murmurs, rubs, or gallops. Abdomen: Soft, nontender, nondistended. Extremities: Warm and well perfused with bilateral pulses. LABORATORY DATA: Urinalysis negative. Electrocardiogram sinus rhythm at 90. Chest x-ray without any cardiopulmonary processes. White count 11.3, hematocrit 42.4, platelet count 254; PT 12.8, PTT 43.3, INR 1.1; sodium 139, potassium 3.6, chloride 103, CO2 25, BUN 13, creatinine 0.7, glucose 146. HOSPITAL COURSE: The patient was admitted to the Cardiothoracic Service, and on the following day, she was brought to the Operating Room. Please see the OR report for full details. In summary the patient underwent coronary artery bypass grafting times two with a LIMA to the left anterior descending and saphenous vein graft to the OM. Her bypass time was 77 min, and cross-clamp time was 48 min. She tolerated the operation well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. At that time her mean arterial pressure was 80, CVP was 8. She was in sinus rhythm at 98 beats per minute. She had Propofol at 20 mcg/kg/min. The patient did well, and in the immediate postoperative period her sedation was discontinued. She was weaned from the ventilator and successfully extubated. On the morning of postoperative day #1, the patient's chest tubes, Foley catheter and pacing wires were discontinued, and she was transferred to the floor for continuing postoperative care and cardiac rehabilitation. Once on the floor with the assistance of the nursing staff and physical therapist, the patient gradually increased her activity level. She remained hemodynamically stable throughout that period. On the morning of postoperative day #3, it was decided that she would be stable and ready for discharge to home on the morning of postoperative day #4. DISCHARGE PHYSICAL EXAMINATION: Vital signs: Temperature 98.9??????, heart rate 89 in sinus rhythm, blood pressure 90/48, respirations 20, oxygen saturation 96% on 2 L nasal prongs, weight preoperatively 63.5 kg, at discharge 68.8 kg. General: The patient was alert and oriented times three, moving all extremities and follows commands. Respiratory: Clear to auscultation bilaterally. Heart: Regular, rate and rhythm. S1 and S2. Chest: Sternum stable. Incision with Steri-Strips, open to air, clean and dry. Abdomen: Soft, nontender, nondistended, with normoactive bowel sounds. Extremities: Warm and well perfused with 1+ pedal edema bilaterally. DISCHARGE LABORATORY DATA: White count 12.5, hematocrit 26.1, platelet count 170; sodium 138, potassium 3.5, chloride 103, CO2 27, BUN 14, creatinine 0.5, glucose 117. DISCHARGE MEDICATIONS: Metoprolol 12.5 mg b.i.d., enteric coated Aspirin 325 mg q.d., Nicotine 14 mg q.d. topically, Lasix 40 mg q.d., Potassium Chloride 20 mEq q.d., Niferex 150 mg q.d., Vitamin C 500 mg b.i.d. In addition, the patient went home on Percocet 5/325 [12-26] tab q.4 hours p.r.n. and Albuterol 2 puffs q.4 hours p.r.n. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: 1. Coronary artery disease status post coronary artery bypass grafting times two with LIMA to the left anterior descending and saphenous vein graft to OM. 2. Status post lumpectomy. FO[Last Name (STitle) ]P: The patient is to follow-up with her primary care physician in two weeks. She is to follow-up with Dr. [Last Name (Prefixes) 411] in four weeks; the patient is to make this appointment. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Name8 (MD) 415] MEDQUIST36 D: [2155-5-5] 15:18 T: [2155-5-5] 15:18 JOB#: [Job Number 48149]	[ "41401", "3051" ]
Admission Date: [2196-10-7] Discharge Date: [2196-10-11] Date of Birth: [2134-2-11] Sex: M Service: This is a 62-year-old male who presented with a history of chest pain who came for cardiac catheterization. Catheterization showed multi vessel disease and the patient was taken to the Operating Room on [2196-10-7] where a coronary artery bypass graft x2 was performed. The patient did well postoperatively and was transferred to the CSRU. He was fully weaned from his ventilator and was extubated. He required transfusions for a low hematocrit and for hemodynamic stability. The patient had an intra-aortic balloon pump placed during cardiac catheterization which postoperatively was removed on day 1 with no issues. PT was consulted for ambulation and he was slowly weaned from his ventilator and extubated. The patient had his chest tube removed and his diet was slowly advanced. Physical therapy evaluated him throughout his IC course as well as on the floor. He did well. His chest tube was removed and he was transferred to the floor. His Foley was also removed at that time. He did well and continued to ambulate on a regular diet. His pain was controlled. On postoperative day #4, his JP drain was removed. His wires were removed and the patient was evaluated per PT. He was discharged home in stable condition with neurologic services. The patient was instructed to follow up with is primary care physician who is also a cardiologist in one to two weeks and instructed to return to cardiothoracic surgery in two weeks for follow up for staple removal. The patient is discharged home in stable condition. The patient is discharged home on Percocet 1 to 2 tablets po q4h, Colace 100 mg po bid, Synthroid 50 mcg po qd, inhalers 2 puffs q6h, albuterol, ipratropium, enteric coated aspirin 325 po qd, Lopressor 25 po bid, Lasix 20 mg po bid and Protonix 40 mg po qd. The patient is discharged home in stable condition. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Last Name (NamePattern4) 7148] MEDQUIST36 D: [2196-10-11] 11:14 T: [2196-10-11] 13:28 JOB#: [Job Number 29838]	[ "41401", "496", "4240", "25000", "2859", "2720" ]
Admission Date: [2186-6-14] Discharge Date: [2186-6-21] Date of Birth: [2120-1-2] Sex: M Service: MEDICINE Allergies: Pneumovax 23 Attending:[First Name3 (LF) 800] Chief Complaint: Mental Status Changes/Hypoxia Major Surgical or Invasive Procedure: Lumbar Puncture History of Present Illness: This is a 66 year old male with hepatitis C, history of alcohol abuse, bipolar affective disorder, atrial fibrillation, and a recent admission to [Hospital1 18] for pneumonia who was transferred from an outside hospital where he had presented with mental status changes and dyspnea. The patient was not able to give a full account of the circumstances leading to his admission, but per his family he had increasing dyspnea and confusion starting approximately five days prior to presentation. He may have had chills but no fevers and he was noted to be extremely fatigued. At the outside hospital he was febrile, bradycardic, hypotensive, non-verbal, pale, and not following commands reliably. After initial lab results did not reveal a clear source of his illness he was transferred to [Hospital1 18] for further management. In the [Hospital1 18] ED, initial vitals were T 100, BP 89/40, HR 45, RR 16, 94% on 2L. Over his ED course he became progressively more hypoxic and eventually required 4.5L of O2 by nasal cannula to maintain a sat of 92%. He was initially bradycardic with rates in the 40's but this spontaneously improved to 70s-90s without interventions. His SBP's improved to 90's-100's with 2L IVF. His chest radiograph revealed a right middle lobe infiltrate, which he had recently been treated for at [Hospital1 18] (admission until [2186-5-10]). He received vancomycin and levofloxacin for a possible pulmonary infection as well as IV metronidazole as the patient had diarrhea and had C diff in [Month (only) 958]. He was transferred to the ICU for further management. Past Medical History: - Atrial Fibrillation - History of clostridium difficile - Bipolar Affective Disorder - History of hepatitis C - History of rheumatic heart disease - History of right middle cerebral artery aneurysm clipped in [2167] at [Hospital6 1708] - History of pernicious anemia - Gastroesophageal reflux disease Social History: He lives with his wife. [Name (NI) ] has a history of alcohol abuse but this was greater than twenty years ago. He stopped smoking after his previous hospitalization (about one month prior to presentation) but previously had a 40 pack year history. He had been discharged from his last hospitalization with oxygen but had not been using this prior to admission. Family History: His father had lung cancer and his mother had congestive heart failure. Physical Exam: On Presentation to ICU VS - T 96.2; BP 103/86; HR 88; RR 12; O2sat 97% on 4L NC Gen: appears older than stated age, no acute distress HEENT: NCAT, PERRL, EOMI, dry MM, poor dentition CV: irreg, irreg, no m/r/g Chest: limited cooperation with exam, CTAB, no w/r/r appreciated Abd: +BS, soft, mildly distended, non-tender Ext: 1+ bilateral LE edema Skin: abrasion on L knee, old blisters on the dorsal aspect of all 5 left toes. Neuro: A+O x 3 (name, [Hospital1 18], [2186-5-17]), grossly intact Pertinent Results: LABORATORY RESULTS ====================== On Presentation: WBC-6.6 RBC-3.28* Hgb-10.4* Hct-31.6* MCV-97 RDW-16.3* Plt Ct-114* ---Neuts-66.6 Lymphs-25.3 Monos-7.6 Eos-0.3 Baso-0.3 PT-15.2* PTT-37.1* INR(PT)-1.3* Glucose-93 UreaN-20 Creat-1.0 Na-141 K-3.3 Cl-103 HCO3-27 ALT-10 AST-33 LD(LDH)-186 AlkPhos-168* TotBili-0.6 CK 152 CK-MB-3 cTropnT-<0.01 Calcium-7.6* Phos-3.0 Mg-2.2 On Discharge: WBC-5.7 RBC-3.26* Hgb-10.4* Hct-31.2* MCV-96 RDW-16.2* Plt Ct-110* PT-14.6* PTT-67.5* INR(PT)-1.3* Glucose-88 UreaN-8 Creat-0.7 Na-140 K-3.7 Cl-107 HCO3-28 ALT-5 AST-27 LD(LDH)-168 AlkPhos-168* TotBili-0.8 Other Results: VitB12-1063* Folate-9.7 Hapto-160 Ammonia: 53-31 Digoxin-0.4 Urinalysis: Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.012 Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG RBC-40* WBC-3 Bacteri-FEW Yeast-NONE Epi-0 CSF Analysis: WBC-0 RBC-216* Polys-14 Lymphs-36 Monos-43 Eos-7 TotProt-20 Glucose-53 LD(LDH)-20 HSV PCS: negative for HSV 1 and 2 Culture negative for growth MICROBIOLOGY ============== All Blood and Urine Cultures negative for growth Campylobacter culture of stool: Negative Microscopic exam of stool: negative for ova and parasites C diff toxin assay 2: Negative OTHER STUDIES =============== ECG on Presentation: sinus at 72 with frequent PACs, nl axis, nl intervals, no ischemic changes; prior was afib with rvr, but otherwise unchanged Portable Chest Radiograph [2186-6-14]: IMPRESSION: Persistent unexplained dense consolidation and volume loss of the right middle lobe. CT Head [2186-6-14]: IMPRESSION: No acute intracranial hemorrhage Transthoracic Echocardiogram [2186-6-14]: Conclusions The left atrium and right atrium are normal in cavity size. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The estimated right atrial pressure is 0-5 mmHg. 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 moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. -Compared with the prior study (images reviewed) of [2186-5-3], the estimated pulmonary artery systolic pressure is slightly higher. Liver/Gallbladder Ultrasound [2186-6-14]: IMPRESSION: No focal liver lesions. No ascites. Abdomen Radiograph [2186-6-14]: IMPRESSION: No evidence of obstruction or ileus. CT Chest W/O Contrast [2186-6-15]: IMPRESSION: 1. Persistent severe consolidation in the right middle lobe, showing improved aeration, but no bronchial obstruction, probably inadequately treated pneumonia. 2. Bilateral pleural effusion, small on the right, very small on the left, improved since [5-4], and lymphatic engorgement in the upper lungs, probably indication of cardiac dysfunction as well as volume overload. Probable calcific aortic stenosis. 3. Stigmata of cirrhosis, not fully evaluated on this study. CT Head W/O Contrast [2186-6-16]: IMPRESSION: No acute abnormality seen. EEG [2186-6-17]: IMPRESSION: This is an abnormal routine EEG recording due to the slow and disorganized pattern, the left anterior temporal lower amplitude recording and the right temporal intermittent focal slowing. The first abnormality suggests widespread mild encephalopathy of a metabolic, ischemic, or medication etiology. The second abnormality suggests a cerebral or extra-cerebral abnormality interfering with the voltage of the recording such as a hematoma or severe cortical abnormality. The last abnormality suggests a subcortical dysfunction in the right temporal area. Of note was the atrial fibrillation. If capturing discrete episodes of unconsciousness or unresponsiveness is the main objective of this study, a more prolonged EEG telemetry should be considered. Chest Radiograph [2186-6-18]: FINDINGS: Lungs are hyperinflated and the diaphragms are flattened, consistent with COPD. Compared with [2186-6-14], there is a new small right pleural effusion extending into the minor fissure. Again seen is patchy opacity at the right base, consistent with collapse and/or consolidation. No CHF. The right mid and upper zones of the left lung remain grossly clear. No gross left-sided effusion. Asymmetric pleural thickening is noted at the right lung apex. Brief Hospital Course: 66 year old male with cirrhosis, paroxysmal atrial fibrillation, history of tobacco abuse and recent pneumonia presenting with dyspnea, fevers, and mental status changes. 1) Altered mental status: At presentation the patient was minimally responsive and seemed quite somnolent. As he was started on treatment for presumed infection and hydrated his mental status improved so that later in the day on [2186-6-14] (the patient was admitted overnight) his family thought his ability to answer questions and participate with conversation was near his baseline though his responses were still delayed. The patient continued to have a rather odd affect and answered questions with brief, simple responses but he was alert and oriented3 and could answer questions in an appropriate manner. He maintained minimal insight, however, into the the circumstances of his hospitalization or his health in general. On [2186-6-16] the patient was noted to have a decompensation where he would transiently have periods of staring into space and becoming less responsive for seconds at at time. Between these episodes he appeared in his normal state of alertness. He was evaluated by neurology, had a second head CT (that remained without acute changes), and had an essentially benign lumbar puncture. EEG on [2186-6-17] revealed a diffuse slowing pattern consistent with unclear encephalopathy but was negative for epileptiform activity. Neurology also considered a diagnosis of parkinsomism being responsible for his delayed responses and somewhat labored speech perhaps worsened by his chronic anti-psychotic drug therapy. Nevertheless, as the patient was switched to a different pneumonia regimen (see below) and generally improved back to his baseline the suspicion was that the patient had intermittent toxic-metabolic delirium due to his presumed pneumonia that improved with treatment of his infection. B12 levels and TSH levels were also checked to rule out reversible causes of delirium and were normal. At time of discharge, the patient's wife thought his mental status was at his baseline. 2) Pneumonia: At presentation the patient had a persistent infiltrate consistent with unresolved pneumonia. Further imaging including CT chest were consistent with this. The patient initially received pipercillin-tazobactam and vancomycin in the ICU but this was switched to levofloxacin and vancomycin on his first full day in the hospital as despite his pneumonia his presentation seemed less consistent with sepsis and this was thought unlikely to be hospital-associated pneumonia as it had been over a month since his previous discharge. His respiratory symptoms improved somewhat though he continued to get asymptomatically hypoxic to the high 80's on room air and even at the time of discharge required 2-3L O2 by nasal cannula to maintain O2 sats >92%. He also continued to spike fevers. On [2186-6-17] he was switched from levofloxacin to pipercillin tazobactam with eventual resolution of his fevers. His persistent hypoxia was thought most likely consistent with resolving pneumonia in the context of his underlying lung disease (COPD). He was discharged to finish an additional seven days of pipercillin-tazobactam therapy (for a total of ten days on this antibiotic). Given concern for his mental status and aspiration a repeat speech and swallow evaluation was performed and consistent with the results of the last such evaluation during his previous hospitalization he was not observed to be aspirating. 3) Hypotension: The patient was hypotensive at presentation but this resolved with fluid boluses and never recurred. Presumably, this initial hypotension was due to volume depletion in the context of decreased PO intake in the context of illness and increased insensible losses due to fever. 4) Paroxysmal atrial fibrillation: On presentation the patient was bradycardic but this resolved without intervention. He then became tachycardic with Afib with RVR to rates in the 120's. He was restarted on his home flecainide dose with better rates. He was also continued on his home aspirin (he is not on coumadin as he has been considered a fall risk). Eventually, low dose beta blocker was added for additive rate control. 6) Cytopenias: The patient has chronic anemia and thrombocytopenia that were essentially stable during his hospital course. Given his history of pernicious anemia and lack of B12 supplementation B12 level was checked and was supra-normal (folate level was also normal). He has had past hematologic work up for this problem without a clear source identified though he is on multiple medications (valproate, flecainide) that can cause marrow suppression and he also had signs of cirrhosis on imaging, which can lead to cytopenias due to sequestration. Once hemolysis was ruled out by smear and labs and has his counts remained stable further work up was deferred in the context of his more acute issues. 7) Bipolar Affective Disorder: The patient was continued on his home doses of valproate and olanzapine with stable affect. 8)Cirrhosis: Imaging findings on his CT exam were consistent with cirrhosis and previous notes mention a history of hepatitis C though he has had negative antibody tests in the past (antibodies to Hep B have also been negative). Possible etiologies could include past alcohol use vs Non-alcoholic steatohepatitis vs cryptogenic cirrhosis. As there were no signs of acute decompensation this issue was deferred to outpatient management and he was set up for outpatient follow up in hepatology clinic. 9) Recent fall: The patient had a recent fall leading to abrasions on his lower extremities. These were cared for with local measures. PT evaluation suggested the patient would need near constant assistance and recommended acute rehab. He and his wife expressed a preference for being sent home with multiple services including home PT and this was set up prior to discharge. The patient was fed a full, cardiac diet. He was full code. Medications on Admission: Olanzapine 5 mg PO daily Rantidine 50 mg PO daily Thaimine 100 mg PO daily Vanco 125 mg aily Albuterol PRN ASA 325 choleystyramine Dig 0.125 PO daily Ferrous gluconate 324 mg PO daily Flecainide 50 mg Po daily furosemide 50 daily Lopresor 25 mg PO BID Depakote 500 mg QAM, 1000 mg QPM Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO BID (2 times a day). 3. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QAM (once a day (in the morning)). 4. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO QPM (once a day (in the evening)). 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Flecainide 50 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 11. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 7 days. Disp:14 gram Refills:0 12. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: 4.5 grams Intravenous Q8H (every 8 hours) for 7 days. Disp:qs grams Refills:0 13. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Ten (10) ML Intravenous PRN (as needed) as needed for line flush: Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. Disp:1000 ML(s) Refills:0 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever,pain. Discharge Disposition: Home With Service Facility: [Company 1519] Discharge Diagnosis: Primary Diagnoses: Pneumonia Bipolar Affective Disorder Parkinsonism ? Discharge Condition: All vital signs stable, Mental status back to baseline. 96% on 3L via nasal cannula. Afebrile x 24 hours. Discharge Instructions: You were admitted for altered mental status and trouble breathing. Ultimately, we think this was due to your pneumonia recurring. We gave you antibiotics to treat your pneumonia but because your mental status remained a bit worse than normal we also did scans of your head and a lumbar puncture to make sure you didn't have infection or bleeding. Your studies did not show these. You are being discharged to finish recovering from pneumonia. Your medications have been changed. Please take your medications as prescribed. Please come to your local ED or call your doctor if you have worsening of your breathing, chest pain, fevers, chills, shortness of breath, or any other concerning changes in your health. Followup Instructions: MD: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2204] Specialty: PCP Date and time: [2186-7-3] 1:00pm Location: [Apartment Address(1) 2942], [Location (un) ] Phone number: [Telephone/Fax (1) 2205] Appointment #2 MD: Dr. [First Name8 (NamePattern2) 2943] [Name (STitle) 696] Specialty: Gastroentrologist- Liver Center Date and time: [2186-6-29] 8:00am Location: [Hospital Unit Name 2944], [Location (un) 86] Phone number: [Telephone/Fax (1) 2422] Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 677], M.D. Phone:[Telephone/Fax (1) 62] Date/Time:[2187-2-7] 2:40 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 810] MD, [MD Number(3) 811]	[ "486", "42731", "496", "2875" ]
Admission Date: [2142-1-8] Discharge Date: [2142-2-10] Date of Birth: [2092-4-6] Sex: M Service: NEUROLOGY Allergies: Iodine; Iodine Containing / Bactrim Attending:[First Name3 (LF) 13252] Chief Complaint: Weakness Major Surgical or Invasive Procedure: ACDF History of Present Illness: 49 year-old man with PMH DM type I, HTN, ESRD on HD for 4 years now s/p kidney transplantation [9-/2141] complicated by delayed graft function who p/w pain in both hands, radicular type pain in his right leg, diffuse weakness, mostly proximal; R>L. Patient had a renal transplant in [9-/2141] complicated by delayed graft function. He also developed 3 weeks after transplant pain in both his hands, he described as a "pricky" sensation in all fingers and palm of his hands. He denied numbness. At that time he had an elevated level of Prograf; ([12-21]; 47.8); reduction of medication dosing correlated with improvement in his hand pain. He reports that he has had for several years decreased sensation in both feet. He has lost a significant amount of weight since his transplant (around 30 pounds); he feels weaker throughout. He has had more difficulty to walk; he has had more frequent falls (last one today, he thought he tripped over on the floor). He also has complaints of worsening pain irradiating through the right leg, posteriorly, down to R foot. He also thinks that his hands and arms are weaker bilaterally; he has had trouble to open the bottles of his medications, to comb his hair along the past few months. He underwent an [Month (only) 2841] today performed by Dr. [Last Name (STitle) 1206] which revealed progression of his polyneuropathy, but also denervation in an L5 distribution and proximal myopathic changes and was referred to ED for admission for further work-up. Past Medical History: 1. CAD s/p [Last Name (STitle) ] to OM1 in [9-2] and [Month/Day (1) ] to RCA in [5-5] 2. End-stage renal disease, on HD since [6-3] (MWF) 3. Diabetes mellitus, type I: Diagnosed at age 20, on insulin, c/b nephropathy, neuropathy, and retinopathy status post multiple laser surgeries. Right upper extremity fistula. Chronic ulcers on left foot. 4. Hypertension 5. Hyperlipidemia 6. Obstructive sleep apnea 7. G6PD deficiency 8. Right fifth toe amputation, [2137-3-29]. 9. History of hepatitis B infection 10. Sexual dysfunction s/p penile prosthesis implantation 11. Kidney transplant, right iliac fossa [2141-10-14]. 12. Celiac disease Social History: The patient lives with his wife and 2 sons in [Name (NI) 669]. Previously worked at NSTAR as a janitor, and is currently on diability. No tobacco or EtOH use. Family History: There is no family history of premature coronary artery disease or sudden death. Mother has diabetes mellitus. Father is healthy and multiple half brothers and sisters. Two children, both boys, are healthy. Multiple aunts and uncles decreased from complications of diabetes. No family hx of Wegener's or [Last Name (un) 95749]-[Doctor Last Name 3532] disease. Physical Exam: T98.6 HR 73 BP 129/63 RR16 O2 100% RA Gen: Awake, alert, lying in bed; looks cachetic Skin: No rashes. Abrasions on R knee (reportedly from fall) Heent: NCAT, no conjunctival injection, mucous membranes moist, oropharynx clear. Neck: Supple, no meningismus. Extrem: no edema Neuro: MS - Awake, alert, interactive. Oriented to person, place, and date. Speech is fluent, with intact registration/recall, repetition, naming, comprehension. Could say [Doctor Last Name 1841] backwards.. No left-right confusion. Cranial Nerves ?????? PERRL 3-->2, EOM smooth and full, no diplopia; no nystagmus; Visual field mild/mod restricted in all directions, intact facial sensation, face symmetric with full strength of facial muscles, hearing intact to finger rub bilaterally, palate elevation is symmetric, and tongue protrusion is symmetric and full movement. Trazpezius full bilat. Motor: diffuse atrophy; R pronator drift Delt [Hospital1 ] Tri WrEx FEx FFlx IO [Location (un) ] / IP Quad Ham Gastr TA [Last Name (un) 938] R 4- 5 4- 5- 4+ 5- 5- 5- 4- 5 5- 5- 5- 5- L 4 5 4+ 5- 4+ 5- 5- 5- 4+ 5 5- 5- 5- 5- Reflexes - Biceps Triceps Brachioradialis Patellar Ankle R 3+ 3+ 3+ trace 0 L 3- 3+ 3+ trace 0 Plantar responses mute Sensation - Decreased sensation to pinprick and JPS distally in hands (fingers), cold sensation intact in UEs but slightly less at distal hands. Decreased sensation to cold, pinprick and vibration below the knees in LEs, JPS absent at the toes. Coordination - No dysmetria and smooth finger to nose. RAMs normal and symmetric. Gait - Wide based; very unsteady, falls to both sides Pertinent Results: Admission Labs: 140 112 31 185 AGap=13 -----------< 4.7 20 1.8 WBC5.0 Hv 11.6 plat235 Ht36.9 N:81.4 L:13.9 M:3.0 E:0.9 Bas:0.8 Imaging: MRI CERVICAL SPINE: Bone marrow signal is abnormally hypointense on all sequences, similar to that seen on the prior examination and may relate to the patient's underlying hemosiderosis. There is 2 mm of retrolisthesis of C3 on 4. There is extensive [Last Name (un) 13425]-type 2 and 3 endplate changes and to a lesser extent [Last Name (un) 13425] type 1 endplate change centered at C3-C4. No additional marrow signal abnormalities are appreciated. At C2-3, there is no canal or foraminal narrowing. At C3-4, there is a progressive spondylosis with a central disc herniation resulting in severe canal narrowing with cord deformity and abnormally increased T2 signal. There is severe bilateral foraminal narrowing. At C4-5, there is a spondylotic ridge with a broad central disc herniation resulting in moderate canal narrowing as well as mild bilateral foraminal narrowing. There is flattening of the ventral cord surface without abnormal cord signal. At C5-6, there is a broad spondylotic ridge with a central disc protrusion resulting in mild canal narrowing with slight flattening of the ventral cord surface. There is mild bilateral foraminal narrowing, left greater than right. At C6-7, there is mild spondylosis and facet arthropathy without significant canal or foraminal narrowing. At C7-T1, there is no significant canal or foraminal narrowing. IMPRESSION: 1. Severe canal and bilateral foraminal narrowing at C3-4 with cord deformity and abnormally increased T2 signal. 2. Moderate canal narrowing at C4-5. 3. Additional degenerative changes as detailed. LUMBAR SPINE: Bone marrow signal is abnormally hypointense on all sequences, similar to that seen on the prior examination and may relate to the patient's underlying hemosiderosis. Sagittal alignment is satisfactory. The conus terminates at T12-L1. Again noted is extensive multilevel [Last Name (un) 13425] type 2 endplate change with [Last Name (un) 13425] type 1 endplate change at L4-5 and to a lesser extent L5-S1. There is a rudimentary disc space at S1-2. At L3-4, there is mild disc desiccation without significant canal or foraminal narrowing. At L4-5, again noted is a disc bulge with central annular tear and a small inferiorly migrated disc fragment creating moderate bilateral subarticular zone narrowing. When combined with the facet arthropathy and endplate spur, there is severe right foraminal narrowing and mild left foraminal narrowing. At L5-S1, there is a disc bulge and facet arthropathy with a central/left paracentral inferiorly migrated fragment resulting in severe narrowing of the left subarticular zone and lateral recess with potential for compression of the traversing left S1 root. Additionally, there is severe narrowing of the left neural foramen and moderate right foraminal narrowing. There is a right pelvic kidney. IMPRESSION: 1. Diffusely abnormal hypointense bone marrow signal is unchanged from the prior study and likely relates to hemosiderosis. There are superimposed [Last Name (un) 13425] type 1 and 2 endplate changes. 2. Moderate bilateral subarticular zone narrowing at L4-5 with severe right foraminal narrowing, similar to that seen on the prior study. 3. Severe narrowing of the left subarticular zone and lateral recess as well as the left neural foramen at L5-S1 with potential for compression of the left L5 and/or S1 roots. The appearance is similar to that seen on the prior study. Bone Scan: INTERPRETATION: Whole body images of the skeleton were obtained in anterior and posterior projections. There is focused increased radio-isotope uptake probably in the 6th rib in the rib-end. No other increased radio-isotope uptake is seen, in particular, there is no abnormal uptake in C3. The above described findings are consistent with non-specific likely inflammatory changes or post traumatic changes of the right 6th rib. The renal transplant is visualized in the right iliac fossa, and urinary bladder is also visualized, due to the normal excretion of the radio-isotope. Discharge Labs: 139 \| 108 \| 26 --------------< 103 4.8 \| 26 \| 1.2 Ca: 9.6 Mg: 1.9 PO4: 2.3 9.5 2.7 >-----< 159 32.5 Tacro level: 4.1 Brief Hospital Course: 49 year old man with PMH DM, HTN, ESRD on HD for 4 years now s/p kidney transplantation [9-/2141] complicated by delayed graft function who p/w BL hand pain, diffuse weakness, mostly proximal R>L. Mr. [Known lastname 449] had an MRI which showed severe stenosis with cord deformity at C3/C4. He had a bone scan which showed no signs of metastasis or infection. On [1-11] he underwent an ACDF. Per Orthopedics, he will need to undergo a posterior fusion in the future, but it is not required during this admission. Post-operatively he was noted to have an extremely swollen left arm. This was thought to be due to an infiltrated IV. Additional IV access was unable to be obtained, so a PICC was placed. His arm was elevated and warm compresses were applied, with significant improvement. PICC should be discontinued as soon as IV access is no longer needed. Post-operatively the patient complained occasionally of the sensation of food sticking in his throat. A swallowing evaluation showed normal swallowing ability, but given post-operative pain it was recommended that his diet consist of ground solids and thin liquids. This should be reassessed as his post-operative pain improves. Overnight on [1-16] Mr. [Known lastname 449] did have a temperature of 101.3. He had urine and blood cultures that have been negative to date, and a chest X-ray with no signs of infection. His wound was assessed by ortho, and showed no signs of infection. It was thought this may be due to post-operative atelectasis, and he has been afebrile since. For his DM, the patient was followed by [Last Name (un) ] during his hospitalization, and his current regimen consists of 46U NPH in am and 34U NPH [Last Name (un) ]. He also has a Lispro sliding scale detailed in the discharge paperwork. The renal transplant team also followed Mr. [Known lastname 449] while he was hospitalized. His tacrolimus levels were followed. His level on admission was 11, so his dose was initially decreased to 2.5mg [Hospital1 ], however his level decreased to 4, so he was increased back to his admission dose of 3mg [Hospital1 ], with the level at discharge being 4.1. Please check tacrolimus level in 1 week, with a goal of [8-7]. He was also given a dose of pentamidine for PCP [Name Initial (PRE) 1102]. Valgancyclovir was discontinued on Given his report of significant weight loss, calorie counts were obtained, which showed initial poor PO intake, which was primarily attributed to post-operative pain, and improved Exam at discharge was notable for mild proximal weakness in his upper extremities, and significant bilateral foot drop ([3-2] bilateral at TA). He has a significant peripheral neuropathy, with decreased proprioception to the level of his knees. Medications on Admission: -albuterol -ergocalciferol 50,000 Q weekly -insulin lispro 10Uam; 12U pm -Insulin NPH SS -isosorbide mononitrate 60mg daily -lipitor 80mg daily -lyrica 50mg [Hospital1 ] -loperamide 2mg PRN -metoprolol succinate 200mg [Hospital1 ] -CellCept 500mg QID -NitroQuick 0.4mg SL PRN -pentamidine 300mf [Male First Name (un) ] -ranitidine 150mg daily -tacrolimus 3mg [Hospital1 ] -trazodone 50mg HS -valgancyclovir 900 mg Qday Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO BID (2 times a day). 3. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a day). 7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 12. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane TID (3 times a day) as needed for meals. 13. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 14. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 15. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 17. Humalog 100 unit/mL Solution Sig: Sliding scale Subcutaneous AC and HS: 71-150 6U 151-200 8U 201-250 10U 251-300 12U 301-350 14U 351-400 16U. 18. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Forty Six (46) units Subcutaneous Qam. 19. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Thirty Four (34) Units Subcutaneous at bedtime. Discharge Disposition: Extended Care Facility: [Location (un) 86] Center Discharge Diagnosis: Primary: Severe C3 stenosis with cord compression Secondary: Diabetes. ESRD s/p kidney transplant. Celiac disease. Peripheral neuropathy. Discharge Condition: Mild proximal upper extremity weakness (5- in triceps bilaterally, 4+ in L deltoid). Right IP 4+, left full strength. Bilateral foot drop ([3-2] in both TA). Significant decrease in proprioception to the knees bilaterally. Discharge Instructions: You were admitted with increasing weakness and loss of stool. This was found to be secondary to severe cervical stenosis with compression of the spinal cord, for which you underwent surgery. Medication changes: Pregabalin increased to 75mg [Hospital1 ] Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. If you notice any of the concerning symptoms listed below, please call your doctor or come to the emergency department for further evaluation. Followup Instructions: Neurology: Dr. [Last Name (STitle) 1206] on [2142-3-2]. Please call [Telephone/Fax (1) 2846] with questions. Ortho: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1007] [Telephone/Fax (1) 1228] on [2-9] at 7:40 on the [Location (un) ] of the [Hospital Ward Name 23] building PCP: [Last Name (NamePattern4) ]. [Last Name (STitle) ] [Telephone/Fax (1) 250] on [1-25] 9:40am [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 13255]	[ "5845", "486", "2762", "5180", "4280", "32723", "2724", "4019", "41401", "V4582" ]
Admission Date: [2132-4-27] Discharge Date: [2132-5-1] Date of Birth: Sex: F Service: Neurology Patient is a [Age over 90 ]-year-old Russian female found unresponsive on [2132-4-26] and brought to the Emergency Department at the [Hospital1 69]. Subsequent workup showed large interventricular hemorrhage in all four ventricles and hydrocephalus and subarachnoid hemorrhages bilaterally. Patient was deemed to be DNR/DNI, and was initially transferred to the Neuro/ICU here at the [Hospital1 346]. While in the ICU, the patient has been somnolent and unable to be aroused. Neurosurgical consult was called on the patient and they did not recommend intervention at family's request. She developed bilateral pleural effusions in the ICU from CHF that had been treated with p.o. Lasix, yet remained persistent. Her blood pressure was controlled with IV medications, but now that has been D/C'd. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Chest x-ray. 3. Hypertension. 4. Degenerative joint disease. 5. Gastroesophageal reflux disease. 6. Essential tremor. 7. Urinary incontinence. After extensive discussion and education with the patient's family and healthcare proxy, it was decided that a non- aggressive palliative approach would be adopted in directing care for this patient given the poor prognosis with the interventricular hemorrhage complicated the goal of the patient's admission. PHYSICAL EXAMINATION: Temperature 99.4, blood pressure 142/76, pulse 108, respiratory rate 16, and 98 percent on 35 percent O2 face mask. Physical examination was pertinent for the following: The patient was an elderly female lying in bed in modest distress with labored breathing. Decreased breath sounds on pulmonary exam halfway up both lungs. Patient's heart rhythm was regular. There was a 3/6 systolic ejection murmur radiating to the right upper sternal border. On neurologic examination, on mental status: The patient grimaces and opens eyes to vigorous sternal rub, but prefers her eyes closed. On cranial nerve examination, the patient has dolls intact, corneal intact, and gag reflex intact. Pupils are surgical bilaterally. Motor examination: The patient moves right upper extremity to painful stimulus, but there is no movement in the left upper extremity to painful stimulus. Patient dorsiflexes both lower extremities to pain, but does not withdraw. Patient has flexor plantar responses bilaterally. LABORATORIES: Patient had CBC, Chem-8, and chest x-rays in a serial fashion drawn throughout the admission. Chest x-ray showed static bilateral pleural effusions despite treatment with Lasix. Follow-up head CT showed blood in all ventricles, positive atrophy, and questionable hydrocephalus, which remains unchanged from initial head CT. Patient had an elevated sodium at 146 and BUN of 31. Patient also had a troponin of 0.25 on serial cardiac enzymes that were drawn throughout the admission. HOSPITAL COURSE: Given the patient's palliative goal, patient was kept DNR/DNI throughout the admission, and comfort care was established after the patient was transferred to the Neurologic floor on [Hospital Ward Name 121] 5 from the Neuro/ICU. Patient was given Lasix for symptomatic relief of bilateral pleural effusions and aortic stenosis. Patient's mental status remained static on the Neurology floor. She was unresponsive to voice and vigorous painful stimulus. Neurosurgical consult signed off on the case after deeming that the patient was not a surgical candidate. On [2132-4-30], the patient's daughter decided to make the patient comfort care only. Morphine drip was started. Patient's respirations and vital signs were monitored regularly to assess comfort. Palliative Care consult was called, which recommended scopolamine patch for secretions, Tylenol for fever, and Morphine drip. Patient then expired on [2132-5-1]. Family was informed. Autopsy was accepted. DR.[Last Name (STitle) ],[First Name3 (LF) ] 13-279 Dictated By:[Doctor Last Name 37530] MEDQUIST36 D: [2132-6-18] 11:41:44 T: [2132-6-18] 12:44:41 Job#: [Job Number 37531]	[ "4280", "5119", "4241", "41401", "53081", "4019" ]
Admission Date: [2141-3-8] Discharge Date: [2141-3-30] Date of Birth: [2068-2-28] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Last Name (NamePattern1) 1167] Chief Complaint: Chest pain and abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: This is a 73 year old male with past medical history significant for CAD s/p CABG and PCI to LCx, aortic stenosis, VT/VF arrest s/p ICD, CHF (EF 20%) s/p BiV pacer, afib on coumadin, CRI and diverticulosis who presents with 1 hour of chest pain similar to anginal equivalent that radiated to abd and back. Assocated with nausea. Took ntg tab w/o relief. No pleuritic chest pain. The abd pain is LLQ predominant w/o radiation. He states that he has had black stools on both of the last 2 days associated with changed smell of the stools. He has had no bloody stool. The abd pain usually is better after eating. There have been no new foods and no sick contacts. . Of note the patient was recently in the [Hospital1 18] for abdominal pain in [1-20]. At which time his labs were unremarkable. A CT abd showed no acute pathology to explain his pain. He received IV fluids and slowly advanced his diet to normal prior to discharge. . In ED, initial vitals were 97.8 120/70 100 14 100%RA. Stools brown and OB negative. ECG was V-paced at 85bpm, cardiac enzymes were negative. Patient given aspirin, nitro tabs, morphine. . On floor, patient was with decreasing chest pain but still with nausea. The abdominal pain is also improved. . 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, hemoptysis, he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. his weight has been stable at 222-223pounds. His baseline function is 1 flight of stairs. All of the other review of systems were negative. . Cardiac review of systems is notable for paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: CAD status post CABG with simultaneous aortic aneurysm repair in [2133], history of stenting of the left circumflex artery [2135] s/p VT/VF arrest, s/p ICD placement in [2135] iCMP (EF 20%) s/p BiV pacer [10-18] Chest wall cellulitis over pacer site [3-19] vs. ICD pacer pocket infection AFib (not anti-coagulated due to recurrent GI bleeds) CKD Stage III b/l Cr. ~1.6 Hyperlipidemia Asthma Anxiety Alzheimer's dementia Hypothyroidism Diverticulosis GERD s/p cholecystectomy . CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension Social History: married, lives with wife. [Name (NI) ] originally from [Country 4754]. No history of smoking. Patient was a heavy drinker until 20 years ago. No history of illicit drugs Family History: No family history of early MI, otherwise non-contributory. Physical Exam: On admission- VS: 98.5 100/71 82 16 99%2L wt. 222 lbs GENERAL: WDWN obese male 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: Supple with JVP of 8 cm. CARDIAC: PMI laterally displaced. RR, normal S1, S2. [2-17] systolic murmur at RUSB c/w AS. No 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, minimal tender to LLSB. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. guiaiac negative brown stool. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Neuro: -MS alert and oriented x3. coherent response to interview -CN II-XII intact -Motor moving all 4 extremities symmetrically. -[Last Name (un) ] light touch intact to face/hands/feet Pertinent Results: ======== Labs ======== [2141-3-30] 11:51AM BLOOD Hct-27.8* [2141-3-30] 11:51AM BLOOD PT-22.2* PTT-91.8* INR(PT)-2.1* [2141-3-30] 04:09AM BLOOD WBC-9.2 RBC-2.92* Hgb-8.4* Hct-26.2* MCV-90 MCH-28.8 MCHC-32.1 RDW-15.5 Plt Ct-255 [2141-3-30] 04:09AM BLOOD Glucose-193* UreaN-31* Creat-2.0* Na-132* K-4.5 Cl-97 HCO3-27 AnGap-13 [2141-3-11] 06:37AM BLOOD WBC-6.5 RBC-4.10* Hgb-11.9* Hct-35.6* MCV-87 MCH-29.1 MCHC-33.5 RDW-14.6 Plt Ct-144* [2141-3-10] 05:15AM BLOOD WBC-7.4 RBC-4.16* Hgb-12.2* Hct-35.8* MCV-86 MCH-29.2 MCHC-34.0 RDW-14.7 Plt Ct-136* [2141-3-9] 05:15AM BLOOD WBC-8.7 RBC-4.14* Hgb-12.3* Hct-35.7* MCV-86 MCH-29.7 MCHC-34.5 RDW-14.5 Plt Ct-145* [2141-3-8] 06:45PM BLOOD WBC-9.2 RBC-4.44* Hgb-13.0* Hct-38.5* MCV-87 MCH-29.2 MCHC-33.7 RDW-14.5 Plt Ct-193 [2141-3-11] 06:37AM BLOOD Glucose-86 UreaN-17 Creat-1.6* Na-140 K-4.0 Cl-103 HCO3-27 AnGap-14 [2141-3-10] 05:15AM BLOOD Glucose-72 UreaN-20 Creat-1.5* Na-138 K-3.8 Cl-103 HCO3-27 AnGap-12 [2141-3-9] 05:15AM BLOOD Glucose-86 UreaN-25* Creat-1.6* Na-140 K-4.4 Cl-102 HCO3-29 AnGap-13 [2141-3-8] 06:45PM BLOOD Glucose-95 UreaN-26* Creat-1.7* Na-138 K-4.3 Cl-100 HCO3-31 AnGap-11 [2141-3-10] 05:15AM BLOOD ALT-42* AST-47* AlkPhos-132* Amylase-112* [2141-3-9] 05:15AM BLOOD LD(LDH)-276* CK(CPK)-86 Amylase-208* [2141-3-8] 06:45PM BLOOD ALT-20 AST-30 CK(CPK)-96 AlkPhos-92 Amylase-137* TotBili-0.3 [2141-3-11] 06:37AM BLOOD Lipase-33 [2141-3-10] 05:15AM BLOOD Lipase-46 [2141-3-9] 04:05PM BLOOD Lipase-58 [2141-3-9] 05:15AM BLOOD Lipase-164* [2141-3-8] 06:45PM BLOOD Lipase-124* [2141-3-9] 05:15AM BLOOD CK-MB-NotDone cTropnT-0.01 [2141-3-8] 06:45PM BLOOD cTropnT-<0.01 [2141-3-8] 06:45PM BLOOD Digoxin-0.7* . ========= Radiology ========= CXR [3-8] FINDINGS: PA and lateral views of the chest are obtained. Three-lead pacer device is unchanged with lead tips positioned in the expected location. Midline sternotomy wires are unchanged. Cardiomegaly is stable. There is no CHF or evidence of pneumonia. No pleural effusion or pneumothorax is seen. Osseous structures are intact. IMPRESSION: No significant change with persistent cardiomegaly and no evidence of CHF or pneumonia. . RUQ U/S [3-9] RIGHT UPPER QUADRANT ULTRASOUND: The liver appears unremarkable in echotexture and architecture, without focal liver lesion seen. Flow in the main portal vein is in normal hepatopetal direction. No intra- or extra- hepatic biliary ductal dilatation is noted, with the common duct measuring 5 mm. Again the gallbladder is absent, consistent with prior cholecystectomy. Visualization of the pancreatic tail is slightly limited due to overlying bowel gas however the visualized pancreas appears unremarkable and unchanged. No pancreatic ductal dilatation is noted. No ascites is seen. The spleen is enlarged, measuring 13.8 cm. IMPRESSION: 1. Patient is status post cholecystectomy. No intra- or extra-hepatic biliary ductal dilatation is noted. No choledocholithiasis seen. 2. Incidentally noted splenomegaly. . =========== Cardiology =========== TTE [3-9] Conclusions The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is severely dilated. Overall left ventricular systolic function is severely depressed (LVEF= 20 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size is normal. with borderline normal free wall function. with focal hypokinesis of the apical free wall. The aortic root is mildly dilated at the sinus level. There are focal calcifications in the aortic arch. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. The main pulmonary artery is dilated. The branch pulmonary arteries are dilated. Compared with the findings of the prior study (images reviewed) of [2140-10-12], no major change is evident. . Myocardial perfusion study [3-11] IMPRESSION: 1) Severe left ventricular enlargment 2) Probably some viability within an inferior wall defect. TTE [2141-3-14] The left ventricular cavity is dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is severely depressed (LVEF= 20 %). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets are mildly thickened. The mitral valve leaflets are mildly thickened. Mild to moderate ([1-13]+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Focused views. Severe left ventricular sysolic dysfunction. Mild to moderate mitral regurgitation. Compared with the prior study (images reviewed) of [2141-3-9], this is a limited/emergent/focused study and direct comparison cannot be made. Cardiac Cath [2141-3-20] COMMENTS: 1. Coronary angiography of this right dominant system demonstrated no angiographically apparent flow-limiting coronary artery disease. 2. Non-selective arteriography of the LIMA-LAD showed no apparent flow-limiting disease. 3. Limited resting hemodynamics revealed a central aortic pressure of 134/92 mmHg. FINAL DIAGNOSIS: 1. No angiographically apparent flow-limiting coronary artery disease. 2. Patent LIMA-LAD. [2141-3-26] LEFT UPPER EXTREMITY VENOUS ULTRASOUND: [Doctor Last Name ]-scale and color and pulsed wave Doppler examination was performed over the right subclavian vein as well as the left internal jugular, subclavian, axillary, brachial, basilic, and cephalic veins. Note is made of nearly occlusive thrombosis of the left cephalic, basilic, brachial, and axillary veins. Flow is demonstrated in the left and right subclavian veins. More proximally, note is made of likely pacemaker wire entering the left subclavian vein. The internal jugular vein demonstrates normal compressibility and flow. IMPRESSION: Left upper extremity DVT extending from the superficial cephalic and basilic veins into the brachial and axillary deep veins. CXRs: [2141-3-28] PORTABLE SEMI-UPRIGHT RADIOGRAPH OF THE CHEST: The distal tip of right PICC projects in the mid SVC. There has been interval removal of the endotracheal tube and NG tube. The remainder of the study including the position of the AICD leads and the cardiopulmonary status appear unchanged. IMPRESSION: Standard position of the right PICC with no complication. Pertinent Micro data [2141-3-22] 2:00 pm URINE Source: Catheter. FINAL REPORT [2141-3-24] URINE CULTURE (Final [2141-3-24]): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S GRAM STAIN (Final [2141-3-21]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [2141-3-24]): MODERATE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S C diff negative Blood cx ngtd Brief Hospital Course: # VT: Initially on home meds of mexilitine and sotalol. On the floor, had an episode VT on telemetry and lost pulses. He [Month/Day/Year 1834] CPR, receiving a total of 4 shocks, 4mg of epinephrine, amiodarone 150mg x 2, Lidocaine 100mg x 1, magnesium 2mg, bicarb 1 amp, and calcium. Pacer interrogation showed his VT was below the rate of detection. He was manually paced out of VT several times but with return to VT each time. Finally, lidocaine and amiodarone gtts were started and the patient was successfully converted back to a paced rhythm. His mexilitine and sotalol were held. He was intubated during the code, but rapidly extubated afterward. From [3-15] to [3-21], he had repeated episodes of VT, receiving multiple ICD shocks each time, with conversion to a paced rhythm. The first of these episodes was associated with hypotension, but subsequent episodes showed good BP. He was given ativan for sedation due to the multiple shocks, and was reintubated [3-19] for airway protection from sedation. Over the course of these several episodes, he received multiple amiodarone and lidocaine boluses, and was variably on and off drips of these medications. On [3-21], he had an EP study and had 1 circuit ablated and an epicardial circuit interrupted. He was transitioned to a final regimen of oral mexilitene alone. After the study, he was kept sedated and initially required phenylephrine and vasopressin. He had multiple VT episodes on [3-22], but successfully paced out without shocks. He was weaned off pressors and extubated, and subsequently started on metoprolol, which was uptitrated to 25mg TID. His only further VT was on [3-28], and he was successsfully paced out. EP recommends that he continue on telemetry monitoring for 48 hours after discharge. # Chest pain: Has a history of CAD, although cardiac cath done during admission was clean and biomarkers on admission for chest pain in the ER were negative. After CPR, patient had significant reproducible chest wall tenderness that was due to the direct trauma of chest compressions. This pain was not felt to be ischemia. He was treated initially with IV morphine and hydromorphone, but received better pain control after transitioning to oral MS contin. He is also on [Month/Year (2) 1988] tylenol and a lidocaine patch. # Anxiety: Patient has known anxiety, and this was significantly worsened in the setting of recurrent VT and receiving many ICD shocks. Psychiatry was consulted and advised seroquel PRN in addition to his standing doses. He was also continued on citalopram and low dose clonazepam. Despite this, he continued to have significant anxiety; he would have episodes of lightheadedness and palpitations, despite normal vital signs and no telemetry changes. Also, he at times thought his ICD had fired, but review of telemetry showed this was not the case. He also becomes diaphoretic, but per patient and wife, this is long-standing and his baseline. # Abdominal pain: Presented with nausea, vomiting, abdominal pain and elevated lipase, otherwise normal LFTs. No cholethiasis on abdominal u/s. He was ruled out for acute cardiac event. He was treated with bowel rest and his diet was slowly advanced as tolerated. # DVT: LUE had swelling and ultrasound was positive. He was started on a heparin drip and bridged to warfarin before discharge. Continued on PPI and sucralfate given history of GI bleeds and ASA was lowered from 325mg to 81mg daily. He will need a follow up ultrasound in [3-15] mos. # Pump: LVEF 20% on TTE [10-19]. Also has known AS, although during admission patient was refusing AVR and valvuloplasty. He became hypervolemic around [3-18], requiring a lasix gtt. His volume status improved and he was transitioned to his home dose of lasix 40mg PO daily. His digoxin was stopped due to arrhythmogenic concerns. Beta blocker continued as above. Spironolactone was increased from 12.5 to 25mg daily. # CKD: Baseline Cr around 1.6. Prior to discharge, his creatinine trended up to 2.0 in the setting of increased ACE-I and restarting furosemide. Per discussion with his outpatient cardiologist, this is acceptable for now and can be followed after discharge, with med changes made as needed. # MRSA Pneumonia: Pt developed MRSA pneumonia with sputum growing MRSA. He was treated with Vancomycin 8 day course which he completed on [2141-3-29] # UTI: Pt had E coli UTI. He was initially on pip-tazo for empiric pneumonia coverage, but changed to ceftriaxone once sensitivities returned. He completed a 7 day course of antibiotics. # CODE: Code status had been changed to 1 externmal shock if neccessary but no compressions. This was reversed on [2141-3-28] when patient expressed desire to be full code. Medications on Admission: Sotalol 80 mg [Hospital1 ] Levothyroxine 112 mcg daily Citalopram 60 mg daily Quetiapine 50 mg QAM Quetiapine 25 mg daily at noon Quetiapine 75 mg QHS Sucralfate 1 gram QID Mexiletine 150 mg Q8H Pantoprazole 40 mg Q12 Atorvastatin 20 mg daily Fluticasone-Salmeterol 250-50 mc 2 puffs [Hospital1 ] Donepezil 5 mg QHS Metoprolol Succinate 50 mg QHS Furosemide 40 mg daily Spironolactone 12.5 mg daily Nitroglycerin 0.3 mg PRN (as needed) as needed for chest pain. Clonazepam 0.5 mg TID (3 times a day) as needed for anxiety. Trazodone 50 mg qhs:prn insomnia Metoclopramide 25 mg q8 prn Digoxin 0.0625 mcg daily Albuterol 90 mcg prn Aspirin 81 mg daily K-Dur 20 mEq daily . Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Furosemide 40 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). 6. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 9. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): at noon. 10. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 11. Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 12. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day: Hold for loose stools. 15. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed. 17. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day) as needed for anxiety. 18. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 19. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 20. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 21. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO four times a day. 22. 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. 23. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold SBP< 90. 24. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 25. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 26. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 27. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 28. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. 29. Morphine 15 mg Tablet Sustained Release Sig: [1-13] Tablet Sustained Releases PO every eight (8) hours as needed for chest pain. 30. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO once a day. 31. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: check INR on [2141-4-1]. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 86] Discharge Diagnosis: Primary: Pancreatitis, Ventricular Tachycardia, Hypotension, Pneumonia Secondary: Aortic stenosis, Coronary artery disease Discharge Condition: stable, tolerating oral intake Discharge Instructions: You presented to the hospital with chest pain and abdominal pain. There was some initial concern that you were having a heart attack, but this was ruled out by basic lab work. Your chest pain resolved in the emergency room and you were chest pain free on the cardiology floor. It was recommended that you consider valvuloplasy and angioplasty for your tight aortic valve in your heart and your blocked blood vessels in your heart, but you refused this intervention. Your abdominal pain was felt to be due to inflammation in the pancreas. An ultrasound of your abdomen did not reveal any stones as the cause of this inflammation. Your pancreas improved with gently hydration. While you were in the hospital, you also developed worsening of your abnormal heart rhythm, requiring many shocks by your ICD. You were kept sedated and with a breathing tube since the shocks were so uncomfortable. You [Location (un) 1834] a procedure to help improve your heart rhythm, and this helped your heart rhythm considerably. You also developed pneumonia while you were in the hospital, and we are treating you with antibiotics. We have made several medication changes as listed below. . We made the following changes to your medications: - sotalol - we discontinued this medication - trazodone - we discontinued this medication - spironolactone - we increased this medication from 12.5mg once a day to 25mg daily. - reglan - we have decreased this medication from 25mg three times a day as you need it to 10mg three times a day as you need it. - magnesium repletion as given at home. -your Toprol was changed to short acting metoprolol -your fluticasone was changed to Advair. -we started tylenol around the clock, a lidoderm patch and long acting morphine to treat your chest pain caused by rib fractures. -Warfarin to treat the clot in your left arm . Please seek immediate medical attention if you experience worsening shortness of breath, abdominal pain, dizziness, bloody bowel movements, black tarry bowel movements or any other change from your baseline health status. Weigh yourself every morning, [Name8 (MD) 138] MD if weight > 3 lbs in 1 day of 6 pounds in 3 days Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Gastroenterology: Please follow up with Dr. [Last Name (STitle) 3708] on [4-7] at 12:30pm. [Hospital Ward Name 452] 1, [Location (un) ], [Hospital Ward Name 516] entrance, [Hospital1 18]. If you need to change this appointment please call [Telephone/Fax (1) 463]. . Cardiology: Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 437] Phone: ([Telephone/Fax (1) 2037]. Date/Time: [Telephone/Fax (1) 766] [4-3] at 1:00 pm. [Hospital Ward Name 23] Building, [Location (un) 436] [Hospital Ward Name 516], [Hospital1 18] . Primary care: Pleaes call your primary care doctor [First Name (Titles) ] [Last Name (Titles) ] an appointment after you leave the rehabilitation facility to discuss this hospital stay Completed by:[2141-3-30]	[ "5990", "5845", "4280", "4241", "42731", "V5861", "49390", "2724", "V4581", "2449" ]
Admission Date: [2177-4-10] Discharge Date: [2177-4-12] Date of Birth: [2095-1-5] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Cephalexin / Cefazolin / Opioids-Morphine & Related Attending:[First Name3 (LF) 10552] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: Mrs. [Known lastname 19672] is an 82 year old woman with a past medical history significant for dementia, DM 2, CAD s/p CABG, systolic CHF hypothyroid, known UTI, and two recent admissions for UGIB/CoNS bacteremia and AMS/ARF now admitted with hypotension from presumed urosepsis. The patient's daughter states that last week she has had intermitent vomiting described as NBNB emesis every 3-4 days and lethargy. She had a urinalysis and urine culture drawn last Friday, and was called by her PCPs office yesterday and was prescribed nitrofurantoin. Of note, the patient has had a chronic indwelling foley catheter since [3-7], with a voiding cystogram done on [4-2] that was unremarkable. Over the past week, her daughter reports that she has had decreased PO intake, and this afternoon was found to be lethargic. At that point, she was brought into the [Hospital1 18] ED for further evaluation. . Of note, the patient presented to the ED on [3-4] for abdominal pain. At that time, she was evaluated by Surgery and felt to not have an acute process and was found to have pyuria on UA treated with 3 days of cipro 250 mg daily with no urine culture sent. She was also admitted to [Hospital1 18] from [Date range (1) 19675] for AMS felt to be secondary to ARF. During that admission, she failed a voiding trial and has since had a chronic indwelling foley cathter. In addition, she was admitted for [Hospital1 18] from [Date range (1) 19676] for a duodenal ulcer bleed requiring 6 units PRBC transfusion with hospital course complicated by CoNS bacteremia treated with 7 days of vancomycin. . In the [Hospital1 18] ED, initial VS 98.8 75 69/34 14 99%RA. Labs notable for a lactate of 3.3 down trending to 3 and a UA with >100 WBC with <1 epithelial. The patient received vanco, levofloxacin, flagyl, 100 mg hydrocortisone, and 6L IVF, and was then admitted to the MICU for further management. . Currently, the patient is resting comfortably. On ROS, she endorses pain with palpation of her chest, shoulders, back, and abdomen. Past Medical History: -Dementia -Diabetes mellitus type II -Coronary artery disease s/p CABG x 3 in 7/92 -Vasculopathy -Status post laminectomy at L4-L5 for spinal stenosis on [2166-6-7] -Ventral hernia since [2159] s/p repair in 6/93 -Hashimoto's hypothyroidism -HTN -s/p appendectomy -s/p cholecystectomy via paramedial incision -s/p total abdominal hysterectomy via the same paramedial incision -s/p bilateral salpingo-oophorectomy via midline incision -osteoarthritis -irritable bowel syndrome -esophageal stricture s/p dilation -s/p benign polypectomy -nephrolithiasis. Social History: Lives with 84yo husband and daughter [Name (NI) 717] at home, husband is her primary caretaker, daughters and sons as well as friends take turn at home to care for her. Remote tobacco, no alcohol or drugs. Family History: Her mother died of CAD at 74. Four siblings (three brothers and a sister) with MI prior to age 60. Physical Exam: ADMISSION VS: 96 (ax) 84 89/34 16 98%RA Gen: Elderly woman, comfortable appearing. HEENT: MM dry CV: Nl S1+S2. Harsh II/VI systolic murmur loudest at the base radiating to the carotids. JVP<10 cm. Pulm: Scattered crackles b/l Abd: S/ND +bs. Mild TTP throughout, no rebound or guarding. Ext: No c/c/.e Neuro: Oriented to person. CN II-XII intact. At discharge: same as above except: Abd: non-tender Psych: agitated at times, easily redirected by family Pertinent Results: ADMISSION LABS: [2177-4-10] 04:00PM [Month/Day/Year 3143] WBC-9.7 RBC-3.72* Hgb-10.9* Hct-31.9* MCV-86 MCH-29.4 MCHC-34.3 RDW-15.3 Plt Ct-276 [2177-4-10] 04:00PM [Month/Day/Year 3143] Neuts-94.9* Lymphs-3.2* Monos-1.3* Eos-0.4 Baso-0.2 [2177-4-10] 05:29PM [Month/Day/Year 3143] PT-11.4 PTT-23.6 INR(PT)-0.9 [2177-4-10] 04:00PM [Month/Day/Year 3143] Glucose-86 UreaN-29* Creat-1.3* Na-128* K-4.6 Cl-92* HCO3-24 AnGap-17 [2177-4-10] 04:00PM [Month/Day/Year 3143] ALT-19 AST-66* AlkPhos-74 TotBili-0.5 [2177-4-10] 04:00PM [Month/Day/Year 3143] Lipase-29 [2177-4-10] 04:00PM [Month/Day/Year 3143] cTropnT-<0.01 [2177-4-10] 04:00PM [Month/Day/Year 3143] Albumin-3.9 [2177-4-10] 09:51PM [Month/Day/Year 3143] TSH-4.3* [2177-4-10] 09:51PM [Month/Day/Year 3143] Free T4-1.2 [2177-4-10] 04:17PM [Month/Day/Year 3143] Lactate-3.3* [2177-4-11] 05:21AM [Month/Day/Year 3143] Lactate-2.0 . DISCHARGE LABS: [2177-4-12] 08:10AM [Month/Day/Year 3143] WBC-6.2 RBC-3.21* Hgb-9.4* Hct-28.2* MCV-88 MCH-29.3 MCHC-33.3 RDW-15.1 Plt Ct-236 [2177-4-12] 08:10AM [Month/Day/Year 3143] Glucose-87 UreaN-24* Creat-1.0 Na-134 K-3.6 Cl-106 HCO3-18* AnGap-14 [2177-4-12] 08:10AM [Month/Day/Year 3143] Albumin-3.0* Calcium-8.8 Phos-1.6* Mg-2.1 . URINE: [2177-4-10] 04:30PM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.003 [2177-4-10] 04:30PM URINE [Month/Day/Year ]-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG [2177-4-10] 04:30PM URINE RBC-2 WBC-116* Bacteri-FEW Yeast-MOD Epi-<1 [2177-4-10] 04:30PM URINE CastHy-3* [2177-4-10] 04:30PM URINE Hours-RANDOM Creat-60 Na-47 K-42 Cl-52 [2177-4-10] 04:30PM URINE Osmolal-301 URINE CULTURE (Preliminary): YEAST. >100,000 ORGANISMS/ML.. ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML. . PCP Urine Culture results obtained, E. faecium >100K organisms, sensitive to linezolid. . [Month/Day/Year ] cultures no growth to date at time of discharge . . IMAGING: PCXR: FINDINGS: Single AP upright portable view of the chest was obtained. The patient is status post median sternotomy and CABG. No focal consolidation, pleural effusion, or pneumothorax is seen. The cardiac and mediastinal silhouette, and the hilar contours are stable. IMPRESSION: No significant interval change. No focal consolidation seen. Brief Hospital Course: Mrs. [Known lastname 19672] is an 82 year old woman with a past medical history significant for dementia, DM 2, CAD s/p CABG, systolic CHF, hypothyroid, known UTI, and two recent admissions for UGIB/CoNS bacteremia and AMS/ARF now admitted with hypotension. 1. Hypotension: Given pyuria on UA consistent with UTI, hypotension likely in part caused by urosepsis, although lack of >WBC/<WBC, tachycardia, or tachypnea is inconsistent with SIRS physiology for UTI. In addition, intravascular volume depletion in setting of decreased PO intake likely contributing a great deal, as the hemodynamics and lactate improved after 8L IVF. Patient was was treated broadly with linezolid and meropenem given history of VRE and prolonged use of ciprofloxacin for recurrent UTIs. Antihypertensives and furosemide held at admission and only furosemide and lisinopril restarted at discharge. Carvedilol should be reintroduced as soon as BP and HR tolerates, hopefully at PCP visit [Name9 (PRE) 766] or Tuesday. SBPs ranged 110-140 on day of discharge without tachycardia. BP check to be done by VNA on day after discharge. 2. UTI: Patient was was treated broadly with linezolid and meropenem given history of VRE and prolonged use of ciprofloxacin for recurrent UTIs. Antibiotic coverage was narrowed to PO linezolid 600mg [Hospital1 ] x total 7 days at time of discharge. This decision was based on urine culture report obtained from Quest lab, ordered by PCP prior to admission which showed E. faecium >100K organisms, sensitive to linezolid. Foley replaced at admission. 3. Hyponatremia: Likely in setting of intravascular hypovolemia. Resolved with IVF. 4. Renal failure: Cr improved to baseline 0.9-1 after IVF. ACEI and furosemide held during admission. 5. Anemia: Hct at baseline and stable this admission. 6. Goals of care: Discussed at length with daughter/HCP. Confirmed DNR/DNI status. Family is in agreement that patient would not want extensive life support, but would be amenable to CVL and arterial line. 7. CAD/CHF: Patient with known LVEF 25-30%. Carvediilol, lisinopril,furosemide held at admission and carvedilol held at discharge (see above). No need for supplemental O2 despite poor EF and aggressive IVF resuscitation. 8. DM 2: Held orals, accuchecks with HISS with good control. 9. Hypothyroid: Continued levothyroxine. 10. Duodenal ulcer: Continued PPI, Hct stable. . 11. Delirium/Dementia: Continued home donepizil, held mirtazapine per report from home that being held. Patient developed significant delirium upon transfer to the floor, requiring sitting at nurses station and eventual 2 point restraints for pulling on Foley. No response to low dose quetiapine or Zydis. . 12. Urinary retention: Foley placed last admission given failed void trial. Changed when admitted to the MICU. Discharged with Foley in place. Patient should have voiding trial as outpatient and Foley should be removed ASAP to avoid further risk of recurrent UTI. . . TRANSITIONAL ISSUES: - restart Carvedilol once BP and HR tolerates - continue linezolid for total 7 day course - f/u volume status and encourage PO fluid intake - ensure family has adequate support to take care of patient 24/7 - void trial and D/C Foley once spontaneously voiding - attempt to minimize admissions and lengths of stay given significant delirium in hospital repeatedly Medications on Admission: Carvedilol 3.125 mg po bid Sucralfate 1 gram QID Esomeprazole daily Donepezil 10 mg daily Lisinopril 20 mg daily Furosemide 20 mg daily Pravastatin 40 mg daily Memantine 10 mg po bid (on hold) Glipizide ER 2.5 mg daily Metformin 500 mg po bid Levothyroxine 100 mcg daily Ezetimibe 10 mg daily (on hold) Allopurinol 100 mg daily (on hold) Omeprazole 20 mg daily Discharge Medications: 1. linezolid 600 mg Tablet [Hospital1 ]: One (1) Tablet PO twice a day for 6 days. Disp:12 Tablet(s) Refills:0 2. sucralfate 1 gram Tablet [Hospital1 ]: One (1) Tablet PO QID (4 times a day). 3. pravastatin 40 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. 4. donepezil 10 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. 5. lisinopril 20 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. 6. furosemide 20 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. 7. glipizide 2.5 mg Tablet Extended Rel 24 hr [Hospital1 ]: One (1) Tablet Extended Rel 24 hr PO once a day. 8. metformin 500 mg Tablet [Hospital1 ]: One (1) Tablet PO twice a day. 9. levothyroxine 100 mcg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 10. omeprazole 40 mg Capsule, Delayed Release(E.C.) [Hospital1 ]: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home With Service Facility: [Company ] [Location (un) ] Discharge Diagnosis: Primary: 1. Urinary tract infection 2. Hypotension 3. Delirium 4. Acute on Chronic Renal Failure 5. Hyponatremia Secondary: 1. Hypertension 2. Dementia 3. Diabetes 4. Duodenal ulcer Discharge Condition: Mental Status: Confused - always. 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 low [Location (un) ] pressure and vomiting. You were given antibiotics for the infection in your urine and IN fluids. Your [Location (un) ] pressure improved to a normal range. You also developed delirium, or confusion, while in the hospital. We gave you medicines to help with this but the most helpful thing is for you to not be in the hospital. Your family should provide 24 hour care of you. It is important you drink lots of fluids over the next 48 hours. It is also very important that you see your PCP on [Name9 (PRE) 766] or Tuesday. . Some of your medications were changed during this admission: START linezolid STOP carvedilol . You should continue to take all of your other medications as prescribed. Followup Instructions: It is VERY IMPORTANT you call Dr.[Name (NI) 11351] office at [Telephone/Fax (1) 1701] on [Telephone/Fax (1) 766] morning to schedule an appointment to be seen on [Telephone/Fax (1) 766] or Tuesday of this week. Please remember to do this. . Your [Telephone/Fax (1) ] pressure will be checked by a visiting nurse [First Name (Titles) ] [Last Name (Titles) ].	[ "0389", "78552", "5990", "5849", "2761", "99592", "25000", "4280", "2859", "2449", "V4581" ]
Admission Date: [2144-12-27] Discharge Date: [2145-1-9] Service: CHIEF COMPLAINT: 1. Chest pain. HISTORY OF PRESENT ILLNESS: The patient is an 81 year-old man with known CAD medically managed who was transferred to [Hospital1 69] for cardiac catheterization. Prior to his transfer he had been a patient at [Hospital3 ] where he ruled in for MI by enzymes. According to the patient he had been having increasing chest pain over the last several days. On the morning to admission to [Hospital1 2436] he developed substernal chest pain with jaw discomfort not relieved by sublingual nitroglycerin therefore he called EMTs who brought him to the [Hospital3 ]. PAST MEDICAL HISTORY: 1. Coronary artery disease. Most recent catheterization done in [2144-2-13] that showed an ejection fraction 60%, an RCA lesion of 80%, left main 20% with diffuse disease, LAD 80% and circumflex with 80%, increased LVEDP of 18 mm. 2. Paroxysmal atrial fibrillation since [2129]. A pacer was placed in [2144-11-14]. 3. Pituitary adenoma status post resection in [2129] with resulting pan hypopituitary hypothyroid, hypoadrenal, hypogonadal. 4. Glaucoma. 5. Status post cataract removal in [2118]. Left cataract surgery in [2141]. ALLERGIES: 1. Penicillin from which he gets hives. 2. Aspirin causes an upset stomach. He has no history of bleeding with aspirin use. MEDICATIONS: 1. Prednisone 6 milligrams q A.M. and 2.5 milligrams q P.M. 2. Coumadin 5 milligrams q d. 3. Lipitor 10 milligrams q d. 4. Altace 2.5 milligrams q d. 5. Atenolol 25 milligrams q d. 6. Lanoxin 0.025 milligrams q d. 7. Azopt 1 drop OU tid. 8. Sublingual nitroglycerin prn. SOCIAL HISTORY: The patient is a retired policeman. He currently works two days a week as a medical courier. He is married with two sons. [Name (NI) ] tobacco use. Occasional alcohol use in the past. PHYSICAL EXAMINATION: At the time of admission heart rate 60, blood pressure 120/60, respiratory rate 20. In general - pleasant man in no acute distress. HEENT - anicteric, mucous membranes moist. Neck is supple with no JVD. Cardiovascular - regular rate and rhythm, no murmurs, rubs or gallops. Lungs are clear to auscultation bilaterally. Abdomen is soft, nontender, nondistended, positive bowel sounds. Extremities - no cyanosis, clubbing or edema, 2+ dorsalis pedis pulses bilaterally. Groin, femorals 2+ bilaterally, no bruits. LABORATORY DATA: Sodium 134, potassium 4.2, chloride 98, CO2 25, BUN 16, creatinine 1.2, glucose 138, CK MB 12.5, Digoxin 2.0, Troponin 3.9. PT 17.7, PTT 29, INR 2.0. EKG is a paced rhythm at 60. On [2144-12-29] the patient was brought to the cardiac catheterization lab. Please see the cath report for full details. In summary the cath showed an ejection fraction of 40%, left main with mild calcification, LAD with 90% mid segment lesion, left circumflex with 80% lesion and RCA with proximal and mid 90% lesions. Cardiothoracic surgery was consulted. The patient was seen and consented for coronary artery bypass grafting on [2144-12-30]. He was brought to the operating room where he underwent coronary artery bypass graft times three. Please see OR report for full details. In summary he had a coronary artery bypass graft times three with a LIMA to the LAD, saphenous vein graft to OM, saphenous vein graft to PDA. He tolerated the surgery well and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. The patient did well in the immediate postoperative period. His anesthesia was reversed and his sedatives were discontinued. He was slow to awaken and therefore remained intubated throughout the day of his surgery. On postoperative day one the patient was extubated but he continued to need a small amount of Neo-Synephrine to maintain an adequate blood pressure. Therefore he remained in the Cardiothoracic Intensive Care Unit throughout postoperative day one. In addition his chest tubes were discontinued. He was seen by the Endocrine service. On postoperative day two the patient remained hemodynamically stable. His Neo-Synephrine was weaned off and he was transferred to the floor for continuing postoperative care and cardiac rehabilitation. Over the next several days the patient continued to do well on the floor. He remained hemodynamically stable. His activity level was slowly increased with the assistance of the nursing staff and the physical therapy staff. On postoperative day seven the patient complained of acute numbness in his left foot. Upon further examination the left foot was also pale and cool with no pulses by doppler. Vascular Surgery was consulted. The patient was returned to the operating room where he underwent an infrapopliteal thrombectomy. Please see the OR report for full details. Following the surgery the patient was noted to have bleeding from his embolectomy incision site. He was returned to the operating room for re-exploration. Several small venous bleeders were ligated and the incision site was re-closed. Following re-exploration he was returned to the Vascular Intensive Care Unit where he remained overnight. On the following day he was transferred back to 56 for continuing postoperative care and recovery from both his cardiac and vascular surgeries. The patient remained on the floor for two additional days. He remained hemodynamically stable and stable from a vascular standpoint. On postoperative day ten from his cardiac surgery and three from his vascular surgery it was deemed that he was stable and ready to be transferred to rehabilitation. At the time of transfer the patient's physical exam is as follows: Temperature 97.2 F, heart rate 74, atrial fibrillation, blood pressure 110/50, respiratory rate 18, O2 saturation 96% on room air. Weight preoperatively is 67.5 kilograms. At discharge it is 72.2 kilograms. Neuro - alert and oriented times three. He moves all extremities. He is conversant. Respiratory - clear to auscultation bilaterally. COR - irregular rate and rhythm. S1, S2 no murmur. Sternum is stable. Incision with staples open to air, clean and dry. Abdomen is soft, nontender, nondistended. Normoactive bowel sounds. Extremities - 1 to 2+ pedal edema bilaterally. Left embolectomy site with staples, dry dressing, small amount of serous drainage, no erythema. Bilaterally dopplerable dorsalis pedis pulses. Foot is warm to touch. Laboratory Data: White count 14.3, hematocrit 31.7, platelet count 282,000. PT 13.2, PTT 66.4, INR on [2145-1-8] 1.2 to be checked again on [2145-1-9]. Sodium 137, potassium 4.1, chloride 99, CO2 30, BUN 22, creatinine 1.2, glucose 107. DISCHARGE MEDICATIONS: 1. Heparin 700 units per hour. 2. Coumadin 5 milligrams q day. 3. Trusopt 1 drop OU tid. 4. Lipitor 10 milligrams q day. 5. Enteric coated aspirin 325 q day. 6. Prednisone 6 milligrams q A.M.; 2.5 milligrams q P.M. 7. Lopressor 25 milligrams [Hospital1 ]. 8. Zantac 150 milligrams [Hospital1 ]. 9. Lasix 20 milligrams [Hospital1 ]. 10. Potassium Chloride 20 milliequivalents [Hospital1 ]. 11. Percocet 5/325 one to two tablets q four hours prn. 12. Ibuprofen 400 milligrams q six hours prn. 13. Tylenol 650 milligrams q four hours prn. DISCHARGE DIAGNOSIS: 1. Coronary artery disease status post coronary artery bypass graft times three with a LIMA to the LAD, vein graft to OM and a vein graft PDA. 2. Paroxysmal atrial fibrillation status post permanent pacemaker in [2144-11-14]. 3. Pituitary adenoma status post resection in [2129] leading to hypopituitary, hypothyroid, hypoadrenal, hypogonadal syndrome. 4. Glaucoma. 5. Status post cataract surgery in [2141]. 6. Status post left popliteal embolectomy. DISCHARGE STATUS: The patient is to be discharged to rehabilitation. He is to have follow up with Dr. [Last Name (STitle) ] in one month. Follow up with his primary care physician in three to four weeks and follow up with Dr. [Last Name (STitle) 30029] of Vascular Service in two weeks. [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3113] Dictated By:[Name8 (MD) 415] MEDQUIST36 D: [2145-1-8] 12:53 T: [2145-1-8] 13:07 JOB#: [Job Number 30030]	[ "41071", "41401", "42731" ]
Admission Date: [2161-8-30] Discharge Date: [2161-9-2] Date of Birth: [2093-3-11] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 443] Chief Complaint: shortness of breat Major Surgical or Invasive Procedure: Intubated cardiac catheterization History of Present Illness: 68F with hx significant for tobacco abuse, no known medical hx, who presented to [Location (un) ] by EMS today after acute onset shortness of breath and wheezing at her nephew's place this morning. Per family, patient had progressive shortness of breath x 3 days with acute worsening today. At [Location (un) ], she was noted to be short of breath, using accessory muscles of respiration, found to be tachycardic to 140s and hypertensive to 219/120 systolic with O2sat 85% on room air. She started on nitroglycerin drip. Also received IV morphine 2mg to help breathing and BP. CXR showed massive bilateral pulmonary infiltrates; patient was trialed on Bipap and failed for [Last Name (un) 5487] reasons. She was intubated at [Location (un) ] with versed, fentanyl, and etomidate, given 40mg IV furosemide and nitroglycerin drip was weaned off after a propofol drip was started. BNP was 1020, troponin I within normal limits at 0.05, and EKG showed subtle <1mm ST elevations V2-V3 along with q waves in V1-V3, with no prior EKGs for comparison. She was given aspirin 325mg and started on a heparin drip. She was also given a dose of IV solumedrol for unknown reasons. Patient was transferred from [Location (un) ] ED to [Hospital1 18] for further management. Per family, patient was taking no medications at home and did not receive regular medical care for >20 years. She allegedly quit smoking 4-5 months ago. Upon arrival to [Hospital1 18] ED, patient was intubated and sedated on propofol and with heparin drip. SBPs stable in 120s. CXR improved from prior significantly and 1L of urine noted in foley bag. BNP 4531, trop-T 0.03; EKG similar to that at outside hospital. Prior to transfer to CCU, patient's vitals were as follows: HR 70 BP 90/44 98%O2sat intubated on CMV- Vt-450cc RR-14 PEEP 5 40%FiO2. . Review of systems was limited as patient was intubated and sedated on admission. Her nephews are unaware of any additional symptoms besides shortness of breath for the last 3 days as described above. However, the patient usually remains guarded and generally adverse to seeing doctors [Name5 (PTitle) ] discussing health issues. She did not complain of any chest pain. . Past Medical History: PAST MEDICAL HISTORY: Tobacco Abuse . PAST SURGICAL HISTORY: none Social History: Lives alone in house independent with ADLs and IADLs, drives, never married, no children. Closest to 2 nephews and [Name2 (NI) 802] who see her once/week, but talk on phone daily. -Tobacco history: +1ppd for ~50 years; quit 4-5 months ago -ETOH: used to have one drink nightly when smoking, however, more recently only drinks at holidays -Illicit drugs: none Family History: Brother died of [Name (NI) 1932] lymphoma, father died of ?stomach cancer, nephew with diabetes mellitus. No family history of early MI or sudden cardiac death. Physical Exam: PHYSICAL EXAMINATION on Admission: VS: T 98.7 HR 85 BP 133/64 16 100% on settings AC 12 Tv 450 PEEP 5 FiO2 40% GENERAL: Intubated and sedated on propofol, agitated with purposeful movements intermittantly. HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 11 cm. 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. Crackles at bases bilaterally, right sided anterior rhonchi at apex, occasional expiratory wheezes. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No sacral edema. Extremities warm and pink. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ . PHYSICAL EXAMINATION on Discharge: Pertinent Results: Labs on Admission: [2161-8-30] 06:40PM BLOOD WBC-25.7* RBC-4.05* Hgb-11.8* Hct-36.4 MCV-90 MCH-29.1 MCHC-32.3 RDW-14.4 Plt Ct-329 [2161-8-31] 03:30AM BLOOD WBC-15.7* RBC-3.73* Hgb-10.8* Hct-32.9* MCV-88 MCH-28.9 MCHC-32.7 RDW-14.5 Plt Ct-328 [2161-8-30] 06:40PM BLOOD Neuts-96.1* Lymphs-2.4* Monos-1.0* Eos-0.2 Baso-0.3 [2161-8-31] 03:30AM BLOOD Neuts-90.8* Lymphs-6.2* Monos-2.7 Eos-0.1 Baso-0.2 [2161-8-30] 06:40PM BLOOD PT-14.0* PTT-145.6* INR(PT)-1.2* [2161-8-30] 06:40PM BLOOD Plt Ct-329 [2161-8-31] 03:30AM BLOOD PT-14.8* PTT-150* INR(PT)-1.3* [2161-8-31] 03:30AM BLOOD Plt Ct-328 [2161-8-31] 12:30PM BLOOD PTT-35.8* [2161-8-31] 02:33PM BLOOD PTT-32.2 [2161-8-30] 06:40PM BLOOD Fibrino-290 [2161-8-30] 06:40PM BLOOD Glucose-141* UreaN-18 Creat-1.1 Na-143 K-3.8 Cl-102 HCO3-28 AnGap-17 [2161-8-31] 03:30AM BLOOD Glucose-147* UreaN-17 Creat-0.9 Na-141 K-4.1 Cl-103 HCO3-30 AnGap-12 [2161-8-31] 02:33PM BLOOD Na-139 K-4.2 Cl-100 [2161-8-31] 03:30AM BLOOD CK(CPK)-120 [2161-8-30] 06:40PM BLOOD Lipase-30 [2161-8-30] 06:40PM BLOOD CK-MB-6 cTropnT-0.04* proBNP-4531* [2161-8-30] 06:40PM BLOOD cTropnT-0.03* [2161-8-31] 03:30AM BLOOD CK-MB-5 cTropnT-0.03* [2161-8-31] 03:30AM BLOOD Calcium-8.9 Phos-4.6* Mg-1.9 Cholest-185 [2161-8-31] 02:33PM BLOOD Calcium-9.2 Phos-3.6 Mg-2.0 [2161-8-31] 03:30AM BLOOD Triglyc-52 HDL-91 CHOL/HD-2.0 LDLcalc-84 LDLmeas-91 [2161-8-30] 06:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2161-8-30] 06:43PM BLOOD Type-ART Tidal V-450 PEEP-5 FiO2-100 pO2-314* pCO2-57* pH-7.34* calTCO2-32* Base XS-3 AADO2-365 REQ O2-63 -ASSIST/CON Intubat-INTUBATED [2161-8-30] 11:45PM BLOOD Type-ART pO2-117* pCO2-46* pH-7.42 calTCO2-31* Base XS-5 [2161-8-30] 06:48PM BLOOD Glucose-137* Lactate-2.0 Na-143 K-3.7 Cl-100 calHCO3-31* . LABS Upon discharge: . [2161-9-2] 05:58AM BLOOD WBC-15.8* RBC-3.60* Hgb-10.5* Hct-30.5* MCV-85 MCH-29.1 MCHC-34.2 RDW-14.9 Plt Ct-275 [2161-9-2] 05:58AM BLOOD PT-12.5 PTT-27.7 INR(PT)-1.1 [2161-9-2] 05:58AM BLOOD Glucose-107* UreaN-21* Creat-0.7 Na-138 K-4.0 Cl-99 HCO3-32 AnGap-11 [2161-9-1] 08:44PM BLOOD CK(CPK)-134 [2161-9-2] 05:58AM BLOOD Calcium-9.0 Phos-2.7 Mg-2.0 [2161-8-31] 03:30AM BLOOD %HbA1c-5.9 eAG-123 [2161-8-31] 03:30AM BLOOD Triglyc-52 HDL-91 CHOL/HD-2.0 LDLcalc-84 LDLmeas-91 [2161-8-31] 03:30AM BLOOD TSH-0.43 . CXR [2161-9-1]: There is interval improvement in interstitial prominence, in particular in the left lung. There is still present right interstitial engorgement as well as right parahilar opacity which is currently better demonstrated than on the prior studies and might represent either sequela of pulmonary edema or an unrelated process such as focal area of infection in the right lower or right middle lobe or aspiration. . Portable TTE (Complete) Done [2161-8-31] at 8:40:00 AM The left atrium is normal in size. The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild to moderate global left ventricular hypokinesis with anterolateral wall contracting the best and the septum contracting the worst (LVEF = 40 %). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . IMPRESSION: Global left ventricular systolic dysfunction with some regionality which could be consistent with multivessel coronary artery disease. . Cardiac Catheterization: [2161-9-1] FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Mild to moderate biventricular diastolic dysfunction. 3. Moderate pulmonary hypertension. 4. Moderate systemic arterial hypertension. 5. Successful PTCA/stenting of the ostial RCA with a Promus OTW 3.0x12mm drug-eluting stent (DES) post-dilated with a 3.0mm balloon. (see PTCA comments) 6. R 6Fr femoral artery angioseal closure device deployed without complications 7. ASA indefinitely 8. Plavix (clopidogrel) 75 mg daily for at least 12 months Brief Hospital Course: [Known firstname ] [Known lastname 7725] is a 68 year old woman without prior regular medical care and a history of tobacco abuse who presented to an outside hospital with acutely worsening shortness of breath, found to be hypertensive with flash pulmonary edema. She was temporarily started on a nitroglycerin drip, given morphine, failed a trial of BiPAP and was intubated. The nitroglycerin drip was stopped after intubation and her blood pressure was well controlled while on propofol for sedation. After initiation of diuresis, she was transferred to [Hospital1 18] for further management and anticipated cardiac catheterization. . Flash pulmonary edema: The patient's flash pulmonary edema was addressed with continued diuresis with IV furosemide upon admission to the CCU. Repeat chest x-rays at [Hospital1 18] demonstrated improving pulmonary edema. Her flash pulmonary edema was thought to have been caused by her acutely worsening hypertension in the setting of chronic diastolic dysfunction. The morning after admission [2161-8-31] she was extubated successfully and her breathing continued to improve. . Coronary Artery Disease and Cardiac Function: Intial ECG upon admission showed q waves in V1-V2 along with early repolarization changes in V2-V3, no concerning ST/T changes, most consistent with an old anteroseptal infarct. An echocardiogram was completed and showed global left ventricular systolic dysfunction (LVEF 40%) with some regionality which could be consistent with multivessel coronary artery disease and mild MR. She then received a cardiac catheterization that showed two vessel coronary disease (ostial RCA 80% and LAD with 95% mid vessel stenosis involving the major diagonal but with a small distal vessel, LCx has a 30% mid vessel stenosis) along with moderate pulmonary hypertension and biventricular diastolic dysfunction. She received a successful DES to the RCA. The LAD was not stented to due prediction of poor benefit secondary to the thought that her small distal LAD vessel did not cover much perfusion territory. She was continued on a heparin drip (started at outside hospital) for a total of 48 hours. Additionally, she was started on a full dose aspirin daily, atorvastatin, metoprolol, and was initially loaded on admission with plavix 300mg and transitioned to plavix 75mg daily. She was not started on an ACE-I secondary to systolic blood pressures (in the 90s) upon discharge. She will have close follow-up with cardiology and will likely be started on an ACE-I as an outpatient as her blood pressures tolerates. . Pulmonary function: Due to long smoking history and presence of hyperinflated lungs on chest x-ray, there is concern for underlying COPD. She was intermittently treated during admission with ipratropium nebulizers for wheezing. She received IV solumedrol once at the outside hospital which caused a transient leukocytosis that resolved, but did not receive any further steroids at [Hospital1 18]. Upon discharge, she is scheduled to establish care with a new pulmonologist and obtain pulmonary function testing. . The patient wished to find and schedule an appointment with a PCP in her area on her own. She will need outpatient screening (colonoscopy, mammogram and bone density) and routine health care as she has not seen a doctor in greater than 20 years. . The patient was full code for this admission. Medications on Admission: NONE Discharge Medications: 1. Toprol XL 25 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 2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:1 inhaler Refills:0 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): You must continue this medication every day, please do not stop taking this medication without talking to your cardiologist. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Company ] and hospice Discharge Diagnosis: Acute exacerbation of systolic congestive heart failure Coronary artery disease: Partial occulsion of the RCA and LAD (blood vessels in your heart) Pulmonary Edema Hypertension 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 because of shortness of breath. Your symptoms became severe and you required temporary intubation. Your shortness of breath was related to excess fluid in your lungs secondary to decreased heart function and high blood pressure. You received medications to help decrease the fluid in your lungs and your breathing improved. You also received a cardiac catheterization and a stent was placed in one of the arteries in your heart. You were started on new medications to help protect your heart and lower your blood pressure. You may have emphysema or COPD secondary to your smoking, and you will need to see a pulmonologist to determine if you need medications for your breathing. We applaud you for stopping smoking and recommend you do not start smoking again due to significant risks of progressive lung and heart disease. . We have started you on the following new medications: - START Metoprolol tartrate (Toprol XL) 25mg 1 tab by mouth daily - START Aspirin 325mg 1 tab by mouth daily - START Atorvastatin (Lipitor) 80mg 1 tab by mouth daily - START Clopidogrel (Plavix) 75mg 1 tab by mouth daily - START Albuterol inhaler 1-2 puffs up to every 6 hours as needed for shortness of breath of wheezing - You were not started on a medication called an ace-inhibitor such as lisinopril because your blood pressure was low. Your cardiologist may start you on a similar medication in the future. . It is extremely important that you continue taking the above medicines as perscribed. Please continue taking your clopidogrel (Plavix) every day unless instructed otherwise by your cardiologist. Clopidogrel is especially important in preventing a future heart attack and death now that you have new stents placed in the arteries of your heart. . Please follow up with your new cardiologist and pulmonologist. Your cardiologist may start you on additional blood pressure medications as an outpatient. You will also need to make an appointment with a primary care doctor in your area. You should aim for an appointment within the next 2-3 weeks with a primary care doctor. . It was a pleasure taking care of you. We wish you a speedy recovery. Followup Instructions: Please follow up with your new physicians: . CARDIOLOGY: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 62] Date/Time:[2161-9-14] 2:40 [Hospital1 18] [Location (un) 436] [Hospital Ward Name 23] Building . PULMONOLOGY Provider: [Name10 (NameIs) ] [Name8 (MD) 611], M.D. Phone:[Telephone/Fax (1) 612] Date/Time:[2161-9-14] 10:00 [Hospital Ward Name 516] [Hospital Ward Name 23] [Location (un) 436] . You will need to have pulmonary function testing (spirometry) to test your breathing right before your pulmonology appointment as listed above. Please proceed to the [Hospital Ward Name 23] building [Location (un) 436] and they will guide you towards your testing. . Please make an appointment with a new primary care physician in your area to establish care within the next 2-3 weeks. Completed by:[2161-9-2]	[ "4280", "4168", "4019", "V1582" ]
Admission Date: [2107-1-14] Discharge Date: [2107-1-22] Date of Birth: [2037-7-24] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Levaquin / Allopurinol And Derivatives / Rituxan / Droperidol / Doxycycline / Bacitracin Attending:[First Name3 (LF) 2712] Chief Complaint: fever Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: Mr. [Known lastname ] is a 69 yo male with a history of CLL, hypogammaglobulinemia, parkinson's disease, and recurrent PNA who was admitted to [Hospital1 18] on [1-14] with cough and fever, now transferred to the MICU due to tachypnea. He presented with fever, cough, and fatigue in the setting of undergoing bowel prep for colonoscopy (for workup of chronic diarrhea). Of note he had a recent MRSA PNA and Pseudomonas sinus infection (as well a thrush and intertiginous [Female First Name (un) 564]) and had been on vanc and cefepime. CXR in the ED was concerning for an opacity. He was cultured and started on vanc, cefepime, and IVF for possible PNA. . On the floor he was continued on vanc and cefepime (since [1-14]). She was started on oseltamivir on [1-14] on the floor due to concern for flu (he was uptodate with his flu shot). He has had some issues with a.fib with RVR during this hospitalization and his home metoprolol was changed to diltiazem and uptitrated. Azithromycin was started on [1-16] due to concern for atypical PNA. ID was consulted and recommended starting gentamicin if he worsened (which was started early [1-18] prior to transfer). IVIG was recommended, but not given due to concern for administration during fevers. . The afternoon and evening prior to transfer he was noted to be tahypneic to the 30's on a high flow shovel mask. An ABG was 7.49/34/63 on 3.5 L. He was using an acapella valve to help clear secretions. Nightfloat was called to see him due to worsening tachypnea in the 40's and initiated transfer to the MICU. . Currently he denies pain. He feels like his breathing is getting worse and he is tired. . On ROS he admits to loose bowel movements. ROS was limited due to respiratory distress. Past Medical History: - CLL (dx [1-10]) s/p Rituximab, Fludarabine in [2105]. - Hypogammaglobulinemia (IgA, IgM), last given IVIG x1 in [10/2106] -Recurrent Sinusitis, last treated for MRSA and pseudomonal sinusitis in [10/2106] - Recurrent PNA with MRSA, Pseudomonas, M. gordonae (likely contaminant) - Bronchiectasis - HTN - Parkinson's Dz dx [2098] - Rectal cancer in [2084] s/p resection, radiation, 5-FU Social History: (per admit note) The patient is married, lives with his wife in [Name (NI) ]. He has two daughters, both healthy. He is a retired PhD in economics, still working minimally as a professor. [First Name (Titles) 7355] [Last Name (Titles) 83649]. No tobacco. No IVDU or illicits. Family History: (per admit note) Stroke and Parkinson's disease, congestive heart failure, prostate cancer, glaucoma. Physical Exam: GEN: Middle-aged male laying in bed, tired-appearing and very tachpneic with a shovel mask on. HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: Paradoxical abdominal movements, accessory muscle use, patient speaking in short sentences. Appears very tired. Diffusely wheezy and coarse throughout. CV: RRR, no MRG. ABD: +BS, soft NTND EXT: no c/c/e NEURO: Sleepy, but arousable. Oriented to person, place, and time. Grossly nonfocal. . Pertinent Results: Admission labs: Na 134 K 4.7 Cl 101 Bicarb 26 BUN 19 Cr 1.1 Glu 126 Ca 8.3 Mg 2.0 Phos 2.5 . WBC 80.7 Hct 29.5 Plt 100 . Vanc level [1-16] - 7.3 (he got an extra 250 mg IV dose the afternoon of [1-16]) . ABG (1:50 pm) 7.49/34/63 Lactate 0.9 Micro: [1-14], [1-16] BCx: negative [1-17], [1-18] BCx: pending at time of death [1-14], [1-18], [1-19] UCx: negative [1-17] ULegionella: negative [1-15] Sputum: negative [1-16] Sputum: GRAM STAIN (Final [2107-1-16]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): YEAST(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [2107-1-21]): MODERATE GROWTH Commensal Respiratory Flora. YEAST. MODERATE GROWTH. PSEUDOMONAS AERUGINOSA. RARE GROWTH. FUTHER WORK-UP PER DR [Last Name (STitle) ] ([Numeric Identifier ]). MOLD. 1 COLONY ON 1 PLATE. PSEUDOMONAS AERUGINOSA \| CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ 4 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S [1-18] Sputum: ASPERGILLUS SPECIES. 1 COLONY ON 1 PLATE. [1-16], [1-18] Resp viral culture: negative [1-17] Influenza: negative [1-17] Stool microsporidia, cyclospora, O&P, cryptosporidium, c.diff: negative [1-18] Cryptococcus serology: negative [1-18] BAL: Resp culture, legionella, KOH prep, PCP, [Name10 (NameIs) ] fast smear, negative (final). Fungal culture, [Name10 (NameIs) ] fast culture, viral culture, negative (prelim). [1-20] Sinus swab: GRAM NEGATIVE ROD(S). ~1000/ML. [1-21] Stool O&P: pending at time of death [1-22] C. diff: pending at time of death . Imaging: [1-15] ECG: Baseline artifact. The rhythm is likely atrial flutter/coarse atrial fibrillation with rapid ventricular response. Probable left ventricular hypertrophy. Compared to the previous tracing of [2106-10-13] the findings are similar. [1-17] CXR: FINDINGS: As compared to the previous radiograph, the right upper lobe opacity is not relevantly changed. The left lower lobe opacity is slightly more extensive than on the previous examination and is today accompanied by a small left pleural effusion. No evidence of newly appeared focal parenchymal opacities. Unchanged calcified granuloma in the left upper lobe. Unchanged heart size, unchanged mild tortuosity of the thoracic aorta. [1-20] LENIs: No deep venous thrombosis in either lower extremity. . Cytology: [1-18] Bronchial washings: NEGATIVE FOR MALIGNANT CELLS. Brief Hospital Course: Initial differential for his tachypnea and hypoxia included worsening PNA, PE, or acute CHF. Patient was intubated emergently on arrival to MICU for respiratory distress. Microbiology studies were as above; sputum grew pseudomonas and aspergillus. ID was consulted for antimicrobial management; the patient was treated with vancomycin, meropenem, and voriconazole. His respiratory status continued to worsen, and he required increasing levels of ventilatory support. IP was consulted for possible u/s guided thoracentesis of left pleural effusion but were unable to locate a big enough pocket of fluid. Blood pressures were initially stable but the patient eventually developed likely septic shock, and became vasopressor dependent. He was not given his rate control agents for atrial fibrillation, given his hypotension. His renal function worsened acutely the day after transfer to the MICU, and BUN/creatinine continued to worsen through the rest of his hospitalization. His CLL was evident with leukocytosis beyond his baseline WBC levels. His hypogammaglobulinemia was demonstrated with low IgG, IgM, and IgA levels. IVIG was considered, but ultimately not given in his state of acute critical illness and fevers. He was also continued on his chronic Parkinson's medications. The patient's family had been kept aware of his worsening condition. On [1-22], after further discussions with the family, the decision was made to transition the patient's care to comfort measures only. His vasopressors were stopped, and he passed away with his family at his side, several hours thereafter. Medications on Admission: Alprazolam 0.75mg qhs Amitriptyline 25mg qhs Carbidopa-levodopa 25mg-100mg 2 tabs 7am, 1.5 tabs 10:30am, 1 tab 2pm, 1 tab 5:30pm Diphenhydramine 50mg [Hospital1 ] prn Metoprolol succinate 25mg daily Rasagiline 0.5mg daily Ropinirole 3mg at 7am, 10:30m, 2pm, 5:30pm Ascorbic [Hospital1 ] B complex vitamins 1 tab daily Calcium 1000mg daily Coenzyme Q10 400mg daily Docusate calcium 240mg daily Guaifenesin 1200mg [Hospital1 ] Omega 3 fatty acids Psyllium Hydrocortisone 0.5% lotion daily prn Mupirocin wash 2-3x/day Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Primary: Septic shock Pneumonia Secondary: Chronic lymphocytic leukemia Hypogammaglobulinemia Parkinson's disease Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a	[ "0389", "99592", "78552", "51881", "5849", "5119", "42731", "4019", "2767" ]
Admission Date: [2183-9-29] Discharge Date: [2183-9-29] Date of Birth: [2108-1-29] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 2704] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None. History of Present Illness: 75 yo M with CAD, CHF, spinal stenosis, who presents with several hours of increasing SOB. He denies CP, palps. He was feeling in his usual state of health on morning of presentation to ED and sx came on during the early evening of [2183-9-28]. He denies dietary indescretion and medication noncompliance. He does endorse episodes of SOB causing him to wake up during the night presumed to be secondary to his sleep apnea. He notes a 15 lb weight gain and increase in abdominal girth over past few weeks. He stopped his plavix sometime in the spring. He presented to ED with BP of 210/110, oxygen sat 100% on NRB, desatting to 80's on NC. He was given lasix 80 mg IV x1 and started on nitro gtt, heparin gtt. He was given one dose of levofloxacin for possible pneumonia on CXR. He put out 500 ml urine in ED. He denies cough, fevers, chills. Past Medical History: CAD CHF Spinal stenosis PFTs with decreased DLCO Sleep apnea CKD Social History: Former smoker, quit 25 yrs ago, smoke 5 PPD x15 yrs, former heavy drinker - drank a fifth nightly for about 15 years, denies drugs. Family History: Fa: HTN, mother died of breast ca Physical Exam: BP 210/110 -> 140/70's, HR 70's, 24, 100% on NRB, 80's on 4L NC GENL: obese male in NAD HEENT: thick neck, unable to appreciate JVP, no carotid bruits CV: RRR, no MRG Lungs: crackles at bases bl, bronchial breath sounds on R Abd: distended, tympanitic, unable to appreciate organomegaly Ext: 1+ pitting edema in lower legs bl, 2+ pedal pulses Neuro: A&Ox3 Pertinent Results: ADMISSION LABS: [2183-9-28] 08:50PM PT-12.3 PTT-20.4* INR(PT)-1.1 [2183-9-28] 08:50PM PLT COUNT-261 [2183-9-28] 08:50PM ANISOCYT-1+ [2183-9-28] 08:50PM NEUTS-79.2* LYMPHS-17.2* MONOS-2.8 EOS-0.6 BASOS-0.2 [2183-9-28] 08:50PM WBC-25.3# RBC-4.85 HGB-14.2 HCT-42.1 MCV-87 MCH-29.4 MCHC-33.8 RDW-16.3 [2183-9-28] 08:50PM CALCIUM-9.4 PHOSPHATE-6.3* MAGNESIUM-1.9 [2183-9-28] 08:50PM cTropnT-0.24* [2183-9-28] 08:50PM GLUCOSE-137* UREA N-50* CREAT-2.4* SODIUM-143 POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-25 ANION GAP-20 [2183-9-28] 09:57PM LACTATE-1.7 [2183-9-28] 11:05PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.007 [2183-9-28] 11:05PM URINE GR HOLD-HOLD [2183-9-28] 11:05PM URINE HOURS-RANDOM [2183-9-28] 11:05PM TRIGLYCER-110 HDL CHOL-60 CHOL/HDL-2.9 LDL(CALC)-89 [2183-9-28] 11:05PM ALBUMIN-4.0 CHOLEST-171 [2183-9-28] 11:05PM CK-MB-12* MB INDX-7.2* cTropnT-0.40* [2183-9-28] 11:05PM ALT(SGPT)-108* AST(SGOT)-36 CK(CPK)-166 ALK PHOS-43 TOT BILI-0.7 . DISCHARGE LABS: [2183-9-29] 03:22AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2183-9-29] 03:22AM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.007 [2183-9-29] 06:56AM PT-14.9* PTT-103.1* INR(PT)-1.3* [2183-9-29] 06:56AM PLT COUNT-209 [2183-9-29] 06:56AM WBC-15.4* RBC-4.14* HGB-12.1* HCT-35.7* MCV-86 MCH-29.2 MCHC-33.9 RDW-16.5* [2183-9-29] 06:56AM CALCIUM-9.2 PHOSPHATE-5.2* MAGNESIUM-1.8 [2183-9-29] 06:56AM CK-MB-11* MB INDX-5.2 cTropnT-0.30* [2183-9-29] 06:56AM CK(CPK)-211* [2183-9-29] 06:56AM GLUCOSE-134* UREA N-52* CREAT-2.6* SODIUM-141 POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-28 ANION GAP-19 . MICRO DATA: [2183-9-28]: Blood and Urine cultures: Pending at discharge . IMAGING: Chest X Ray [2183-9-29]: Previous mild pulmonary edema has improved, previous right lower lobe atelectasis has cleared, left lower lobe consolidation or atelectasis persists. Heart size top normal, unchanged. No pneumothorax or pleural effusion. . ECHO [2183-9-29]: Pending at discharge Brief Hospital Course: 1. Shortness of Breath: The differential diagnosis originally included MI, CHF exacerbation, pneumonia, PE. He was started on a nitro drip and given Lasix 80mg IV in the ED and was brought to the floor. His oxygenation improved, and by morning he was oxygenating well on room air. He did not complain of further shortness of breath. A follow up CXR showed improvement. An ECHO was performed and the final [Location (un) 1131] was pending at discharge. Because is cardiac enzymes had been elevated, including CK-MB and Troponin, and his EKG showed ST changes, and because of his significant cardiac history, he was also given ASA and started on a heparin drip. We had wanted to perfrom a cardiac catheterization, but the patient refused. He claimed he did not need such a test. The cardiology fellow explained the test, risks and benefits, and that we thought it would be wise to have. After hearing the risks and benefits of the test, the patient still refused. His cardiologist Dr. [Last Name (STitle) ] also spoke with the patient, trying to convince him to stay in the CCU for catheterization. The patient refused. His PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] was also [Last Name (STitle) 653] and was to visit him in the CCU that day. The patient left AMA before his PCP could arrive. His PCP was [Name (NI) 653]. Further work up for his SOB could not be performed. Upon leaving AMA, the patient did not complain of any symptoms. In addition to his outpatient medications, the patient was written prescriptions for Metoprolol, Atorvastatin, and Lasix 40mg PO qDay. he was also told to take aspirin. . 2. Hypertension: On admission the patient's BP was in the 200s systolic. The patient responded well to the nitro drip, metoprolol, and lasix. His BP returned to the 110-120 systolic. He did not experience any symptoms. Upon leaving AMA, the patient's BP was stable off of the nitro drip. Further work up could not be performed, but he was advised to follow up with his cardiologist and PCP immediately to address his blood pressure. . 3. Lymphocytosis: The patient had an elevated count on admission. However, the patient was afebrile and did not have any localizing symptoms. He was given a dose Levaquin in the ED. Blood and urine cultures were sent. However, the patient left AMA before further work up could be performed. Cultures were still pending at the time of leaving AMA. . 4. Disposition: The patient left AMA despite being urged to stay. We told him that we were concerned about his heart, and that we would want perform a cardiac catheterization to assess his heart disease. The patient was decribed the consequences of leaving and the risks/benefits of staying, including suffering a heart attack or other acute event if he did not stay, and he understood the risks and benefits. He was urged to follow up with his PCP and cardiologist within a week. He was urged to return to the hospital with any symptoms. He was also given prescriptions for his medications and urged to take them consistently and as prescribed. His blood and urine cultures will need to be followed up, as well as his blood pressure and respiratory symptoms. Medications on Admission: Lipitor Toprol XL 25 mg QD (patient was unsure) Testosterone tp MVI HCTZ 25 QD ASA 325 mg QD Lasix (patient could not recall the dose) Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Hypertensive urgency 2. Non-ST Elevation Myocardial Infarction . Secondary Diagnosis: 2. Pulmonary edema 3. Chronic kidney disease Discharge Condition: Afebrile, hemodynamically stable. - PATIENT LEFT AGAINST MEDICAL ADVICE Discharge Instructions: Please take all medications as prescribed. Please keep all follow up appointments. Please return to the hospital immediately if you experience chest pain, shortness of breath, fevers/chills, or any other symptoms that concern you Followup Instructions: Please follow up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] within 1 week [Telephone/Fax (1) 693]. Please follow up with your Cardiologist Dr. [Last Name (STitle) ] within 1 week.	[ "41071", "4280", "5859", "41401", "4019", "32723" ]
Admission Date: [2156-3-26] Discharge Date: [2156-4-7] Date of Birth: [2096-7-28] Sex: F Service: NEUROSURGERY Allergies: Metoprolol Attending:[First Name3 (LF) 1271] Chief Complaint: Cerebellar hemorrhage Major Surgical or Invasive Procedure: Cerebral Angiogram External Ventriculostomy Drain placement History of Present Illness: 59yo F h/o HTN who was in good health until she woke at 3am on [3-26] with headache, nausea and dizziness which caused her to fall twice at home going to the restroom (presumably vertiginous). She sustained no traumatic injury in these falls and at 6:30am she called in sick to work, due to the dizziness. At 10:30am, she went to her PCP but while in the waiting room, she became unresponsive and limp, with eyes deviated to the right while sitting in a chair and was taken emergently to [Hospital ] Hospital. Exam there was documented as "pt now awake, understands staff, answers yes & no questions with nods. Points with both hands." There, head CT found cerebellar hemorrhage and she was given dilantin IV and was intubated (with paralytics) for transport here for neurosurgical intervention. On arrival here she had an EVD placed. Past Medical History: HTN fibromyalgia h/o vasovagal syncope [1-20] PSH: s/p tonsilectomy s/p appendectomy Social History: Works as teacher is married Family History: Non-contributory Physical Exam: Admission Exam: VS 99.0 83-91 91-104/45-63 15 100% ICP 17 VD@20cm Gen Lying in bed in NAD Neck supple CV rrr no bruits Pulm ctab Abd soft benign Ext no edema NEURO MS [Name13 (STitle) ] to voice and opens her eyes. Follows commands to look to the right/left. Squeezes fingers b/l. Wiggles her toes b/l to command. Shows 2 fingers to command on R. CN CN I: not tested CN II: Pupils , 4->3 L, 3->2 R and briskly reactive. CN III, IV, VI: Full right gaze and conjugate. Does not bury the sclera on left gaze CN V: b/l corneal reflex CN VII: full facial symmetry CN VIII: hearing intact to FR b/l Motor Raises right forearm antigravity but not at deltoid. Squeezes hand on the left but cannot raise it. Does not lift the left leg and it drops to the bed when we drop it. No withdrawal to pain on the left. Reflexes toes up b/l Coordination not assessed Gait deferred Pertinent Results: [2156-4-7] 02:50AM BLOOD WBC-15.0* RBC-3.71* Hgb-12.1# Hct-35.2# MCV-95 MCH-32.7 MCHC-34.5 RDW-14.1 Plt Ct-433 [2156-4-7] 02:50AM BLOOD Neuts-85.7* Lymphs-9.0* Monos-4.2 Eos-0.4 Baso-0.6 [2156-4-7] 02:50AM BLOOD Plt Ct-433 [2156-4-7] 02:50AM BLOOD Glucose-108* UreaN-39* Creat-0.6 Na-145 K-3.8 Cl-107 HCO3-30 AnGap-12 [2156-4-7] 02:50AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.4 [2156-4-7] 12:33PM BLOOD Glucose-115* Lactate-0.8 Na-142 K-3.4* Cl-105 MRI: [3-29]: Today's exam is correlated with the head CT from [2156-3-27]. There is a small area of increased T2 signal within the right thalamus, which does not appear to have slow diffusion. This could represent a subacute infarct. There is a large cerebellar hemorrhage as on the head CT, involving both the left and right cerebellar hemispheres as well as the vermis. There is considerable mass effect upon the fourth ventricle. Hydrocephalus remains, although the size and shape of the lateral ventricle is unchanged from the head CT. The right frontal ventriculostomy catheter has been repositioned since the head CT. The tip now terminates approximately 1 cm within the mid brain. I discussed positioning with [First Name4 (NamePattern1) 7306] [Last Name (NamePattern1) ], M.D., from neurosurgery and the catheter has been pulled back. There continues to be tonsillar herniation. There are no definite areas of enhancement with no definite underlying masses. Followup examination can be obtained once the edema resolves and the blood products evolve. IMPRESSION: Subarachnoid and intraventricular hemorrhage as well as large posterior fossa hemorrhage causing compression of the fourth ventricle. No change from the head CT in the degree of hydrocephalus. The ventriculostomy catheter has been repositioned but now has tip terminating in the midbrain. Small subacute infarct in the right thalamus. CXR [4-6]: AP chest compared to [3-30] through 19: Pulmonary edema. Previous pleural effusions and left lower lobe atelectasis have all resolved. Feeding tube ends in the stomach. Heart size is normal. Fullness at the thoracic inlet suggests enlargement of the right lobe of the thyroid gland. CT of Head [4-6]: Progression of ascending transtentorial herniation compared to [2156-4-5]. Slight possible increase in right cerebellar hemispheric edema and hemorrhage. Interval removal of right ventriculostomy catheter with associated interval pneumocephalus within the ventricular system and associated increased lateral ventricular and third ventricle size. Brief Hospital Course: Ms [Known lastname 71733] was admitted and emergently had a right sided EVD placed. She was started on Mannitol, admitted to the ICU her BP was kept strictly below 140. She was noted to have increased triponins from 0.19 to 0.91. An MRI was performed which showed no masses or underlying lesions. Her EVD drain was noted to be near the midbrain and was pulled back twice. The patient was followed closely with serial CTs showing intraventricular and posterior fossa hemorrhage. She was extubated on [3-27], Her examined improved daily but was noted to have a left gaze palsy, she would follow commands and have attempt to speak [12-16] words. She failed a speech and swallow video swallow and was receiving tube feeds. She was found to be VRE positive and was on day 4 of Levofloxacin on discharge. She was MRSA negative. Her EVD was weaned over 3 days and she was transferred to the step down. She was making good progress and her vent drain was weaned over three days and removed on [4-5]. On the morning of [4-6] she was found to have more lethargic and febrile a stat CT showed a hydrocephlus and herniation and question of increase cerebellar blood. She was taken emergently to the OR and had a EVD placed on left side ICP were noted to be [4-24]. CSF cultures were sent and they have been preliminary negative along with urine cultures. Chest XRays showed: Pulmonary edema. Previous pleural effusions and left lower lobe atelectasis have all resolved. On day of transfer she was intubated but followed commands in all extremities, answered yes/no question appropriately. Her right pupil has been larger than left but reactive since admission and she continued with left gaze palsy. She appeared to be moving all extremities symmetrically and with good strenght. An angiogram was performed to assess for possible new posterior fossa blood and a 2cm AVM was found at the L ICA/SCA junciton and a 9mm draining anuersym. She is transferred for vascular neurosurgery care. Medications on Admission: HCTZ 25 Lisinopril 20 Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q4-6H (every 4 to 6 hours) as needed for hypertension. 7. Ancef 1 g Recon Soln Sig: Two (2) Injection three times a day. 8. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 9. Levofloxacin in D5W 750 mg/150 mL Piggyback Sig: One (1) Intravenous DAILY (Daily). Discharge Disposition: Extended Care Discharge Diagnosis: Cerebellar Bleed, Intracranial AVM and Aneursym Discharge Condition: Neurologically guarded Discharge Instructions: You are being transferred for further vascular neurosurgery care to [Hospital6 1708] Dr[Name (NI) 4213] [Name (STitle) 4869] Keep drain clamped for transfer Followup Instructions: Per Dr [Last Name (STitle) ] [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2156-4-7]	[ "486", "2760", "4019" ]
Admission Date: [2125-4-9] Discharge Date: [2125-4-21] Date of Birth: [2070-11-11] Sex: M Service: CARDIAC SURGERY CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: The patient is a 54 year-old male who was recently evaluated for chest pain in [Month (only) 547] and had a positive stress test. Cardiac catheterization was done recently and cardiothoracic surgery was consulted. He is now in the hospital for a bypass. PAST MEDICAL HISTORY: Hypercholesterolemia, osteoarthritis of knees, lipoma excision [2117], umbilical hernia [2123]. ALLERGIES: Penicillin. MEDICATIONS: Lipitor 25 mg q.d., aspirin. HOSPITAL COURSE: The patient underwent a coronary artery bypass graft times four on [2125-4-10] with left internal mammary coronary artery to left anterior descending coronary artery, right saphenous vein graft to obtuse marginal, radial right coronary artery to posterior descending coronary artery. He was extubated to Post Surgery and after surgery he was noted to be in and out of atrial fibrillation. An EP consult was obtained and he was started on Amiodarone infusion. He was also started on Diltiazem. The early a.m. on postoperative day three he had a pulse less ventricular tachycardia arrest and had to be defibrillated times two. At this time he was intubated. He was also noted to be in atrial fibrillation and another Amiodarone load was given. He underwent a bronchoscopy, which showed a small amount of thick yellow secretions. Subsequently he was noted to be hypoxemic and have a high oxygen requirement. Chest x-ray done at this point was noncontributory. On postoperative day four he underwent a catheterization after the ventricular tachycardia arrest. This revealed stenosis of the radial graft and this was stented. A pulmonary consult was obtained on postoperative four for increasing oxygen requirements. Their recommendation for diuresis was followed. They also recommended a CT angiogram to rule out a pulmonary embolus. He continued to remain intubated and was in and out of atrial fibrillation. He was also heparinized at this point. He underwent a echocardiogram on postoperative day five, which showed an left ventricular ejection fraction of 50%. His chest CT showed no pulmonary emboli. His lower extremities noninvasives were negative for deep venous thrombosis. Subsequently his ventilatory status slowly improved. He was extubated on postoperative day seven. From then his condition steadily improved. His respiratory function improved. He was continued on the heparin drip and the Coumadin. The Electrophysiology study was planned. This could not be done, however, and has been postponed to be done as an outpatient. He is now stable to discharge home. He will be discharged to home when his INR is nearly therapeutic levels on his Coumadin. He will be discharged home on Amiodarone and anticoagulation and will follow up with EP study in one week. MEDICATIONS ON DISCHARGE: Plavix 75 mg q.d., aspirin enteric coated 325 mg q.d., isosorbide mononitrate 60 mg q.d., Lopressor 25 mg b.i.d., Levofloxacin 500 mg q.d., Protonix 40 mg q.d., Amiodarone 400 mg q.d., Coumadin dose to be adjusted. INR to be checked by primary care physician. Follow up with EP in one week, with primary care physician in two weeks and with Dr. [Last Name (STitle) 70] in six weeks. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern1) 2209] MEDQUIST36 D: [2125-4-21] 23:57 T: [2125-4-25] 05:46 JOB#: [Job Number 38968]	[ "41401", "42731", "2720" ]
Admission Date: [2140-1-19] Discharge Date: [2140-1-23] Date of Birth: [2099-9-21] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1253] Chief Complaint: CC: nausea, vomiting, unable to take po's. Reason for MICU transfer: diabetic ketoacidosis. Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [Known firstname ] [Known lastname 36072] is a 40-year-old man with history of Gitelman's Syndrome and insulin-dependent diabetes mellitus who presented to the ED overnight with nausea, vomiting, and inability to tolerate pos. Per ED report, he stated he had been non-compliant with insulin for "months" and was complaining of fatigue, malaise, low grade headaches, and episodes of nausea and vomiting on the day of admission. Per report, patient was noted to say "I know I am in DKA now." He had not taken any insulin since Saturday. He denied abdominal or chest pain, shortness of breath, fevers, or chills. No difficulty or pain with urinating. His initial vitals in the ED were T 97.8, HR 128, BP 142/99, RR 18, satting 97% RA. CBC showed a white count of 14.5 with 84% polys, no bands, hematocrit of 46.9 (from baseline low 40s), and platelets of 237. Electrolytes were notable for potassium of 3.8, bicarb of 8 (from baseline 30), anion gap of 35, and BUN/creatinine of 22/1.9 (from baseline ~25/1.3). Urine ketones were positive. Patient was given 2L normal saline followed by 1L D5 [2-14] with 40 mEq KCl. He was started on an insulin drip without bolus. A repeat set of labs, prior to admission, shwoed sodium of 140, potassium of 4.3, chloride of 100, bicarb of 10 and glucose of 345. Vitals at time of transfer were HR 110, BP 121/69, RR 18, sat 100% RA. For access patient currently has [3-4] gauge IV. Currently, patient says that he feels better than this morning. He denies nausea, abdominal pain, chest pain, cough, shortness of breath, or pain with urination. VS currently: 97.6, 99, 118/80, 100% on RA. Past Medical History: - maturity-onest diabetes of the young ([Doctor Last Name ]), on insulin - Gitelman's syndrome, followed in renal clinic, managed by a high-potassium diet - chronic kidney disease stage III (creatinine 1.2-1.6), secondary to [Doctor Last Name ] and Gitelman's syndrome - neuropathy, likely secondary to diabetes - abnormal LFTs, unclear etiology - renal cysts - absent dorsal pancreas, atrophic head and uncinate process only Social History: Patient lives with his wife. [Name (NI) ] does not work; he is on disability. He denies smoking, drinking, or illicit drug use. Family History: Non-contributory. Physical Exam: General: thin but generally well-appearing young man in no acute distress Vitals: HR: 108, BP 118/80, SpO2 100% HEENT: Anicteric sclera. Noninjected. Dry MM. no oral lesions/ulcers. 1cm pustule noted to right of nasal labial fold. No cervical LAD. Lungs: CTABL. No w/r/r Heart: Hyperdynamic. Strong S1/S2. No M/R/G's Abdomen: Soft. NT. NBS. No rebound. Negative [Doctor Last Name 515] sign. Extremities: Small eschar on shins bilaterally. Strong dorsal pedal pulses. Poor nail hygiene. Skin: scattered pimples but no obvious signs of cellulitis. Pertinent Results: [2140-1-19] 10:30PM BLOOD WBC-14.5* RBC-5.72 Hgb-15.9 Hct-46.9 MCV-82 MCH-27.8 MCHC-33.9 RDW-13.6 Plt Ct-237 [2140-1-21] 07:55AM BLOOD WBC-7.0 RBC-3.99* Hgb-11.3* Hct-31.9* MCV-80* MCH-28.4 MCHC-35.5* RDW-13.3 Plt Ct-210 [2140-1-19] 10:30PM BLOOD Glucose-347* UreaN-22* Creat-1.9* Na-135 K-3.8 Cl-92* HCO3-8* AnGap-39* [2140-1-22] 07:55AM BLOOD Glucose-359* UreaN-15 Creat-1.2 Na-137 K-3.5 Cl-101 HCO3-27 AnGap-13 [2140-1-20] 01:44AM BLOOD ALT-5 AST-4 LD(LDH)-65* AlkPhos-40 Amylase-22 TotBili-0.1 [2140-1-19] 10:30PM BLOOD CK-MB-9 cTropnT-<0.01 [2140-1-20] 02:55AM BLOOD CK-MB-7 cTropnT-<0.01 [2140-1-20] 07:07AM BLOOD CK-MB-6 cTropnT-0.01 [2140-1-20] 01:44AM BLOOD Calcium-3.1* Phos-0.5# Mg-0.4 [2140-1-22] 07:55AM BLOOD Calcium-8.4 Phos-2.0* Mg-1.1* Beta-Hydroxybutyrate 5.2 H (<0.4 mmol/L) . CXR IMPRESSION: Vague right lower lung opacity. Per discussion with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3636], clinician caring for the patient, there are no clinical signs or symptoms of pneumonia. Recommend repeat radiograph in [2-14] months to assess for interval change. Brief Hospital Course: MICU COURSE 40-year-old man with history of Gitelman's Syndrome and [Doctor Last Name ] presents with diabetic ketoacidosis. # Diabetic ketoacidosis: pt reported not taking his insulin since the Saturday prior to admission. Denied any viral prdoromes, nausea, vomiting, diarrhea. No focal consolidations on CXR. No fevers, chills. No chest pain. CE negative x2. Presented with AG metabolic acidosis with HCO3 of 8 and AG of 39. Received insulin and bolus resuscitation in the ED. Hypomagnesemic, hypophosphatemic, and relatively hypokalemic on presentation. Insulin gtt started at 8 U an hour with fluid rescusitation initially with NS+40 meq potassium. ABG attempted multiple times but could not be processed [3-17] clotting. BG continued to downtrend from baseline >450 to 200's within [3-18] hours of presentation. Patient began to clinically deteriorate, with difficulty breathing, nausea/vomiting, profound weakness, and lethargy over the first few hours of ICU presentation. Laboratory data revelaed profund hypophophatemia at 0.7. Immediate po repletion attempted but patient could not tolerate PO secondary to vomiting. Also hypomagnesmic at 0.8. Aggressive resuscitation with Potassium Phosphate, magnesium sulfate, with running insulin gtt was performed. Patient's symptoms stabalized and was able to tolerate PO by 7AM. Magnesium and Phosphate levels corrected to 1.7 and >2.0 respectively. AG closed by 7 AM. BG's steady in the 150-200 range. Potassium repletion continued with levels >3.5. Stopped insulin drip and restarted home Lantus when anion-gap narrowed to <12 and bicarb >18 with overlap of [2-14] hours. [Last Name (un) ] consulted instructing to continue home insulin dosing at 26U glargine in the AM with SSI. Patient tolerating PO's by ICU day 2. He was transferred out to the floor for ongoing care, however he remained hyperglycemic into high 300's despite ongoing insulin titration with [Last Name (un) ]. Patient subsequently eloped, and refused ongoing inpatient care. He refused to wait for discharge instructions or prescriptions. # Atypical RML finding on CXR: so incidental increased radioopacity around RML on CXR. Radiology requested oblique film for better analsysis. Radiology recommended repeat radiograph in [2-14] months to assess for interval change. # Leukocytosis with neutrophilic predominance: Worked up for possible infection. No source was found. Most likely due to increased sympathetic tone and increased cortisol in setting of hypoglycemia. # Acute on chronic renal failure: thought to be prerenal azotemia in the setting of volume depletion from glucosuria and osmotic diuresis. Also, given ketoacidosis, falsely elevates Cr. Resolved with aggressive fluid resuscitation. # Gitelman's syndrome: most recent outpatient nephrology note mentions maintaining diet high in potassium. Patient confirms that he tries to eat fruits high in potassium to maintain normal potassium levels. No other clear interventions at this time. Close monitoring of potassium as above, with aggressive repleteion during DKA. Stable during ICU stay. Pt's potassium was repleted as able, however due to his Gitelman's only modestly improved. Pt was not interested in electrolyte repletion. # Chronic diabetic neuropathy: continued home gabapentin, oxycodone, and baclofen # Emergency contact: wife [Name (NI) 382]. # Code status: full code. DISP: Pt eloped from the medical floor, despite ongoing insulin titration and severe hyperglycemia. Pt was addressed in the elevator, encouraging him to stay for ongoing care, however pt refused and left against medical advise. Pt acknowledged the risk with leaving AMA, including, but not limited to redevelopment of DKA and possible death. Medications on Admission: - baclofen 20 mg twice daily - gabapentin 300 mg three times daily - insulin glargine 26 units in the morning - insulin lispro per sliding scale, with meals - lisinopril 2.5 mg once daily - oxycodone 15 mg twice daily as needed for neuropathic pain - cholecalciferol 1,000 units once daily Discharge Medications: pt eloped Discharge Disposition: Home Discharge Diagnosis: pt eloped Discharge Condition: ambulatory. pt eloped. Discharge Instructions: pt eloped Followup Instructions: pt eloped	[ "5849", "V5867" ]
Admission Date: [2153-11-8] Discharge Date: [2153-11-21] Date of Birth: [2081-1-23] Sex: F Service: MEDICINE Allergies: Bactrim Attending:[First Name3 (LF) 2901] Chief Complaint: Eye blurriness and Shortness of Breath Major Surgical or Invasive Procedure: Right and Left Heart Catheterization Mitral valve valvuloplasty History of Present Illness: 72 year old female with h/o CAD s/p CABG in [2138], PCI [2151], and left CEA who presented with left eye blurriness one week ago and was found to have severe carotid restenosis of CEA. She is being transferred from her outpatient cardiologist's office at [Hospital6 33]. She states that she has had multiple episodes of left eye blurriness that she describes as "grey veil" that comes down over her eye. Her most recent episode was 5 days ago and lasted approximately 1-1.5 hours. She denies any other symptoms such as dizziness, HA, weakness, dysphagia, slurred speech, or altered mental status. She does mention that she feels neck tenderness on the left side that developed about the same time as her symptoms. She also mentions chronic progressive dyspnea on exertion that has worsened substantially since the spring of this year. She states that she can walk a flight of stairs, but it takes her a very long time. She gets short of breath going to the bathroom across the room. She denies orthopnea or peripheral edema. She occasionally wakes up at night short of breath, but this happens rarely. She also endorses a chronic cough. She denies any history of chest pain. On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CAD s/p CABG: in [2138] following an RCA-dissection complicating cardiac catheterization (saphenous vein graft to PDA, saphenous vein graft to OM1, saphenous vein graft to OM2). -Aortic valve replacement in [2145] with Bovine prosthetic valve -Mild-to-moderate mitral stenosis PERCUTANEOUS CORONARY INTERVENTIONS: Non-ST elevation myocardial infarction in [2151-9-14], subsequent cath showed the distal RCA with 80% stenosis, total occlusion of left circ, patent saphenous vein graft to the RCA, total occlusion of saphenous vein graft to OM1, 80% stenosis the saphenous vein graft to OM2 had 80% stenosis with thrombus within the graft which was intervened upon and angioplastied with subsequent placement of two mini vision stents 2.5 x 18 and 2.5 x 12 mm. OTHER MEDICAL HISTORY -Left carotid endarterectomy in [2139] and known occluded right subclavian artery -Lung cancer status post right upper lobectomy in [2145], deemed currently cured -Remote history of ruptured intracranial aneurysm in [2124], status post clipping -COPD -Obesity Social History: Lives with her husband in 3 house complex. Daughters and grandchildren also live in complex. -Tobacco history: Prior tobacco use, quit in [2128]. -ETOH: Rarely -Illicit drugs: None Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: 97.6 143/97 91 18 93%RA GENERAL: Awake, alert, 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: Supple with JVP of 8cm. Slightly tender to palpation on left. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Regular rate and rhythm with occasional ectopy. III/VI systolic murmur heard best at LUSB. 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: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: Admission Labs: [2153-11-8] 02:08PM WBC-7.6 RBC-4.71 HGB-13.6 HCT-41.4 MCV-88 MCH-29.0 MCHC-32.9 RDW-15.2 [2153-11-8] 02:08PM PLT COUNT-295 [2153-11-8] 02:08PM GLUCOSE-104 UREA N-31* CREAT-1.4* SODIUM-144 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-32 ANION GAP-15 [2153-11-8] 02:08PM %HbA1c-7.0* [2153-11-8] 02:08PM PT-12.2 PTT-23.8 INR(PT)-1.0 [2153-11-8] ECG: Sinus rhythm. Normal tracing. Compared to the previous tracing there is no significant change. [2153-11-8] Chest Xray: Mild cardiomegaly and a small right pleural effusion. [2153-11-8] CTA Head/Neck: 1. High-grade stenosis of the proximal left internal carotid artery associated with soft plaque and presence of a "string sign" extending over an approximately 5-6 mm segment. 2. 40% stenosis of the proximal right internal carotid artery. 3. Moderate atherosclerotic disease at the aortic arch with 40-50% stenosis at the origins of the common carotid arteries, bilaterally. 4. High-grade stenosis of the proximal right subclavian artery with what appears to be complete occlusionl, with reconstitution just proximal to the origin of the right vertebral artery, raising the possibility of "subclavian steal" syndrome; this should be closely correlated clinically. 5. 3-mm left anterolaterally-oriented aneurysm arising from the anterior communicating artery, related to aplastic A1 segment of the left ACA. 6. Post-surgical changes following aneurysm clipping in the region of the right carotid terminus. 7. Mediastinal adenopathy and interlobular septal thickening at the left apex, which could be further evaluated with a dedicated chest CT. Reportedly, the patient does have a history of lung cancer, which further raises concern of recurrent or metastatic disease given the superior mediastinal adenopathy; there is possible lymphangitic carcinomatosis in the left lung apex (these findings are incompletely imaged). [2153-11-9]: Transthoracic Echo The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. The right ventricular free wall is hypertrophied. The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The diameters of aorta at the sinus, ascending and arch levels are normal. The number of aortic valve leaflets cannot be determined. There is no significant aortic stenosis or regurgitation. The mitral valve leaflets are severely thickened/deformed. There is severe thickening of the mitral valve chordae. There is moderate to severe mitral stenosis (area 1.0 cm2). The tricuspid valve leaflets are mildly thickened. The tricuspid valve leaflets fail to fully coapt. Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate to severe mitral stenosis. Small and hypertrophied left ventricle with preserved global systolic function. Dilated and hypertrophied right ventricle with mild systolic dysfunction and evidence of pressure overload. Severe tricuspid regurgitation. Severe pulmonary hypertension. [2153-11-12] CT Chest with Contrast: No comparison is available. Status post right upper lobectomy. No evidence of local recurrence. Small bilateral pleural effusions. Postsurgical scarring without evidence of lung nodules. Findings consistent with chronic airways disease, including mucus bronchial plugging. No pathologically lymph node enlargement in the mediastinum. Status post cholecystectomy. No adrenal pathology. [2153-11-13] Cardiac catheterization: 1. Selective coronary angiography of this right dominant system demonstrated a severe three vessel disease with patent SVG to RCA and SVG to OM1. The LMCA had a proximal 20% stenosis. The LAD had mild disease throughout with 10% stenoses. The LCX was occludded. The RCA was known to be occludded. 2. Venous conduit arteriography showed that the SVG/OM1 was occluded. The SVG to RCA was widely patent with a long 20-30% stenosis. The SVG to OM2 had a widely patent stent and no flow limiting stenoses. 3. Limited resting hemodynamic revealed elevated RVEDP at 19 mmHg. The mean PA pressure was 46 mmHg (phasic 90/26 mmHg). The PCWP was 29 mmHg. The cardiac index was mildly depressed at 2 L/min/m2. The mean systemic arterial blood pressure was 101 mmHg (phasic 145/72 mmHg). 4. Distal aortography revealed mild diffuse distal disease. The renal arteries were patent bilaterally. The CIA, IIA, CFA, PFA and proximal SFA were all widely patent bilaterally. FINAL DIAGNOSIS: 1. Severe two vessel coronary artery disease with patent SVG to OM2 and RCA. 2. Occluded SVG to OM1. 3. Severe right ventricular diastolic dysfunction. 4. Severe pulmonary hypertension. 5. Unchanged coronary artery disease. 6. Patent distal vasculature. [2153-11-14] Carotid Series Complete Right ICA stenosis 70-79%. Retrograde flow right vertebral artery with monophasic flow right brachial artery representing a right subclavian steel. Left ICA stenosis 80-99%. [2153-11-16] Transthoracic Echo The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The aortic valve is reported to be a bioprosthesis, but is not well seen. The measured transvalvular gradients would be normal for an aortic bioprosthesis. The mitral valve leaflets are severely thickened/deformed. There is moderate valvular mitral stenosis (area 1.0-1.5cm2). Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is no pericardial effusion. IMPRESSION: Moderate valvular mitral stenosis. Severe tricuspid regurgitation. Mild symmetric left ventricular hypertrophy with preserved global and regional systolic function. Dilated and hypokinetic right ventricle with signs of pressure overload. Severe pulmonary hypertension. [2153-11-19] Transthoracic Echo A secundum type atrial septal defect is present. The right atrial pressure is indeterminate. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. No aortic regurgitation is seen. The mitral valve leaflets are severely thickened/deformed. There is moderate valvular mitral stenosis (area 1.3cm2). No mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2153-11-16], the transmitral gradient is lower, the estimated pulmonary artery systolic pressure is slightly reduced and a secundum type atrial septal defect is now seen with bidirectional flow. No significant pericardial effusion is seen on either study. [2153-11-19] Femoral Ultrasound No evidence of hematoma or pseudoaneurysm. Brief Hospital Course: 72 year old female with h/o CAD s/p CABG in [2138], PCI [2151], and left CEA who presented with shortness of breath on exertion and transient left-sided visual blurriness. #. Shortness of Breath/Mitral Stenosis: She has a known diagnosis of COPD and was found to have moderate-severe mitral stenosis (mean gradient 15mmHg, MV area 1.0cm2) on transthoracic echo. She also had severe pulmonary hypertension and evidence of right-sided pressure overload on admission. She was aggressively diuresed after admission. She underwent right and left heart catheterization which showed significantly elevated right and left-sided filling pressures. Her mitral stenosis improved to moderate with diuresis but she remained with significant dyspnea even with ambulating a few steps. She was also given scheduled nebulizers for wheezing which gave her a small amount of subjective improvement. She underwent mitral valvuloplasty without complication and her shortness of breath substantially improved after the procedure. Repeat echo showed a lower transmitral gradient, slightly reduced pulmonary artery systolic pressure, and a secundum type ASD (mean gradient 8mmHg, MV area 1.3cm2). She was able to ambulate without oxygen on discharge. #. Hypotension: After her mitral valvuloplasty, she was admitted to the CCU overnight for transient hypotension. She required phenylephrine briefly in PACU but none in the ICU. Cath sites were intact and she had a negative groin check. #. Coronary artery disease: She remained without chest pain throughout her admission. She was continued on aspirin and her dose of pravastatin was increased to 80mg daily. Her Plavix was held during most of the hospitalization in preparation for possible intervention. #. CEA: She originally presented with transient left eye blurriness that was concerning for amaurosis fugax. She was evaluated by neurology and ophthalmology who felt that her symptoms were not typical of amaurosis fugax but felt that carotid stenosis was the major concern. CTA head/neck and carotid duplex showed tight stenosis (80-99%) of the left internal carotid artery and significant stenosis of the right internal carotid artery (70-79%). She was evaluated by vascular surgery who felt that carotid endarterectomy was very high risk and recommended stenting. This was deferred on this hospitalization, but she will likely need carotid stenting in the near future. She was instructed to follow-up with vascular surgery as an outpatient. #. Atrial flutter: She had multiple transient episodes of atrial flutter with rapid ventricular response that converted back to normal sinus rhythm without intervention. She remained mainly in normal sinus rhythm and was started on a heparin drip for anticoagulation with plan to bridge to Coumadin. She was also started on a beta blocker for rate control. #. Hypertension: She was continued on her home lisinopril. Amlodipine was also added for hypertension temporarily which she tolerated well, but this was discontinued after her mitral valvuloplasty as her blood pressure returned to [Location 213] range after this procedure. #. Prophylaxis: She was given SQ heparin for DVT prophylaxis #. Code Status: She was full code during this admission Medications on Admission: Plavix 75mg po daily Spiriva daily Pravastatin 40mg po daily Aspirin 325mg po daily Furosemide 20mg po daily Lisinopril 20mg po BID Tricor 48mg po daily Albuterol prn Calcium Vitamin D Centrum Ibuprofen prn for pain Discharge Medications: 1. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Puff Inhalation once a day. 2. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day: Please start taking this medication on [2153-11-23]. 5. Tricor 48 mg Tablet Sig: One (1) Tablet PO once a day. 6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 7. Calcium Oral 8. Vitamin D Oral 9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO twice a day: Please STOP taking this medication now. Do not restart until you see your primary care doctor. 10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:60 Tablet(s) Refills:2 11. Metoprolol Succinate 25 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 Discharge Disposition: Home With Service Facility: [Location (un) 2203] VNA Discharge Diagnosis: Primary Diagnosis: Mitral Stenosis Carotid Stenosis Secondary Diagnosis: Coronary Artery Disease COPD Discharge Condition: Good, alert and oriented, ambulating independently. Slightly orthostatic on discharge. Discharge Instructions: You were admitted to the hospital due to shortness of breath. You were found to have stenosis (narrowing) of the mitral valve in your heart. You underwent a cardiac catheterization to measure the pressures in your heart. You then underwent a mitral valvuloplasty in order to help open up your mitral valve. You had an ultrasound (echocardiogram) of your heart after the procedure which showed that your valve is now more open than it was previously. You were also found to have significant stenosis (narrowing) of the carotid arteries in your neck. It was decided to delay any treatment for this narrowing until your shortness of breath had resolved. You should follow up with a vascular surgeon regarding these stenoses. While you were in the hospital, your heart went into an abnormal rhythm called atrial flutter. Your heart rate has been very well-controlled on a new medication called metoprolol. You were also started on a blood thinner called Coumadin (warfarin). You will need to have your blood levels of this drug checked very closely. Please have your primary care doctor check your INR on Friday, [11-23]. On the day of discharge, your blood pressure dropped slightly when you were standing. Please drink lots of fluids today and don't take your dose of Lasix tomorrow. Please have your primary care doctor check your blood pressure while sitting and standing (orthostatic blood pressure) during your next appointment. CHANGES to your medications: STOP taking Plavix START taking Coumadin 2mg by mouth daily START taking metoprolol succinate 25mg by mouth daily HOLD (do not take) lisinopril 20mg by mouth daily until you see your primary care doctor HOLD (do not take) your Lasix tomorrow, then restart Lasix at 20mg by mouth daily If you experience any of the following, please return to the hospital: Worsening shortness of breath Dizziness Syncope (passing out) or feeling as though you are going to pass out Chest pain If you experience any of the following, please call your primary care doctor: Worsening swelling in your legs Fever or chills Nausea Vomiting Diarrhea Followup Instructions: You have the following appointments scheduled: Dr. [First Name (STitle) 39968], [Hospital ] Medical Associates 541 Main Steet, [Apartment Address(1) ], [Location (un) 936], [Numeric Identifier 2876] Phone: [Telephone/Fax (1) 14967] Fax: [Telephone/Fax (1) 39969] Friday, [2153-11-23] at 3:00pm Please also call and make an appointment with your cardiologist, Dr. [Last Name (STitle) 2077] or whoever you choose to follow up with within the next 2 weeks. You should also follow up with a vascular surgeon. The telephone number for the [Hospital1 18] vascular surgery clinic is ([Telephone/Fax (1) 39970] if you would like to follow up with the vascular surgeons at our hospital. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2908] MD, [MD Number(3) 2909]	[ "4240", "5849", "41401", "4280", "5859", "40390", "25000", "2724", "53081", "4168", "412", "V4582", "V5861", "V1582" ]
Admission Date: [2197-12-23] Discharge Date: [2198-1-3] Date of Birth: [2197-12-23] Sex: F Service: NEONATOLOGY HISTORY: This is the 1.32 kilogram product of a 32 and [6-20] week triplet gestation, born to a 30 year old gravida II, para 0 to [Name (NI) 1105] mother. Prenatal screens showed maternal blood type A positive antibody negative, RPR nonreactive, rubella immune, hepatitis B surface antigen negative, Chlamydia negative, GC negative, group B Streptococcus unknown. The children were born by cesarean section. The patient emerged vigorous with Apgar scores of seven at one minute and eight at five minutes. HOSPITAL COURSE: 1. Respiratory - The child always remained in room air without requiring other intervention. At the time of transfer, the child was comfortable with no spells. 2. Cardiovascular - The patient always remained cardiovascularly stable without any intervention. 3. FEN - The child was started on intravenous fluids and feeds were advanced to 150 cc/kilogram of enteral feeds. At the time of transfer, the child was tolerating 150 cc/kilogram of PE 28 with ProMod. 4. Hyperbilirubinemia - The child had some mild hyperbilirubinemia which responded to phototherapy. 5. Infectious disease - The child was started on Ampicillin and Gentamicin. Cultures remained negative after 48 hours and these antibiotics were discontinued. On physical examination, the child is nondysmorphic with clear breath sounds, no murmur. The abdomen is soft, nondistended. Normal female genitalia. At the time of transfer, her weight was 1.405 kilograms. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To level II nursery at [Hospital3 1280] Hospital. CARE RECOMMENDATIONS: To continue to advance oral feeds as tolerated and to wean from the isolette. DISCHARGE DIAGNOSES: 1. Mild prematurity. 2. Rule out sepsis. 3. Status post hyperbilirubinemia. [Doctor Last Name ] [Last Name (NamePattern5) 36094], M.D. [MD Number(1) 36095] Dictated By:[Name8 (MD) 44795] MEDQUIST36 D: [2198-1-3] 17:49 T: [2198-1-3] 19:25 JOB#: [Job Number 44976]	[ "7742", "V290" ]
Admission Date: [2124-6-17] Discharge Date: [2124-6-27] Date of Birth: [2045-8-27] Sex: M Service: MEDICINE Allergies: Penicillins / simvastatin Attending:[First Name3 (LF) 2290] Chief Complaint: Abdominal pain x 2-3 weeks Major Surgical or Invasive Procedure: Placement of percutatenous chole drain History of Present Illness: 78 y/o Cantonese speaking man with history of CAD s/p CABG ([2118]), HTN, HLD, and emphysema who presented on [2124-6-17] to the medical floor with 2 weeks epigastric pain. CT abdomen showed severe duodenitis; surgery and GI were consulted. His original abdominal exam was consistent with guarding and surgery was concerned about a perforation but a repeat CT and abdominal X-ray were not consistent with free air. However, gallbladder wall thickening with pericholecystic fluid were noted, and his LFTs were consistent with obstruction, leading to concern for cholecystittis/cholangitis, and the patient was started on meropenem and vancomycin. Shortly after his repeat CT scan, he developed SOB and was tachycardic to the 140s with 3mm ST elevations in the lateral leads but troponins were negative and he did not complain of chest pain. There was a concern for demand ischemia and he was started on heparin gtt. The patient became hypotensive to an SBP in the 80s after he received metoprolol, and was transferred to the ICU. He was bolused with IV fluids and his metoprolol and lisinopril were held; he received a percutaneous chole drain and he continued to receive meropenem and vancomycin pending results of blood cultures. His vital signs stabilized nicely and he was transferred to medicine for further management. On arrival to the medicine floor, his vitals were T99 BP 101/47 HR 75 94% 4L. He complains of RUQ pain. He denies SOB or chest pain. Past Medical History: - Coronary artery disease s/p CABG [3-/2119] (LIMA to the LAD and -separate SVGs to the PDA and an OM) - HLD - HTN - BPH - Emphysema per ct scan - TB many years ago, treated for 2 years Social History: 20-pack-year smoker, discontinued 20 years ago. Occupation, retired machine operator. Lives with his family. Alcohol, none. Exposure, none. Family History: Mother had hypertension and history of cancer. Coronary artery disease in the family. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 98.5 74 137/54 18 96%5L. GENERAL: Elderly chinese man, alert oriented, uncomfortable with movement in bed, ambulatory HEENT: PERRL, EOMI +arcus senilis NECK: no carotid bruits, JVD LUNGS: CTA b/l no wrc HEART: RRR, normal S1 S2, no MRG. Sternal scar c/w CABG ABDOMEN: Tense abdomen with guarding diffusely. TTP diffusely, more so in epigastrium. Moderate distension. +BS. No palpable masses. EXTREMITIES: No c/c/e NEUROLOGIC: A+OX3 Discharge exam: Pertinent Results: Admission Labs: [2124-6-16] 06:00PM BLOOD WBC-10.2# RBC-4.79 Hgb-15.3 Hct-44.4 MCV-93 MCH-31.8 MCHC-34.4 RDW-13.5 Plt Ct-294 [2124-6-16] 06:00PM BLOOD Neuts-88.6* Lymphs-7.8* Monos-2.8 Eos-0.7 Baso-0.1 [2124-6-16] 06:00PM BLOOD Plt Ct-294 [2124-6-16] 06:00PM BLOOD Glucose-126* UreaN-15 Creat-0.9 Na-137 K-3.9 Cl-101 HCO3-26 AnGap-14 [2124-6-16] 06:00PM BLOOD ALT-31 AST-26 AlkPhos-99 TotBili-0.4 [2124-6-16] 06:00PM BLOOD cTropnT-<0.01 [2124-6-16] 06:00PM BLOOD cTropnT-<0.01 [2124-6-16] 06:00PM BLOOD Albumin-4.2 [2124-6-17] 10:15AM BLOOD Calcium-8.4 Phos-2.6* Mg-1.7 [2124-6-16] 08:09PM BLOOD Lactate-2.9* CT AP ([2124-6-17]) ======================== INDICATION: Abdominal pain for two to three weeks. Comparison chest CT available from [2121-11-20]. TECHNIQUE: MDCT-acquired 5-mm axial images through the abdomen and pelvis were obtained following the uneventful administration of 130 ml of Omnipaque intravenous contrast. Coronal and sagittal reformations were performed at 5-mm slice thickness. CT OF THE ABDOMEN WITH IV CONTRAST: Included views of the lung bases demonstrate moderate-to-severe emphysema with superimposed bibasilar fibrosis which has progressed since the most recent chest CT examination from [2121-11-20]. There is no pericardial or pleural effusion. The heart size is top normal. Extensive stranding surrounds the proximal duodenum (2:26, 27). No focal fluid collections are identified. There is no free air. Perihepatic free fluid is present. A short segment of the proximal jejunum is mildly distended (2:48), with neighboring loops demonstrating mild fecalization (2:31). No transition point is seen. The remaining loops of small and large bowel are within normal limits. The stomach, spleen, pancreas, adrenal glands, kidneys, and gallbladder are normal. A well-circumscribed hypodense hepatic lesion within segment [Doctor First Name 690] (2:11) is minimally enlarged since [2120], likely representing a small cyst or biliary hamartoma. A 15 mm partially exophytic cyst arising from the interpolar region of the right kidney (2:35) is slightly enlarged since [2120]. There are moderate atherosclerotic calcifications throughout the abdominal aorta and iliac branches. The celiac trunk, SMA, and [Female First Name (un) 899] are patent and normal in caliber. There is no mesenteric or retroperitoneal lymphadenopathy. CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, urinary bladder, intrapelvic loops of small and large bowel are normal. The prostate is moderately enlarged (2:83). There is no intrapelvic free fluid or lymphadenopathy. OSSEOUS STRUCTURES: The patient is post-median sternotomy. No acute fracture is detected. There are no bony lesions concerning for malignancy or infection. IMPRESSION: 1. Severe duodenitis. No secondary signs of perforation. EGD is recommended to assess for further evaluation. 2. Mild dilatation of a short segment of jejunum, with fecalization of contents without transition point. Findings may represent a focal ileus. 3. Progression of moderate to severe emphysema and bibasilar interstitial fibrosis compared to the [2120] CT chest examination. 4. Small amount of perihepatic ascites. No drainable fluid collections. 5. Moderately enlarged prostate. The study and the report were reviewed by the staff radiologist. DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] DR. [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] KUB [2124-6-17] ====================== ABDOMEN INDICATION: Duodenitis, evaluation for free air. COMPARISON: No comparison available at the time of dictation. FINDINGS: Documentation is provided by two radiographic images. No free intra-abdominal air. Several small air-fluid levels projecting over nondistended bowel loops in the mid abdomen. Colonic air filling and stool filling of the ascending and descending colon. Contrast material in the bladder. Diffuse gas feeling of small bowel loops without evidence of wall thickening. No pathologic calcifications. No foreign bodies. CT AP [2124-6-18] ========================== INDICATION: Duodenitis with increasing abdominal tenderness. COMPARISON: CT available from [2123-12-17]. TECHNIQUE: MDCT-acquired 5-mm axial images of the abdomen and pelvis were obtained following the uneventful administration of Gastrografin and 130 ml of Omnipaque intravenous contrast. Coronal and sagittal reformations were performed at 5-mm slice thickness. DLP: 363 mGy-cm CT OF THE ABDOMEN WITH IV CONTRAST: Moderate right basilar atelectasis is new since the [2123-12-17] examination (2:5). Again seen is moderate-to-severe bibasilar emphysema with superimposed peripheral fibrosis. There is no pericardial or pleural effusion. The heart size is normal. Mild heterogenous liver perfusion is noted, predominantly in the right anterior and left medial lobes (2:19). A well-circumscribed subcentimeter hypodense hepatic lesion within segment [Doctor First Name 690] (2:11) likely represents a small cyst or biliary hamartoma. The portal and hepatic veins remain patent. Again seen is moderate stranding around the proximal duodenum (2:27), minimally changed since [2124-6-16], now with new mild stranding about the proximal CBD and gallbladder. The gallbladder and CBD remain non-distended though gallbladder is mimially hyperemic. The pancreas, adrenal glands, kidneys, and intraabdominal loops of small and large bowel are normal. A 15 mm partially exophytic cyst arising from the interpolar region of the right kidney (300B:40) is unchanged. There is no free air or free fluid. There is no mesenteric or retroperitoneal lymphadenopathy. CT OF THE PELVIS WITH IV CONTRAST: A small amount of intrapelvic free fluid (2:83) is new since [2124-6-16]. The rectum and bladder are normal. Moderate prostate hypertrophy is again seen (2:86). There is no intrapelvic lymphadenopathy. Small fat-containing bilateral inguinal hernias are again seen (2:81). OSSEOUS STRUCTURES: There is no fracture. There are no bony lesions concerning for malignancy or infection. The patient is post-median sternotomy. IMPRESSION: 1. Moderate stranding about the proximal duodenum appears minimally changed since [2124-6-16], but hyperemia and minimal stranding about the gallbladder and proximal CBD appears new. Cholecystitis would be somewhat unusual given the non-distended appearance of the gallbladder. Nonethelesse, correlate with clinical presentation and consider US examination for further evaluation. 2. Small amount of intrapelvic free fluid is new since [2124-6-16]. 3. Slight hyperenhancement of the right anterior and left medial liver of uncertain significance. It is unclear if this is related to the adjacent gallbladder. 4. No free air. 5. Moderate prostate hypertrophy. The study and the report were reviewed by the staff radiologist. CXR ([2124-6-18]) ======================= CHEST RADIOGRAPH INDICATION: Hypoxemia, evaluation for pulmonary edema. COMPARISON: [2123-12-17]. FINDINGS: As compared to the previous radiograph, the lung volumes have decreased, likely reflecting a lesser inspiratory effort. Widespread bilateral interstitial opacities, better characterized on previous CT examinations. No additional or secondary parenchymal opacities. Sternal wires, moderate cardiomegaly, no larger pleural effusions. No pneumothorax. DR. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4130] [2124-6-19] - CXR FINDINGS: Compared to the previous radiograph, there are new focal parenchymal opacities that have occurred in both the left lung and at the right lung base. The distribution and morphology of these opacities are highly suspicious for pneumonia. Unchanged borderline size of the cardiac silhouette without overt pulmonary edema. No pleural effusions. No pneumothorax. Unchanged mild right apical pleural thickening. EKG [2124-6-21]: Sinus rhythm. Non-specific anterior T wave changes. Compared to the previous tracing of [2124-6-18] anterior T wave changes are new. Clinical correlation is suggested. Rate PR QRS QT/QTc P QRS T 66 148 82 [Telephone/Fax (2) 46125] 32 Brief Hospital Course: 78 yo Cantonese-speaking male w/ PMH HTN, BPH, CAD s/p CABG [2118] p/w 2-3 weeks abdominal pain, found to have cholecystitis. ACTIVE ISSUES: #Acute cholecystitis with Septic Shock: Patient presented complaining of new RUQ pain and was found to have leukocytosis (15-17) with fever (T101) while on medicine floor. Repeat CT done on [6-18] showed gallbladder wall thickening and pericholecystic fluid and LFTs were drawn and found to be elevated. Shortly after repeat CT the patient triggered for low oxygen saturation, tachycardia, and hypotension and was found with ST changes on EKG. He was transferred to the ICU. In the ICU, the patient was put on meropenem and vancomycin, and had a percutaneous chole drain placed with IR with bile cultures positive for E. coli. He drained serosanguinous fluid until [2124-6-24] until he started to drain bile. He stabilized nicely in the ICU with fluid boluses and did not require pressor support. He was transferred back to the floor and switched to cefepime once E. coli sensitivities returned. He will need cefepime until [7-5] and he is planned to have a cholecystectomy on [2124-7-6]. #Ileus: On the evening of [2124-6-23], patient complained of epigastric pain. KUB showed ileus. Bowel regimen was started and his pain resolved and bowel movements became regular. # Duodenitis: Patient reported 2-3 weeks of intermittent epigastric abdominal pain and nausea, with no noted melena, hematemesis, hematochezia. On abdominal CT, the patient was noted to have severe duodenitis although no free air/fluid and surgery and GI were consulted. Surgery felt no intervention necessary at that time, and GI plans to do EGD on [2124-6-29]. An abdominal plain film was done to evaluate for free air which was negative. A repeat CT was also obtained which showed no signs of perforation, minimal change in duodenitis from prior study, no free air/fluid. H. pylori serology was sent and was positive, but stool antigen remains pending. # Myocardial strain: Patient triggered on [6-18] - nursing found patient did not look well after returning to floor from CT, found with oxygen saturation in 60s and HR 150s; patient reported shortness of breath but not chest pain. EKG showed ST-depressions in V3-V6, I, aVL, II. Nebulizers, aspirin, morphine, and Metoprolol were given, and repeat EKG was improved but still with ST-changes, and the patient had troponins of 0.05 x2. These changes resolved on his next EKG. Troponins 0.05 x 2. Cardiology was consulted felt that the EKG changes were secondary to demand ischemia. The patient was started on heparin gtt in addition to his regimen. His heparin was drip was discontinued after transfer to medicine and the patient has not complained of shortness or chest pain and was stable on tele and repeat EKGs were unchanged. # PNA: The patient was diagnosed with bilateral pneumonia on hospital day 2 and developed hemoptysis. Because of his history of TB, the patient was placed in respiratory isolation and ruled out for TB with 4 negative sputums. Because of concern for MRSA pneumonia, pt was started on vancomycin, which was continued until [6-26]. He has no respiratory symptoms on discharge. CHRONIC ISSUES: # Coronary artery disease s/p CABG. # HLD - On atorvastation per cardio reccs. # HTN - cont lisinopril, metoprolol # BPH - held doxazosin given hypotension. # Restless leg syndrome - held Requip. TRANSITIONAL ISSUES: He will need to obtain a follow up appointment with cardiology EGD on [2124-6-29] Cholecystectomy on [2124-7-6] Cefepime to continue until [2124-7-5] (total 14 day course) Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Family/Caregiver. 1. Doxazosin 4 mg PO DAILY 2. Ropinirole 1 mg PO TID 3. Omeprazole 40 mg PO DAILY 4. Lisinopril 2.5 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Lisinopril 2.5 mg PO DAILY 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Doxazosin 4 mg PO DAILY 5. Omeprazole 40 mg PO DAILY 6. Ropinirole 1 mg PO TID 7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheezing 8. Atorvastatin 10 mg PO DAILY 9. CefePIME 2 g IV Q12H Duration: 9 Days 10. Docusate Sodium 100 mg PO BID:PRN constipation 11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 12. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB/wheeze 13. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX Oxecta 5 mg 1 tablet(s) by mouth q6H PRN pain Disp #15 Tablet Refills:0 RX oxycodone 5 mg 1 tablet(s) by mouth q6H PRN pain Disp #15 Tablet Refills:0 14. Polyethylene Glycol 17 g PO DAILY:PRN constipation 15. Senna 1 TAB PO BID:PRN constipation 16. Pantoprazole 40 mg PO Q24H Discharge Disposition: Extended Care Facility: [Hospital ] Healthcare Center - [Location (un) ] Discharge Diagnosis: Cholecystitis Pneumonia Demand myocardial ischemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname ], It was a pleasure taking care of you during your stay at the [Hospital1 18]. You were admitted for evaluation of abdominal pain. You were found to have an infection in your gallbladder which was treated with placement of a drain and use of antibiotics. You were also found to have developed pneumonia and were treated for antibiotics. You tested negative for tuberculosis. The stress associated with your gallbladder and infection caused your blood pressure to decrease during your stay and may have lead to minor damage to your heart. Please follow up with surgery for evaluation for surgery to remove your gallbladder on [2124-7-6], at 3:15 PM. In addition, please make an appointment to follow up with cardiology in the future. Followup Instructions: Department: WEST PROCEDURAL CENTER When: THURSDAY [2124-6-29] at 1:15 PM With: WPC ROOM THREE [Telephone/Fax (1) 5072] Building: [Hospital Ward Name 121] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: GI-WEST PROCEDURAL CENTER When: THURSDAY [2124-6-29] at 1:15 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7937], MD [Telephone/Fax (1) 463] Building: [Hospital Ward Name 121] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: GENERAL SURGERY/[Hospital Unit Name 2193] When: THURSDAY [2124-7-6] at 3:15 PM With: ACUTE CARE CLINIC [Telephone/Fax (1) 600] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Completed by:[2124-6-28]	[ "0389", "78552", "99592", "4019", "2724", "2859", "V4581", "V1582" ]
Admission Date: [2129-11-27] Discharge Date: [2129-12-6] Date of Birth: [2059-9-2] Sex: F Service: MEDICINE Allergies: Percocet Attending:[First Name3 (LF) 1990] Chief Complaint: lethargy, instability, anorexia Major Surgical or Invasive Procedure: None History of Present Illness: 70yo F w/ alzheimer's, recent diagnosis of [First Name3 (LF) 2320], thryoid illness p/w worsening lethargy, confusion, instability, decreased po intake x 3 days. Also, family reports new urinary incontinent. Brought to [Hospital1 18] ED by family. In the ED: initial vitals: 99.6, 141/64, 125, 20, 96RA. Initial labs are notable for Na 162, glucose 632, bicarb 19, cr 1.6 (bl 0.9) [Doctor First Name 674] 939 AP 138. Her urine is significant for 1000 glucose and 150 ketones. She was given 6u of regular insulin and 2L of NS. A CT of the head showed stable prominent ventricular system, no ICH. Her CXR was without acute cardiopulm process. Past Medical History: alzeimer's htn hyperlipidemia [Doctor First Name 2320] Social History: No smoking, no alcohol, no drug use. Lives with husband, cannot perform her own ADLs. She can feed herself and go to bathroom independently. Attends [First Name8 (NamePattern2) ] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Program 3x week. Originally from Montserrat in the West Indies. Family History: sisters with [Name (NI) 2320]. Physical Exam: VS: Temp: 97.5 BP:140/61 HR:79 RR: 18 O2sat 99RA GEN: lethargic but arousable, confused (at baseline), laying comfortably in bed. HEENT: PERRL, very dry mucous membranes, thrush NECK: no JVD RESP: CTA b/l with good air movement throughout CV: tachycardic, regular rhythm, no murmurs ABD: thin, hypoactive bs, pulsatile abd. (approx 4cm abdominal aorta). slight tenderness in RUQ. EXT: non edematous NEURO: oriented to first name. Does not answer questions appropriately. Does not recognize family. Pertinent Results: [2129-11-27] 12:20PM WBC-15.6# RBC-4.89 HGB-15.4 HCT-49.3 MCV-101* MCH-31.5 MCHC-31.2 RDW-12.3 [2129-11-27] 12:20PM NEUTS-92.1* LYMPHS-4.7* MONOS-3.1 EOS-0 BASOS-0.1 [2129-11-27] 12:20PM PLT COUNT-262 [2129-11-27] 12:20PM LACTATE-2.8* [2129-11-27] 12:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2129-11-27] 12:20PM OSMOLAL-394* [2129-11-27] 12:20PM ACETONE-MODERATE [2129-11-27] 12:20PM LIPASE-27 [2129-11-27] 12:20PM ALT(SGPT)-31 AST(SGOT)-37 ALK PHOS-138* AMYLASE-939* TOT BILI-0.5 [2129-11-27] 12:20PM GLUCOSE-624* UREA N-39* CREAT-1.6* SODIUM-164* POTASSIUM-5.8* CHLORIDE-120* TOTAL CO2-20* ANION GAP-30* [2129-11-27] 12:30PM URINE GRANULAR-<1 [2129-11-27] 12:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Brief Hospital Course: 70 yo F w/ alzheimers dementia, [Month/Day/Year 2320], htn, hyperchol, presents with severe hyperglycemia, ketonuria, hypernatremia, dehydration. . # Hypergylcemia: recently diagnosed with [Month/Day/Year 2320] on metformin at home. Presents with glucose of 600's on presentation. Likely a mixed picture on hyperosmolar state and DKA. Initially managed in ICU, then, with [Last Name (un) ] assistance, sugars ultimately controlled with once daily glargine and tid ac repaglinide. . # Seizure - on [12-1], pt noted to be unresponsive with seizure-like stereotyped movements. This lasted approx. two minutes and resolved. MR was ordered - no path. identified to explain etiology. Neuro consulted: The MRI did not demonstrate a seizure focus or stroke and only supported the presence of ventriculomegaly. The episode may merely have been do a brief episode of hyper- or hypo-glycemia and unless it recurs or the patient begins to have new neurological issues, I see no need to pursue further studies at this time at is very clear that she is at her normal baseline according to her family. Should she have any additional episodes, an EEG would be the next reasonable test. No further seizure like activity seen this admission. # CXR c/w pneumonia - treated with course of levofloxacin and flagyl. . HTN - stable; given relative hypotension this admission, antihypertensives held and pt. BP stable without these. Medications on Admission: aricept 10mg qday asa 81mg qday citalopram 10mg qday lipitor 20mg qhs lisinopril 10 qday metformin 500 [Hospital1 ] Discharge Medications: 1. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day: Hold for loose stools. Disp:60 Capsule(s) Refills:0 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:1 4. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:15 Tablet(s) Refills:0 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Repaglinide 2 mg Tablet Sig: One (1) Tablet PO TIDAC (3 times a day (before meals)): Do not give if pt. is not going to eat a meal afterwards. Disp:90 Tablet(s) Refills:0 7. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18) Units, insulin Subcutaneous at bedtime. Disp:10 mL Refills:0 8. commode chair (three in one) Sig: One (1) chair once a day. Disp:1 chair Refills:0 9. Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Diabetic ketoacidosis Seizure Discharge Condition: Stable Discharge Instructions: Take all medications as prescribed. Return to the [Hospital1 18] Emergency Department for: Fever Confusion/change in mental status Uncontrolled blood sugars Followup Instructions: [Last Name (LF) ],[First Name3 (LF) ] E. [Telephone/Fax (1) 719] - call for follow up appointment for within one month of leaving the hospital Provider: [Name10 (NameIs) 1592] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 719] Date/Time:[2130-1-23] 1:00 Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], [Name12 (NameIs) 280] Phone:[Telephone/Fax (1) 719] Date/Time:[2130-2-7] 11:30 Provider: [Name10 (NameIs) ] [Last Name (NamePattern4) 1401], M.D. Phone:[Telephone/Fax (1) 2386] Date/Time:[2130-8-24] 4:00	[ "5070", "2760" ]
Admission Date: [2104-7-23] Discharge Date: [2104-8-1] Date of Birth: [2022-7-18] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: unstable angina Major Surgical or Invasive Procedure: Emergent coronary artery bypass grafts x 4 (LIMA-Dg,SVG-LAD,SVG-PDA,SVG-PLV) [2104-7-26] Placement of intra-aortic balloon pump [2104-7-26] left heart catheterization, coronary angiogram [2104-7-23] History of Present Illness: This 82 year old white male is s/p LAD stenting in [Month (only) 547] of this year. He presented to an outside hospital wiht 2 weeks of intermittent chest pain and dyspnea while walking, relieved with sublingual Nitroglycerin. He was transferred to [Hospital1 18] for further evaluation. Past Medical History: CAD: RCA PCI [2095] LAD PCI 4/ [2103] LAD and Diagonal POBA [5-/2104] Hypertension Dyslipidemia TIA (15-20 yrs ago) Epistaxis (no problems in 3 years)- uses humification Rectal Cancer Past Surgical History s/p bowel resection for rectal cancer s/p gum surgery for teeth Social History: noncontributory Family History: Family History: non contributory Race: Caucasian Last Dental Exam: 3 months ago Lives with: spouse Occupation: retired firefighter Tobacco: denies ETOH: 1 glass a month Physical Exam: admission: Pulse: 47 Resp: 12 B/P Right: Left: 97/53 General: no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] anterior Heart: RRR [x] Irregular [] Murmur none Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no palpable masses Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [x] Neuro: alert and oriented x3 nonfocal - unable to assess gait Pulses: Femoral Right: cath site Left: +2 DP Right: +2 Left: +2 PT [Name (NI) 167]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: no bruit Left: no bruit Pertinent Results: [2104-7-25] Echo Conclusions Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function appears normal (LVEF>55%). The aortic valve leaflets are mildly thickened (?#). Mild (1+) aortic regurgitation is seen. On either 1:1 or 1:2 IABP setting, the AI appears similar. Compared with the prior study (images reviewed) of [2104-7-24], no definite change. IABP may be new. [2104-8-1] 04:25AM BLOOD WBC-5.6 RBC-2.72* Hgb-8.9* Hct-25.5* MCV-94 MCH-32.6* MCHC-34.9 RDW-14.7 Plt Ct-292 [2104-7-31] 09:45AM BLOOD PT-14.1* INR(PT)-1.2* [2104-8-1] 04:25AM BLOOD Glucose-72 UreaN-17 Creat-1.0 Na-137 K-4.1 Cl-104 HCO3-23 AnGap-14 Brief Hospital Course: Following admission he under went catheterization which demonstrated diffuse in-stent restenosis, including a 70% bifurcatrion lesion, 60-70% stenosis of the PDA and marginal origin of a small right posterolateral vessel. He received Plavix and was then referred for surgical consideration. He was transferred to the floor, on no intravenous anticoagulants or Nitroglycerin. He had several episodes of angina at rest in the next couple of days and in the early morning of [7-25] had 10/10 chest pain. Cardiac Surgery was notifed and an intra-aortic balloon was placed by cardiology. He was stable and painfree then and in the afternoon he was taken to the Operating Room where revascularization was performed. He weaned from bypass in stable condition with the balloon pump in place. The following morning the balloon was removed, he was awakened and extubated. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. He did develop post-op atrial fibrillation and was treated with amiodarone, titration of beta blocker and coumadin was initiated for anti-coagulation. He did experience urinary retention and his foley was re-placed. Flomax was initiated and following removal of the foley catheter, the patient did void. Narcotics were discontinued for post-op confusion. The confusion improved with Haldol and sleep. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD seven the patient was ambulating freely, the wound was healing, pain was controlled with oral analgesics, and his confusion resolved. The patient was discharged in good condition with appropriate follow up instructions. Medications on Admission: ASPRIN Dosage uncertain CLOPIDOGEL - 75 mg Tablet daily ISOSORBIDE MONONITRATE - 30 mgBID LISINOPRIL 10 mg daily METOPROLOL SUCCINATE 25 mg daily SIMVASTATIN 20 mg Tablet daily TAMSULOSIN [FLOMAX] - 0.4 mg daily Discharge Medications: 1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. Multivitamin 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. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. Disp:30 Tablet(s) Refills:0 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. 13. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 14. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed for itchiness. 15. Simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable PO TID (3 times a day) as needed for hiccoughs. 16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 14 days. 17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 14 days. 18. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: Take 400mg daily for 1 week, then decrease to 200mg daily ongoing. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: unstable angina s/p coronary artery bypass grafts hyperlipidemia s/p coronary stents/angioplasties hypertension h/o rectal carcinoma Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon:Dr. [Last Name (STitle) 914] ([Telephone/Fax (1) 170]) on Date/Time:[2104-8-25] 1:00 Cardiologist: Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4469] [8-29] at 1pm Please call to schedule appointments with: Primary Care Dr. [Last Name (STitle) 47377] [Name (STitle) 111423] ([Telephone/Fax (1) 17503]) in [2-25] 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:[2104-8-1]	[ "41401", "9971", "4241", "42731", "V4582", "40390", "5859" ]
Admission Date: [2164-6-27] Discharge Date: [2164-7-2] Date of Birth: [2099-3-16] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1990] Chief Complaint: Fever and Hypotension Major Surgical or Invasive Procedure: PICC line removal central line placement History of Present Illness: 65 yo Spanish speaking male with paraplegia, neurogenic bladder with chronic indwelling Foley, recurrent UTIs, chroncic stage IV decubitus ulcer c/b chronic osteomyelitis supposed to be on vanco/zosyn however currently off after seeing ID and was doing better, who presents with fever to 103.4 this AM. Patient is currently on bactrim for UTI VS at Cooligde house 105/60,108,18 103.4, 95% RA. . Patient was recently admitted [Date range (1) ]/08 with hypotension and sepsis requiring ICU admission. Patient had completed antx for 2 weeks prior to that admission and then Vanco/Zosyn/Bactrim was restarted for empiric chronic osteo treatment. Patient had a UTI with mixed organisms, blood cultures remained negative. MRI was equivocal for worsening ostemyelitis however his inflammatory markers have been trending upwards despite ongoing treatment. Patient subsequently returned to [Hospital3 2558] with 8 more days of Zosyn but then was off all antibiotics for osteomyelitis. He was last seen in [Hospital ] clinic [2164-6-15] at which point it looks like the team thought he was on IV Vanco/Zosyn. After calling coolige house and finding out that he was indeed off antibiotics the decision was made to hold further treatment given that he was clinically doing well. . In the ED, given Cefepime, Vanco. A RIJ was placed due to persistent hypotension initially SBP 70-->100s, down to 80s again. He received a total of 4L IVF with lacate 1.1-->0.8. CVP was 6, SVO2 was 82. CXR no infiltrate. . Upon arrival to the floor, patient denies any pain, no sob, feels very dry and thirsty. No CP, abd pain, hip pain intermittently Past Medical History: 1. Paraplegia (fell 13 years ago working on construction) 2. Depression 3. Frequent Urinary tract infections --Enterobacter and Pseudomonas 4. GERD 5. Indwelling foley with persistent L sided hydronephrosis (per last DC summary from [1-/2164]) 6. Anemia (Hct baseline 28-30) 7. Sacral decubitus, stage IV, with recent osteomyelitis, s/p approximately 11 wks of Vanc/Zosyn (completed [2164-5-7]), followed by ID (Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1075]) 8. H/o sepsis requiring ICU admission Social History: No smoking, no alcohol, no drug use. Currently at [Hospital3 2558] - [Location (un) ]. Patient may be loosing his apartment due to lack of paying rent while at [Hospital3 ]. Family History: Mother: no history of MI, CA Father: no history of MI, CA Physical Exam: VS: 98.4 83 80/47 11 96% RA GEN: NAD, lying in bed HEENT: OP very dry, anicteric PERRL NECK: supple, RIJ c/c/i CV: nl S1 S2, distant, no m/r/g LUNGS: CTA, decreased at bases ABD: soft, NT N EXT: dry, wasted, no c/c/e NEURO: A&O x 3, moves upper extremities, no meningismus, CN grossly intact. Pertinent Results: [2164-6-29] 02:35AM BLOOD WBC-5.8 RBC-2.49* Hgb-7.8* Hct-23.6* MCV-95 MCH-31.3 MCHC-33.1 RDW-12.6 Plt Ct-208 [2164-6-27] 10:30AM BLOOD WBC-10.0# RBC-3.25* Hgb-10.3* Hct-30.4* MCV-94 MCH-31.7 MCHC-33.9 RDW-13.7 Plt Ct-334 [2164-6-27] 10:30AM BLOOD Neuts-57.1 Lymphs-37.5 Monos-3.8 Eos-1.0 Baso-0.7 [2164-6-28] 05:26AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Stipple-1+ [2164-6-27] 04:02PM BLOOD PT-14.0* PTT-29.9 INR(PT)-1.2* [2164-6-27] 10:30AM BLOOD PT-14.5* PTT-28.9 INR(PT)-1.3* [2164-6-27] 04:02PM BLOOD ESR-81* [2164-6-28] 05:26AM BLOOD Ret Aut-1.7 [2164-6-29] 02:35AM BLOOD Glucose-91 UreaN-17 Creat-0.9 Na-131* K-3.5 Cl-105 HCO3-19* AnGap-11 [2164-6-27] 10:30AM BLOOD Glucose-107* UreaN-40* Creat-1.5* Na-130* K-5.4* Cl-100 HCO3-20* AnGap-15 [2164-6-27] 04:02PM BLOOD ALT-39 AST-41* LD(LDH)-161 AlkPhos-70 TotBili-0.4 [2164-6-29] 02:35AM BLOOD Calcium-7.9* Phos-1.4* Mg-1.6 [2164-6-27] 04:02PM BLOOD Albumin-2.8* Calcium-7.8* Phos-2.5* Mg-2.0 [2164-6-28] 05:26AM BLOOD VitB12-1293* Folate-GREATER TH [2164-6-27] 10:30AM BLOOD Cortsol-19.7 [2164-6-27] 10:30AM BLOOD CRP-28.3* [2164-6-29] 02:35AM BLOOD Vanco-27.3* [2164-6-27] 04:56PM BLOOD Type-ART pO2-92 pCO2-34* pH-7.35 calTCO2-20* Base XS--5 [2164-6-27] 04:56PM BLOOD Lactate-0.8 K-3.7 [2164-6-27] 04:56PM BLOOD O2 Sat-96 echo [6-28]: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. 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, but cannot be fully excluded due to suboptimal image quality. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. IMPRESSION: No evidence of endocarditis or clinically-significant regurgitant valvular disease. Normal global and regional biventricular systolic function. Dilated aortic root. CXR: HISTORY: 65-year-old male with fever, hypertension, and central line placement. Please evaluate for central line placement. COMPARISON: Chest radiograph from 40 minutes prior. SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: A right internal jugular line has been partially retracted, and now terminates just at or below the cavoatrial junction. The wire has been removed from the right PICC line, obscuring the termination of the catheter tip. Lung volumes are again low, and there are likely small bilateral pleural effusions. The lungs are otherwise clear. The bony thorax is unremarkable. IMPRESSION: Interval partial retraction of right IJ central line and removal of right PICC wire. BLOOD CULTURES: 2/4 BOTTLES OF GPC IN CLUSTERS, AWAITING SPECIATION PICC LINE TIP CULTURE: [2164-6-28] 12:59 pm CATHETER TIP-IV Source: PICC. FINAL REPORT [2164-6-30] WOUND CULTURE (Final [2164-6-30]): No significant growth. SURVEILLANCE BLOOD CULTURES: NGTD Brief Hospital Course: A/P: 65 M with paraplegia, chronic stage VI decubitus ulcer and osteomyelitis, recurrent UTI [2-25] to neurogenic bladder and chronic Foley placement who presents with fever and hypotension off antibiotics from nursing home. Sepsis: Initially hypotensive, febrile and bacteremic, GPC in clusters. Likely staph auerus (MRSE). Vanc x 2 weeks. PICC line removed as likely source. Wound looked good, no pus drainage, no + wound culture, per plastics seemed to be improving. Despite treatment for infection patient would still become hypotensive with SBP in the high 60s or 70s during deep sleep, UOP was > 100cc / hr and he would mentate perfectly when awoken so likely some degree of hypotension purely related to sleep and possibly some autonomic dysfucntion but no evidence of poor perfusion. A new PICC line was placed after a 3 day line holiday. He will follow up with [Hospital ] clinic next week. ARF. Improved immeidately with fluids, Cr 1.5 to 0.9. Electrolytes remained stable. Chronic Sacral Decubitus Ulcer/Osteo: healing well. Wet to dry dressing changes per wound care consult. per plastic surgery is improving. - continued Zinc, vit C Anemia. baseline hct mid 20s. Anemia of chronic disease according to iron studies, normal B12 and folate, retic inappropriately low at 1.7 %. Smear not notable for significant abnormalities. Neurogenic Bladder. Changed foley. He appears to have chronic colonization. His bactrim was stopped on admission. Depression: continued venlafaxine Medications on Admission: - Fluticasone 2 sprays [Hospital1 ] - Prilosec 20 mg daily - MVI - Trazadone 50 mg q AM - Zinc 220 daily - Colace 100 [Hospital1 ] - Effexor 75 mg [Hospital1 ] - Vit C 500 [Hospital1 ] - Ibuprofen 400 tid - Remeron 7.5 mg HS - Dulcolax 20 po/pr daily prn - Metamucil - Tylenol prn - Milk of mag prn - Percocet 5/325 mg 1-2 tabs q 4 hrs - Sodium bicarb 650 daily - HiCal shake 120 cc QID - Bactrim DS 1 tab po BID --since UCx +?? [6-17] - Lactobacillus 1 tab po bid x 10 days Discharge Medications: 1. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous twice a day for 10 days. 2. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: sepsis bacteremia neurogenic bladder acute renal failure anemia Discharge Condition: stable Discharge Instructions: You were admitted with sepsis from a line infection. You have a new IV that was placed during this hospitalization. You will need to have antibiotics for a total of 14 days. Please return to the ER if you develop fevers, chills, confusion or new symptoms. Followup Instructions: Provider: [Name10 (NameIs) ] [Name8 (MD) ], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2164-7-6] 9:00 Provider: [Name10 (NameIs) ] SURGERY CLINIC Phone:[Telephone/Fax (1) 4652] Date/Time:[2164-7-20] 1:00	[ "0389", "5849", "53081", "2859", "311" ]
Admission Date: [2113-3-2] Discharge Date: [2113-3-4] Date of Birth: [2077-7-18] Sex: M Service: MEDICINE Allergies: Haldol Attending:[Doctor First Name 3290] Chief Complaint: Bizarre, combative behavior, s/p fall Major Surgical or Invasive Procedure: [2113-3-2] - Intubation with mechanical ventilation [2113-3-3] - Extubation History of Present Illness: Patient is a 35 year old male with recurrent alcohol withdrawal and prior history of suicidal ideations was brought by ambulance after his roommate was concerned about his odd behavior. He was found by roommate to be drinking 'alot' this morning (vodka), also not sure if pt took medications (depakote), then roommate found patient walking around apartment building lobby in underwear. Fell down over stairs per report. Patient's speech is slurred, no obvious deficits, combative, moving all extremites. Not oriented to place and time but oriented to self. Pt does not recall going to lobby in underwear. fbs 88. Spent some time at [Location (un) 1475]. Denies drug use. . On arrival to the ED, initial vitals:97.9 119 117/89 18 98%. pupils dilated but slightly reactive. Combative, tachycardic, lungs clear to anterior auscultation, fast but regular heart rate, no murmurs. Required intubation for further imaging studies given combativeness and audio-visual hallucinations. Received ativan 4 mg (2mg x2) with minimal improvement. Got intubated on sedation. Urine tox was positive for methadone and serum tox was negative. Depakote level was <3. CT of the spine showed a T1 anterior fracture of unclear duration. Ortho spine saw patient and recommended [Location (un) 2848] J-collar until neck can be clinically cleared. He was transferred to the ICU on a vent. . On transfer to the ICU, patient's vitals are T96.3, HR58, BP110/80, RR16, 100% on vent (PEEP5, FiO230%). He is intubated and sedated without signs of agitation, exam shows warm and well perfused extremities. . ROS: unable to obtain while sedated Past Medical History: Borderline personality disorder Schizoaffective d/o PTSD Polysubstance abuse (patient adamantly denies history of IVDU) ADHD (on Ritalin as a child) Anxiety d/o Hepatitis C Ab positive (patient adamantly denies) Social History: MI in father at 35 (fatal), grandfather died of MI at early age. Mother lung cancer 38 (deceased). -Etoh: [12-19] gallon of vodka daily, alcohol use at age 12, daily use at age 16. Prior dx of alcohol hallucinosis. AA support in past, attending meetings occassionaly currently. Used to live in sober house. History of DTs. Last drink today. -Tobacco: 1.5 ppd -Illicit Drug Use: Ongoing MJ use. Denies other drug use currently, although tox screen pos for benzos and amphetamines in past. Use of marijuana, LSD in past per OMR. Used heroin in [2099] per OMR. -has 2 children in DSS custody, lives with girlfriend [Name (NI) ] who "babysits" him. -no pets in home. -works as a chef, but has not worked for over a year due to right hand injury. Family History: MI in father at 35 (fatal), grandfather died of MI at early age. Mother lung cancer 38 (deceased). Physical Exam: Physical Exam on Admission: Vitals: T96.3, HR:58, BP:110/80, RR:16, O2sat:100% on vent (PEEP5, FiO230%) General: sedated HEENT: dime-sized laceration on mid forehead, focal swelling of left anterior forehead of egg-size, Sclera anicteric, MMM, intubated Neck: in [Location (un) 2848] J-collar Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, right third MCP joint is seemingly absent with overlying surgical scar Pertinent Results: Lab Results on Admission: [2113-3-2] 11:45AM BLOOD WBC-6.0 RBC-4.46* Hgb-14.5 Hct-42.1 MCV-94 MCH-32.5* MCHC-34.4 RDW-12.8 Plt Ct-265 [2113-3-2] 11:45AM BLOOD Neuts-75.8* Lymphs-19.9 Monos-3.5 Eos-0.4 Baso-0.4 [2113-3-2] 11:45AM BLOOD PT-12.2 PTT-34.8 INR(PT)-1.1 [2113-3-2] 11:45AM BLOOD Glucose-82 UreaN-16 Creat-1.0 Na-140 K-4.3 Cl-104 HCO3-23 AnGap-17 [2113-3-2] 11:45AM BLOOD ALT-23 AST-30 AlkPhos-79 TotBili-0.6 [2113-3-2] 11:45AM BLOOD Albumin-5.0 [2113-3-3] 01:15AM BLOOD Calcium-8.0* Phos-3.4# Mg-1.8 [2113-3-2] 11:45AM BLOOD Valproa-<3* [2113-3-3] 01:15AM BLOOD Valproa-6* [2113-3-2] 11:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2113-3-2] 02:49PM BLOOD Type-ART Rates-16/ Tidal V-500 PEEP-5 FiO2-100 pO2-504* pCO2-40 pH-7.37 calTCO2-24 Base XS--1 AADO2-181 REQ O2-39 -ASSIST/CON [2113-3-2] 02:49PM BLOOD Lactate-1.0 [2113-3-2] 02:49PM BLOOD O2 Sat-99 [2113-3-3] 05:30AM BLOOD freeCa-1.17 Brief Hospital Course: ASSESSMENT/PLAN: Patient is a 35yo male with PMH of alcohol withdrawal with seizures, substance abuse, and schizoaffective disorder who presents with odd behavior following alcohol drinking and a fall at home who had to be intubated and sedated for lack of cooperation with imaging exams and severe agitation/hallucinosis to rule out injuries. His imaging revealed a wedge fracture of the T1 vertebrae, likely old, and no neck fracture. . #. Agitation/ETOH withdrawal: Patient was agitated in the ED with reported A/V hallucinations and not cooperating with attempted imaging of the neck. For that reason, he was intubated and sedated to undergo imaging. The source of the agitation is likely from alcohol withdrawal with a probable component of underlying mood disorder as patient has not been taking his depakote as evidenced by low serum levels. He was dosed chlordiazepoxide per CIWA sliding scale with beneft. . #. Respiration: Patient was mechanically ventilated on admission following intubation given combative behavior. He had excellent oxygenation on minimal vent settings, but mild respiratory acidosis when on CPAP and propofol gtt. He was not acidotic when on AC previously. We minimized sedation and he was transitioned to CPAP with successful extubation on [2113-3-3] without issues. He was quickly weaned to room air. . #. Psychiatric disorders: Patient has a history of substance abuse, borderline personality disorder, and schizoaffective disorder for which he normally is on seroquel and depakote at home with likely methadone from a methadone clinic as evidenced by positive urine screen for methadone on arrival. He is subtherapeutic on depakote, adding to his roomate's suspicion that he hasn't been taking it at home. We confirmed and restarted his depakote medication and seroquel, as well as Librium as noted above for acute withdrawal concerns. His QTc was monitored and it was 415 msec . #. s/p fall: Patient experienced a fall down stairs at home with resultant abrasions and swellings of the forhead and legs. He is also describing back pain. Imaging revealed a likely old T1 fracture but no other acute bony injury to the spine. Head and abdominal CT also showed no acute injury. However, because patient could not cooperate with exam due to combativeness then sedation, his spine could not be clinically cleared initially. Following extubation, Ortho-Spine noted a C1-2 fracture that was stable but warranted [Location (un) 2848]-J hard collar adherence for 6 weeks until following with [Hospital 28823] clinic. He can remove the collar for feeding and showering only. He received tetanus toxoid [3-3]. On the day of [2113-3-4] he became quite combative in requesting more pain medicine although he appeared to be in no distress. When the team did not administer additional medication, he refused to stay in the hospital. He denied any suicidal ideation and was able to clearly articulate the consequences of medication non compliance as well as non compliance with his collar. Medications on Admission: (obtained list through [Location (un) 535], compliance is not clear) Seroquel 300mg tabs 1 tab QAM, 2 tabs QPM Ativan 0.5mg tabs, 1 tab QHS Depakote 500mg tabs 1 tab PO BID Discharge Disposition: Home Discharge Diagnosis: Alchol abuse Schizophrenia Fall Discharge Condition: Stable Discharge Instructions: Patient was strongly advised to continue his home medications as well as to use his C collar. Because he left against medical advice, no written instructions were given to him Followup Instructions: With orthopedics.	[ "51881" ]
Admission Date: [2136-3-15] Discharge Date: [2136-3-19] Date of Birth: [2068-5-16] Sex: F Service: HISTORY OF THE PRESENT ILLNESS: This is a 67-year-old female, apparently healthy until one month ago, when she suddenly developed depressed mood related to family stressors. The family noticed that the patient in the last week had becoming increasing confused, had trouble with speech. The patient was taken to her primary care physician [Last Name (NamePattern4) ] [3-14] and she was found to have a systolic blood pressure greater than 200. She was started on antidepressants. She was taken home. The patient showed up to the emergency room on [2136-3-15]. She was brought to the emergency room by her family with worsening symptoms. CAT scan was done in the emergency room and a 3-cm area of increased edema in the left lateral margin of the left lateral ventricle. There was surrounding edema and no shift. PAST MEDICAL HISTORY: 1. Hyperlipidemia. 2. Hypertension. 3. Depression. ADMITTING MEDICATIONS: 1. Celexa. 2. Tenormin. 3. Accupril. 4. Lipitor. ALLERGIES: The patient has no known drug allergies. PHYSICAL EXAMINATION: Examination revealed the following: VITAL SIGNS: Temperature 100.6, blood pressure 198/80, heart rate 82, respirations 18, pulse oximetry 96%. The patient appeared elderly, but in no obvious distress. The patient had a shuffling gait. The patient was alert and oriented times three. Speech was significant for word-finding difficulties and intermittent pauses, not garbled, no word salad. Pupils equal, round, and reactive to light, 2 cm to 3 cm bilaterally and normal extraocular movements. The patient had a positive right sided facial droop and shoulder shrug was 5 out of 5. The patient had a right pronator drift and bilateral symmetrical motor strength of 5 out of 5. Sensation was grossly intact. Reflexes were 2+ throughout. Plantars were downgoing bilaterally. LABORATORY DATA: Laboratory data revealed the following: WBC 7.9, hematocrit 41.2, platelet count 228,000, sodium 135, potassium 4.4, BUN 13, creatinine 0.6, glucose 210. Toxicology screen was negative. HOSPITAL COURSE: The patient was admitted to the neurology Intensive Care Unit for frequent neurological checks every q hour for blood pressure control with the use of Nipride as needed. MRI scan was done to rule out any underlying mass lesion. It showed a left deep white matter above the basal-ganglion periventricular was irregular and a lesion greater than or equal to 3.5 cm; minimal surrounding edema. Impression was metastais versus glioma. The patient was scheduled to have stereotactic biopsy. The patient's family and the patient agreed to have this procedure done. The patient was monitored in the neurological SICU with the neurological remaining neurologically stable. Blood pressure remained in the systolic range of 130 over diastolic range of 40s to 50s. The patient remained in the Intensive Care Unit until [2136-3-17], where she was transferred out to the general neurological floor. During the [Hospital 228] hospital stay she did have constant temperature in the range of 100 to temperature of 102 on [2136-3-18]. She was cultured at that the, both urine and blood cultures. Urinalysis was negative for signs of infection. Blood cultures and urine cultures are still pending at this time. The patient and the patient's family have opted to be transferred to the [Hospital6 1129]. The patient will be transferred via ambulance to [Hospital6 1129] on the following medications: DISCHARGE MEDICATIONS: 1. Atenolol 50 mg p.o.q.d. 2. Quinapril 20 mg p.o.q.d. 3. Lovastatin 20 mg p.o.q.d. The patient was transferred to [Hospital6 1129] under the care of Dr. [Last Name (STitle) 101092] in stable condition. [First Name11 (Name Pattern1) 125] [Last Name (NamePattern4) 342], M.D. [MD Number(1) 343] Dictated By: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], NP MEDQUIST36 D: [2136-3-19] 09:58 T: [2136-3-19] 10:09 JOB#: [Job Number ]	[ "4019", "2724" ]
Admission Date: [2141-12-8] Discharge Date: [2141-12-14] Date of Birth: [2117-8-7] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[First Name3 (LF) 8104] Chief Complaint: abdominal pain & hypertension Major Surgical or Invasive Procedure: Hemodialysis PICC Line [12-11] History of Present Illness: Ms [Known lastname ] is a 24 year old woman with a history of CKD V (on HD) from lupus nephritis, chronic intermittent abdominal pain, and multiple prior ICU admissions for hypertensive urgency who presented to the ED complaining of two days' of abdominal pain, nausea, and loose stools. She was feeling well until after her hemodialysis session on Wednesday. Thereafter, she complained of nausea with occasional vomitting and has been unable to keep down any of her oral medications. She also has had diffuse abdominal pain consistent with her prior flares of pain as well as her typical diffuse headache. The headache in particular was worsening and, for her, this is a sign of poorly-controlled hypertension so she came to the [Hospital1 18] ED. Upon arrival to the ED, she was afebrile, BP 240/184, HR 109, RR 16, Sat 99% on room air. She was given 4 mg of IV ondansetron, [1-11] inch intropaste, 1 mg of IV hydromorphone x3, 1000cc of NS, and was put on a labetalol drip which had to be increased up to 2 mg/min. A head CT showed no acute abnormality (including hemorrhage) and an abdominal CT showed some possible mild colitis, though it is unclear if this is due to her recent peritoneal dialysis. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [2134] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([2139]) and ESRD ([2135]) 2. CKD/ESRD: - Diagosed [2135] - Initiated dialysis [2137] but refused it as of [2140], has survived despite this - PD catheter placement [5-18] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with LE paresis in [2140] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([2139]); related to a catheter - Negative lupus anticoagulant ([4-/2138], [8-/2138], [9-/2140]) - Negative anticardiolipin antibodies IgG and IgM x4 ([2137]-[2140]) - Negative Beta-2 glycoprotein antibody ([4-/2138], [8-/2140]) 6. HOCM: Last noted on echo [8-17] 7. Anemia 8. History of left eye enucleation [2139-4-20] for fungal infection 9. History of vaginal bleeding [2139] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [6-16] and [5-17] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [2140-4-10]. 4. PD catheter placement in [2141-5-11]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [2141-10-27] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 97.9 BP 165/120 HR 93 RR 12 Sat 100% ra Gen: mildly fatigued, but no distress HEENT: oropharynx clear Neck: no JVP, no LAD Chest: clear to auscultation throughout, no w/r/r CV: reg rate/rhythm, nl s1s2, ? s4, no murmurs or rubs heard Abdomen: soft, tender diffusely to moderate palpation without rebound or guarding; hyperactive bowel sounds; no masses or HSM, PD catheter in palce Extr: no edema, 2+ PT pulses Neuro: alert, appropriate, strength grossly intact in all four limbs Skin: no rashes Pertinent Results: [2141-12-14] 05:53AM BLOOD WBC-4.3 RBC-2.81* Hgb-8.6* Hct-25.6* MCV-91 MCH-30.7 MCHC-33.8 RDW-19.3* Plt Ct-148* [2141-12-14] 05:53AM BLOOD PT-42.6* PTT-51.0* INR(PT)-4.7* [2141-12-10] 05:10AM BLOOD Ret Aut-2.5 [2141-12-14] 05:53AM BLOOD Glucose-83 UreaN-21* Creat-5.1# Na-138 K-5.3 Cl-105 HCO3-24 AnGap-14 [2141-12-10] 05:10AM BLOOD LD(LDH)-234 Amylase-347* TotBili-0.1 [2141-12-7] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [2141-12-10] 05:10AM BLOOD Lipase-72* [2141-12-14] 05:53AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.7 [2141-12-10] 05:10AM BLOOD Hapto-142 [2141-12-8] 04:02AM BLOOD calTIBC-138* VitB12-445 Folate-18.5 Ferritn-220* TRF-106* ON ADMISSION: [2141-12-7] 09:50PM BLOOD WBC-4.5 RBC-2.78* Hgb-8.4* Hct-25.2* MCV-91 MCH-30.2 MCHC-33.3 RDW-19.2* Plt Ct-158 [2141-12-7] 09:50PM BLOOD Neuts-65.2 Lymphs-23.4 Monos-8.0 Eos-2.9 Baso-0.4 [2141-12-7] 09:50PM BLOOD PT-14.7* PTT-33.4 INR(PT)-1.3* [2141-12-8] 04:02AM BLOOD Ret Aut-2.5 [2141-12-7] 09:50PM BLOOD Glucose-89 UreaN-25* Creat-5.1# Na-139 K-4.8 Cl-104 HCO3-26 AnGap-14 [2141-12-7] 09:50PM BLOOD ALT-14 AST-51 AlkPhos-94 TotBili-0.3 [2141-12-7] 09:50PM BLOOD Lipase-89* [2141-12-7] 09:50PM BLOOD Albumin-3.3* Calcium-8.3* Phos-4.9* Mg-1.9 [2141-12-7] 09:54PM BLOOD Glucose-75 Lactate-1.3 Na-139 K-4.8 Cl-101 calHCO3-23 Micro: Blood Cx: [12-7], [12-7], [12-11], [12-11] No growth FECAL CULTURE (Final [2141-12-10]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [2141-12-10]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [2141-12-8]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2141-12-8]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). CT HEAD [2141-12-8]: IMPRESSION: 1. No acute intracranial pathology including no hemorrhage. 2. The hypodensities noted in the parietal white matter are stable. However in the setting of the hypertension, PRES cannot be excluded. If further evaluation is required MR can be obtained. CT Abdomin/Pelvis [2141-12-8] IMPRESSION: 1. Moderate amount of free fluid in the pelvis is compatible with the patient's known peritoneal dialysis. Unchanged peritoneal enhancement. 2. Stable liver hemangioma. CXR [12-11] IMPRESSION: Small left pleural effusion. Left lower lobe opacity which is either atelectasis versus pneumonia. Brief Hospital Course: 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. MICU course: Current plan on transfer 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. 1. Hypertensive urgency: The patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. Initially her blood pressure over-corrected to SBPs in the 80s (patient was asymptomatic). Her clonidine patch and hydralazine was held and she again became hypertensive with SBPs 190s. The patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. The following dialysis the patient asymptomatic with SBPs in 80s, MAPs 60s asymptomatic again. Her hydralazine was stopped and continued on all her other home medications at the advice of renal. The patient was transferred to the floor on [12-10] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. On [12-11] the patient's SBP dropped to the 80's and due to her pain medications she was extremely lethargic, but arousable. A PICC line was placed because lack of access and she was bolused 250cc NS. The patient's pressures responded and additional narcotics were held due to her mental status. The patient's blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. The patient did require IV hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. A possible component to the patient's malignant hypertension is likely due to OSA. An inpatient sleep study was performed overnight on [12-13] and the patient was sent home on BiPAP for OSA. The patient was continuned on her admission hypertensive regimen. . 2. Abdominal pain: The etiology of her abdominal pain is unclear, but has been a chronic issue for her. A CT scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. The patient also had diarrhea, but stool studies were negative. The patient's pain was initially treated with hydromorphone, but because of the patient's lethargy on [12-11] they were initially held. She continued to complain of severe abdominal pain. She was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. Surgery was consulted in regards to removal of her PD catheter, but given that she may return to PD it was deferred to the outpatient setting. 3. CKD V from lupus nephritis: The patient was continued on HD during her admission. She was also continued on her home prednisone dose. She was closely followed by the renal team. . 4. History of SVC/subclavian vein thrombus: The patient was found to have a subtherapeutic INR on admission 1.3. She was started on a heparin gtt and continued on coumadin. The patient's heparin gtt was hled on [12-10] because of access issues, but was restarted on [12-11] after her PICC line was placed. She was therapetuic the same day and her heparin gtt was stopped. On discharge her coumadin was supratherapeutic (4.7) and was held. She will have her INR checked at HD. . 5. Anemia: The patient's Hct slowly trended down. She was guaiac negative and hemolysis labs were negative. She was transfused 1U pRBC at HD on [12-12]. She was also given epo at HD. Medications on Admission: prednisone 4 mg daily clonidine 0.3 mg/day patch qWeek ergocalciferol 50,000 units qMonth nifedipine SR 90 mg daily hydralazine 100 mg q8h citalopram 20 mg daily warfarin 2 mg qhs gabapentin 300 mg [Hospital1 ] hydromorphone 4 mg q4h prn clonazepam 0.5 mg [Hospital1 ] alikiren 150 mg [Hospital1 ] docusate 100 mg [Hospital1 ] senna 8.6 mg [Hospital1 ] prn acetaminophen prn labetalol 800 mg q8h bisacodyl 5 mg daily prn Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. [Hospital1 ]:84 Tablet(s) Refills:0 7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 13. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed: please take as needed for anxiety prior to CPAP at bedtime. [Hospital1 ]:30 Tablet(s) Refills:0 14. CPAP Home CPAP Dx: OSA Prefer: AutoCPAP/ Pressure setting [5-20] Alt: Straight CPAP/ Pressure setting 7 Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertensive Urgency Abdominal Pain ESRD on HD SVC Thrombus Secondary: Systemic lupus erythematosus Malignant hypertension Thrombocytopenia HOCM Anemia History of left eye enucleation History of vaginal bleeding Thrombotic microangiopathy Discharge Condition: Stable Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted to [Hospital1 18] because of elevated blood pressure and abdominal pain. You were initially admitted to the ICU and your blood pressure was controlled. You were stabilized and transferred back to th floor. Your pressures remained stable throughout the rest of your stay. Additionally, you had abdominal pain and diarrhea. Your stool was tested for infections and was negative. Your diarrhea resolved without intervention. Your abdominal pain was controlled with pain medications. You had a sleep study in the hospital which showed that you had sleep apnea. Please continue to take your medications as prescribed. 1. Please do not take your coumadin until your doctor tells you to. Please follow up with the appointments below. Please call your PCP or go to the ED if you experience chest pain, palpitations, shortness of breath, nausea, vomiting, fevers, chills, or other concerning symptoms. Followup Instructions: You will have dialysis at [Location (un) ] Dialysis on your normal schedule. You need to go to dialysis on Saturday. Please follow-up with the Sleep Clinic in [12-19] @ 11:45 Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 612] Please follow-up with your PCP [Last Name (NamePattern4) ] [1-11] weeks PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 250] Completed by:[2141-12-16]	[ "2875", "32723" ]
Admission Date: [2132-4-8] Discharge Date: [2132-4-20] Service: SURGERY Allergies: NSAIDS / Salicylates Attending:[First Name3 (LF) 4748] Chief Complaint: Acute onset of lower back pain Major Surgical or Invasive Procedure: None History of Present Illness: 89 [Hospital ] transfered from an OSH with the chief complaint of lower back pain for the past 1 week. This was sudden in onset, progressively worsening, constatnt in nature with no aggravating or relieving factors, associated with nausea. No fever, chills or vomiting. No h/o any trauma to the back. Past Medical History: PMH: CAD with non STEMI in [2130-5-24], paroxysmal atrial fibrillation, HTN, hypercholesterolemia, hypothyroidism, CHF (EF -50%), moderate to severe mitral regurgittation, mild aortic and pulmonary in sufficiency, pulmonary HTN, AAA, legally blind Past Surgical History: appendectomy, hysterectomy, oophorectomy, uterine cancer, C section, spine surgery Social History: Lives alone, smoked <1 ppd for about 40 years Family History: significant for CAD and colon cancer Physical Exam: Vital Signs: Temp: 96.6 F RR: 14 Pulse: 78 BP: 186/93 Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules, No right carotid bruit, No left carotid bruit. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: large ventral hernia, well healed midline surgical incision seen, no Guarding or rebound,No hepatosplenomegally. Rectal: Not Examined. Extremities: No popiteal aneurysm, No femoral bruit/thrill, No RLE edema, No LLE Edema, No varicosities, No skin changes. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RUE Radial: P. Ulnar: P. Brachial: P. LUE Radial: P. Ulnar: P. Brachial: P. RLE Femoral: P. Popiteal: P. DP: P. PT: D. LLE Femoral: P. Popiteal: P. DP: P. PT: D. Pertinent Results: [2132-4-7] 03:05PM BLOOD WBC-4.2 RBC-3.65* Hgb-11.0* Hct-33.0* MCV-90 MCH-30.1 MCHC-33.4 RDW-15.5 Plt Ct-160 [2132-4-7] 03:05PM BLOOD Neuts-74* Bands-1 Lymphs-17* Monos-7 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [2132-4-7] 03:05PM BLOOD PT-13.3 PTT-27.2 INR(PT)-1.1 [2132-4-7] 03:05PM BLOOD Glucose-96 UreaN-25* Creat-1.5* Na-143 K-4.1 Cl-115* HCO3-20* AnGap-12 [2132-4-7] 03:05PM BLOOD ALT-13 AST-20 AlkPhos-84 Amylase-48 TotBili-0.5 [2132-4-7] CTA abdomen: IMPRESSION: 1. Bilobed fusiform abdominal aortic aneurysm with overall dimensions measuring up to 4.8 x 5.2 cm. No definite signs of rupture. 2. Mildly dilated small bowel with segments which appear hyperenhancing and slightly thickened which raises concern for an inflammatory or an infectious etiology. Please correlate clinically. 3. Soft tissue nodularity involving the pelvic floor/perineum which could reflect old inflammatory changes though clinical correlation is advised. 4. Bilateral renal scarring and renal hypodensities, the largest of which appear to represent simple cysts. 5. Complex ventral hernia, containing non-obstructed small and large bowel. 6. Extremely demineralized bony pelvis with evidence of old insufficiency fractures. Stabilization hardware in the lower lumbar spine. [2132-4-8] ECHO: The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60%); however, the basal inferior and posterior segments are hypokinetic. The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened (?#). Mild to moderate ([11-25]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are myxomatous. There is mild posterior leaflet mitral valve prolapse. An eccentric, anteriorly directed jet of moderate (2+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. [2132-4-10] Left Hip XR: IMPRESSION: 1. No evidence of acute fractures or dislocations. MRI is the recommended study of choice if clinical suspicion for occult fracture is high. 2. Unusual mottled appearance of bilateral iliac bones, of nonspecific etiology. [2132-4-11] CTA abdomen: IMPRESSION: 1. Stable abdominal aortic aneurysm without signs of acute rupture. No retroperitoneal hematoma. 2. Fluid-filled distended loops of small bowel, without discrete transition point, findings suggestive of ileus. 3. Cystic lesions within the kidneys, the largest in the left upper pole of indeterminate attenuation. Followup renal ultrasound should be considered. 4. Stable ventral hernia without evidence of acute obstruction. 5. Stable severely mottled pelvic bones of uncertain etiology. 6. New small bilateral pleural effusions. [2132-4-16] KUB: Increased gaseous distension of several bowel loops. When compared with recent CT, this most likely represents continued ileus; however, obstruction cannot be excluded. Brief Hospital Course: The patient was admitted to the surgery service for evaluation and treatment. HD 1- She was transferred from an OSH with the chief complaint of acute onset of lower back pain and a CT scan s/o increase in size of her preexisting AAA. She required a nitroprusside drip won the day of admission to keep her SBP in the range of 100- 110 mmHg. She was then transferred to the CVICU for close monitoring. HD 2- The patient was doing well. her pain was well controlled with IV morphine and she remained hemodynamically stable. A cardiology consult was sought to assess the cardiac risk for possible surgical repair of the AAA. They recommended giving ASA, lopressor and a perfusion scan. An ECHO was done to assess the current cardiac functional status. HD 3- The patient was started on a small dose of PO lopressor and she stayed stable throughout the day. She was transferred out of the CVICU to the VICU. HD4 - A sudden increase in the Serum creatinine from 1.6 t 1.9 was noted. Also, there was a deacrease in the hourly urine output. She recieved 2 boluses of NS of 500cc each followed by mIVF. Her lisinopril was stopped and a FeNa was calculated which was found to be 0.2%. HD 5 - She started complaining of pain in the left hip in the morning. She was hen sent down for an XR of the hip that showed no e/o any fracture. Also, a wound care consult was sought to assess her bed sore. HD 6 - She started complaining of increased abdominal pain and was slightly tender on physical examination. A CT scan of the abdomen was done to diagnose an increase in size of the AAA and any other ongoing pathological process. The ACS team was consulted at this time and no surgical intervention was recommended by the team. HD 7 - There was an improvement in her Creatinine which was down to 1.6. She c/o nausea on multiple occasions following which an EKG was done to r/o ongoing myocardial ischemia. her cardiac enzymes were also negative. HD 8 - Ciprofloxacin and FLagyl were started due to concern for bowel ischemia. Once again, there was a sudden increase in the creatinine from 1.6 to 1.9. She was given 2 boluses of IVFs, 500 cc each and the mIVF rate was also increased. Starting on HD 9, patient began to have worsening crampy abdominal pain. She was no longer having bowel movements. Her antibiotics were discontinued as her C-diff was negative. KUB was performed that was consistent with ileus. Patient had intermittent episodes of emesis, but did not require an NGT. General surgery was re-consulted and did not feel that this was due to the patient's ventral hernia, and suggested no intervention. This new pain was also not felt to be due to her AAA. Geriatrics was consulted and felt this was likely due to her colonic stricture that was diagnosed a year prior after a lower GI bleed episode. The patient was started on a very aggressive bowel regimen to soften her stools. On HD11, patient finally began to have severaly loose stools, and began to feel much better. GI was also consulted and suggested that if she has these obstructive symptoms again that a stent could be considered for palliation. HD 12 - She began complaining of jaw pain and was evaluated by OMFS service. Their evaluation was that she had a close lock consistent with anterior displaced disc without reduction and recommended a soft diet and motrin 600mg prn and heat pack to the face if pain developed/persisted. In addition, she should follow-up with her usual dentist or the OMFS service for this. Overall, after long discussions with the family it was decided to not pursue surgical intervention for her AAA. Given her several cardiac problems, it was deemed too risky to proceed with surgery. The patient and the family agreed with this and she was discharged to rehab in stable condition without any acute issues. Medications on Admission: Lisinopril 5mg OD, Levothyroxine 100mcg OD, vicodin 1 tab prn, Vit B12 1000mcg OD, latanoprost 0.005% ED HS, lotemax 0.5 ED [Hospital1 ], dorzolamide ED [Hospital1 ] Discharge Medications: 1. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 4. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours). 10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 12. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection Injection TID (3 times a day). 13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. hydralazine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. hydralazine 20 mg/mL Solution Sig: One (1) Injection Injection Q6H (every 6 hours) as needed for SBP>150. Discharge Disposition: Extended Care Facility: [Location (un) 32944] Village & Rehabilitation Center - [Location (un) 32944] Discharge Diagnosis: Abdominal aortic aneurysm. 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: Please call your doctor if you develop fever > 101.5, chills, nausea, vomiting, severe pain not controlled by medications, or if anything else concerns you. You should continue to eat a low residue soft diet to help soften your stools and to prevent further jaw pain. Please take all new medications as prescribed. You may continue all of your prior medications. You may continue your normal activity as tolerated. Followup Instructions: For your jaw pain Please follow up with your regular dentist or with OMFS service at: - [Hospital1 2177] Outpatient Clinic Info: [Last Name (NamePattern1) ] , ACC-Yawkey Building, [Hospital 40530] Clinic [Location (un) ] Phone #[Telephone/Fax (1) 68463]. Please call Dr[Doctor Last Name ] office (Vascular Surgery) at [Telephone/Fax (1) 1393] on as needed basis.	[ "5849", "42731", "4168", "41401", "412", "40390", "5859", "4280", "2449", "2720", "4240" ]
Admission Date: [2193-8-24] Discharge Date: [2193-8-27] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Lisinopril Attending:[First Name3 (LF) 4588] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [Known lastname 77230] is an 87F with a PMH s/f CHF with an EF of 30%, A fib s/p pacemaker not anticoagulated, on home O2 who presented on [2193-8-24] after developing acute onset of shortness of breath with a new O2 requirement (her baseline is 92% on 2L, and she was requiring 6L NC to maintain sats). Otherwise her ROS was negative. She ruled out for an MI by enzymes. The team attempted to diurese her for a presumed CHF exacerbation based on her CXR findings of cephalization and pleural effusions, they anticoagulated her for suspicion for a PE and a chads score of 4, and put her in for an echo and CTA of the chest. Initially her hemodynamics improved with diuresis, with a decrease in her creatinine, so the team attempted further diuresis today. She has recieved a total of 160mg of IV lasix, and has put out approximately 1100cc of urine. Today the patient was noted to drop her sats to 70s on room air whenever she would take her face mask off. She was in no acute respiratory distress, and was mentating well with this. An ABG was obtained which showed 7.44/41/48. She was taken down for a STAT CTA, and transferred to the ICU for closer monitoring. Past Medical History: - Atrial fibrillation not anticoagulated - S/p pacemaker - HTN - Chronic systolic and diastolic CHF, last EF 30% in [12-22] - Hypothyroidism - DM type II - Depression - Dementia - Gout - H/o falls - Urinary incontinence - Uterine cancer s/p hysterectomy 10 years ago - Pulmonary nodules, followed by thoracic oncology, serial CT scans revealing no change - Home oxygen (was discharged on oxygen from last hospitalization in [12-22] with oxygen) Social History: Lives at [Hospital 100] Rehab. Walks with a walker. Son [Name (NI) ] is involved in her care (HCP). Family History: NC Physical Exam: VS: T 98.3 BP 153/64 P 66 RR 18 Initially 86% on 4L, then up to 91% on 6L GEN: Comfortable appearing, NAD HEENT: NCAT, EOMI, PERRL, oropharynx clear and without erythema or exudate, NC in place NECK: Supple, elevated JVP CV: RRR, 3/6 SEM loudest at LUSB, no murmurs, rubs or gallops PULM: Rales at bases, occasional expiratory wheeze, good air movement bilaterally ABD: Soft, NTND, normoactive bowel sounds, no organomegaly EXT: Warm and well perfused, full and symmetric distal pulses, no pedal edema NEURO: Minimal english, but responds appropriately to questions, CN 2-12 grossly intact Pertinent Results: [2193-8-23] 11:55PM BLOOD WBC-8.6# RBC-4.41 Hgb-13.7 Hct-39.0 MCV-89 MCH-31.1 MCHC-35.1* RDW-16.1* Plt Ct-217 [2193-8-27] 04:40AM BLOOD WBC-5.7 RBC-3.85* Hgb-11.6* Hct-34.5* MCV-90 MCH-30.1 MCHC-33.6 RDW-15.9* Plt Ct-185 [2193-8-25] 03:49AM BLOOD PT-13.2 PTT-27.8 INR(PT)-1.1 [2193-8-23] 11:55PM BLOOD Glucose-134* UreaN-41* Creat-2.0* Na-144 K-4.2 Cl-108 HCO3-26 AnGap-14 [2193-8-27] 04:40AM BLOOD Glucose-130* UreaN-38* Creat-1.7* Na-142 K-4.3 Cl-105 HCO3-32 AnGap-9 [2193-8-24] 05:15PM BLOOD ALT-23 AST-23 LD(LDH)-243 CK(CPK)-31 AlkPhos-85 Amylase-55 TotBili-1.0 [2193-8-24] 05:15PM BLOOD calTIBC-306 VitB12-250 Folate-18.8 Hapto-45 Ferritn-225* TRF-235 Brief Hospital Course: Ms. [Known lastname 77230] is an 87F with a PMH s/f chronic systolic HF (EF 30%), afib off coumadin, with baseline home O2 requirement who presents with acute worsening of dyspnea and new oxygen requirement. 1)Respiratory distress: Likely CHF exacerbation given Chest X-ray findings. She is normally on 2L of O2 at home, which increased to 6L during her hospital stay. She received 160mg IV Lasix on the floor with 2L of urine output. In the MICU, she received an additional 80mg IV. Cardiac enzymes were negative. Her oxygen requirements continued to improve with diuresis. On the day of discharge, she was at baseline of 2 liters and satting at 90-91%. She had been adequately diuresed and it was felt that low baseline saturations were likely secondary to bibasilar atelectasis as identified on Chest CT. Her home Lasix dose was increased and she was discharged on 60mg PO BID, (vs 40mg PO BID on admission). Clinically she appeared euvolemic at the time of discharge. Discharged with instruction to encourage ambulation, incentive spirometry to improve air movement. 2)Acute on chronic renal failure: Baseline Cr 1.3-1.5; elevated to 2.0 on admission. Her Cr was monitored closely and her medications were renally dosed. Her creatinine stabilized at 1.7 and it was felt that this liekly represents new baseline creatinine for her. 3)Chronic systolic/diastolic heart failure: Patient was diuresed as above. Losartan was held in light of elevated creatinine, but restarted prior to discharge. She was continued on beta-blocker. ECHO showed improvement of global systolic function with EF of 50-55%, improved from [2193-1-10] Echo with 30% EF. 4)HTN: She was continued on home regimen of Amlodipine and Metoprolol. 5)Atrial fibrillation: s/p pacemaker. She is not on anticoagulation as an outpatient. She was continued on beta-blocker for rate control. Her outpatient PCP at [Name9 (PRE) 15303] rehab was contact[Name (NI) ] and it was recommended that anticoagulation be initiated for atrial fibrillation.He will investigate why this was not previosuly done and consider starting. No anticoagulation was started while inpatient. 6)Dementia: Continued on Aricept and Namenda. 7)Hypothyroidism: Continued on Levothyroxine. 8)DM type II: Patient is on Glipizide as outpatient; this was held in light of her acute renal failure. She was placed on an insulin sliding scale with good blood sugar control. Prior to discharge, glipizide was restarted at home dose. 9)Gout: Continued on Allopurinol which was renally dosed. 10)Depression: Continued on Paxil. Medications on Admission: Allopurinol 100 mg daily Amlodipine [Norvasc] 10 mg daily Donepezil [Aricept] 10 mg daily Furosemide [Lasix] 40 mg [Hospital1 ] Levothyroxine 50 mcg daily Losartan [Cozaar] 50 mg daily Memantine [Namenda] 10 mg [Hospital1 ] Metoprolol Succinate 100 mg daily Paroxetine HCl [Paxil] 40 mg daily Simvastatin [Zocor] 20 mg daily Tolterodine [Detrol LA] 4 mg Capsule, Sust. Release 24 hr daily Zolpidem [Ambien] 5 mg QHS Acetaminophen [Tylenol] 650 mg Q4H prn Aspirin 325 mg daily Bisacodyl [Dulcolax] 5 mg daily Calcium Carbonate 650 mg (1,625 mg) [Hospital1 ] Ergocalciferol (Vitamin D2) [Vitamin D] 1,000 unit daily Glipizide XL 5mg daily Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Namenda 10 mg Tablet Sig: One (1) Tablet PO twice 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. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Tolterodine 4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 12. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 13. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every four (4) hours as needed for pain. 14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Calcium Carbonate 650 mg (1,625 mg) Tablet Sig: One (1) Tablet PO twice a day. 16. Ergocalciferol (Vitamin D2) 400 unit Tablet Sig: Two (2) Tablet PO once a day. 17. Glipizide 5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis 1. CHF exacerbation 2. Bibasilar Atelectasis Secondary Diagnosis Atrial fibrillation not anticoagulated S/p pacemaker HTN Chronic systolic and diastolic CHF, last EF 30% in [12-22] Hypothyroidism DM type II Depression Dementia Gout H/o falls Urinary incontinence Uterine cancer s/p hysterectomy 10 years ago Pulmonary nodules, followed by thoracic oncology, serial CT scans revealing no change Home oxygen (was discharged on oxygen from last hospitalization in [12-22] with oxygen) Discharge Condition: Good. hemodynamically stable and afebrile. At baseline oxygen saturation of 90-92% on 2 liters Discharge Instructions: You were admitted to the hospital with shortness of breath. Your symptoms were secondary to an exacerbation of congestive heart failure. We made the following changes to your medications. 1. Lasix from 40mg twice daily to 60mg twice daily Please return to the ER or call your primary care doctor if you have worsening shortness of breath, chest pain, worsening leg edema, fever, chills, or any other concerning symptoms. You should weigh yourself every day and call your primary care doctor if you have weight gain of more than 2lbs daily. You should adhere to a low sodium diet. Followup Instructions: Please follow up with your primary care physician as needed. Completed by:[2193-8-27]	[ "5849", "5180", "4280", "40390", "5859", "25000", "2449", "42731" ]
Admission Date: [2114-3-21] Discharge Date: [2114-3-26] Date of Birth: [2056-1-8] Sex: M Service: [Hospital Ward Name 332] ICU/Medicine Acove Team REASON FOR ADMISSION: Shortness of breath and hypoxia, status post pulmonary vein atrial fibrillation, isolation procedure. HISTORY OF PRESENT ILLNESS: This is a 58 year old gentleman with multiple medical problems, namely paroxysmal atrial fibrillation for which he is status post pulmonary vein ablation procedure at [Hospital6 256] on [2114-3-21] followed by a Prednisone taper started by the electrophysiology team as a standard practice for prophylaxis against pulmonary vein stenosis. The patient notes being in his usual state of health post ablation in normal sinus rhythm until [3-20], at noon when he noted the onset of acute shortness of breath, wheezing and marked dyspnea on exertion while visiting his family in [Hospital1 ] [State 350]. Of note, he had no associated chest pain, lightheadedness, dizziness, diaphoresis, palpitations, nausea or vomiting at the time. His family took him to [Hospital ] Hospital Emergency Room where initial vital signs demonstrated a temperature of 101.3, heart rate of 122, blood pressure of 237/137, respirations 48, oxygenation at 81% on room air. An electrocardiogram at that time showed a sinus tachycardia with ST depressions in leads V5 through V6 at a ventricular rate of 114. A computerized axial tomography scan was performed and was negative for pulmonary embolus or evidence of pulmonary vein stenosis. BMP level was drawn, not suggestive of congestive heart failure. The patient was given intravenous fluids, given history of chronic renal insufficiency and chest x-ray demonstrating bilateral infiltrates thought to be secondary to aspiration pneumonia. He was started on Rocephin, Azithromycin and transferred to [Hospital6 256] Emergency Room for further management. Of note, the patient has a history of a C5-C7 vertebral injury, status post cervical fusion with incomplete repair and he was wearing a soft collar for this. Thus, if he were intubated he would require fiberoptic intubation. On physical examination at the [Hospital6 1760] Emergency Room his vital signs were as follows, temperature 96.8, blood pressure 123/86, heart rate 83 and regular, respirations 28. He was 97% on a nonrebreather facemask. Clindamycin was added to his regimen initially given his bilateral infiltrates and concern for aspiration pneumonia. A repeat electrocardiogram showed a normal sinus rhythm at 83 beats/minute with no ST or T wave changes. He was transferred to the [Hospital Ward Name 332] Intensive Care Unit for management of aspiration pneumonia. PAST MEDICAL HISTORY: Atrial fibrillation, paroxysmal for the past 15 to 20 years with persistent atrial fibrillation for the past seven months, status post failed cardioversion, now status post pulmonary vein ablation on [2114-3-19] at [Hospital6 256]. Of note, this pulmonary vein ablation procedure required the patient to be intubated fiberoptically for approximately two hours. He did tolerate the intubation well and was extubated without complications. C5-C7 bilateral facet fracture, status post cervical fusion in [2112-4-23]. Hypertriglyceridemia. Hypertension. Question of coronary artery disease, however, normal exercise treadmill test with MIBI imaging in [2112-5-23], going 9.5 minutes on [Initials (NamePattern4) ] [Last Name (NamePattern4) ] protocol with an ejection fraction of 61% and normal perfusion of the imaging portion. Gout, maintained on Allopurinol. Gastrointestinal bleed, in [2105] with black stools, decreased hematocrit, likely secondary to increased use of non-steroidal anti-inflammatory drugs for back pain. Gastroesophageal reflux disease. Status post left inguinal hernia repair. Status post bilateral shoulder surgery, type and details unknown. Chronic renal insufficiency with a baseline creatinine of 1.1. KNOWN ALLERGIES: Zanaflex lead to a cardiac dysrhythmia of unknown type. SOCIAL HISTORY: The patient is originally from [State 3908], he is a pipe welder by trade. He is married. He quit smoking tobacco in [2087]. He does consume approximately one to two servings of alcoholic beverages per [Known lastname ]. FAMILY HISTORY: Positive for multiple relatives with coronary artery disease, further details unknown. MEDICATIONS ON ADMISSION: Amiodarone 200 mg p.o. q.d., Oxycontin 20 mg b.i.d., Cartia XL 180 mg b.i.d., Lopid 600 mg b.i.d., Allopurinol 300 mg q.d., Valium 10 mg q. 8 hours, Diovan 160/25 q. AM, half of a pill q. PM, Prednisone taper as dictated by the Electrophysiology Service. Coumadin 5 mg p.o. q.d. PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.5, heart rate 80 and regular, blood pressure 139/77, respirations 25, oxygenation 93% on a nonrebreather facemask. General: The patient is in a stiff [Location (un) 2848] J neck brace. He is responsive to voice and external stimuli. He is in moderate respiratory distress with accessory muscle use. Head, eyes, ears, nose and throat, extraocular movements intact, pupils equal, round and reactive to light and accommodation, moist mucous membranes, no evidence of jaundice. Neck collar is in place, well-positioned. Cardiovascular, regular rate and rhythm. S1 greater than S2 at the apex. No evidence of rub, clicks or gallops. There is a faint I/VI systolic murmur at the left lower sternal border without radiation. Lungs, coarse throughout. Abdomen, moderately distended with decreased bowel sounds, soft and generally nontender. Extremities, 1 to 2+ pitting edema bilaterally in the lower extremities with dopplerable pulses bilaterally. Neurologic examination reveals [3-28] motor function in all flexors and extensors. Sensation grossly intact to light touch. Cranial nerves II through XII grossly intact. However, cranial nerve [Doctor First Name 81] could not be fully assessed at this time. LABORATORY DATA: Initial data on admission revealed white blood cells 15.2 with 17% bandemia, hematocrit 30.2, platelets 246. INR 1.4, troponin was 1.65 with a CK of 110, MB fraction of 5. Chem-7 was as follows, 137, 4.8, 104, 21, 29, 1.3, 176 with an anion gap of 12. The lactate was 1.6. The initial blood gas on nonrebreather facemask was 7.37/40/126. Chest x-ray showed bibasilar infiltrates in all lung fields. A computerized tomographic angiography of the chest demonstrated no filling defects in the pulmonary arteries or veins. Evaluation of left atrium and pulmonary veins demonstrates two major pulmonary veins in both the right and left side, pulmonary vein draining the right middle lobe, draining into the inferior most right pulmonary vein. The pulmonary vein draining the lingula drains into the superior most left pulmonary vein, the superior most right pulmonary vein measures 26 by 19 mm. The inferior most right pulmonary vein measures 19 by 23 mm, the superior most left pulmonary vein measures 20 by 13 mm. The inferior most left pulmonary vein measures 18 by 14 mm. The ridge between the two right pulmonary veins measures 18 mm in length. The ridge between the two left pulmonary veins measures 10 mm in length. An electrocardiogram at the time of admission demonstrates a normal sinus rhythm at 85 beats/minute with low QRS voltage in the limb leads. PR interval 170. QTC 419, normal axis. Mild approximately 0.[Street Address(2) 1755] upsloping depression in leads V3 through V6. Urine cultures and urinalysis were negative. HOSPITAL COURSE: Respiratory failure, a broad differential diagnosis was initially considered for the patient's respiratory failure. Given the fact that he was febrile and the infiltrate was most prominent in the right middle lobe, it was felt that the respiratory failure was secondary to aspiration pneumonia. He was placed on a regimen of Clindamycin, Ceftriaxone and Azithromycin for coverage of anaerobes as well as community-acquired pathogens. Sputum cultures and blood cultures were negative at the time of dictation. Legionella antigen was sent and was negative. Other possibilities in the differential diagnosis would include congestive heart failure, given the patient's known 1 to 2+ mitral regurgitation and the incidence of approximately 3% of congestive heart failure post pulmonary vein atrial fibrillation ablation, it was felt the patient may have been in congestive heart failure. He was aggressively diuresed on the floor with 40 to 80 mg of Lasix b.i.d. with excellent urine output and marked improvement in oxygenation. He was not placed on steroid taper, in fact, the previous steroids were held given that he had only received one dose. Pulmonary embolus, the patient had a computerized tomographic angiography which was negative for pulmonary embolus. It is possible, however, that he did have a pulmonary embolus which had dissolved, however, this is rather unlikely given that the patient was still markedly hypoxic and dyspneic throughout his hospital course. The next possibility would include chronic obstructive pulmonary disease, given wheezing on examination and emphysema by chest x-ray. However, the patient had normal pulmonary function tests in [2110]. He was placed on nebulizers which seemed to have minimal effect throughout his hospital course. Other considerations would include a subacute anaphylaxis due to exposure at cats at his aunt's house, however, this is considered much less likely. Other considerations would include intra-abdominal bleed, status post right and left heart catheterization with a mild hematocrit drop compared to his baseline and moderate intra-abdominal swelling, post procedure, however, this did not seem to be a likely cause at least at the time of the dictation. Thus, it was felt that the cause of the respiratory distress was most likely secondary to aspiration pneumonia with superimposed congestive heart failure in the setting of mitral regurgitation and new onset of normal sinus rhythm. Coronary artery disease, the patient did have ST depressions on an outside hospital electrocardiogram. However, serial electrocardiograms in-house seemed to show no evidence of ST depressions. His creatinine kinase were cycled and were negative times three. He was continued on 81 mg of Aspirin, Gemfibrozil and Valsartan. Beta blocker was not an issue at the time of dictation. Hypertension, the patient was continued on Valsartan as well as Hydralazine in order to decrease the afterload with arterial dilators. This seemed to have good effect on both the blood pressure and the patient's pulmonary function. Electrophysiology, the patient was followed by the Electrophysiology Service while in the hospital. He was maintained on Telemetry and remained in normal sinus rhythm until the time of dictation. He remained on Coumadin with an INR goal of 2 to 2.5 as well as Amiodarone with good effect on both rhythm and rate. Mitral regurgitation, he had 2+ mitral regurgitation noted on echocardiogram on [2114-3-21] with an ejection fraction of 55%. His afterload was reduced with Valsartan and Hydralazine and he was preload reduced with the help of Lasix, both standing and prn. Neck fracture, status post failed cervical fusion, according to the orthopedics recommendation from Intensive Care Unit he should retain a hard collar while ambulatory, but a soft collar while in bed. He was continued on Valium for muscle spasm and it should be noted that he will need a fiberoptic intubation if he is to be intubated. Of note, he was not intubated during this hospital course until the time of dictation. Gout, The patient was maintained on renally dosed Allopurinol. Chronic renal insufficiency, the patient's creatinine remained stable at the time of dictation. Anemia, iron studies were drawn and were consistent with an anemia of chronic disease with an elevated ferritin. His MCV was 80. He was typed and screened and all stools were guaiaced and were guaiac negative. He was not transfused at least until the time of dictation. He will need an outpatient colonoscopy to work up the source for this anemia, especially given that he is on Coumadin. Fluids, electrolytes and nutrition, given the aggressive diuresis, electrolytes were checked b.i.d. The patient was maintained on a cardiac/congestive heart failure diet. A further discharge summary addendum will be dictated at a later time. DR.[Last Name (STitle) ],[First Name3 (LF) ] 12-ADF Dictated By:[Last Name (NamePattern1) 1811] MEDQUIST36 D: [2114-3-23] 19:24 T: [2114-3-23] 21:25 JOB#: [Job Number 33114]	[ "5070", "4280", "5849", "42731", "4240" ]
Admission Date: [2179-4-27] Discharge Date: [2179-5-4] Date of Birth: [2109-9-30] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6075] Chief Complaint: Acute gait disturbance Major Surgical or Invasive Procedure: CT head History of Present Illness: 69yo RH M who presented to the ED yesterday after a fall. He reports that he woke in the morning to go to the bathroom and then after taking a few steps he fell, because he "wasn't paying enough attention". He cannot specify further details or provide a better explanation; he denies that his legs were weak or that he felt off balance. Per Dr.[Name (NI) 12343] note, his wife noted that his left arm was hanging and that he could not dress himself (patient denies) and that he could not figure out how to walk or "how to use his legs". He was taken here for evaluation and head CT revealed an intracerebral hemorrhage. He denies that he had headache or vertigo. No nausea or vomiting. It is unclear whether he lost consciousness but there were no shaking movements. He presented to our ED and was given decadron and loaded with dilantin. Past Medical History: ?TIA [2176-5-11] HTN & DM, both resolved after he lost weight per his wife Hyperlipidemia Prostate CA [2176] s/p resection TB s/p treatment TBI from MVA in [2159], with persistent facial asymmetry, L eye injury, personality changes and cognitive dysfunction Dementia (ApoE 4+), followed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 6817] Cataracts Waldenstrom macroglobulinemia, on chlorambucil s/p gunshot wound to right face (no residual deficits) Latent TB - started INH and pyridoxine in [2178-1-11] Social History: Walks with cane (was not using it yesterday morning when he fell). No etoh, tob, drugs. Lives with his wife and attends an adult day program. Family History: mother had a stroke in 70's Physical Exam: VS 97.7/97.7 69-83 117-140/58-69 [12-28] 99% 490/275 Gen Lying in bed in NAD Neck supple CV rrr no bruits Pulm ctab Abd soft benign Ext no edema NEURO MS Awake, alert. Fully oriented. MOYB intact. Speech fluent, with normal naming, [Location (un) 1131], writing, comprehension and repetition. Counts two people on the right side of the cookie jar picture. When asked if anything is pink in his room (it is to his left), he searches to the right side predominantly and does not find it. Nor does he find the computer to his left. And he counts chairs only to his right side. He denies all deficits, apart from those which are old. L arm apraxic. CN CN I: not tested CN II: VFF to confrontation, no extinction. Pupils 3->2 on R, non-reactive on the L. CN III, IV, VI: L eye has upgaze paresis and on downgaze, it intorts (due to IV action). The left eye is esotropic CN V: intact to LT throughout, but extinguishes on the left to DSS CN VII: L facial droop, with incomplete eye closure on the left CN VIII: hearing intact to FR b/l (no extinction to DSS) CN IX, X: palate rises symmetrically CN [Doctor First Name 81]: shrug [5-15] and symmetric CN XII: tongue midline and agile Motor Normal bulk and tone. Needs encouragement for power testing on the left ( motor impersistence) D B T WE FE FF IP Q H DF PF TE R 4 5 5 4- 3 5 4 5 5- 5- 5 5- Sensory intact to LT, PP, JPS, vibration throughout. Extinguishes to DSS in the left arm and left leg. Reflexes 2+ throughout, toes mute Coordination R action tremor. L arm apraxic. Gait deferred Pertinent Results: Imaging NCHCT [4-28]: Comparison with [2179-4-27], 19:46 p.m. Similar appearance of the frontoparietal intraparenchymal hemorrhage. No significant interval change in size. Scattered opacification of scattered ethmoid air cells is noted. Evidence of previous frontal sinus surgery. No significant change since examination of eight hours prior. . NCHCT [4-27]: Acute right frontoparietal intraparenchymal hemorrhage with questioanble fluid level and small subarachnoid component. Mild surrounding edema and leftward subfalcine herniation. Differential for this lesion includes amyloid angiopathy with underlying intraparenchymal mass and sequelae of trauma felt slightly less likely. The fluid level within the hemmorhage is suggestive of a coagulopathy . . LABS on Admission: WBC-4.4 RBC-3.97* HGB-11.6* HCT-33.3* MCV-84 MCH-29.2 MCHC-34.7 RDW-14.0 PLT COUNT-253 PT-12.7 PTT-32.0 INR(PT)-1.1 ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG . A1c 6.91 Cholest 213 Triglyc 381 HDL 109 CHOL/HD 2.0 LDL 96 . Labs on discharge [2179-5-4] Chemistry 143 107 9 88 AGap=11 3.5 29 0.7 Ca: 8.5 Mg: 2.2 P: 2.9 Hematology 87 4.4 10.7 257 31.4 Brief Hospital Course: Mr. [Known lastname 1661] is a 69-year-old right-handed man with a history of traumatic brain injury, dementia, Waldenstrom's macroglobulinemia, hypertension, and diabetes who was brought to the ED after a fall at home following the acute onset of dressing apraxia and gait apraxia. His exam was also notable for left-sided neglect and extinction to double simultaneous stimuli. His brief hospital course by problem is as follows: . 1. Intraparenchymal hemorrhage. During evaluation of his neurologic symptoms, a non-contrast head CT revealed a right frontoparietal hemorrhage with a small subarachnoid component and surrounding edema causing a 2-3 mm subfalcine herniation. Based on the radiographic appearance, it was thought that the most likely underlying etiology is amyloid angiopathy. He was initially admitted to the neuro ICU for frequent monitoring. Aspirin and chlorambucil were held due to concerns of exacerbating the bleeding. Blood pressure was closely monitored, and there was no need to restart antihypertensives, which he had been on in the distant past but not recently. He was initially loaded with dilantin. No seizures occurred and this was discontinued on [2179-4-28]. Repeat head CTs showed stable appearances of hemorrhage. MRI/MRA was not performed due to facial shrapnel following previous gun shot wound. . His stay in the ICU was uncomplicated and he was transferred to the floor on [2179-4-29]. He continued to recover on the [Hospital1 ], receiving PT and OT. On discharge, the LL quadrantanopia remains in addition to mild LUE weakness. He will benefit from further inpatient rehabilitation and has neurology follow-up arranged with his neurologist Dr [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. . Given the risk of further bleeding with amyloid angiopathy, we would not recommend restarting aspirin unless he should develop some clear vascular indication requiring secondary prevention. . 2. Diabetes mellitus, type 2. This continues to be diet-controlled. . 3. Dementia. He was continued on donepezil. . 4. Waldenstrom's Macroglobulinemia. The chlorambucil was also held due to concern regarding altered platelet function. This was discussed with his oncologist Dr [Last Name (STitle) ], who was in agreement with short term holding of this medication. This should be restarted around [5-11]. . 5. Mr [Known lastname 1661] had several loose stools prior to discharge. C. diff negative and symptoms settling. . 6. CODE: FULL . 7. Dispo: He was discharged to an extended-care facility for further physical and occupational therapy. Medications on Admission: Aricept 10 ASA 81 Chlorambucil 6mg daily . Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:2 2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:50 Tablet(s) Refills:2 3. Chlorambucil 2 mg Tablet Sig: Three (3) Tablet PO once a day: Take 3 pills once a day in the morning, starting from [5-11] . Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: Intracranial hemorrhage Amyloid angiopathy Discharge Condition: Stable. Mild left arm weakness persists. Discharge Instructions: You have had an episode of bleeding in the brain. You have not been restarted on aspirin because of this. Chlorambucil was also held to minimize risk of worsening the bleeding. You should restart the chlorambucil on [5-11]. Please take other medications as prescribed and keep follow up appointments. Please seek further medical assistance for any new symptoms of weakness or altered sensation, speech or swallowing difficulties, unsteadiness or visual difficulties or any other concerns. Followup Instructions: Please arrange to see your PCP DR [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 4844] in the next week, phone number [Telephone/Fax (1) 250] . Neurologist: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 8384], MD Phone:[Telephone/Fax (1) 1690] Date/Time: [2179-5-10] 12:30 [Hospital Ward Name 860] Building, [Location (un) 551], Rm 253, [Hospital Ward Name 516] of [Hospital1 18] . You also have the following appointments scheduled: 1. Provider: [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) 26] [Last Name (NamePattern1) 8914] Phone:[Telephone/Fax (1) 1047] Date/Time:[2179-5-5] 10:00 2. Provider: [Name10 (NameIs) ] FERN, RNC Date/Time:[2179-5-5] 9:00	[ "2724", "25000", "4019" ]
Admission Date: [2196-3-9] Discharge Date: [2196-3-14] Date of Birth: [2143-6-4] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 896] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 10794] is a 52M with h/o dilated CM (EF 30-35% on [2195-12-10]), crack cocaine abuse c/b crack/toxic pneumonitis, h/o MRSA PNA, COPD, and Type I DM who presents with dyspnea on exertion over the last 36 hours. He noticed his dyspnea yesterday when he noticed he could not walk more than [2-21] of one block without stopping to catch his breath. This morning he was dyspneic in bed while supine after waking up. Going to a sitting position improved his dysnea somewhat. He walked back and forth to the bathroom and became extremely short of breath prompting him to call an ambulance. He had epigastric discomfort last night but declines chest pressure. He declines fevers, chills, nausea, vomiting, and diarrhea. Declines night sweats. . Of note, he has had multiple admissions for SOB and chest tightness in the setting of crack cocaine use and attributed to crack pneumonitis, most recently [Date range (1) 35039]/12 and [2196-2-29] - [2196-3-5]. During his last admission from [Date range (1) 63678], he was treated for with solumedrol, oxygen, and lasix for presumed toxic pneumonitis and systolic CHF exacerbation. He was in the MICU but not intubated and then transferred to the medicine floor during that admission. He was initially treated with antibiotics in the MICU, but these were discontinued on the floor as there was no evidence of infection. . In the ED, initial VS were: 163/122 159 37 96% on NIPPV. H was treated with ASA 300mg, nitro gtt, solumedrol 125mg iv once, levofloxacin 750mg iv, ceftriaxone 1g iv, lasix 80mg iv. Stopped Nitro gtt given bp 85/53 as of 0700. . On arrival to the MICU, the patient reported that his breathing felt much better than it did when he arrived to the ED. TTE was obtained which showed a decrease in LVEF to 20%. He was treated agressively with steroids and lasix. His edema and shortness of breath resolved within one day and he was subsequently transferred to general medicine. Past Medical History: Crack pneumonitis Type I Diabetes Hyperlipidemia HTN Nonischemic dilated cardiomyopathy ([10/2195]-LVEF 30-35%, mild RV dilation, borderline function, 1+ MR) Hepatitis C antibody positive MRSA pneumonia (requiring trach) COPD Substance abuse (cocaine) Tobacco abuse Schizophrenia Social History: - history of multiple incarcerations (>6 months in [2193]) - lives with sister - walks w/ cane due to right sided foot drop - Tobacco history: current smoker, 1 cig per day - ETOH: denies - Illicit drugs: reports last use [2167] though evidence of use prior Family History: - Father: pacemaker, deceased Physical Exam: Physical Exam on admission: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Physical Exam on discharge: Vitals: 98.6, [ 100-131]/[ 65-81], HR 86-97, 96 RA FS 382,261,159. GENERAL - well developed middle aged man in NAD, appears anxious, animated HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD LUNGS - clear to ausculation b/l, no adventitious breath sounds, I>E.No excess work of breathing. HEART - tachy regular rythm, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e SKIN - no rashes or lesions LYMPH - no cervical or submandibular LAD NEURO - awake, A&Ox3. Pertinent Results: Labs on admission: [2196-3-9] 06:54AM [Month/Day/Year 3143] WBC-11.8* RBC-3.74* Hgb-9.9* Hct-32.8* MCV-88 MCH-26.4* MCHC-30.1* RDW-17.2* Plt Ct-298 [2196-3-9] 06:54AM [Month/Day/Year 3143] Neuts-80.9* Bands-0 Lymphs-14.7* Monos-2.6 Eos-1.5 Baso-0.2 [2196-3-9] 06:54AM [Month/Day/Year 3143] Hypochr-2+ Anisocy-1+ Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Bite-OCCASIONAL [2196-3-9] 06:54AM [Month/Day/Year 3143] PT-10.8 PTT-31.3 INR(PT)-1.0 [2196-3-9] 06:54AM [Month/Day/Year 3143] Glucose-316* UreaN-24* Creat-1.0 Na-139 K-4.8 Cl-106 HCO3-24 AnGap-14 [2196-3-9] 06:54AM [Month/Day/Year 3143] CK(CPK)-171 [2196-3-9] 06:54AM [Month/Day/Year 3143] CK-MB-6 proBNP-3025* [2196-3-9] 06:54AM [Month/Day/Year 3143] cTropnT-0.02* [2196-3-9] 01:14PM [Month/Day/Year 3143] cTropnT-0.02* [2196-3-9] 06:54AM [Month/Day/Year 3143] Calcium-8.3* Phos-4.2 Mg-1.9 [2196-3-9] 06:54AM [Month/Day/Year 3143] ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2196-3-9] 09:24AM [Month/Day/Year 3143] Type-ART pO2-106* pCO2-43 pH-7.40 calTCO2-28 Base XS-0 [2196-3-9] 07:12AM [Month/Day/Year 3143] Lactate-2.3* [2196-3-9] 09:24AM [Month/Day/Year 3143] Lactate-1.2 [2196-3-9] 08:33AM URINE Color-Straw Appear-Clear Sp [Last Name (un) ]-1.005 [2196-3-9] 08:33AM URINE [Month/Day/Year ]-NEG Nitrite-NEG Protein-NEG Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [2196-3-9] 08:33AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [Month/Day/Year ] cx [3-9] x 2: pending Imaging: Echo [3-9]: The left atrium is moderately dilated. The left atrium is elongated. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed secondary to moderate-severe global hypokinesis. The basal-mid infero-lateral segments contract best. Quantitative (biplane) LVEF = 20 %. The right ventricular cavity is moderately dilated with borderline normal free wall function. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. Mild to moderate ([12-21]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a very small circumferential pericardial effusion without evidence of tamponade. CXR on admission ([3-9]): IMPRESSION: Increased asymmetric predominantly basilar diffuse airspace opacifications likely represent acute non-cardiac edema vs pulmonary toxicity from inhaled substance. Labs while on general medicine: [2196-3-14] 07:55AM [Month/Day/Year 3143] WBC-8.4 RBC-3.72* Hgb-9.8* Hct-32.7* MCV-88 MCH-26.2* MCHC-29.9* RDW-17.2* Plt Ct-236 [2196-3-13] 08:40AM [Month/Day/Year 3143] WBC-10.4 RBC-3.84* Hgb-9.8* Hct-34.0* MCV-89 MCH-25.6* MCHC-28.9* RDW-16.9* Plt Ct-268 [2196-3-12] 07:50AM [Month/Day/Year 3143] WBC-10.7 RBC-3.66* Hgb-9.4* Hct-32.2* MCV-88 MCH-25.8* MCHC-29.3* RDW-17.1* Plt Ct-271 [2196-3-14] 07:55AM [Month/Day/Year 3143] Glucose-352* UreaN-34* Creat-1.0 Na-138 K-3.8 Cl-100 HCO3-29 AnGap-13 [2196-3-13] 08:40AM [Month/Day/Year 3143] Glucose-248* UreaN-31* Creat-0.9 Na-139 K-3.9 Cl-100 HCO3-32 AnGap-11 [2196-3-12] 07:50AM [Month/Day/Year 3143] Glucose-267* UreaN-31* Creat-0.9 Na-141 K-4.1 Cl-104 HCO3-30 AnGap-11 [2196-3-11] 05:39AM [Month/Day/Year 3143] Glucose-208* UreaN-33* Creat-1.0 Na-142 K-4.2 Cl-102 HCO3-30 AnGap-14 [2196-3-10] 01:59AM [Month/Day/Year 3143] Glucose-312* UreaN-34* Creat-1.3* Na-140 K-5.2* Cl-101 HCO3-25 AnGap-19 *PENDING LABS NEUMONITIS HYPERSENSITIVITY PROFILE Results Pending [2196-3-12] 07:50AM [Month/Day/Year 3143] PNEUMONITIS HYPERSENSITIVITY PROFILE-PND . [2196-3-9] 7:00 am [Month/Day/Year 3143] CULTURE [Month/Day/Year ] Culture, Routine (Pending): Brief Hospital Course: Mr. [Known lastname 10794] is a 52M with dilated cardiomyopathy (EF 20%), crack cocaine abuse c/b crack pneumonitis, COPD, and Type I DM who presented to the ED with dyspnea on exertion for 36 hours. He was admitted secondary to hypoxemia a combination of acute systolic heart failure with an LVEF of 20% and hypersensitivity pneumonitis secondary to extensive history of smoking crack-cocaine and cigarettes. Problems: 1. Acute respiratory distress secondary to acute on chronic systolic heart failure 2. Hypoxemia secondary to hypersentivity pneumonitis secondary to crack-cocaine exposure 3. Diabetes, type I uncontrolled with complications 4. Schizophrenia Mr. [Known lastname 10794] presented to the ED with acute respiratory distress, hypoxemia, and extensive pitting lower extremity edema several days after being discharged from [Hospital1 18] for a previous episode of crack-cocaine induced pneumonitis. During this time, he reports smoking the occasional cigarette but his dual diagnosis rehab program noted that it was very unlikely that he was actively abusing crack. Given the degree of his hypoxemia, he had to be placed on NIPPV and was sent to the medical ICU for close monitoring. Given his known history of non-ischemic dilated cardiomyopathy with a depressed ejection fraction. An echo was obtained in the MICU which showed a depressed LVEF of 20%. His carvedilol was increased to 12.5mg [Hospital1 ] and he was aggressively treated with lasix. By hospital day 2, his lungs were clear to auscultation bilaterally and he had no lower extremity edema. He was put on Lasix 40mg po qd and remained euvolemic throughout the remained of his hospital stay on a non fluid restricted diet. Dr. [Last Name (STitle) ] was made aware of his depressed ejection fraction and said that Mr. [Known lastname 10794] could attend heart failure clinic, but Dr. [Last Name (STitle) ] expressed concerns that Mr. [Known lastname 10794] would be non-compliant. In addition, Mr. [Known lastname 10794] has follow up with Dr. [Last Name (STitle) ] [Last Name (STitle) ] cardiology for possible placement for an AICD. Pulmonary medicine was consulted and they recommended that the patient's respiratory distress was a direct result of reactive inflammatory changes secondary to crack and other unknown environmental triggers which resulted in a picture of hypersentivity pneumonitis. Given the very low suspicion for acute bacterial pneumonia his antibiotics were stopped after one dose. He was treated with high dose steroids which dramatically improved his breathing. He was started on a 20 day course of tapered prednisone starting at 60mg x5 days, 40mg x5 day, 20mg x 5 days, and 10mg x 5 days. He his breathing showed daily improvement while on steroids. On the day of discharge he no longer required supplemental oxygen and could ambulate with Sa02 in the 90's on room air. A hypersensitivity panel was sent off and the results of these tests are still pending. The patient has follow up with Dr. [Last Name (STitle) ] for PFTs and further pulmonary work-up in [Month (only) 547]. A complication of his high dose steroids was very high [Month (only) ] glucose levels. Despite 80mg of lantus with an aggressive humalog sliding scale, his finger sticks would be as high as 400. During his hospitalization, he never became ketotic nor did he become hypoglycemic. He was discharged on lantus 60mg [Hospital1 ] and a novolog sliding scale. This will have to be closely monitored as his steroid taper decreases. His schizophrenia is currently well controlled on seroquel. He shows no signs of paranoid, delusional, or disorganized thinking. Upon discharge, he was able to go live at home with his sister. In addition, he will continue to attend the [Hospital1 1680] dual diagnosis program as the patient is committed to quitting crack cocaine. He also has a prescription for cardiopulmonary rehabilitation at [Hospital1 2025]. Medication Changes** 1. Carvedilol increased to 12.5mg [Hospital1 ] 2. Predisone taper as listed above 3. Lantus 60mg [Hospital1 ] (same novolog SSI). Transitional Issues 1. Pending labs: [Hospital1 ] Cultures from [2196-3-9]. 2. Hypersensitivity Pneumonitis Work Up: Labs Pending. Appointment with Dr. [Last Name (STitle) ] for PFT's and follow up labs in [3-22]. Dilated cardiomyopathy: patient has an appointment with Dr. [Last Name (STitle) ] [Last Name (STitle) ] evaluation for AICD for prevention of sudden cardiac death. In addition, if the patient and PCP agree he is welcome to attend heart failure clinic. 4. Steroid taper causing hyperglycemia: Mr. [Known lastname 10794] [Last Name (Titles) ] sugar is very difficult to control while on corticosteroids. Per recommendations of Pulmonary medicine, he is on a large dose of prednisone with a long taper. As a result, his [Last Name (Titles) ] glucose will need to be vigilantly monitored and insulin regimen customized to reflect his steroid taper. Medications on Admission: -ipratropium bromide 0.02 % INH q6hrs prn -albuterol sulfate 90 mcg INH 1-2 puffs q 4-6 hrs prn -fluticasone-salmeterol 250-50 mcg/dose [Hospital1 ] -furosemide 40 mg daily -carvedilol 6.25 mg PO BID -lisinopril 5 mg daily -omeprazole 20 mg daily -aspirin 81 mg Tablet daily -atorvastatin 20 mg daily -quetiapine 100 mg qhs -ferrous sulfate 300 mg daily -nicotine 14 mg/24 hr Patch 24 hr Sig -insulin glargine 50 units qhs -Novolog sliding scale -tramadol 50 mg q4-6hrs prn Discharge Medications: 1. ipratropium bromide 0.02 % Solution Sig: One (1) unit Inhalation every six (6) hours as needed for sob/wheezing. 2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 *] (2 times a day). 4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:60 Tablet(s)* Refills:2 6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. quetiapine 50 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 12. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 14. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever/pain: do not drink alcohol when taking. Take less than 4gm per day. . 15. insulin glargine 100 unit/mL Solution Sig: Sixty (60) Units Subcutaneous twice a day: Please take at breakfast and bedtime. . Disp:3000 Units Refills:2 16. Novolog 100 unit/mL Solution Sig: As directed Units Subcutaneous with meals : As directed by sliding scale . 17. prednisone 10 mg Tablet Sig: 1-6 Tablets PO once a day for 17 days: Take 6 tabs for 2 days, then 4 tabs for 5 days, then 2 tabs for 5 days, then 1 tab for 5 days. Disp:47 Tablet(s) Refills:0 18. Outpatient Physical Therapy [Hospital ] rehabilitation 19. Glucometer Please provide patient with Glucometer 20. Glucometer Test Strips Please provide patient with glucometer test stripe Discharge Disposition: Home Discharge Diagnosis: 1. Respiratory failure (hypersensitivity pneumonitis) 2. Insulin dependent diabetes mellitus with complications 3. Compensated Systolic heart failure with an ejection fraction of 20% 4. Schizophrenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 10794], You were admitted for respiratory failure and pulmonary edema caused by lung irritation secondary to former crack cocaine and cigarette smoking. Also, you have heart failure which means your heart does not pump [Known lastname ] as well as it should, so fluid can accumulate in your lungs. Going forward you should return to your dual diagnosis partial hospital program at [Hospital 1680] Hospital in [Location (un) 18293]. At this program, they will help you with your addiction to crack cocaine. You also have a previous perscription to [Hospital 63676] rehab. Please attend this program as it will your ability to perform day-to-day activities without becoming short of breath. Since you are going to the [Hospital1 1680] program VNA will not be able to visit you while you are at this program. Please discuss resuming home VNA with your PCP after you complete the program. Your previous history of smoking has caused significant damage to your lungs. We are discharging you on a steroid taper. It is important that you take this medication specifically as directed. Also it is important to know that this medication can cause your [Hospital1 ] sugar to be higher than normal so it is important that you pay close attention to what you eat and monitoring your [Hospital1 ] sugar closely. Also prednisone can cause agitation and insomnia. If you are having difficult side effects from prednisone please talk to Dr. [First Name (STitle) 31365]. If your [First Name (STitle) ] sugar is consistently above 400, please call your PCP [Name9 (PRE) ],[Name9 (PRE) ] [Name Initial (PRE) ]. [Telephone/Fax (1) 7976] for help controlling your [Telephone/Fax (1) ] sugar. Please resume your normal home medications. We have made some changes as listed below. We are STARTING you on the following medication: 1. Start oral Prednisone taper as directed for the next 17 days: Prednisone taper as follows: 60 mg by mouth daily for 2 days, then 40 mg by mouth daily for 5 days, then 20 mg by mouth daily for 5 days, then 10 mg by mouth daily for 5 days. We are increasing your insulin glargine: 2. Please take Lantus (insulin glargine) 50units TWICE a day. Once at breakfast and once at 10pm. We are increasing your carvedilol. 3. Carvedilol 12.5mg tab by mouth TWICE a day. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. If you experience any of the danger symptoms below, please call your primary care doctor and go to the nearest emergency department. Followup Instructions: Department: [Hospital1 7975] INTERNAL MEDICINE When: MONDAY [2196-3-21] at 6:00 PM With: [First Name11 (Name Pattern1) 2801] [Last Name (NamePattern4) 14773], NP [Telephone/Fax (1) 7976], NP[MD Number(3) 12768] with Dr. [First Name (STitle) 31365] Building: [Hospital1 7977] ([Location (un) 686], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: [Hospital 7975] [Hospital ] HEALTH CENTER When: TUESDAY [2196-3-22] at 2:20 PM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 22387], MD [Telephone/Fax (1) 7976] Building: [Hospital1 7977] ([Location (un) 686], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: Free Parking on Site = Department: [Hospital 7975] [Hospital ] HEALTH CENTER When: TUESDAY [2196-3-22] at 3:30 PM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 12898], DPM [Telephone/Fax (1) 7976] Building: [Hospital1 7977] ([Location (un) 686], MA) [Location (un) ] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: CARDIAC SERVICES When: FRIDAY [2196-4-1] at 12:00 PM With: [Name6 (MD) ] [Name8 (MD) 163], 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: PULMONARY FUNCTION LAB When: MONDAY [2196-4-25] at 4:10 PM With: Dr. [Last Name (STitle) ] @ PULMONARY FUNCTION LAB [Telephone/Fax (1) 609] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "51881", "4280", "496", "V5867", "3051" ]
Admission Date: [2102-3-30] Discharge Date: [2102-4-3] Date of Birth: [2042-8-25] Sex: M Service: CARDIOTHORACIC Allergies: simvastatin Attending:[First Name3 (LF) 1505] Chief Complaint: coronary artery disease Major Surgical or Invasive Procedure: coronary artery bypass graftsx2(LIMA-LAD,SVG-DG) [2102-3-30] History of Present Illness: This 59 year old white male notes about a two month history of anterior neck pain. Initially he was aware of it most of the day, but more recently it has seemed to correlate only with exertion such as ambulating briskly for [Age over 90 ] yards. The discomfort typically resolves with rest but he has tried SL nitroglycerin which has been effective. He denies any chest discomfort or dyspnea. Exercise stress testing was notable for throat discomfort and 2mm ST depression in V5 and V6. He has since been put on Aspirin,a beta blocker and Plavix and is referred for left heart catheterization. Catheterization earlier revealed diffuse Left Cx and LAD disease. He was referred for coronary revascularization and is admitted as a same day surgery. Past Medical History: Hypertension Dyslipidemia Psoriatic arthritis Allergic Rhinitis Vasovagal syncope x 2 in the setting of medical valuation/procedures Anal fissure Herpes Simplex Type I s/p Umbilical hernia repair s/p [2097] resection of melanoma from back Social History: Race: Caucasian Last Dental Exam: 1 month ago with temp crown placed Lives with: Wife - Married with three children. Occupation: Social studies teacher Contact for discharge: [Doctor First Name ]- [Name (NI) ] [Name (NI) 59917] (wife) - [Telephone/Fax (1) 92509] Cigarettes: Smoked no [x] yes [] last cigarette Other Tobacco use: ETOH: < 1 drink/week [] 1 drink per week [2-14] drinks/week [] >8 drinks/week [] Illicit drug use - none Family History: Family History:Premature coronary artery disease Father is 85 with angina. Grandfather with a "heart condition", dying at age 84. Physical Exam: Pulse:57 Resp:20 O2 sat:100% RA B/P Right:119/61 Left:131/78 Height: 5'9" Weight:195# General: AAOx 3 in NAD Skin: Dry [x] intact [x] Psoriasis lower extremities, Rosea on cheeks 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: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:cath site Left:2+ DP Right:2+ Left:2+ PT [Name (NI) 167]:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit Right:none Left:none Pertinent Results: [2102-4-1] 03:45AM BLOOD WBC-9.6 RBC-3.21* Hgb-9.3* Hct-29.8* MCV-93 MCH-28.9 MCHC-31.1 RDW-13.1 Plt Ct-130* [2102-4-3] 04:40AM BLOOD WBC-6.9 RBC-3.21* Hgb-9.1* Hct-30.1* MCV-94 MCH-28.5 MCHC-30.4* RDW-13.1 Plt Ct-179 [2102-4-3] 04:40AM BLOOD UreaN-10 Creat-0.8 Na-138 K-4.2 Cl-103 Brief Hospital Course: He was taken directly to the Operating Room where surgery was done uneventfully. He weaned from bypass easily and transferrred to the ICU. He awoke, weaned and was extubated. Beta blockers were begun and he was diuresed towards his preoperative weight. He was transferred to the floor on POD1. and Physical Therapy worked with him. CTs and wires were removed per protocols uneventfully. A routine CXR on the day after CT removal was notable for a 3cm right pneumothorax and he was assymptomatic. A repeat film the next day showed the lung to have partially resolved and he remained well. At discharge wounds were healing well, he was independently ambulating and all follow up appointments were made. Medications on Admission: ATORVASTATIN 10 mg Tablet daily BISOPROLOL FUMARATE 5 mg daily CLOPIDOGREL 75 mg qam LISINOPRIL 20 mg Tablet daily NITROGLYCERIN 0.4 mg Tablet PRN ASCORBIC ACID 500 mg daily ASPIRIN 81 mg Tablet daily MULTIVITAMIN SALMON OIL-OMEGA-3 FATTY ACIDS [SALMON OIL-1000] daily Discharge Medications: 1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:50 Tablet(s) Refills:0 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 6. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital3 3765] Hospice Program Discharge Diagnosis: coronary artery disease s/p coronary bypass grafts dyslipidemia psoriatic arthritis s/p resection of malignant melanoma hypertension Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments: Surgeon:Dr.[Last Name (STitle) ]([Telephone/Fax (1) 170]) on [4-10]/512 at 10:30am Cardiologist:Dr.[Last Name (STitle) 7526] on [2102-4-11] at 10:30am Wound check in [Last Name (un) 6752] 2A on [2102-4-13] at 10:30am Please call to schedule appointments with: Primary Care: Dr.[First Name11 (Name Pattern1) 5279] [Initial (NamePattern1) ] [Last Name (NamePattern4) 59917]([Telephone/Fax (1) 21640]in [4-13] weeks Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Completed by:[2102-4-3]	[ "41401", "2851", "4019", "2724" ]
Admission Date: [2151-7-11] Discharge Date: [2151-8-3] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4748] Chief Complaint: thoracic aortic aneurysm Major Surgical or Invasive Procedure: [2151-7-12] L carotid to subclavian bypass [2151-7-13] thoracic aortic stent graft [2151-7-28] Tracheostomy and PEG History of Present Illness: 87F with a known thoracic aneurysm presents for preadmission hydration for a left carotid to subclavian bypass graft. She reports she has been well since her last admission. She reports no [Month/Day/Year 5162], chilld, chest/back/abdominal pain. No dyspnea. Past Medical History: - breast cancer 6-7 years ago s/p left lumpectomy and 5 years of Tamoxifen - L CEA [2-22] - HTN - hyperlipidemia - TAA - seasonal allergies Social History: smoked [1-15] ppd x 20 years, quit 40 years ago, drinks 1 glass, was previously working in real estate. Lives with daugther who assists with ADLs and medications. Family History: pt reports mother with HTN and stroke in 80s. Denies family history of MI. Physical Exam: VS: T 98.7 HR 78 SR, BP 136/52 RR 19-20 on CPAP/Vent O2 sat 100% Gen: Awake, alert, following commands and MAE. Neck: w/ seroma(visibly swollen, stable. Cards: RRR, VSS Lungs: CTA b/l Abd: soft, NT, ND Ext: well perfused, no edema Pertinent Results: [2151-7-28] 12:42PM BLOOD Hct-26.1* [2151-7-28] 02:42AM BLOOD WBC-7.4 RBC-2.83* Hgb-8.6* Hct-26.8* MCV-95 MCH-30.5 MCHC-32.2 RDW-14.5 Plt Ct-367 [2151-7-28] 02:42AM BLOOD Plt Ct-367 [2151-7-28] 02:42AM BLOOD Glucose-100 UreaN-36* Creat-1.1 Na-139 K-3.7 Cl-101 HCO3-28 AnGap-14 [2151-7-27] 05:29AM BLOOD Glucose-107* UreaN-36* Creat-1.1 Na-141 K-3.9 Cl-101 HCO3-31 AnGap-13 [2151-7-22] 02:09AM BLOOD Lipase-53 [2151-7-14] 02:38AM BLOOD Lipase-17 [2151-7-17] 12:38PM BLOOD CK-MB-NotDone cTropnT-0.02* [2151-7-17] 04:20AM BLOOD CK-MB-2 cTropnT-0.02* [2151-7-28] 02:42AM BLOOD Calcium-10.9* Mg-2.3 [2151-7-27] 05:29AM BLOOD Calcium-11.4* Phos-2.5* Mg-1.9 Radiology: CXR (PORTABLE AP) Study Date of [2151-7-28] 1:19 PM FINDINGS: As compared to the previous radiograph, the endotracheal tube has been removed. The patient has undergone tracheostomy, the tracheostomy tube is in correct position. The left-sided chest tube has been removed. There is minimal pneumopericard, but no evidence of pneumothorax. Status post removal of the nasogastric tube. No other relevant changes. CT CHEST W/O CONTRAST Study Date of [2151-7-22] 10:47 AM IMPRESSION: 1. Minimal enlargement largely serous left supraclavicular fluid collection since [2151-7-15], new small high-density component suggests prior bleeding. CTA would be required to exclude vascular connections, but the absence of appreciable change argues against active bleeding. 2. No change in the appearance or location of the left subclavian artery stent and aortic endoprosthesis. No enlargement of aortic aneurysm. 3. Probable pulmonary artery hypertension, calcific aortic stenosis, and possible mitral annulus dysfunction from calcification. 4. Mild bronchiolitis, improved right upper lobe, increased right lower lobe suggests aspiration. Complete left lower lobe collapse is stable, subtotal lingular atelectasis worsened, right basal segmental atelectasis stable. CT CHEST W/O CONTRAST Study Date of [2151-7-15] 10:59 PM IMPRESSION: 1. Left supraclavicular fluid collection might be related to post-operative seroma. 2. Small bilateral pleural effusions, new, left more than right. Worsening of bibasilar atelectasis, now involving the entire left lower lobe. 3. Stent graft in place, patency assessment is limited without contrast, overall appears to be unremarkable. 4. The NG tube tip impinging the stomach wall and should be pulled back approximately 5 cm. 5. Centrilobular nodules seen in the right lung as described, grossly unchanged since [2151-6-22], may represent airway infection/inflammation. No evidence of interstitial lung disease seen. 6. Several pulmonary nodules that might be of different origin and might be followed in six months if clinically warranted. Attention to the left lower lobe collapse should be given with subsequent imaging to document its resolution. CHEST (PRE-OP PA & LAT) Study Date of [2151-7-11] 9:04 PM IMPRESSION: PA and lateral chest read in conjunction with a chest CT scan, particularly frontal and lateral scout views on [2151-6-22]. Allowing for differences in radiographic technique there is no evidence of change since [6-22] in the heavily calcified thoracic aorta with aneurysmal dilatation of the ascending and arch portions, left lower lobe collapse, normal heart size. Heavy aortic valvular calcifications not appreciated on the conventional radiographs, but clearly seen on the CT scan. Lungs are otherwise clear. No pleural effusion. Cardiology: Portable TTE (Complete) Done [2151-7-17] at 11:05:18 AM FINAL Conclusions The left atrium is elongated. The estimated right atrial pressure is 10-15mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. There is moderate valvular mitral stenosis (area 1.0-1.5cm2). Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Moderate concentric left ventricular hypertrophy. Hyperdynamic left ventricular function. Moderate mitral stenosis. Mild aortic stenosis. Moderate pulmonary hyeprtension. ECG Study Date of [2151-7-13] 12:36:02 PM Baseline artifact. Sinus tachycardia. Otherwise, probably normal. Compared to the previous tracing of [2151-7-11] the findings appear similar, although comparison of atrial rhythm and atrial morphology is difficult because of underlying artifact. ECG Study Date of [2151-7-11] 9:58:58 PM Normal sinus rhythm. Axis is 0 degrees. Late transition. Compared to the previous tracing of [2151-6-22] no diagnostic interval change. Brief Hospital Course: [2151-7-11] Admitted to Vascular Surgery for hydration and pre-op left carotid to subclavian bypass graft in preparation of endograft repair of thoracic AAA. Routine nursing, ECG and CXR were done. Made NPO fater MN, IV hydrated. [2151-7-12] HD1: Cardiothoracic surgery consulted for Thoracoabdominal aneurysm-recs -endo candidate and that pre procedure left corotid subclavian bypass should be done due to lack of sufficient landing zone in her aortic arch. Taken to OR and underwent Left common carotid to subclavian artery bypass, PTFE graft from the common carotid artery to the subclavian artery. Tolerated procedure well, recovered in the PACU then transferred back to the VICU for further observation. Patient was Was pre-oped and consented for Stent graft repair of thoracic aortic aneurysm in am. [2151-7-13] Taken to the angio suite and underwent Stent graft repair of thoracic aortic aneurysm. Post-op patient was placed on BIPAP for respiratory acidosis. Transferred to CVICU. [2151-7-14] Remained in CUICU, required low dose Neo for BP support. Remained on BIPAP. Had periods of agitation requiring medication. RISS per CVICU, electrolytes repleted. 7/2-14/09: Pt. developed respiratory distress and was re-intubated, agitated and confused requiring sedation w/ Propofol. Her CT chest done- showed a new basal L pleural effusion. This was followed by serial CXRs, and a L CT was placed on [2151-7-21] that has drained 65 mls SS in the last 24 hrs. The CT is placed anteriorly and is not draining the fluid present in the dependant postero basal part of the pleural cavity. On [2151-7-22] CT showed LLL consolidation with mild to moderate element of pleural effusion. Also noted to have left neck seroma. BAL/BRONCHOSCOPY was positive for gm -rods/+cocci, Vanc and Zosyn were started. Had some problems w/ tachycardia resumed beta blockers. DVT prohylaxis w/ heparin SC. Transfused w/ 2 units of packed cells for low HCT. Patient became febrile on [2151-7-22] Urine cx- showed UTI- added Cipro to ABX. Cental line d/c'd- tip cultured. Pan cultured, ID consulted- presumed VAP and poss line sepsis-recs continue Vanc/Zosyn. Pulmonary consut for vent weaning. [7-28]: Pt to OR for Percutaneous tracheostomy (#7 Portex cuffed), Placement of PEG tube, Therapeutic bronchoscopy. Patient unable to be separated from vent. [2062-7-28]: Patient stable with tracheostomy, receiving tube feeds via PEG, and continuing antibiotics until [8-5] for VAP, possible line infection. Awaiting vent rehab placement. [2151-8-3]: No acute events. Rehab bed offer at the [Hospital1 ] in [Location (un) 701], Patient was discharged in good condition, to continue IV antibiotics till [2151-8-5]. Neuro: Patient alert and oriented following commands. Patient had problems w/ agitation w/ intubation, off and on IV sedation for agitation management. Currently on Oxycodone-acetaminophen elixer for pain and Haldol prn for agitation. Resp: Patient developed VAP, treated w/ Vanco and Zosyn to continue till [2151-8-5]. Prolonged intubation and failed ventilator weaning, trached on [7-28], failed trache collar attemps. Mechanical Ventilation: MMV (Volume targeted - Mechanical Breaths Optional)mv target: 4.0 l/m Tidal volume (mechanical): 400 cc Respiratory rate: 10 Pressure support level: 10 cm/h2o PEEP: 5 cm/h2o FIO2: 40 %. Requested for [Hospital 5442] rehab placement on [2151-7-29]- bed offer Cards: Patient had been on sinus rythm during her hospital stay, there were issues w/ tachycardai managed w/ home dose beta blockers. GI: PEG on [2151-7-28], used after 24 hours. Tube feeds (Pulmonary Nutren): Goal rate: 40 ml/hr Residual Check: q4h Hold feeding for residual >= : 100 ml Flush w/ 30 ml water q12h, Reglan as needed for nausea. Moving bowels, last BM [2151-8-2]. GU: Foley remained from day of surgery [2151-7-12], adequate urine output, had UTI by Urine cultures, treated w/ Cipro. Endo: Patient had been on Glargine at HS and RISS for glycemic control. Skin: intact, no decubiti or skin breakdown, L neck seroma is stable. ID: ID following: [7-21] Blood Cultures: positive for [2-15] Coag neg staph, [7-21] sputum cultures STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML.GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML. Diagnosed w/ VAP as well as possible line infection- treated w/ Vanco and Zosyn. [7-26] C-diff cultures negative. Medications on Admission: Metoprolol Tartrate 50 [Hospital1 ] Lisinopril 10 mg qd Aspirin 81 mg qd Atorvastatin 10 mg qd Allopurinol 200 mg qd Discharge Medications: 1. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: Two (2) Recon Soln Intravenous Q6H (every 6 hours) for 2 days: 2.25grams IV. Discontinue on [8-5]. Disp:16 Recon Soln(s) Refills:0 2. HydrALAzine 10 mg IV Q4H:PRN SBP >150 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) 100mg PO BID (2 times a day). Disp:60 100mg Refills:2 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheezes. 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Dorzolamide-Timolol 2-0.5 % Drops Sig: Two (2) Drop Ophthalmic QHS (once a day (at bedtime)). 10. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [Hospital1 ] (2 times a day). 11. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO DAILY (Daily). 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain, fever. 13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) 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. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 16. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 19. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 2.5-5 MLs PO Q6H (every 6 hours) as needed for pain. 20. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. 21. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 22. Regular Insulin SC Sliding Scale Q6H Glucose Insulin Dose 0-60 mg/dL 4 oz. Juice 61-100 mg/dL 0 Units 101-130 mg/dL 3 Units 131-160 mg/dL 6 Units 161-200 mg/dL 9 Units 201-240 mg/dL 12 Units > 240 mg/dL Notify M.D. 23. Glargine 20 Units subcutaneously every bedtime 24. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous Q 24 h for 2 days: D/C [2151-8-5]. Discharge Disposition: Extended Care Facility: [Hospital1 700] TCU - [Location (un) 701] Discharge Diagnosis: Thoracic aneurysm Pneumonia-VAP Sepsis-r/t central line, line was d/c'd, treated w/ Vanco/Zosyn Post-op Respiratory failure- requiring re-intubation, failed vent wean and eventual tracheostomy Anemia-acute requiring blood transfusion UTI- from urine cultures, treated w/ Cipro- resolved History of: HTN hyperlipidemia hypercholesterolemia gout acute renal failure thoraco-abdominal aortic aneurysm PSH: s/p hysterectomy [2102], s/p, left lumpectomy [6-20] yrs ago s/p tamoxifen treatment, s/p Left MRM ~02, s/p RT TKR [2142], s/p lt CEA Discharge Condition: Stable Discharge Instructions: Vascular Surgery Discharge Instructions - You were admtted for Thoracic aneurysm, you underwent [2151-7-12] L carotid to subclavian bypass and [2151-7-13] thoracic aortic stent graft after which you developed difficulty of weaning from the ventillator that required you to have Tracheostomy and PEG on [2151-7-28]. - You were discharged to rehab, for ventillator weaning and physical therapy, - Continue all your medications as precribed, - You may shower, no baths, - Diet for now is Pulmonary Nutren w/ a goal of 40 cc per hour via PEG, you will remain NPO until your trache is discontinued, and possibly swallowing studies, - You will FU w/ Dr. [Last Name (STitle) 1391], please call his office for an appointment, - You will also, FU w/ Dr. [Last Name (STitle) ] after you are discharged from rehab, please call his office for an appointment [Telephone/Fax (1) 18152]. - Followup Instructions: Call Dr.[Name (NI) 1392] office for follow up in 2 weeks. Phone: [Telephone/Fax (1) 1393] Call Dr.[Name (NI) 7446] office after you are discharged from rehab, call his office for an appointment [Telephone/Fax (1) 9393]. Completed by:[2151-8-3]	[ "2851", "5849", "0389", "99592", "2762", "5990", "4019" ]
Admission Date: [2172-11-18] Discharge Date: [2172-11-27] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 905] Chief Complaint: Evaluation for IR procedure for LGIB of unknown etiology Major Surgical or Invasive Procedure: 1. Upper endoscopy 2. Colonoscopy 3. CT Angiography 4. Tagged RBC Scan 5. Bilateral lower extremity ultrasound 6. Infrarenal IVC filter placement History of Present Illness: Ms. [Known lastname 13144] is a 87-year old woman with history of CAD CHF and previous history of internal hemorrhoids transferred from OSH for 3 days of LGIB. She initially presented on [11-15] from an [Hospital3 ] facility with an episode of BRBPR in her bathroom to [Hospital ] hospital, with an initial Hct of 31.9. Ms. [Known lastname 13144] was hemodynamically stable and admitted to the floor where she sustained a gradual drop in her Hct (naidr 22.9) and platelets (89K) and subsequently transfused and. She received a colonoscopy that demonstrated old/fresh blood throughout colon with diverticular disease most pronounced on the left. The bleeding source could not be identified. She continued to bleed and was then transferred to the ICU. . On the morning [2172-11-17], Ms. [Known lastname 13144] received a tagged RBC scan that demonstrated no active bleeding. Later that day, she began to bleed again and a repeated tagged RBC scan (11hrs post contrast) showed diffuse activity throughout the colon with the most likely origin near the hepatic flexure. (Poor localization of bleeding by tagged RBC scan is noted). Concerned about the risks major surgery, GI and surgery at [Location (un) ] thought IR might a good therapeutic option. . Ms. [Known lastname 13144] was therefore tranfered to the [Hospital1 ] for evaluation for possible IR. At the time of transfer, SBP ranged 110s-120s, HR 80s, O2 Sat 98-100% 2L NC. She had one episode of tachycardia for which she received a single dose of a beta blocker (her home beta blocker had been held up to this point). . <strong> Summary of events and interventions at OSH: 6 units PRBCs, 1 unit plts, intermittent episodes of BRBPR (~300cc in total) during transfer. Cause of bleeding unclear. OSH Hct 22 -> 27 </strong> . On [2172-11-18], at arrival at [Hospital1 18] she was calm and in no acute distress. MICU ([2172-11-18] - [2172-11-21]) interventions events: 2 units PRBC, intermittent episodes of bloody BMs, imaging studies (EGD, colonoscopy, angiography) inconclusive. . # [2172-11-18] - 1 unit PRBCs (Hct 28.1 --> 28.5 --> 28) . # [2172-11-19] - Tachycardic to 120s, treated with diltiazem 5mg, HR decreased to 60s but pt remained in Afib - NG lavage w/traumatic epistaxis (Pt became tachycardic to 120s, treated with diltiazem 5mg, HR decreased to 100) - EGD: Erythema in the pre-pyloric region. Otherwise normal EGD to third part of the duodenum. - Colonscopy: 2 large sigmoid nonbleeding diverticuli, sigmoid 1.4cm flat polyp. More blood in left colon than right colon. No source of bleeding within the colon was identified - Maroon BM w/stable Hct (26-28) . # [2172-11-20]: - Hct AM 24.4 in setting of bloody BM -> 1uPRBC -> Hct 29.9; Hct remained stable - Angiography: No sign of active bleeding - Stools: 3 bloody BL prior . Prior to transfer from the ICU, vital signs were Tmx: 98.9 Tcur: 98.2 HR 77 BP 115/52 (110-144/42-106) RR 21 (14-28) O2 Sat 97% on RA. . Upon arrival to the floor, Ms. [Known lastname 13144] reports no acute distress, however, she does report feeling somewhat lightheaded. Her mental status has been stable. She had 1x bloody bowel movement approximately <150 ml. Her Hct has remained stable at 27.6. Since her initial presentation at [Location (un) ] and arrival to the floor, she has received a total of 10 units PRBCs. . Past Medical History: - Coronary artery disease - GERD - Internal hemorrhoids - ? CHF (baseline EF unknown) - Interstitial lung disease - Hypertension - Benign positional vertigo (recurrent) - Left bundle branch block - Urinary urgency with incontinence - Panic attacks - Essential tremor - Osteoarthritis - Sinusitis Social History: Widowed. Moved from [State 108] recently. - Tobacco: None - Caffeine: 2 cups of coffee per day - Alcohol: None currently, drank 1 drink per day prior to [6-/2172] hospitalization - Illicits: Denies illicit drug use Family History: Noncontributory Physical Exam: ON ADMISSION: Vitals: afebrile 125/50 81 18 100/3L General: Alert, oriented, c/o mild abdominal pain, acutely aware of bowel movements, no acute distress HEENT: Sclera anicteric, dry MM Neck: no JVP elevation, collapsable on U/S exam Lungs: Sparse scattered crackles but otherwise clear CV: RRR, II/VI SEM Abdomen: soft, mildly diffusely tender, non-distended, +BS, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: cold but with palpable pulses, no edema Skin: dry, pale Rectal: ~[1-18] cup of maroon liquid stool AT DISCHARGE: 97.1 afebrile 136/60 (90-136/60s) 75 (65-86) 20 95% RA General Appearance: Well nourished, no acute distress, wrapped up in a blanket General: Alert, oriented, no acute distress HEENT: Sclera anicteric, mmm Neck: No JVP elevation Lungs: CTAB, wheezing much improved (just had an ipratropium neb per pt), good inspiration no accessory muscle use, no rhonchi, or rales CV: RRR (not tachy or irreg sounding this AM), II/VI SEM, no carotid bruits appreciated. Abdomen: Soft, non tender, non-distended, +BS, no rebound tenderness or guarding Ext: WWP; +1 edema, some discomfort with squeezing but otherwise improvd Skin: Dry, pale. Limited skin exam. Pertinent Results: On admission: [2172-11-18] 04:30AM BLOOD WBC-7.7 RBC-3.12* Hgb-9.8* Hct-26.9* MCV-86 MCH-31.4 MCHC-36.3* RDW-17.2* Plt Ct-114* [2172-11-18] 04:30AM BLOOD Neuts-76.8* Lymphs-18.0 Monos-4.0 Eos-0.8 Baso-0.4 [2172-11-18] 04:30AM BLOOD PT-12.9 PTT-27.2 INR(PT)-1.1 [2172-11-18] 04:30AM BLOOD Fibrino-174 [2172-11-18] 04:30AM BLOOD Glucose-113* UreaN-18 Creat-0.3* Na-140 K-3.9 Cl-109* HCO3-29 AnGap-6* [2172-11-18] 10:28AM BLOOD CK-MB-3 cTropnT-<0.01 [2172-11-18] 04:30AM BLOOD Calcium-7.2* Phos-1.8* Mg-2.0 [2172-11-18] 08:33AM BLOOD Type-MIX pH-7.28* Comment-GREEN TOP [2172-11-18] 08:33AM BLOOD Lactate-1.4 [2172-11-18] 08:33AM BLOOD freeCa-1.05* . Labs on Discharge: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2172-11-27] 06:12 6.4 3.34* 10.4* 30.1* 90 31.0 34.4 17.4* 130* . STUDIES: # ECG [2172-11-18]: Normal sinus rhythm. Complete left bundle-branch block. Low voltage in the lateral precordial leads. Frontal plane axis at minus 25 degrees. No previous tracing available for comparison. . # TTE [2172-11-18]: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Mild symmetric left ventricular hypertrophy with normal biventricular systolic function. Moderate tricuspid regurgitation. Moderate pulmonary artery systolic hypertension. . # CT Abdomen/pelvis [2172-11-18]: <I>CT Abdomen w/ & w/o Intravenous Contrast</I> There is dependent atelectasis at the lung bases, without nodule, mass, consolidation, or pleural/pericardial effusion. There is a moderate hiatus hernia. . The liver is normal in size and attenuation. There are no focal liver lesions identified. The hepatic vasculature is widely patent. Incidental note is made of a replaced right hepatic artery, arising from the SMA. There is no intra- or extra-hepatic biliary ductal dilation. The gallbladder is unremarkable. . The spleen is normal in size. Pancreas enhances homogeneously. The main pancreatic duct is mildly prominent, measuring 3 mm, but there are no obstructing mass lesions identified. There are no adrenal nodules or masses. Kidneys enhance symmetrically. Punctate hypodensities, cortically based are noted within the right kidney, too small to characterize though likely representing cysts. There are no enhancing renal mass lesions. There is no nephrolithiasis or hydronephrosis. . Accounting for hiatus hernia, the stomach, duodenum, and intra-abdominal loops of small bowel are normal. There is no bowel distention, and there is no bowel wall thickening. The colon is similarly unremarkable. Scattered sigmoid diverticula are noted, without evidence of acute diverticulitis. There is no active extravasation identified within the gastrointestinal tract to localize the patient's source of bleeding. . The aorta is atherosclerotic, but normal in caliber. There is narrowing at the origin of the celiac axis, though the celiac artery remains patent, and there is no post-stenotic dilation. The SMA and [Female First Name (un) 899] are well opacified. Single renal arteries are patent bilaterally. The common, external, and internal iliac arteries are patent, as are the visualized portions of the common, superficial, and deep femoral arteries. Visualized deep veins are similarly normal. . There is no free fluid or free air in the abdomen. There is no mesenteric or retroperitoneal adenopathy. . <I>CT Pelvis w/ & w/o Intravenous Contrast</I> Bladder is decompressed by a Foley catheter. Uterus is unremarkable, and there are no adnexal masses. Multiple phleboliths are noted. There is no free fluid in the pelvis, and there is no pelvic or inguinal adenopathy. . BONE WINDOWS: Extensive degenerative change is identified in the visualized thoracolumbar spine. A non-aggressive lucent lesion in noted in the L4 vertebral body, without suspicious lytic or sclerotic osseous lesion . IMPRESSION: 1. No active extravasation identified within the gastrointestinal tract. Sigmoid diverticulosis is noted, but there is no definite source of gastrointestinal hemorrhage is identified. 2. Small hiatus hernia. 3. Replaced right hepatic artery, arising from the SMA. 4. Moderate stenosis at the origin of the celiac artery. . # Chest (Portable AP) [2172-11-18]: Heart size top normal. Elevation of right hemidiaphragm probably due to eventration. Lungs grossly clear. No pleural effusion. Healed fracture posterior left middle rib should not be mistaken for a lung nodule. . # Colonoscopy [2172-11-19]: Findings: - Contents: Red blood was seen in the entire colon, more in the left colon than in the right. There was no blood in the terminal ileum. - Protruding Lesions: A single sessile 14 mm polyp was found in the descending colon. This was not removed given current bleeding. A single sessile 5 mm polyp was found in the sigmoid colon. This was not removed given current bleeding. - Excavated Lesions: A few diverticula with large openings were seen in the sigmoid colon. . Impression: Blood in the colon Diverticulosis of the sigmoid colon Polyp in the descending colon Polyp in the sigmoid colon Otherwise normal colonoscopy to terminal ileum . Recommendations: No source of bleeding within the colon was identified. If recurrent bleeding immediate angiography. . # Upper endoscopy [2172-11-19]: Findings: Esophagus: Normal esophagus. Stomach: Mucosa - Erythema of the mucosa was noted in the pre-pyloric region. Duodenum: Normal duodenum. . Impression: Erythema in the pre-pyloric region Otherwise normal EGD to third part of the duodenum . Recommendations: No upper GI source of bleeding found . # Chest XRay [2172-11-22] FINDINGS: Thoracolumbar levoscoliosis, mild cardiomegaly, tortuosity of the descending thoracic aorta are unchanged since [2172-11-18]. Lung volumes are decreased. There is no evidence of new consolidation or effusion. . IMPRESSION: 1. No evidence of pneumonia. 2. Decreased lung volumes. . # EKG [2172-11-22] Probable atrial fibrillation with rapid ventricular response. Left bundle-branch block. Since the previous tracing of [2172-11-20] sinus rhythm has been replaced by probable atrial fibrillation. . # TAGGED RED BLOOD CELL: GI Bleeding Study [2172-11-24] Following intravenous injection of autologous red blood cells labeled with Tc-[Age over 90 ]m, blood flow and dynamic images of the abdomen were obtained for 2 hours. A left lateral view of the pelvis was also obtained. Blood flow images show no evidence of GI bleeding. Dynamic images show no evidence for active gastrointestinal bleeding two hours after injection. The study was terminated at this point due to patient request. . # Bilateral Lower Extremity Ultrasound Grayscale and Doppler examination of the right and left common femoral, superficial femoral, popliteal and calf veins were performed. There is occlusive thrombus within the right peroneal vein and non-occlusive thrombus within the right posterior tibial vein. The right popliteal, superficial femoral and common femoral veins are patent with normal compressibility and respiratory variation in flow. There is also a large 5.6 x 3.1 x 1.9 cm [Hospital Ward Name 4675] cyst in the right popliteal fossa. . Within the left leg, there is non-occlusive thrombus within one of the deep intramuscular veins of the posterior calf, possibly the gastrocnemius vein. The other deep veins including the left common femoral, superficial femoral, popliteal, peroneal and posterior tibial veins are patent with normal compressibility and respiratory variation and flow. . Brief Hospital Course: 87 year old woman with history of [Hospital ] transferred from OSH for evaluation for IR procedure for LGIB of unclear exact source. No fevers, leukocytosis. . # LGIB: Pt presented to OSH with LGIB and Hct lowest at 22.9. She was transfused 6units PRBCs at OSH. Colonoscopy and imaging there had suggested colonic origin. She was transferred to [Hospital1 18] where CT abdomen/pelvis revealed sigmoid diverticulosis but no active extravasation. She underwent colonoscopy under anesthesia that revealed diverticulosis of sigmoid colon and polyps in descending and sigmoid colon but did not identify site of bleeding. NG lavage returned bright red blood. Endoscopy was performed that again did not identify bleeding. She required 4 additional units of PRBCs during ICU course for Hct below 25. She continued to have multiple episodes of dark maroon colored output from rectum. She was taken for CT angiography that was also negative for active extravasation. After all these procedures and her last unit of transfused PRBCs, Hct remained stable at 27-29 and she was transferred to the floor at that point. Surgery consult team was made aware of the patient how given inability to localize bleeding no surgical intervention was recommended. Pt continued to ooze initially while on the floor and require additional unit of blood for a total of 11units during her stay. Tagged red blood cell scan failed to localize the bleeding. Pt's bleeding improved and stool changed from maroon to brown w/out evidence of frank blood. HCT stablized and was 30-32 at time of discharge. GI follow-up is planned as outpt. . # DVT: On the floor, pt complained of leg pain. On exam was tender to palpation and legs showed +1 edema. LENIS was performe and demonstraed b/l dvts. Because of continued bleed, the pt could not receive anticoagulation so a IVC filter was placed w/out complications. . # CAD: Pt's history of CAD was unclear. She had known LBBB, Q waves on EKG. Pt does not believe any past AMI. Denies any chest pain or new onset SOB. Metoprolol and aspirin were initially held in setting of GIB. Metoprolol was eventually restarted along with diltazem (see below) given afib. Isosorbide mononitrate continued to be held given concern over bleeding and risk of hypotension. . # CHF: TTE performed at admission showed preserved EF > 55% and mild symmetric left ventricular hypertrophy with normal biventricular systolic function, moderate tricuspid regurgitation, and moderate pulmonary artery systolic hypertension. Home triamterene and HCTZ were held during ICU stay due to LGIB. These need for restarting these [Hospital1 4085] will need to be re-evaluated as an outpt as the pt recovers. Currently blood pressure is stable on metoprolol 25mg TID and diltizem 30mg QID. . # Rapid afib: In the ICU, HR increased to 120s on HD2; she was given one time dose of diltiazem 5mg which decreased HR to 60s but pt remained in afib. She was given low dose beta blocker and converted back to sinus rhythm. On the floor, pt had 2 episodes of afib w/RVR which required pushing of IV diltiazem and support with IV fluids given low blood pressure. Rates were in the 160s and pt was becoming hypotensive; on heart rate measure showed rate of 207 but repeat was in the lower 100s. Pt broke and returned to sinus with IV diltazem. Pt was eventually placed on a regimen of 25mg metoprolol TID and 30mg Diltiazem QID; this may need to be adjusted and she recovers. . # ?Sleep apnea: Oxygen saturation in high 90s on room air but fell to 80s while asleep. She preferred to sleep w/O2 at night which improved sats. She should be assessed with sleep study as outpatient. . # Interstitial lung disease: Pt had unclear history of interstitial lung disease and had been on low dose prednisone at home. This was held during ICU course and continued to be held on the floor due to bleeding concerns. Pt also had some wheezing and coarse lung sound whihc improved w/nebulizer treatments. Howver, albuteol could not be used b/c of afib so ipratropium was used. Will need to reassess as outpt the need for prednisone. . # Urinary retention: Patient is being treated for urinary urgency with incontinence. She had an episode of urinary retention for ~8hrs in which she was found to have 750 mL of urine in her bladder. This resolved without intervention with a post-void volume of ~300 mL. . Pt has GI follow-up planned. Pt is going to rehab facility to complete recovery and then will return to her [Hospital3 ] facility. . Medications on Admission: HOME MEDS: - Metoprolol succinate, 25 mg SR, 1 tablet daily - omeprazole, 20mg EC 1 capsule PO daily - prednisone, 5 mg tab PO daily - isosorbide mononitrate, 30 mg tab SR 24 hr QHS - sertraline, 50 mg tab 1 tab PO daily - tolterodine, 4 mg Capsule SR 1 PO daily - triamterene-hydrochlorothiazide, 37.5 mg-25 mg, 1 tablet PO MWF - ibandronate, 150 mg tablet monthly - fluticasone, 50 mcg Spray, suspension, 2 sprays nasal daily - pyridoxine 100 mg tab PO daily - ascorbic acid, 500 mg SR daily - calcium carb-D3-mag cmb11-zinc 333 mg-200 unit-[Unit Number ] mg-5 mg 1 tab daily - cholecalciferol (vitamin D3), 400 unit daily - cyanocobalamin (vitamin B-12), 1,000 mcg tablet SR daily - ginger (zingiber officinalis), 500 mg capsule daily - naproxen 250 mg tablets, unknown dose - omega-3 fish 1 tablet PO QAM - omega-3 fatty acids-vitamin E 1,000 mg (120 mg-180 mg) capsule daily . MEDICATIONS At TRANSFER TO [Hospital1 18] - Nexium 40mg IV BID - Lopressor 2.5mg Q4H prn HR > 110 - Flonase 2 sprays [Hospital1 ] . Discharge Medications: 1. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. pyridoxine 100 mg Tablet Sig: One (1) Tablet PO once a day. 4. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days: 6 day course to be completed on [11-28] (last day of abx). 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing, SOB. 9. metoprolol succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 10. metoprolol succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 11. diltiazem HCl 120 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [Hospital ] Rehabilitation and Nursing Center - [Location (un) 701] Discharge Diagnosis: Primary: lower GI bleed from unknonw source hypotension anemia due to acute blood loss atrial fibrillation w/rapid ventricular rate . Secondary: bilateral DVT requiring placement of an IVC filter UTI GERD Interstitial lung disease 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 because you were having bleeding from your lower gastrointestinal track. You needed to be admitted to the ICU because of the extent of your bleeding and the need for significant blood transfusions and blood pressure support. Multiple attempts were made to determine the source of the bleeding including a colonoscopy and a special imaging scan. Unfortunately, we could not identify the source of your bleeding. However, you were given multiple units of blood and were stablized in the ICU. Your condition improved and you were able to be moved out of the ICU to the regular medicine floor. Your bleeding slowed and finally stopped. However, while on the medicine floor, you had several episodes of a fast irregular heart beat called atrial fibrillation which resulted in low blood pressure. Medications were given to control your heart rate so that it would go at normal rate and your blood pressure improved. In addition, you had lower leg pain. A special ultrasound was performed which showed that your had clots in both of your legs. Ususually this would be treated with anticoagulation [Location (un) 4085]; however, you could not receive these medications while you were in the hospital because of your bleeding. To prevent the clots from moving into your heart and lung, a special filter was placed in the vein leading to your heart. You were also found to have a urinary tract infection and were treated with antibiotics. Your condition improved and you were able to be discharge to a rehabiliation facility to complete your recovery. . The following changes were made to your medications: - Please START taking metoprolol succinate 75mg daily. - Please START taking diltaziam XR 120mg daily. - Please START taking pantoprazole 40mg daily instead of omeprazole - Please complete a 6 day course of Ciprofloxacin 500 mg daily to be finished on [2172-11-28]. - Please continue using Ipratropium nebulizers to help with your wheezing every 6hrs. - Please STOP taking your prednisone. You will need to speak to your doctors regarding this [Name5 (PTitle) 4085] change and whether or not you should restart or stop this [Name5 (PTitle) 4085]. - Please STOP taking isosorbide mononitrate. You will need to speak to your doctors regarding this [Name5 (PTitle) 4085] change and whether or not you should restart or stop this [Name5 (PTitle) 4085]. - Please STOP taking triamterene-hydrochlorothiazide. You will need to speak to your doctors regarding this [Name5 (PTitle) 4085] change and whether or not you should restart or stop this [Name5 (PTitle) 4085]. - Please STOP taking naproxen, aspirin, ibuprofen or any other NSAIDS you may take over the counter (you can take tylenol for pain). - Please continue to take all of your other home medications as prescribed. Please be sure to take all [Name5 (PTitle) 4085] as prescribed. Please be sure to keep all follow-up appointments with your PCP, [Name10 (NameIs) ], cardiologist and other health care providers. . It was a pleasure taking care of you and we wish you a speedy recovery. . Followup Instructions: You will need to speak to your doctors regarding this [Name5 (PTitle) 4085] change and whether or not you should restart or stop this [Name5 (PTitle) 4085]. . Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [2172-12-9] at 1:30 PM With: [Initials (NamePattern4) ] [Last Name (NamePattern4) 11716] [Name8 (MD) 11717], MD [Telephone/Fax (1) 463] Building: Ra [Hospital Unit Name 1825] ([Hospital Ward Name 1826]/[Hospital Ward Name 1827] Complex) [Location (un) ] Campus: EAST Best Parking: Main Garage Department: CARDIAC SERVICES When: FRIDAY [2172-12-25] at 1:40 PM With: [Name6 (MD) 251] [Last Name (NamePattern4) 677], 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 [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910] Completed by:[2173-1-17]	[ "2851", "5990", "42731", "4280", "2875", "53081", "311", "41401" ]
Admission Date: [2116-9-24] Discharge Date: [2116-10-12] Date of Birth: [2067-1-16] Sex: M Service: GENERAL SURGERY, BLUE CHIEF COMPLAINT: Right-sided abdominal pain. HISTORY OF PRESENT ILLNESS: This was a 49-year-old man with hypertension and diverticulosis who presented to [Hospital6 1760] on [2116-9-24], with an acute onset of right lower quadrant pain and fever to 102??????. He began feeling fatigued at the beginning of [Month (only) 216]. He began having fevers to 102-103?????? with a dry cough. It was felt that he had bronchitis which was treated first with Ceclor for a 10-day course. The patient still complained of mild stomach pains in the upper abdomen prior to this antibiotic treatment and then stated that after Ceclor, he began having diffuse abdominal pain with tenderness and nausea but not vomiting. The cough continued. The Ceclor was finished on [9-19], five days prior to admission. He felt better with decreased abdominal pain. On the day of admission while at work, the patient noted increasing abdominal pain, acute onset on the right side, with sharp "explosive" pain. In fact, he complained that he was unable to move secondary to this increased pain. He also noted constipation for quite a while and significant distention of the abdomen, as well as decreased appetite, associated with a small intentional weight loss. The patient presented to an outside right after the increased abdominal pain and was transferred to [Hospital6 649]. At the outside hospital, he was noted to be tachycardiac with shortness of breath, unable to take a deep breath secondary to pain, as well as being febrile. PAST MEDICAL HISTORY: Hypertension. Knee surgery. Pesticide exposure. Diverticulosis. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS: Atenolol 10 mg once a day, Naproxen p.r.n., Ceclor as mentioned above. SOCIAL HISTORY: The patient has 4-5 beers a day. He has a 20 pack-year smoking history. Denied intravenous drug use. He works as a grounds keeper and had a recent camping trip in [State 531] state. FAMILY HISTORY: The patient's grandmother has had gastric cancer. PHYSICAL EXAMINATION: Vital signs: The patient was afebrile at 99.2??????, but was 102.5?????? at the outside hospital. He was tachycardiac at 102. Blood pressure 124/60, respirations 23, oxygen saturation 100% on room air. General: The patient was in no acute distress. Cardiovascular: Regular, rate and rhythm. Lungs: Clear to auscultation bilaterally. Abdomen: Obese and distended abdomen with tenderness in the right upper quadrant and left lower quadrant. No guarding noted. Rectal: Nontender. Guaiac positive. Extremities: Warm. LABORATORY DATA: On presentation to [Hospital6 649] his white blood cell count was 12.8, 53% neutrophils, 27% bands, 10% lymphocytes, hematocrit 38.3, platelet count 610; PT 15.2, PTT 26.2, INR 1.5; sodium 133, potassium 4.9, chloride 99, bicarb 24, BUN 19, creatinine 1.8, glucose 132; ALT 61, AST 79, alkaline phosphatase 139, total bilirubin 0.9, amylase 22, albumin 2.3; urinalysis on [9-25] showed a large amount of blood with trace amounts of protein, ketones and leukocytes. CAT scan at the outside hospital showed free fluid in the abdomen, liver, spleen and in the pelvis. He had a collapsed colon. There was a 4 x 4 cm round collection in the left lobe of the liver with mass formation about the anterior left lobe and transverse colon. No free air. The patient was considered to have a liver abscess/phlegmon involving the left lobe of the liver and perhaps the transverse colon. The etiology was most likely diverticulitis, considering the patient's prior medical history. The patient was admitted to Surgery, made NPO with intravenous fluids, given intravenous antibiotics, and blood cultures were sent. In placed on CIWA prophylaxis for his alcoholism. A percutaneous liver biopsy and biopsy to the mass of the liver were also planned. Subsequently this liver biopsy revealed a significant amount of fibrosis and inflammation but no tumor etiology. At this point, the patient was either deemed to have liver abscesses or metastasis, and the patient was managed expectantly over the next few days. Gastroenterology and Hepatology were consulted on the patient's care. It was noted over the next few days, that the patient began to have some mental status changes. These were noted to coincide with an increased ammonia level but also increasing white blood cell count levels. On the morning of [9-27], the patient was noted to have an increasing white blood cell count jumping to 19.6 from the admission value of 12.8. Based on this lab value, the slowly deteriorating mental status, the slight tachycardia and the persistent low-grade fevers the patient had on the first few days of admission, the patient was taken for paracentesis on [9-27] prior to going to the Operating Room. The paracentesis revealed purulent fluid within his peritoneal cavity with increased white blood cells and increased red blood cells. This also was the significant reason why the patient was taken to the Operating Room. After being appropriately consented, the patient was taken to the Operating Room for exploratory laparotomy where lysis of adhesions were also performed. The patient was noted during this surgery to have 4 L of pus within his abdominal cavity, as well as three large hepatic abscesses. These abscesses were unroofed, and biopsies were performed of the abscesses. The patient was left packed, and drains were placed to allow drainage of the abscess cavities. The patient was then transferred to the Intensive Care Unit with the plan of reexploring him in two days. The patient's course in the Intensive Care Unit over the next two days was uneventful except for several fluid boluses, as well as several transfusions of packed red blood cells. On [9-29], the patient was reexplored via the prior laparoscopic scar. He was washed out, and the abdomen was closed. He returned to the Intensive Care Unit and underwent an otherwise unremarkable course. During the rest of the Intensive Care Unit stay, the patient was again monitored with a Swan-Ganz catheter for volume status and hemodynamics. He had fluid repletion for his hypervolemia and also had electrolyte repletion multiple times for hypokalemia and hypomagnesemia. Cultures taken during the operations revealed scant growth of Streptococcus milleri, on the 26th, Streptococcus it was revealed that there was scant growth of Corynebacterium and [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 29361]. A transesophageal echocardiogram on [10-1] revealed no vegetations consistent with endocarditis. In addition, the left ventricular ejection fraction was greater than 55%. There was no mass or vegetations seen on any of the valves. There was pericardial effusion. On [10-5], the patient was noted to be draining some frank blood from his fourth suction bulb drain. A CAT scan on [10-6] revealed a new left rectus sheath hematoma. Since the patient's hematocrit at this time was stable, this hematoma was managed conservatively and subsequently continued to drained out blood but soon dried up, and the drain was removed shortly after on [10-6]. On [10-8], the patient was considered stable enough to be transferred to the floor. The patient was transferred to the floor and had a benign course. While on the floor, the patient's hyperalimentation and total parenteral nutrition was discontinued. He was maintained on a regular diet with Boost supplement. His central line and Foley were both discontinued. The patient was continued on pulmonary treatment with nebulizers to assist his saturations, as well as BIPAP machine at night to help his oxygen saturations. Stool was sent for C-diff while the patient was on the floor but was negative. A disposition screen was performed by Physical Therapy who stated that the patient would do well from a short stay in a rehabilitation facility. He was therefore considered stable enough to go to a rehabilitation facility today on [10-12]. Today the patient is afebrile, slightly tachycardiac at 108, blood pressure 150/94, 95% on 3 L. He is tolerating a good p.o. diet and has good urine output. He still has a drain that is putting out serosanguinous fluid with a slight greenish tinge that may be bilious, and we will therefore keep this drain in. On discharge exam, the patient is alert and oriented, sleeping comfortably without his BIPAP machine. He is in no apparent distress. Heart rate regular, rate and rhythm. Lungs are clear to auscultation bilaterally. His abdomen is soft, obese, nontender, with dressings that are clean, dry, and intact. His JP is in the left upper quadrant with a slight drainage. He is therefore being discharged in good condition to the [Hospital6 14480] Facility in [Location (un) 38], [State 350]. DISCHARGE DIAGNOSIS: 1. Hypertension. 2. Diverticulosis. 3. Status post ultrasound-guided liver biopsy. 4. Status post peritonitis and sepsis. 6. Multiple liver abscesses. 7. Status post exploratory laparotomy times two. 8. Status post lysis of adhesions. 9. Status post unroofing of hepatic abscesses. 10. Status post suction bulb placement times four. 11. Status post paracentesis. 12. Chronic blood loss anemia requiring multiple red blood cells transfusions. 13. Hypovolemia requiring fluid resuscitation. 14. Hypokalemia requiring Potassium repletion. 15. Hypomagnesemia requiring Magnesium repletion. 16. Hemodynamic monitoring with Swan-Ganz catheter. 17. Hyperalimentation. 18. Left rectus sheath hematoma. 19. Sleep apnea requiring BIPAP. 20. Exchange of central line over the wire. DISCHARGE MEDICATIONS: Metoprolol 25 mg p.o. twice a day, hold for heart rate less than 60 and systolic blood pressure less than 110, Dilaudid 2-4 mg p.o. every 3-4 hours as needed for pain, Furosemide 40 mg p.o. twice a day, Fluconazole 200 mg p.o. once a day, Levaquin 500 mg p.o. once a day, Metronidazole 500 mg 3 times a day, Pantoprazole 40 mg p.o. once a day, Atrovent inhaler 2 puffs every 4-6 hours as needed, Albuterol 2 puffs every 4 hours as needed, Heparin subcue t.i.d. DISCHARGE INSTRUCTIONS: Drain care twice a day, daily lab tests as per the written discharge summary. The abdominal dressings should be changed twice a day. FOLLOW-UP: The patient has a follow-up appointment with Dr. [First Name8 (NamePattern2) ] [Name (STitle) 468] in two weeks; please call to schedule an appointment with him. [First Name8 (NamePattern2) 251] [Name8 (MD) ], M.D. [MD Number(1) 4984] Dictated By:[Doctor Last Name 52112] MEDQUIST36 D: [2116-10-12] 12:42 T: [2116-10-12] 12:49 JOB#: [Job Number 52113]	[ "0389", "4019" ]
Admission Date: [2130-9-29] Discharge Date: [2130-10-1] Date of Birth: [2058-11-17] Sex: F Service: MEDICINE Allergies: Shellfish / Percocet / Zosyn / Amiodarone Attending:[First Name3 (LF) 2297] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: Placement of central venous line Tracheal intubation History of Present Illness: 71 year old female, chronically trach'ed and vented, h/o multiple hospitalizations since [4-10], h/o multiple psedomonal PNAs, ARDS, COPD, chronic hypercarbia, presented to the ED after being discharged from the ICU to rehab 2 days ago. . The patient has had extensive recent hospitalizations. Last hosp was for 1 month from [Month (only) ] to mid [Month (only) ]. During the most recent admission, she was tx'd for hypotension, hypercarbic respiratory failure, recurrent multi-drug resistant pseudomonal pneumonia, (for which she completed a 21 day course of meropenem, altered mental status and rapid atrial fibrillation. When the patient was discharged, she was stable on PSV 10/5 FIO2 0.4, pulling normal tidal volumes. Although a chronic CO2 retained, pt left the hospital in no respiratory distress. . Reportedly, last night, while on SIMV mode, the patient was anxious, agitated, awake the whole night and was medicated with ativan total of 1.5mg, and then fell asleep. Per rehab notes, at 7am, the patient was not arousable, and ABG done, pCO2 92 (80s baseline) with O2 sats in the high 80s. Pt was switched back to AC, given 80 IV lasix w/o improvement, pCO2 on re-check was 132. Pt was then sent to [Hospital1 18] ED. . Upon arrival to the [Hospital1 18] [Name (NI) ], pt's abg was 7.34/90/112. Her UA was also + and Ucx was sent. The patient was admitted to the MICU for lethargy, hypercarbic resp failure. Past Medical History: 1. Influenza A in [4-10] complicated by ARDS eventually leading to intubation, ventilatory support, and tracheostomy. 2. Remote history of pneumonia. 3. Status post left eye cataract surgery. 4. Anxiety 5. DMII Social History: no significant tobacco or alcohol use. Family History: non-contributory. Physical Exam: T: 97.8 BP:110/45P: 70 (AFib) RR: 23 O2 sats: 98% Gen: Cachexic elderly female with tracheostomy in mild resp distress, slightly tachypneic HEENT: OP clear. track in place CV: +s1+s2 irregular No Murmurs Resp: Coarse air movement anteriorly. Abd: Tender over umbilicus and to the right of the umbilicus. +R CVA angle tenderness There is some guarding. No rebound tenderness. Back: Scoliotic Ext: 2+ pretibial/pedal edema Neuro: A&O x 3 Pertinent Results: [2130-10-1] 04:40AM BLOOD WBC-7.7 RBC-2.72* Hgb-8.3* Hct-24.0* MCV-88 MCH-30.5 MCHC-34.6 RDW-17.3* Plt Ct-25* [2130-10-1] 12:24AM BLOOD WBC-6.4 RBC-2.30* Hgb-6.8* Hct-20.5* MCV-89 MCH-29.4 MCHC-33.0 RDW-16.9* Plt Ct-35* [2130-9-30] 05:30PM BLOOD WBC-5.4 RBC-2.31* Hgb-6.8* Hct-20.9* MCV-91 MCH-29.5 MCHC-32.5 RDW-16.7* Plt Ct-34* [2130-9-30] 04:42AM BLOOD WBC-5.7 RBC-2.86* Hgb-8.6* Hct-25.6* MCV-89 MCH-30.0 MCHC-33.5 RDW-16.6* Plt Ct-47* [2130-9-29] 11:45AM BLOOD WBC-8.8 RBC-2.97* Hgb-9.1* Hct-27.2* MCV-92 MCH-30.6 MCHC-33.4 RDW-16.5* Plt Ct-84# [2130-9-29] 11:45AM BLOOD Neuts-91.5 Bands-0 Lymphs-6.4* Monos-1.2* Eos-0.7 Baso-0.2 [2130-10-1] 04:40AM BLOOD PT-26.1* PTT-42.5* INR(PT)-2.7* [2130-10-1] 04:40AM BLOOD Glucose-96 UreaN-80* Creat-1.4* Na-138 K-4.7 Cl-92* HCO3-38* AnGap-13 [2130-9-29] 11:45AM BLOOD Glucose-148* UreaN-64* Creat-1.0 Na-137 K-4.2 Cl-88* HCO3-47* AnGap-6* [2130-10-1] 04:40AM BLOOD ALT-790* AST-865* AlkPhos-120* Amylase-48 TotBili-2.2* [2130-10-1] 04:40AM BLOOD Calcium-7.5* Phos-6.5# Mg-2.8 [2130-10-1] 10:17AM BLOOD Hgb-7.5* calcHCT-23 O2 Sat-92 [2130-10-1] 10:17AM BLOOD freeCa-1.16 . CXR: : Comparison is made to previous study from [2130-9-29]. The tracheostomy tube and left-sided central venous catheter are unchanged in position and appropriately sited. There is cardiomegaly, unchanged. There are again seen diffuse airspace opacities throughout both lungs, which have worsened and have more confluent opacification within the left mid-to-lower lung field. There is a prominent retrocardiac opacity. There is also increased density seen in the lung apices. This may represent loculated fluid. The patient has severe scoliosis. These diffuse airspace opacities are nonspecific and could be due to a combination of extensive pulmonary edema versus infectious/inflammatory process. Alveolar hemorrhage would also have a similar appearance. . CT abd / pelvis: IMPRESSION: 1. No evidence of retroperitoneal hematoma. 2. No evidence of hydronephrosis or hydroureter. 3. Continued pulmonary consolidations consistent with pneumonia. 4. Cholelithiasis. Brief Hospital Course: 71F with chronic respiratory failure secondary to influenza/ARDS, reccurent pseudomonal pneumonias, afib, bronchiectasis admitted with changes in mental status and hypercarbic respirator failure. She placed back on AC ventilation, and was treated with steroids and inhalers. Her respiratory status was continuing to decline, and she also developed acute renal failure (oliguric), as well as thrombocytopenia and coagulaopathy. Her BP was trending downward, and she was requiring medications to maintain MAP of 55. It was unclear the etiology of her thrombocytopenia, and there was concoern for HIT or DIC. There were multiple family meetings with the MICU team, including Dr. [Last Name (STitle) ]. The decision was made to make her comfort measures only, which was amenable to the entire family. She expired in the presence of her family, peacefully, and in no apparent distress. THe family declined an autopsy. Medications on Admission: lansoprazole sertraline 50qd tylenol prn sotalol 40qd diltiazem 30 qid atrovent inh albuterol inh hydral 25 q 6h epogen [2124] u sc q mo we fri senna colace warfarin 4mg qd prednsione 60qd (to be started on a taper week of [10-7]) lasix 120 iv qd Discharge Medications: na Discharge Disposition: Expired Discharge Diagnosis: Respiratory failure THromobctopenia UTI Acute renal failure Discharge Condition: na Discharge Instructions: na Followup Instructions: na	[ "5990", "42731", "5849", "496", "2875", "99592", "25000", "2859" ]
Admission Date: [2139-11-26] Discharge Date: [2139-12-19] Date of Birth: [2108-10-17] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 78] Chief Complaint: Sudden onset headache and Right sided weakness Major Surgical or Invasive Procedure: [11-24]: Placement of External Ventricular Drain / right side [11-25]: Angiogram and embolization of a-comm aneurysm [11-29]: Re-Placed EVD right side [12-4] evd removal on right/evd placed on left /cerebral angioplsty [12-7] and [12-8] cerebral angiogram History of Present Illness: HPI:Pt. is a 31 year old male, who per his mother has been having occipital headaches for the past few weeks. per outside ED report pt. was shoveling manure today when he developed a sudden onset headache and right sided weakness. He was taken to an outside facility where his headache was accompanied by sever N/V and questionable seizure activity and decerebrate posturing, pt. was intubated there after CT scan showed diffuse SAH greatest in the region of the ACOM, and he was transferred to [Hospital1 18]. Past Medical History: PMHx: none Social History: Social Hx: + tobacco ( approx. 1-2 packs) pt. rolls own No ETOH Family History: Family Hx:NC Physical Exam: PHYSICAL EXAM: O: T: BP: 133 /70 HR: 50's R: vented 16 O2Sats 100% Gen: Intubated and sedated IN ICU HEENT: Pupils: 2mm, minimally reactive EOMs: unable to eval. Extrem: Warm and well-perfused. Neuro: + cough and gag Mental status:intubated sedated, not following commands Cranial Nerves: I: Not tested Motor: slight decerebrate posturing seen in ED Dishcarge Exam: AOx2-3, MAE with full strength. No prontator drift Pertinent Results: [2139-11-26] 12:22AM WBC-22.0* RBC-4.34* HGB-13.9* HCT-39.9* MCV-92 MCH-32.0 MCHC-34.8 RDW-13.9 [2139-11-26] 03:16AM PT-13.4 PTT-24.1 INR(PT)-1.2* [2139-11-26] 12:22AM GLUCOSE-160* UREA N-11 CREAT-0.8 SODIUM-139 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15 [2139-11-30] 06:29PM CEREBROSPINAL FLUID (CSF) WBC-1500 HCT,Fl-6.0* Polys-88 Lymphs-2 Monos-8 Macroph-2 CTA [11-25] IMPRESSION: 1. Anterior communicating artery aneurysm, 9 x 5 mm. 2. Massive intraparenchymal and intraventricular hemorrhage with hydrocephalus. Small amount of subarachnoid hemorrhage. CT Perfusion [11-27] IMPRESSION: 1. Relatively unchanged appearance of diffuse subarachnoid, predominantly right frontal intraparenchymal and extensive intraventricular hemorrhage. Persistent perihemorrhagic edema around the right frontal hematoma causing mild subfalcine herniation measuring up to 7 mm, unchanged. 2. Interval clippage of the anterior communicating artery aneurysm with no signifacnt residual within limits of the sreak artifact from the coils. No other abnormalities noted. CTA [11-29]: CONCLUSION: No change in ventricular calibers since study of [2139-11-29]. No evidence of new hemorrhage. Status post coiling of anterior communicating artery aneurysm with residual intraparenchymal and intraventricular hemorrhage. The CT perfusion study demonstrates an avascular area corresponding to the right frontal lobe hematoma but no evidence of cerebral ischemia elsewhere. The CTA suggests generalized reduction in caliber of the intracranial arteries with no focal narrowings to suggest vasospasm. Brief Hospital Course: 31M admitted to the ICU on [11-25] with no eye opening(attempted however), follows commands in UEs & LLE. PERRL, and EVD in place. He was extubated on [11-26] and ICPs were WNL. He had a CTA/Perfusion study which showed no vasospasm or ischemia. He then pulled out his EVD on the night of [11-27]. He had a Head CT which showed no worsening hydrocephalus. He did become more lethargic on the [11-29] and the EVD was replaced and emperic treatment antibiotics were started for elevated WBCs in the CSF. ICPs WNL however remained bloody. On [11-30] he began to become more alert and arousable, following commands although only oriented to self. On [12-1] he show improved alertness and orientation. [12-2] decreased mental status in the afternoon- CTA+P sugestive of vasospasm began triple H therapy with goal bp 180 pt scheduled for diagnostic angio [12-4] showed ACA territory vasospasm. He required continued with a EVD at 10. He remained neurologically orientated x1, followed commands difficult with 2 step commands, motor strength full throughout. He had continuous hyponatremia, he was treated with salt tabs with good effect. On [12-7] and [12-8] a diagnositic angio showed vasospasm for which he received verapamil. He remained neurologically with some short term memory issues remembering the date and the name of the hospital. On [12-14] his EVD was removed and [12-15] he was transferred to the neurostep down unit. He progressed well once he was on the floor, he orientated X3, eating well, voiding and having bowel movements. PT and OT were concerned with cognitive abilities and felt he would need 24 hour care. He is being sent home with his parents for 24 hours supervision they have agreed to providing this care. Medications on Admission: None Discharge Medications: 1. Tylenol 325 mg Tablet Sig: Three (3) Tablet PO every [3-21] hours. Tablet(s) 2. Keppra 1,000 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:120 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: A-comm aneurysm rupture subarachnoid hemorrage(atraumatic) vasospasm / cerebral Discharge Condition: stable Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair, as your staples have been removed. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. 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, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office on [2138-12-24] for a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [Telephone/Fax (1) 1669]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [First Name (STitle) ], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast. Completed by:[2139-12-19]	[ "2761", "3051" ]
Admission Date: [2110-3-31] Discharge Date: [2110-4-10] Service: Cardiac Surgery NOTE: Date of discharge pending; awaiting rehabilitation bed. CHIEF COMPLAINT: Chest pain, 3-vessel disease. HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old-female who was transferred to [Hospital1 346] from an outside hospital where she presented with chest pain. The patient was known to have a history of coronary artery disease and paroxysmal atrial fibrillation. A cardiac catheterization was done at the outside hospital and revealed severe 3-vessel disease. She was started on a heparin infusion and transferred to the [Hospital1 188] for definitive management. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease. 2. Asthma, steroid dependent. 3. Hypertension. 4. Coronary artery disease with angina. 5. Anemia. 6. Paroxysmal atrial fibrillation. 7. Degenerative disk disease. 8. Obesity. 9. Spinal stenosis. 10. Gout. 11. History of colonic polyps. 12. Recurrent urinary tract infections. 13. Depression. 14. Peripheral neuropathy. ALLERGIES: An allergy to MORPHINE (causing a rash) ..................... MEDICATIONS ON ADMISSION: Medications prior to admission included Doxepin 100 mg p.o. q.d., clonazepam 0.5 mg p.o. q.d., Plavix 75 mg p.o. q.d., Prevacid, lactulose, Imdur, prednisone 10 mg p.o. q.d., atenolol, trazodone 50 mg p.o. q.d., Cardizem 360 mg p.o. q.d., Bactrim-DS, Bumex 1 mg p.o. q.d., Lasix 60 mg p.o. q.d. HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit, and plans were made for coronary artery bypass graft in the a.m. She underwent a coronary artery bypass graft times three on [2110-4-1] with a left internal mammary artery to left anterior descending artery, saphenous vein graft to DM, saphenous vein graft to posterior descending artery. She was transferred to the Cardiac Surgery Recovery Unit in stable condition. She had [Initials (NamePattern4) ] [Last Name (NamePattern4) 1661]-[Location (un) 1662] drain in the right groin which drained 600 cc over the first 24 hours. She had a hematocrit drop to 20 and was given packed red blood cells. She was extubated on postoperative day one. In the early a.m. on postoperative day two, she was acidotic with stridors and was reintubated and sedated. She was slowly weaned off the ventilator over the next few days. Her heart rhythm was in and out of atrial fibrillation. She slowly improved over the next few days. She was initially confused but improved gradually to the point where she was stable. She was extubated on [4-4]. She continued to make slow progress and was transferred from the Intensive Care Unit to the regular floor on [2110-4-7]. She had been started on amiodarone because of atrial fibrillation. She was in sinus rhythm when she was transferred to the floor. On the floor, her mental condition dramatically improved. Her oxygenation improved, and she was gradually improving in her general condition over the next few days. Her pacing wires were discontinued on postoperative day seven. She was started on p.o. amiodarone. DISCHARGE DISPOSITION: Currently, she is in a stable condition and ready for discharge to a rehabilitation facility. MEDICATIONS ON DISCHARGE: 1. Lopressor 25 mg p.o. b.i.d. 2. Lasix 20 mg p.o. q.d. 3. Potassium chloride 20 mEq p.o. q.d. 4. Colace 100 mg p.o. b.i.d. 5. Aspirin 81 mg p.o. q.d. 6. Prednisone 10 mg p.o. q.d. 7. Doxepin 100 mg p.o. q.h.s. 8. Albuterol and Atrovent puffs q.4h. 9. Amiodarone 400 mg p.o. q.d. 10. Protonix 40 mg p.o. q.d. 11. Coumadin 3 mg p.o. q.d. (goal INR of 2 to 2.5; INR to be checked every day initially and then per primary care physician). 12. A regular insulin sliding-scale. 13. Percocet one to two tablets p.o. q.4-6h. p.r.n. 14. Bumex 1 mg p.o. q.d. 15. Trazodone 50 mg p.o. q.d. CONDITION AT DISCHARGE: Condition on discharge was stable. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 2209] MEDQUIST36 D: [2110-4-10] 19:56 T: [2110-4-10] 20:38 JOB#: [Job Number 9636]	[ "41401", "9971", "42731", "4019" ]
Admission Date: [2168-7-15] Discharge Date: [2168-8-2] Date of Birth: [2099-2-16] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 6169] Chief Complaint: Weakness Major Surgical or Invasive Procedure: Intrathecal methotrexate therapy x2 via lumbar puncture History of Present Illness: HPI: 69 yo man with NHL with CNS involvement (lymphomatous meningitis) s/p intrathecal MTX, Rituxan, Velcade and steroids. Patient presented to ER on [2168-7-15] with progressive weakness of both arms and legs for the last 2-3 weeks. He reports that his weakness (b/l arms and legs, R>L) has been ongoing over the past few months worsening over the past few weeks, mainly over the past 5 days. He walks with a cane at baseline, but has noted that walking up stairs with his left leg leading has become increasingly more difficult due to his weakness. He denies symptoms of bowel/bladder incontinence. . On arrival to ED was found to be tachycardic and hypotensive to systolic near 70s. EKG c/w SVT. He was given adenosine 6 mg then 12, had a 30 sec break, but reverted to SVT. After 1 g procainamide load, he converted to NSR. . Additionally in the ED, CTA was performed which did not show evidence of PE (h/o DVT on coumadin; INR therapeutic) but with new LUL infiltrate. He was seen by Neuro in the ED; weakness thought secondary to patient's underlying disease vs. use of velcade. He underwent MRI of entire spine which has not yest been read. . He was transferred to the [Hospital Unit Name 153] for monitoring. During his 24 h stay patient has remained in NSR. He was started on levofloxacin for possible PNA given LUL consolidation on imaging although not c/o symptoms of pneumonia. . ROS: Pt denies fever or chills. No night sweats or recent weight loss or gain. No headache, rhinorrhea or cough,or congestion. Denied cough, shortness of breath (except transiently in the setting of SVT). Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No melena or BRBPR. No dysuria. Denied arthralgias or myalgias. No rash. Past Medical History: NHL (see below) complicated by lymphomatous meningitis RLE weakness secondary to plexopathy Bilateral upper extremity weakness RLE DVT Hives intermittently over last couple years Raynaud's phenomena LUL lesion in [2129] s/p INH x1yr S/p appendectomy . Onc Hx: Initially presented with palpable lymph node in the groin in [2167-3-4]. Biopsy revealed diffuse large cell lymphoma. S/p R-CHOP x 6 cycles, completed in [2167-7-2]. Patient was well until [Month (only) ]-[2167-11-1] when he developed right lower extremity paralysis. LP at that time was negative for malignant cells but repeat LP on [2168-2-17] revealed malignant cells with MRI showing increased uptake in the sacral plexus. The patient was evaluated by neurology and thought to have a right lumbosacral plexopathy. The patient underwent IVIg therapy without relief. Around mid [2168-2-1] the patient began radiation therapy x9-12 treatments to the sacrum with improvement in pain complaints. He was also initiated on decadron. Since [2168-3-4] the patient receives intrathecal methotrexate every 1-2 weeks. He has regained some use of his right lower extremity. Social History: He is retired and worked as a marine engineer. He is married and never smoked. he has approximately 3 alcholic beverages a night. He has never used any illegal drugs. Family History: His mother died at 93 of old age. His father died at 75 of heart failure. His sister is 65 and has diabetes and hypertension. He has two healthy daughters. Physical Exam: Vitals: T: 99.2 BP: 119/71 P: 86 RR: 20 SpO2: 95% 2L General: Awake, alert, NAD. HEENT: NC/AT, PERRL, EOMI, sclera anicteric. MMM, OP without lesions Neck: supple, no JVD or carotid bruits appreciated Pulm: fine crackles left lung base, no rhonchi nor wheezes Cardiac: RRR, nl S1/S2, no M/R/G appreciated Abdomen: soft, NT/ND, + BS, no masses or hepatomegaly noted. Ext: Right lower extremity 1+ edema. Neurologic: CN 2-12 intact, LUE with 4/5 biceps and triceps strength, 2-3/5 right biceps strength, Right hip flexor [2-5], [6-4] left hip flexor, [5-5] right plantar flexion, [3-7] right dorsiflexion, sensation to soft touch decreased slightly anterior right lower extremity to distal shin. . Pertinent Results: B-glucan= >500 [2168-7-16] CXR: Comparison is made with prior examination performed one day ago. There is persistent ill-defined airspace disease involving left upper lobe likely related to pneumonia. There is increasing density at the right base with blunting of the right costophrenic angle. Findings are suggestive of right basilar atelectasis and small right pleural effusion. Cardiomediastinal silhouette is stable. Central venous catheter is present with tip in the right atrium. . [2168-7-15] MRI spine: Compared to the previous study of [2168-4-2], there are now new focal signal abnormalities identified from L1 to L5 level. The previously noted subtle lesions in some of these vertebral bodies have increased in size. Findings are indicative of lymphoma deposits or metastatic disease. There is increased signal seen on T1- and T2-weighted images in the remaining portions of the lumbar vertebral bodies and sacrum indicative of fatty marrow changes from radiation. Focal signal abnormality in the upper sacrum is also identified on the right side, indicative of metastasis or bony involvement by lymphoma. This has also increased since the previous study. There is no epidural mass seen or thecal sac compression identified. IMPRESSION: New bony metastatic lesions involving the lumbar vertebral body with increase in size of previously noted lesion. No evidence of pathologic fracture or intraspinal mass. . [2168-7-15] CTA chest: 1. No evidence of pulmonary embolus. 2. Patchy ground-glass opacity within the left upper lobe, which is new since [2168-4-1] and likely represent an infectious process. 3. Stable 12 mm prevascular lymph node within the mediastinum. 4. Multiple low density lesions within the liver, which given history of lymphoma may represent metastates, or given pulmonary findings could represent infection. [2168-7-21]:MRI spine, interval increase in size and # of enhancing metastatic foci in LS spine, no involvment of exiting nerve roots or thecal sac. [2168-7-21] MRI brachial plexus: Normal examination of the right and left brachial plexus, without abnormal enhancement. Mild degenerative changes of the cervical spine and focus of signal abnormality in the T6 vertebral body. Parenchymal abnormalities of the left lung apex. [2168-7-24]: CXR:progressive L.apical consolidation, ?radiation pneumonitis, r/o TB [2168-7-15] 10:49PM GLUCOSE-165* UREA N-19 CREAT-0.6 SODIUM-139 POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15 [2168-7-15] 10:49PM CALCIUM-8.5 PHOSPHATE-3.3 MAGNESIUM-2.0 [2168-7-15] 10:49PM WBC-5.3 RBC-4.01* HGB-12.2* HCT-35.5* MCV-89 MCH-30.4 MCHC-34.3 RDW-17.2* [2168-7-15] 10:49PM PLT COUNT-149* [2168-7-15] 10:49PM PT-28.8* PTT-27.2 INR(PT)-3.0* [2168-7-15] 09:00PM CK(CPK)-40 [2168-7-15] 09:00PM cTropnT-0.06* [2168-7-15] 09:00PM CK-MB-NotDone [2168-7-15] 01:18PM COMMENTS-GREEN TOP [2168-7-15] 01:18PM GLUCOSE-133* LACTATE-2.7* NA+-137 K+-4.1 CL--101 TCO2-25 [2168-7-15] 01:10PM GLUCOSE-137* UREA N-25* CREAT-0.6 SODIUM-140 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-24 ANION GAP-18 [2168-7-15] 01:10PM estGFR-Using this [2168-7-15] 01:10PM CK(CPK)-57 [2168-7-15] 01:10PM cTropnT-0.05* [2168-7-15] 01:10PM CK-MB-NotDone [2168-7-15] 01:10PM CALCIUM-9.2 MAGNESIUM-2.4 [2168-7-15] 01:10PM WBC-8.1 RBC-4.53* HGB-13.9* HCT-39.8* MCV-88 MCH-30.8 MCHC-35.1* RDW-17.5* [2168-7-15] 01:10PM NEUTS-94* BANDS-3 LYMPHS-1* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2168-7-15] 01:10PM PLT COUNT-212# [2168-7-15] 01:10PM PT-26.8* PTT-28.8 INR(PT)-2.8* Brief Hospital Course: Assessment and Plan: 69yoM with history of NHL with CNS involvement presented to the ED with worsening b/l UE and LE weakness, found in the ED to be tachycardic to the 180s and hypotensive to the 70s systolic now in NSR and normotensive. . 1.Weakness: Patient was evaulated by neurology and it was thought that patients weakness was either due to CNS lymphatous involvement vs. velade. MRI perforemd showed new focal signal abnormalities from L1-L5 and sacral bony involvement looks worse. However, there was no epidural or thecal compression/involvement found. Treatment was discussed by Dr. [Last Name (STitle) 724]. Patient was given decadron, and received intrathecal methotrexate and high dose intravenous methotrexate. Patient has been working with physical therapy. He continues to regain strenght by the day but still needs to work on his strength with physical therapy as an outpatient. He will follow up with Dr. [First Name (STitle) 1557] on tuesday at 10:00 for examination followed by admission of his next methotrexate treatment. 2. LUL infiltrate: Consolidation was visualized on CXR and CT chest. Patient had been on decadron and was on bactrim DS qMWF at the beginning of admission. Several attempts were made to induce sputum unsuccessfully, the patient was continued on levofloxacin for 14 days. A chest x-rday on [7-23] showed proessive left apical consolidation. Eventually the patient underwent bronchoscopy which showed PCP. [Name10 (NameIs) 2772], there was some question originally as to whether this was radiation pneumonitis. The patient had already been started on atovaquone 750mg [Hospital1 ] by the time of bronchoscopy. The patient is clinically improving. 3. Hypoxia: Very mild, on 2L while in the [Hospital Unit Name 153] without O2 requirement previously at home. The etiology was thought to be due to PCPor LUL infiltrate. The patient eventually was weaned off O2, and is sating well while sitting. He will go home with O2 at bedtime and when active. . 4. SVT: In NSR with normal BPs. CTA performed in the ED was negative for PE. Resolved after procainamide. Troponin up to 0.07 max in this setting. Case discussed with cards in the [Hospital Unit Name 153] and no additional meds/treatments necessary at this time. Patient remained in normal sinus rhythm for the rest of the admission. . 5. Elevated troponin: CK-MBI normal, troponin was elevated to max 0.08 likely in the setting of his SVT which is now resolved. Patient continued to be asymptomatic. . 6. NHL: Followed by Dr. [First Name (STitle) 1557]. Neuropathy thought secondary to velcade, now stopped. Patient had recieved rituxan q2 weeks (has received 3 out of planned 4 doses, last [2168-7-5]). Plan discussed with Dr. [Last Name (STitle) 724]. On [2168-7-23] methotrexate and leucovorin were started and methotrexate levels and labs were followed. Patient was given decadron, and urine pH kept above 7 during treatment. Patient tolerated the treatment well. . 7. RLE swelling: Patient has history of RLE DVT diagnosed in [3-/2168] for which he has been on coumadin. A repeat U/S has been ordered which showed improved clot burden since [Month (only) ]. Patient's coumadin was held and he was started on lovenox. Patient will be transitioned back to coumadin for discharge. . 8.increased LFT's thought to be due to either methotrexate or bactrim. Bactrim d/cd, methotrexate ended, LFT's are decreased. RUQ ultrasound was performed. . Medications on Admission: Medications on admission: Oxycodone 60 mg Sustained Release PO Q12H Pregabalin 100 mg 3 times a day Senna 8.6mg Two (2) Tablet PO 2 times a day as needed. Zantac 150 mg PO twice a day Oxycodone 5 mg PO Q4-6H as needed for Breakthrough pain Warfarin 5 mg QHS Decadron 3 mg qam - 2 mg qpm . Meds on transfer: Bactrim DS qMWF Oxycodone 5-10mg q4-6h prn breakthrough pain Levofloxacin 500mg PO q24h Dexamethasone 2mg PO qpm Dexamethasone 3mg PO qam Ranitidine 150mg PO bid Oxycodone SR 40mg q12h Zolpidem 5mg PO hs prn Acetaminophen 325-650mg PO q4-6hprn Discharge Medications: 1. Atovaquone 750 mg/5 mL Suspension Sig: One (1) PO BID (2 times a day). Disp:60 Refills:2 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:60 Tablet(s) Refills:0 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 5. Fluconazole 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). Disp:60 Tablet(s) Refills:2 6. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:0 7. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 5 days. Disp:20 Tablet(s) Refills:0 8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) for 3 days. Disp:3 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital1 6136] Home Care Discharge Diagnosis: Primary: NHL with CNS involvment hypoxia superventricular tachycardia Seconday: DVT [3-/2168] RLE weakness Discharge Condition: Stable without further decline in weakness, respiratory status improved. Discharge Instructions: You were admitted for worsening weakness. You underwent intrathecal methotrexate therapy x2 with no further decline in your weakness. Additionally, you were given systemic methotrexate with leucovorin rescue. . Please call your doctor or return to the emergency room if you develop worsening weakness, fevers/chills, trouble breathing, bleeding or any other symptoms that concern you. . Please be sure to follow up as outlined below. Followup Instructions: Please follow up with Dr. [First Name (STitle) 1557] on Tuesday [8-9] at 10:00am with an admission to follow for methotrexate treatment. . Please follow up with your appointments as scheduled prior to this admission:	[ "486", "5180", "42789", "2859" ]
Admission Date: [2124-3-6] Discharge Date: [2124-3-10] Date of Birth: [2059-12-17] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1674] Chief Complaint: GIB Major Surgical or Invasive Procedure: Intubated EGD History of Present Illness: 64 M in USOH until 1d PTA. Pt noted mild epigastric discomofort, n, vomitting x 1, non-bloody, "brown". No recent melena. Symptoms persisted on morning of [3-5], decreased PO intake (jello, soup). At 9PM wife heard a thud, and found husband slumped over toilet in restroom, eyes open, but slow to respond, +diaphoresis. EMS activated, BP 110/80 HR 92 RR 26 @ 2159. . Per wife, ROS otherwise negative, no recent f/c/cp/sob/dysuria, melena, diarrhea, rash. . Pt takent to OSH(addison-[Doctor Last Name ]) where VS 98.6 110/59 82 24 100%RA, EKG, CXR unremarkable, +NGL with dark blood only, no BRB. At OSH, pt had CT head, cspine, CT abd/pelvis which were all unremarkable per dictated reports. He was given 1-2U PRBCs [1-29] OSH HCT 28.9 (bl unknown) and 2L IVF, which was still running upon arrival to [Hospital1 18]. Of note, pt was intubated prior to transport from OSH [1-29] significant nausea, vomiting and concern for airway protection. . Upon arrival to [Hospital1 18], VS 96 77 101/69 12 100% AC 100%. pt was guaic positive, abg 7.30/44/520, hct 28.5 wbc 19. Pt given protonix 80mg iv x 1, and admitted to [Hospital Unit Name 153] for GIB. . Of note, pt on [Last Name (LF) 4532], [First Name3 (LF) ] [1-29] h/o cad s/p stenting >1y ago, he has also been taking celebrex for last two weeks [1-29] shoulder injury. Past Medical History: - cad s/p stenting [9-1] w cypher stent to pLAD ([Telephone/Fax (1) ]), cardiologist [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ]. - h/o pud (last in college per wife) -- gastroenterologist dr. [Last Name (STitle) ], at [Hospital ] hospital. - gerd - depression Social History: lives with wife in [Name2 (NI) ] ma, works as school teacher, 1ppd x 1yr, quit 50y ago, [12-29] wine/month, denies IVDU. no h/o hepatitis exposures (no tattoo, msm, prison), though ?blood transfusion < [2095] [1-29] hernia repair. Family History: mother died of amyloid, father of MI in 80s. no family hx of gastric ca. Physical Exam: VS: 95.7 [10/2087] 955 12 100% PS 8/5 50% (MMV rate 8) GEN: NAD HEENT: PERRLA, EOMI, sclera anicteric, MMM, no LAD, no carotid bruits. No JVD. CV: regular, nl s1, s2, no m/r/g. PULM: CTA anteriorly, no r/r/w. ABD: soft, NT, ND, + BS, no HSM. EXT: warm, 2+ dp/radial pulses BL. NEURO: intubated, sedated, alert to voice, PERRLA. Pertinent Results: [2124-3-6] 01:50AM BLOOD WBC-19.3* RBC-3.07* Hgb-9.8* Hct-28.5* MCV-93 MCH-32.1* MCHC-34.6 RDW-13.1 Plt Ct-213 [2124-3-6] 04:16AM BLOOD WBC-17.8* RBC-2.75* Hgb-8.8* Hct-26.0* MCV-95 MCH-32.0 MCHC-33.8 RDW-13.3 Plt Ct-154 [2124-3-6] 03:30PM BLOOD Hct-24.9* [2124-3-7] 06:08AM BLOOD Hct-23.3* [2124-3-8] 05:09AM BLOOD WBC-9.7 RBC-3.54# Hgb-11.1 Hct-31.3* MCV-88 MCH-31.2 MCHC-35.3* RDW-14.8 Plt Ct-149* [2124-3-6] 01:50AM BLOOD Glucose-212* UreaN-38* Creat-1.0 Na-138 K-4.0 Cl-108 HCO3-19* AnGap-15 [2124-3-6] 04:16AM BLOOD ALT-23 AST-23 LD(LDH)-166 CK(CPK)-169 AlkPhos-37* Amylase-50 TotBili-1.1 [2124-3-6] 01:50AM BLOOD CK-MB-5 cTropnT-0.04* [2124-3-6] 04:16AM BLOOD CK-MB-7 cTropnT-0.06* [2124-3-6] 11:00AM BLOOD CK-MB-18* MB Indx-5.6 cTropnT-0.10* [2124-3-6] 08:59PM BLOOD CK-MB-16* MB Indx-4.0 cTropnT-0.26* [2124-3-7] 03:04AM BLOOD CK-MB-10 MB Indx-2.8 cTropnT-0.25* Findings: Esophagus: Normal esophagus. Stomach: Mucosa: Patchy discontinuous erythema and congestion and NG tube trauma of the mucosa with no bleeding were noted in the whole stomach. Duodenum: Excavated Lesions A single cratered 11mm ulcer was found in the distal bulb. A visible vessel suggested recent bleeding. 2 2.5 cc.Epinephrine 1/[Numeric Identifier 961] injections were applied for hemostasis with success. Two clips were successfully placed for hemostasis Impression: Erythema and congestion and NG tube trauma in the whole stomach Ulcer in the distal bulb (injection, ligation) Otherwise normal EGD to second part of the duodenum Brief Hospital Course: # GIB Patient has a history of GIB, and has been using NSAIDS continually over last few weeks. Was found to have coffee ground emesis on NGT lavage at OSH. He was monitored for an additional day in the ICU with no evidence of continued bleeding by stable hematocrit. Patient had a hematocrit of 29 on admission. Underwent an EGD which showed a duodenal ulcer with a visualized bleeding vessel. Epinephrine was injected and two clips were placed. Patient had continued evidence of bleeding following the EGD, requiring transfusion of 3 units of PRBC. He had no complaints of abdominal pain, nausea, or vomiting. Patient was started on a PPI drip, and bleeding decreased. He should be discharged on [Hospital1 ] dosage for two months. Patient's Aspirin and [Hospital1 4532] were held at admission. The aspirin should be restarted after discharge and patient should follow up with outpatient cardiologist to restart [Hospital1 4532]. Pt had intermittent trace amounts of blood in stool prior to dc, GI team advised that this was likely left over blood in intestine, rather than active bleeding. Pt told to have hct checked with PCP [Last Name (NamePattern4) ] 4 days after dc, also if still bleeding in one week, needs repeat endoscopy. Also reminded of need to have colonoscopy. # pulmonary ?????? The patient was intubated for airway protection given continued emesis. Per OSH records, ther was no evidence of hypoxia or hypercarbia. The patient was extubated shortly after arrival, and has been breathing comfortably. # syncope - Syncopal episode in setting of GIB while having a bowel movement. No hypotension at OSH. Likely vaso-vagally related. Has been maintained on telemetry without any arrythmia. Patient had CT of head without any intracranial process and no story of hitting head. C-spine CT was also unremarkable. # cardiac - ## ischemia: Patient with a history of CaD, and had a cypher stend placed in [2121-8-28]. Aspirin/[Year (4 digits) 4532] in setting of bleed. Cardiac enxymes were followed, and showed an elevation up to trop 0.26, and have trended downward. He had no complaints of CP, no evidence of ischemia on EKG. Likely enzyme leak in setting of demand ischemia. Pt told to f/u with primary cardiologist at discharge with follow up aranged in order to work up progression of CAD and to determine whether aspirin should be increased to 325 mg from 81mg, now that he is indefinitely off of [Year (4 digits) 4532]. Medications on Admission: aspirin 81 mg po qdaily [Year (4 digits) 4532] 75mg po qdaily celebrex 200mg po qdaily prozac 40mg po qdaily vicodin - not taking Discharge Disposition: Home Discharge Diagnosis: bleeding duodenal ulcer Discharge Condition: stable Discharge Instructions: Please watch for blood in your bowel movements, if there is any increase in blood please call Dr. [Last Name (STitle) 19634], as you will need your blood level checked sooner. If you are still having blood in your bowel movements in one week please talk to Dr. [Last Name (STitle) 19634] about having a colonoscopy. Stop taking [Last Name (STitle) 4532]. You may restart aspirin 81 mg per day next week if bleeding has stopped. Followup Instructions: Please call Dr. [Last Name (STitle) 19634] on Monday, you will need to have your blood drawn, and may need to be evaluated by him as well. He will discuss with you over phone on Monday. The gastroenterology specialist you saw in the hospital is Dr. [First Name8 (NamePattern2) 1158] [Last Name (NamePattern1) 679] at [Telephone/Fax (1) 682]. You need to be seen by him or your other gastroenterologist in 2 months, to determine whether you can decrease the protonix (pantoprazole) dose. You should see your cardiologist in the next few weeks, to see if he suggests increasing the dose of aspirin now that you are not taking [Telephone/Fax (1) 4532]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 1677] Completed by:[2124-3-15]	[ "2851", "53081", "311", "412", "41401", "V4582" ]
Admission Date: [2145-11-22] Discharge Date: [2146-1-26] Date of Birth: [2074-6-4] Sex: M Service: MEDICINE Allergies: IV Dye, Iodine Containing / Meropenem Attending:[First Name3 (LF) 3913] Chief Complaint: Nausea, vomiting, diarrhea, hypotension and neutropenic fever Major Surgical or Invasive Procedure: Bone marrow biopsy History of Present Illness: Mr. [Known lastname 467] is a 71 yo M with a h/o PMR, C. diff colitis, +PPD treated with INH, and AML s/p allogenic SCT [6-14] with relapse treated w/ decitabine now s/p donor lymphocyte infusion on [11-10] who developed nausea, vomiting, and diarrhea shortly thereafter. He began having nausea and vomiting on the evening of [11-14] shortly after returning to [State 531]. He received chemotherapy (decitabine) from his oncologist in NY on [11-15]. He then developed diarrhea and a bright macular papular rash on the trunk extending to the feet on [11-18] and was admitted to an OSH on [11-19] and is now transferred to [Hospital1 18] with pancytopenia and suspicion of GVHD vs. C. diff colitis or other infection. He presented to an OSH on [11-19] nausea, vomiting, diarrhea and a maculopapular rash. He ran a low grade fever and was found to be pancytopenic with a WBC 0.4, Hct 29 and plt 27. He was initially placed on a low sodium, lactose-free diet with IVF and received his fifth dose of decitabine on that day. On the 16th he spiked a fever in the setting of receiving a transfusion and was pan-cultured. TPN was initiated on [11-21] due to poor PO intake. Per the patient's wife, he spiked a fever to 103 on this date. On [11-22] he was noted to be hypotensive on the floor, but responded to bolused IVF with systolics in teh 90s. There was reportedly also a question of a cavitating mass in his lung. After conversations with the BMT fellow on [11-22] he was started on vancomycin, zosyn (they did not have cefepime on formulary), micafungin, and flagyl (unclear if he received all of these) and received a unit of platelets and solumedrol 30 mg IV for presumed GVHD. En route to [Hospital1 18] SBPs ranged from 76 to 122, but were mostly around/above 100 systolic. . On arrival in [Hospital Unit Name 153], the patient appeared tired and was occasionally dry heaving. He reported some intermittant lightheadedness earlier in the day as well as some lower abdominal pain in a band like pattern similar to his prior C. diff abdominal pain that had since passed. Past Medical History: # ONCOLOGIC HISTORY: - [4-/2142]: note to have a mild leukopenia (WBC 3.9 with mild lymphocytosis) with a normal hemoglobin, hematocrit, and platelets - [6-/2144]: pancytopenic - [8-/2144]: bone marrow aspirate consistent with myelodysplastic syndrome and FISH revealed trisomy 8, blasts were approximately 20%. - [9-/2144]: began monthly azacitidine therapy, until [6-/2145] - [6-/2145]: resumed a transfusion requirement, developed severe bone pain and worsening fatigue. He was admitted on [2145-6-21] when he was noted to have circulating blasts. Repeat marrow was consistent with AML and began therapy with 7+3 on [2145-6-23]. His post induction course was complicated by C. diff. His day 14 bone marrow was hypocellular and consistent with chemotherapeutic effect. His day 30 bone marrow biopsy was mildly hypercellular, erythroid dominant and without definite morphologic evidence of leukemia. - [2145-9-7]: sibling-matched allogeneic stem cell transplant with fludarabine, busulfan, and ATG as his conditioning regimen;discharged on [2145-9-24] - [2145-9-27]: admitted for fever and pelvic pain. bone marrow showed recurrence of disease. went through 1 cycle of decogen. discharged on [2145-10-20]. - [2145-10-27]: admitted to medicine for Leg/pelvic pain w/ 34% blasts in the peripheral blood. The patient tolerated Decitabine and blast count on discharge was 6%. Discharged [2145-11-2]. # OTHER MEDICAL HISTORY: - PMR - hyperlipidemia - +PPD in [2129] with 4 months of INH therapy - BPH - osteoarthritis - H/o C. difficile colitis - s/p TURP [3-/2144] - s/p cholecystectomy in [2125] - s/p tonsillectomy age 11 Social History: Mr. [Known lastname 467] worked as an electrician and plumber with multiple exposures to cleaners and solvents- he retired in [2139]. Married to wife [Name (NI) 14735]. [Name2 (NI) ] has 2 children from a previous marriage. Family History: Mother deceased of a brain tumor in her 70s, father deceased at age 84 from cardiac disease, he has a 74 year old sister and a 60 year old brother who are relatively healthy. Physical Exam: Vitals: T 98.4, HR 91, BP 107/49, RR 23, O2 sat 99% on RA. General: Tired appearing elderly male in no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Crackles at the right base. No wheezes or rhonchi. CV: Regular rate and rhythm, normal S1 + S2. [5-11] early systolic murmur RUSB. Possible S3. Abdomen: Decreased BS, soft, mild LUQ tenderness, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: Cool, 2+ pulses, no clubbing, cyanosis or edema Skin: Faint macular rash resolving on the legs Neuro: A&O, moving all extremities, CNII-XII intact. Discharge: Vitals: T 98.6, HR 74, BP 140/62, RR 20, O2 sat 97% on RA. General: Tired appearing elderly male in no acute distress HEENT: Sclera icteric, dry membranes, exudate on tongue Neck: supple, JVP not elevated, no LAD Lungs: mild wheezes anteriorly. CV: Regular rate and rhythm, normal S1 + S2. [3-13] pan systolic ejection murmur Abdomen: soft, NT/ND, no rebound tenderness or guarding, no organomegaly Ext: [3-10]+ edema of b/l LE; no clubbing, cyanosis Skin: Faint macular rash on arms, legs Neuro: somnolent but arousable,Oriented x3, moving all extremities, CNII-XII intact. Pertinent Results: [2145-11-22] 11:31PM BLOOD WBC-0.2# RBC-3.24 Hgb-10.2* Hct-28.2* MCV-87 MCH-31.4 MCHC-36.2* RDW-16.1* Plt Ct-24* [2145-11-22] 11:31PM BLOOD Neuts-4* Bands-0 Lymphs-78* Monos-0 Eos-0 Baso-0 Atyps-6* Metas-0 Myelos-0 Blasts-12* [2145-11-22] 11:31PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Schisto-OCCASIONAL Burr-1+ [2145-11-22] 11:31PM BLOOD PT-18.9* PTT-39.4* INR(PT)-1.7* [2145-11-23] 04:57AM BLOOD Gran Ct-24* [2145-11-22] 11:31PM BLOOD Glucose-115* UreaN-18 Creat-0.6 Na-133 K-3.8 Cl-105 HCO3-21* AnGap-11 [2145-11-22] 11:31PM BLOOD ALT-19 AST-14 LD(LDH)-156 AlkPhos-65 Amylase-4 TotBili-0.8 [2145-11-22] 11:31PM BLOOD Albumin-2.6* Calcium-7.7* Phos-2.0# Mg-1.8 [2145-11-23] 04:57AM BLOOD Cortsol-40.8 [2145-11-23] 05:45AM BLOOD Lactate-1.1 Urine: [2145-11-23] 03:24AM URINE Color-Yellow Appear-Hazy Sp [Last Name (un) ]-1.024 [2145-11-23] 03:24AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [2145-11-23] 03:24AM URINE RBC-2 WBC-0 Bacteri-NONE Yeast-NONE Epi-<1 [2145-11-23] 03:24AM URINE CastGr-6* CastHy-4* [2145-11-23] 03:24AM URINE AmorphX-RARE [2145-11-23] 03:24AM URINE Mucous-RARE Micro: Bcx [11-22], [11-23]: PND Ucx [11-23] Pnd C diff: Positive Stool Cx: PND Stool ova/parasites: PND CMV viral load: PND Imaging: KUB [11-23]: Nonspecific bowel gas pattern with inadequate views to assess for free air or air-fluid levels. Correlation with chest radiograph for evaluation for subdiaphragmatic free air is recommended. If additional evaluation for free air or air-fluid levels is clinically indicated, then upright view of the abdomen is recommended. No evidence for obstruction or colitis. CXR [11-23]: As compared to the previous radiograph, the lung volumes have slightly decreased. The size of the cardiac silhouette is at the upper range of normal. There is mild to moderate pulmonary edema. Retrocardiac atelectasis. No evidence of pleural effusions. No focal parenchymal opacity suggesting pneumonia. No cavitary lung lesions. Chest CT [11-23]: 1. No evidence of right upper lobe cavitatory lesion. 2. Improving bilateral pleural effusions, minor bilateral lower lobe atelectasis, also improved. 3. Evidence of remote asbestos exposure. 4. Possible mild hydrostatic edema, stable since [2145-10-4]. CT ABDOMEN W/O CONTRAST/CT PELVIS W/O CONTRAST Study Date of [2145-12-10] 4:26 PM IMPRESSION: 1. Diffuse small bowel wall thickening, most apparent distally involving the ileum. Differential includes infectious etiologies and graft-versus-host disease. Clinical correlation is advised. 2. No evidence for colitis. 3. Bilateral renal cysts, with cysts at the lower pole of the right kidney demonstrating either thin peripheral calcification versus a thin calcified septation, Bosniak II. CT CHEST W/O CONTRAST Study Date of [2145-12-11] 4:19 PM IMPRESSION: 1. Focal opacity in the right upper lobe concerning for infectious process as seen on chest radiograph from the same day. 2. Stable bilateral calcified pleural plaques suggesting prior asbestos exposure. 3. Splenomegaly. CT CHEST W/O CONTRAST Study Date of [2145-12-24] 1:40 PM IMPRESSION: 1. Clearing small infection, right upper lobe, could also be cryptogenic organizing pneumonia (COP). 2. 4-mm pulmonary nodules stable over 6-months. Another study in six months is standard of care for non-smokers, and a second in another 18 months for smokers 3. Trace perihepatic free fluid. CT ABDOMEN W/CONTRAST Study Date of [2145-12-28] 12:18 PM IMPRESSION: 1. No evidence of colitis. Resolution of previously seen thickened small bowel. 2. Bilateral renal cysts previously evaluated on ultrasound. 3. Significant resolution of lesions in the spleen compared to study on [2145-7-8]. CT CHEST W/O CONTRAST [2146-1-3]: 1. No new pneumonia. No pleural effusion. 2. Clearing small infection in the right upper lobe could be cryptogenic organizing pneumonia. 3. Stable multiple sub-4-mm pulmonary nodules. Follow-up recommendation provided in CT chest report from [2145-12-24]. 4. Stable asbestos-related calcified pleural plaques without pleural mass. CT Chest w/o Contrast: [2146-1-17]: 1. No evidence of new or active pulmonary infection. Interval decrease in size of the right upper lobe pulmonary consolidation from prior studies. 2. Unchanged pulmonary nodules, 4 mm or less, for which a followup examination was recommended on [2145-12-24]. 3. Mild interstitial pulmonary edema. 4. Evidence of prior asbestosis exposure. Transthoracic Echo [1-18]: No vegetations seen (adequate-quality study). Normal global and regional biventricular systolic function. Calcific aortic valve disease with minimal stenosis and mild regurgitation. In presence of high clinical suspicion, absence of vegetations on transthoracic echocardiogram does not exclude endocarditis. RUQ U/S [2146-1-19]: 1. Mild intrahepatic biliary dilatation. Note that this is a change from the preliminary report. Updated findings were communicated with Dr [First Name (STitle) ] at approximately 3:00 p.m. 2. Splenomegaly. CT Head [1-23]: No acute intracranial pathology, especially no evidence of a new infarct detected. If there is high clinical concern for an acute infarct, an MRI with DWI can be performed for further evaluation. PATHOLOGY: SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY: [2145-12-17] DIAGNOSIS: MARKEDLY HYPERCELLULAR BONE MARROW WITH EXTENSIVE INVOLVEMENT BY THE PATIENT'S PREVIOUSLY DIAGNOSED ACUTE MEGAKARYOBLASTIC LEUKEMIA (FAB M7). BONE MARROW ASPIRATE AND CORE BIOPSY: [2146-1-13] Hypercellular bone marrow with persistent involvement by patient's known acute megakaryoblastic leukemia Discharge Labs: 143 114 36 108 AGap=12 ------------- 3.1 20 1.0 Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional Diabetes Ca: 8.9 Mg: 1.7 P: 2.8 ALT: 24 AP: 233 Tbili: 1.0 Alb: 2.8 AST: 16 LDH: 575 Dbili: TProt: [Doctor First Name ]: Lip: 2.7 > < 35 ∆ 23.7 N:47 Band:0 L:17 M:2 E:0 Bas:0 Other: 34 Gran-Ct: 1283 PT: 19.2 PTT: 38.8 INR: 1.8 Brief Hospital Course: Mr. [Known lastname 467] is a 71 yo M with a history of AML s/p allo BMT with relapse who presents with nausea, vomiting, and diarrhea that developed after receiving DLI. . # AML - History of relapsed AML after allo transplant. Last DLI on [2145-11-10]. Neutropenic throughout his stay with a brief increase in counts and an ANC that peaked at 1700. He then began decreasing his counts. A BM biopsy on [12-17] was done and showed recurrence of AML. He was treated with Decitibine starting on [2145-12-23]. Repeat bone marrow biopsy on [1-13] showed hypercellular bone marrow with persistent involvement by patient's known acute megakaryoblastic leukemia. Patient became increasingly somnolent, though arousable and non con CT head was negative for bleed. He developed generalized pain and weakness attributed to his disease. Further work up with MRI and LP was not pursued as goals of care were shifted towards comfort given the refractory nature of the patient's disease and his multiple infections. He was ultimately discharged home with hospice. Note: medication dosages were changed slightly after discharge to accomodate his needs for the ambulance ride- PO morphine dosage was increased to 10-20 mg PO q2hr PRN. . # N/V/D: Patient was positive for C diff. He was started on PO Vancomycin 250 every 6 hours. His diarrhea was persistent, and because of his risk factors he was increased to 500mg PO Q6H. He has also been on PO Flagyl 500 PO Q8 for this. The first week of [Month (only) ] his abdominal pain increased to [2145-4-8], and he began having [2-6] large volume watery bowel movements. [12-10], he spiked a fever to 101, and a CT abd/pelvis was done. It showed thickening of the ileum concerning for infection vs. GVHD. He also had a new RUL opacity on chest x-ray. He was restarted on broad spectrum antibiotics, and worked up to rule out TB (past + PPD). His diarrhea resolved. He was ruled out for TB and started on Voriconazole for presumed aspergillus. On [12-20], he had return of his diarrhea in the setting of decreasing his PO vancomycin to 125 PO Q12. He was restarted on PO Vanc 500mg Q6 and was tapered to 125 mg PO q6 hours for the remainder of his hospitalization with resolution of his sxs. . # Febrile neutropenia: Patient was placed on IV Vancomycin/Cefepime. He remained afebrile, and after 14 days his IV antibiotics were discontinued. On [12-10] he respiked a fever with possible sources being his abd and lung based on imaging studies. He was restarted on vanc and cefepime. His Culture data was negative with the exception of C diff. He was eventually expanded over the course of a week to IV vancomycin, cefepime, flagyl, and PO vancomycin and voriconazole. He was on Acyclovir and pentamidine PPX. He continued to have fevers approx Q48 hours from [Date range (1) 85919]. During that time he had a repeat bone marrow on [2145-12-17] which showed recurrence of his AML. It was initially thought that the fevers were in part due to recurrence but mycolytic blood cultures were positive for malessezia furfur (believed to be associated with TPN and his central line) and patient was treated with line removal and ambisome transiently (stopped secondary to fevers), and then voriconazole/posaconazole. . #. GVHD: Patient presented with a sandpapery maculopapular rash on arms and legs thought to be GVHD. He was thus started on low-dose IV solumedrol 30 mg daily. He also continued to have loose stools while on the PO Flagyl and vancomycin. GI was consulted and wanted to do a c-scope to evaluate for GVHD of the gut, but held off because of his neutropenia. Repeat imaging showed thickening of the ileum that was concerning for GVHD or infection. He was kept on solumedrol througout his stay. A repeat abdominal CT on [12-28] showed resolution of the ileum thickening and colitis. He continued to have watery bowel movements, but they decreased in frequency. . # RUL lung lesion - Patient has history of +PPD that has been treated with INH for 4 months which was discontinued because of liver toxicity. He was also at risk for invasive fungal infection. He was without cough, but was worked up for fungal and bacterial causes (including induced sputum for TB). He was ruled out for TB, and in the setting of a positive B-glucan he was thought to have a fungal pneumonia, which was treated with voriconazole. On repeat chest CT [12-24], the pneumonia had decreased in size. He was continued on voriconazole throughout his hospitalization. Medications on Admission: 1. Docusate Sodium 100 mg [Hospital1 ] 2. Fluconazole 400 mg PO Q24H 3. Folic Acid 1 mg PO DAILY 4. Gabapentin 300 mg PO HS 5. Multivitamin 1 Tablet PO DAILY 6. Omeprazole E.C. 40 mg Capsule.) PO DAILY 7. OxycONTIN 40 mg PO Q12H 8. Prednisone 15 mg PO DAILY 9. Senna 8.6 mg PO BID PRN constipation 10. Ursodiol 300 mg Capsule PO BID 11. Sulfamethoxazole-Trimethoprim 400-80 mg 1 Tablet PO DAILY 12. Acyclovir 400 mg PO Q8H Discharge Medications: 1. morphine concentrate 20 mg/mL Solution Sig: 5-10 mg PO every four (4) hours as needed for pain. Disp:30 ML Refills:0 2. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours as needed for pain. Disp:1 patch Refills:0 3. ondansetron 4 mg Tablet, Rapid Dissolve Sig: [2-6] Tablet, Rapid Dissolves PO every eight (8) hours as needed for nausea. Disp:4 Tablet, Rapid Dissolve(s) Refills:0 4. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal ONCE (Once). Discharge Disposition: Home With Service Facility: Catskills Area Hospice Care Discharge Diagnosis: Acute myelogenous leukemia C. difficile sepsis Malessezia furfur fungemia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [Known lastname 467], You were admitted to the hospital with sepsis related to an infection called C. difficile. You were treated with antibiotics. While in the hospital you received decitabine for treatment of your AML. You also developed a fungal infection in your blood and were treated with antibiotics and line removal. Towards the end of your hospitalization, you became more drowsy and sleepy- we think this was related to the overall progression of your disease. We shifted goals of care to focus on comfort and you were discharged home with hospice services. It was a pleasure taking part in your care. We wish you and your family all the best. Followup Instructions: Please follow up with the hospice care nurses and doctors. Completed by:[2146-1-26]	[ "2762" ]
Admission Date: [2130-10-13] Discharge Date: [2130-11-30] Date of Birth: [2049-4-17] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7055] Chief Complaint: CHF exacerbation transfer from OSH Major Surgical or Invasive Procedure: Thoracentesis Colonoscopy x 2 EGD x 2 Cardiac Catheterization Central Line Placement Intubation/Extubation PICC placement History of Present Illness: HISTORY OF PRESENTING ILLNESS: . 81 y.o. M with CAD, s/p atrial closure surgery, h/o BPH s/p TURP who presented to [Hospital1 ] last week with an acute on chronic systolic CHF exacerbation and weight gain requiring thoracentesis of 2L of fluid. Patient has been having progressively worsening heart failure symptoms over last 9 months. He has recently moved here from [Country 4194] 5 months ago. Patient was subsequently transferred to [Hospital1 18] for possible MVR/TVR and/or CABG depending on cath results. Patient also unable to lay flat for cardiac catherization Patient's course was complicated by hematuria requiring urology evaluation and subsequently patient is being transfered to cardiology service for further workup. He has been gently diuresed with IV lasix during his CSRU stay. Patien also had L femoral triple lumen catheter inserted. He is transfered to medicine service for continued CHF management. As far as the hematuria, course at OSH was complicated by traumatic foley insertion. A foley was placed with a urologist assistance after he performed a cystoscopy to place a Couniltip catheter over a wire as there were multiple false passages and urethral trauma causing hematuria. Patient continued to have gross hematuria with clots especially since heparin gtt was instituted for management of Afib. Past Medical History: PAST MEDICAL HISTORY: HTN DM2 AF CHF EF 30-35% - ischemic; MT/TR BPH s/p TURP CRI CAD, NO CABG Atrial Septal repair surgery . Social History: No etoh, used to smoke, moved from [Country 4194] 6 mo/ago and lives with son, through whom the history was obtained Family History: Brother with extensive cardiac history including bypass surgery; parents were well without heart disease, no HTN Physical Exam: PHYSICAL EXAMINATION: VS: T 97.2, BP 102/57 SBP (95-120), P 99 (85-100), SaO2 94% 4L -RR 16 GENERAL: No apparent distress, laying comfortably, use of accessory neck muscles HEENT: EOMI, pink conjunctiva. Oral mucosa moist and clear. NECK: supple with ~ JVP of 10 cm. No carotid bruits auscultated. No thyromegaly. CHEST: no deformities, scoliosis or kyphosis. labored respirations with mild use of accessory muscles. decreased BS, with no clear crackles appreciated CVS: RRR, nl S1/S2. ? S4, 3/6 SEM at apex ABD: +BS. soft, NT/ND. mild guarding The abdominal aorta was not palpated. No hepatosplenomegaly. EXT: Warm, without edema. several echymosis with scabs and surrounding erythema - due to recent trauma . Pertinent Results: Diagnostic Imaging: [2130-10-16].Echo. The left atrium is markedly dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild to moderate regional left ventricular systolic dysfunction with inferior akinesis and focal distal septal hypokinesis. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular cavity is mildly dilated. There is mild global right ventricular free wall hypokinesis. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) 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. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . [2130-11-1]. Cardiac cath. COMMENTS: 1. Right heart catheterization revealed elevated right sided filling pressures, with RVEDP of 17 mm Hg and mean RA pressure of 16 mm Hg. There was moderate to severe pulmonary arterial hypertension with PA pressure 64/27 mm Hg. The cardiac index was preserved at 3 l/min/m2. 2. Resting hemodynamics revealed normal systemic arterial pressure of 115/46 mm Hg. FINAL DIAGNOSIS: 1. Elevated cardiac filling pressures. 2. Moderate to severe pulmonary arterial hypertension. . Renal Ultrasound. [2130-10-23]. IMPRESSION: Large simple cysts on the left and on the right a septated cyst as well as multiple cysts TSTC by US; likely simple cysts. . [2130-10-21] Tib/Fib XRAY IMPRESSION: Normal radiographic appearance with no evidence for osteomyelitis. . [2130-10-23] Urine Cytology ATYPICAL. Rare atypical urothelial cells present singly. . [2130-10-23] CT HEAD: FINDINGS: There is no evidence of hemorrhage, edema, masses, mass effect, or major vascular territorial infarction. A small chronic left occipital pole infarct is seen, as well as probable chronic infarcts in the region of the posterior limb of the right internal capsule and subinsular white matter. The ventricles and sulci are unremarkable. Age- related changes are noted. No fractures are identified. Scattered ethmoid sinus mucosal thickening is noted, likely a chronic inflammatory process. The sinuses are otherwise unremarkable. The visualized orbits are normal. . IMPRESSION: No acute intracranial pathology. Probable multiple chronic infarcts, as noted above. . [2130-10-28] CT HEAD: FINDINGS: Nsignificant interval change from [2130-10-23] without evidence for intra- or extra-axial hemorrhage or mass effect. There is mild brain atrophy and a small lacunar infarct in the right thalamus/posterior limb of the internal capsule as well as further periventricular white matter hypodensities that are sequelae of chronic small vessel infarction. There is no evidence for fracture. . IMPRESSION: No intracranial hemorrhage or fracture. . [2130-11-1] Right Heart Catheterization COMMENTS: 1. Right heart catheterization revealed elevated right sided filling pressures, with RVEDP of 17 mm Hg and mean RA pressure of 16 mm Hg. There was moderate to severe pulmonary arterial hypertension with PA pressure 64/27 mm Hg. The cardiac index was preserved at 3 l/min/m2. 2. Resting hemodynamics revealed normal systemic arterial pressure of 115/46 mm Hg. . FINAL DIAGNOSIS: 1. Elevated cardiac filling pressures. 2. Moderate to severe pulmonary arterial hypertension. . [2130-11-3] Pleural Fluid Cytology: Pleural fluid: NEGATIVE FOR MALIGNANT CELLS. Virtually acellular specimen with abundant proteinaceous debris, red blood cell fragments and extremely rare benign- appearing cells, likely histiocytes, mesothelial cells and lymphocytes. . . [2130-11-6] CXR portable: Moderate bilateral pleural effusions greater on the right side are unchanged from [11-5], increased from [11-3]. Left lower lobe atelectasis is persistent. Moderate cardiomegaly is unchanged. The right IJ tip is in the cavoatrial junction, unchanged. NG tube tip is out of view below the diaphragm. ET tube tip is 4 cm above the carina. Mild pulmonary edema is stable. . [2130-11-3] Left Ankle Xray FINDINGS: In comparison with the study of [2130-10-21], there is no interval change. Specifically, no evidence of bone erosion. . [2130-11-11] CXR portable FINDINGS: A single portable image of the chest was obtained and compared to the prior examination dated [2130-11-9] demonstrating no significant interval change. Moderate-sized bilateral pleural effusions persist. There is persistent perihilar fullness associated with indistinct bronchopulmonary vasculature with an appearance most consistent with underlying edema. The right internal jugular central venous line and right PICC line are grossly unchanged and in satisfactory position. The bony thorax is grossly intact. . LABORATORY RESULTS: . [2130-11-14] 06:43AM BLOOD WBC-5.7 RBC-3.15* Hgb-9.2* Hct-29.0* MCV-92 MCH-29.2 MCHC-31.7 RDW-16.3* Plt Ct-421 [2130-11-14] 06:43AM BLOOD PT-15.7* PTT-47.4* INR(PT)-1.4* [2130-10-21] 06:44AM BLOOD ESR-22* [2130-11-14] 06:43AM BLOOD Glucose-94 UreaN-57* Creat-3.1* Na-146* K-3.9 Cl-101 HCO3-39* AnGap-10 [2130-11-10] 04:51AM BLOOD ALT-9 AST-16 TotBili-0.4 [2130-11-3] 05:17AM BLOOD LD(LDH)-270* [2130-11-1] 10:55AM BLOOD ALT-10 AST-16 LD(LDH)-242 AlkPhos-43 Amylase-46 TotBili-0.2 [2130-11-1] 10:55AM BLOOD Lipase-39 [2130-11-1] 10:55AM BLOOD CK-MB-5 cTropnT-0.16* [2130-11-14] 06:43AM BLOOD Calcium-8.3* Phos-5.4* Mg-2.6 [2130-11-7] 04:50AM BLOOD Albumin-2.3* Calcium-7.9* Phos-3.4 Mg-2.1 [2130-10-18] 03:44PM BLOOD %HbA1c-5.9 [2130-11-1] 10:55AM BLOOD TSH-8.0* [2130-11-2] 05:17AM BLOOD T4-3.4* T3-38* [2130-11-1] 03:49PM BLOOD Cortsol-52.1* [2130-11-1] 03:09PM BLOOD Cortsol-44.3* [2130-11-1] 10:55AM BLOOD Cortsol-26.9* [2130-10-21] 06:44AM BLOOD CRP-6.1* [2130-11-1] 02:12AM BLOOD Digoxin-1.6 [2130-11-10] 01:47PM URINE Color-Straw Appear-Hazy Sp [Last Name (un) ]-1.006 [2130-11-10] 01:47PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [2130-11-2] 10:24AM URINE RBC-[2-27]* WBC-[2-27] Bacteri-OCC Yeast-MOD Epi-0-2 [2130-11-2] 10:24AM URINE Mucous-FEW [2130-10-30] 09:55AM URINE Eos-NEGATIVE [2130-10-31] 12:27PM URINE Hours-RANDOM UreaN-456 Creat-139 Na-13 TotProt-81 Prot/Cr-0.6* [2130-11-3] 11:16AM PLEURAL WBC-17* RBC-[Numeric Identifier 3871]* Polys-4* Lymphs-58* Monos-0 Atyps-5* Meso-1* Macro-30* Other-2* [2130-11-3] 11:16AM PLEURAL TotProt-2.0 Glucose-95 LD(LDH)-80 Albumin-1.2 . CULTURE DATA: URINE CULTURE (Final [2130-10-17]): ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SECOND MORPHOLOGY. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. \| ENTEROCOCCUS SP. \| \| AMPICILLIN------------ <=2 S <=2 S NITROFURANTOIN-------- <=16 S <=16 S TETRACYCLINE---------- =>16 R =>16 R VANCOMYCIN------------ 2 S 2 S . WOUND CULTURE (Final [2130-10-17]): STAPH AUREUS COAG +. HEAVY GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Please contact the Microbiology Laboratory ([6-/2429]) immediately if sensitivity to clindamycin is required on this patient's isolate. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| STAPHYLOCOCCUS, COAGULASE NEGATIVE \| \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R =>8 R GENTAMICIN------------ <=0.5 S <=0.5 S LEVOFLOXACIN---------- =>8 R <=0.12 S OXACILLIN------------- =>4 R =>4 R PENICILLIN------------ =>0.5 R =>0.5 R RIFAMPIN-------------- <=0.5 S <=0.5 S TETRACYCLINE---------- <=1 S 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S 2 S . . CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [2130-11-3]): REPORTED BY PHONE TO [Initials (NamePattern4) ] [Last Name (NamePattern4) ], R.N. ON [2130-11-3] AT 0640. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. . [2130-11-3] 11:16 am PLEURAL FLUID PLEURAL FLUID. GRAM STAIN (Final [2130-11-3]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [2130-11-6]): NO GROWTH. ANAEROBIC CULTURE (Final [2130-11-9]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [2130-11-4]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): . . [2130-11-4] 12:03 am SPUTUM Site: EXPECTORATED Source: Expectorated. FINAL REPORT [2130-11-8] GRAM STAIN (Final [2130-11-4]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S) (PROBABLE CELLULAR DEBRIS). SMEAR REVIEWED [2130-11-6]. RESPIRATORY CULTURE (Final [2130-11-8]): OROPHARYNGEAL FLORA ABSENT. YEAST. RARE GROWTH. STAPH AUREUS COAG +. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S . . Blood Cultures: All negative . Brief Hospital Course: In summary, Mr. [Known lastname ] is an 81 year old male with A. Fib, dilated cardiomyopathy, systolic CHF, [Hospital 76187] transferred to [Hospital1 18] for possible mitral and tricuspid valve replacement. Course has been complicated by GI bleed due to healing gastric ulcer, hematuria due to traumatic foley placement, delerium likely due to hypoxia and hypercarbia, and acute on chronic renal failure. He was then transferred to the CCU for treatment of sepsis and hypercarbia/hypoxia, c.diff colitis, and volume overload. He had a prolonged hospital course and eventually developed hypercarbic respiratory failure requiring BiPAP and eventually intubation. He then became hypotensive not responsive to fluid boluses and anuric. His code status was changed to DNR as he was not a candidate for hemodialysis nor was he a surgical candidate for his severe mitral regurgitation. He ultimately died due to multisystem failure. . CAD. Cardiac cath for pre-operative evaluation on [10-18] showed total occlusion of RCA with good collateralization. He has ischemic cardiomyopathy (echo shows multiple focal wall abnormalities and EF of 40-45%). The patient then developed sepsis with hypotension requiring transfer to the CCU. As his sepsis was treated, the patient's BP improved, and he was able to be started on metoprolol for rate control as well as his CAD. He was able to return to the medical floor from the CCU. He did not have any further ischemic issues during his admission. . Pump. Patient has ischemic cardiomyopathy with EF of 40-45% by ECHO. His volume status was aggressively managed while he was admitted, both on the medical floor and in the unit. . Rhythm. Patient was in Atrial Fibrilation during the admission. He was rate controlled with beta blockade, first with Carvedilol, then with Metoprolol as the former caused a more significant decrease in his blood pressures. He was also anticoagulated on a heparin drip which was intermittantly held in the setting of GI bleeding. A GI consult was called, and the patient had an EGD/Colonoscopy which did not show any source of bleeding- likely caused by a small bowel AVMs. His hematocrit remained stable for the duration of his admission. . Pulmonary: The patient had a thoracentesis performed at the OSH prior to transfer to [Hospital1 18]. During this hospitalization, repeated chest x-rays showed reaccumulation of the bilateral pleural effusions, right greater than left. On [11-3], the patient underwent another thoracentesis. The fluid analysis was consistent with a transudative effusion, likely due to his worsening heart failure and valvular disease. As above, his volume status was aggressively managed. He had 2L drained by thoracentesis, however, rapidly reaccumulated his effusions. He was intubated initially for hypercarbic respiratory failure and was extubated prior to transfer to the medical floor. He then required re-intubation after a repeat episode of hypercarbic respiratory failure not improved with BiPAP. He was intubated at the time of his death. . Delerium. Patient has had intermittent delerium since approximately [10-26]. No clear etiology was determined. Head CT was normal twice. Delerium was thought to be due to hypoxia and hypercarbia when nasal canula has fallen off at night. In addition, patient has a history of working night shifts his entire life and has an altered sleep wake cycle. He was treated with zyprexa 2.5 prn for agitation. The patient's mental status never returned to baseline during this hospitalization, but according to his family, he communicated fairly well with them in Portuguese. . Guaiac positive stool. Patient had Colonoscopy [10-25] that showed non-bleeding angioectasia, internal hemorrhoids, and diverticulosis. EGD on [10-23] showed healing gastric ulcer. Gastric biopsy did not show H. pylori. Heparin drip for A. fib was intermittently held due to guiaic positive stools. He was started on a PPI [Hospital1 ] for gastric ulcer. He had another colonoscopy and EGD after he was intubated which did not show any active bleeding source. His bleeding was likely due to an AVM in the small bowel. Hematocrit remained relatively stable for the duration of his admission. . Hematuria. Patient had hematuria due to traumatic foley insertion and was followed by urology. Hematuria resolved during hospital stay. Patient was treated intermittently with CBI. His hemautria was evaluated with renal ultrasounds significant only simple cysts and a single septated cyst. Urine cytology showed rare atypical urothelial cells. He continued to have occasional hematuria during his hospitalization, but heparin was continued for his atrial fibrillation. . Acute on Chronic renal failure. Patient has a baseline creatinine of 2.0 which was stable until approximately [10-27] when it began to rise. Cr rose to 3.9 with little urine output. Renal was consulted and patient was thought to be pre-renal. Urine eosinophils were negative making AIN unlikely. Unresponsive to fluid boluses. With aggressive diuresis, and improvement in his cardiac function and forward flow, the patient's creatinine improved to 2.9. However, patient became septic, likely from C. Diff colitis, and became hypotensive and anuric. Renal consult service continued to follow the patient and did not feel he would be able to tolerate hemodialysis. He received multiple fluid boluses with minimal improvement in his blood pressure or urine output. His creatinine continued to rise and his urine output did not improve. Given his poor functional status secondary to his cardiac and renal disease, his code status was changed to DNR/intubated and he passed away in the CCU. . Infectious Disease: The patient had enterococcus in his urine prior to transfer to CCU. He also had a leg ulcer which was positive for MRSA and was treated with vancomycin and wound care consults were called. He was transferred to the CCU for hypothermia, hypotension, and bradycardia in the setting of likely sepsis. He was found to have MRSA in his sputum, and was positive for c.diff colitis. Initially, he was treated with vancomycin and zosyn, for a 7 day course. He was also treated with a 12 day course of metronidazole for his c.diff. He was initially stable and then became hypotensive, hypothermic and unresponsive. Most likely etiology was his C. Diff. He was treated aggressively with IV Vanc, PO Vanc and Flagyl with no improvement. Medications on Admission: Home Meds: glyburide 2.5 daily prozac 20 mg daily coreg 25 mg [Hospital1 ] lasix 80 mg Daily coumadin 3mg po daily spriva 1 puff [Hospital1 ] Discharge Medications: Not applicable Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis: Severe Mitral Regurgitation Acute on Chronic Systolic Heart Failure Atrial Fibrillation Pseudomembranous Colitis Pneumonia End stage renal disease Secondary Diagnosis: Hypertension Pleural Effusions Gastrointestinal Bleeding Anemia Discharge Condition: Patient expired Discharge Instructions: Patient expired Followup Instructions: Patient expired	[ "4240", "0389", "99592", "51881", "5849", "486", "4280", "40390", "5859" ]
Admission Date: [2194-9-27] Discharge Date: [2194-10-1] Date of Birth: [2131-7-17] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1271] Chief Complaint: headache and mild ataxia Major Surgical or Invasive Procedure: [2194-9-29]: Suboccipital Craniotomy and Mass resection History of Present Illness: This is a 63 year old male with chief complaint of headache and ataxia and a history of RCC, who presented with a new metastasis to the cerebellum. The patient was diagnosed with RCC in [2191] and is s/p left nephrectomy. He also has metastatic disease to the lung, s/p IL2 therapy cycle 1 in [2192-7-25] and cycle 2 in [2192-11-25]. He developed an obstructive right upper lobe lesion in [2193-4-25] and is s/p tumor debridement by rigid bronchoscopy and photodynamic therapy, as well as cyberknife to the right upper lobe lesion. . The patient was doing well after that and at the end of last year even traveled to [Location (un) ]. However over the last 2 weeks he developed a headache that was worsening and over the last week it was associated with ataxia especially when in the dark. He reports "bumping into things" and "almost falling over". The patient went to [Hospital ] Hospital at [State 1727] today where a MRI revealed a cerebellar mass with associated shift. He did received Decadron 10 mg IV. He was transferred here for further oncology care. He currently reports already feeling much improved. . In the ED, the neurological exam was benign except for some mild unsteadiness of the gait. Neurosurgery eval was requested due reported mass effect seen on MRI and q4 neuro checks + dexamethasone was recommended. No indication for surgery currently. . Review of Systems: (+) Per HPI as well as bloating and nausea of last few days, now resolved; also + weight loss of 25lbs recently (per patient due to hard physical labor) (-) Review of Systems: GEN: No fever, chills, night sweats. HEENT: No headache, sinus tenderness, rhinorrhea or congestion. CV: No chest pain or tightness, palpitations. PULM: No cough, shortness of breath, or wheezing. GI: No vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel habits, no hematochezia or melena. GUI: No dysuria or change in bladder habits. MSK: No arthritis, arthralgias, or myalgias. DERM: No rashes or skin breakdown. NEURO: No numbness/tingling in extremities. PSYCH: No feelings of depression or anxiety. All other review of systems negative. Past Medical History: [2191-3-26] Left radical nephrectomy; grade II clear cell carcinoma staged as T2NxMx. CT scan showed 6-mm noncalcified nodule in the anterior right middle lobe and a possible second nodule slightly more inferior; bone scan negative; PET CT showed activity in left kidney tumor but no abnormal FDG uptake in the lungs. A single focus of increased activity in the left lobe of the thyroid was noted and a thyroid ultrasound was recommended. [2192-5-25] surveillance CT scan showed multiple new pulmonary nodules and enlargement of previously noted nodules. The largest of the nodules measured 1 cm. Referred for high-dose IL-2 treatment at [Hospital1 18] [2192-6-25] Multiple R lung wedge resections; RML path shows RCC mets [2192-7-25] IL2 Therapy at [Hospital1 18] [2192-11-25] IL2 Therapy [Date range (1) 83379]; [2111-5-15]: chest CT with post-obstructive consolidation, concerning for endobronchial lesion causing obstruction. [2193-6-14]: Flexible bronchoscopy with obstructing RUL endobronchial lesion and nonobstructing RLL endobronchial lesion. [2193-6-17]: rigid bronchoscopy with mechanical and argon plasma coagulation tumor debridement. Biopsy revealed clear cell carcinoma. [2193-7-5]: bronchoscopy and photodynamic therapy to RUL and RLL endobronchial lesions [2193-7-8]: rigid bronchoscopy with mechanical tumor debridement [2193-8-25]: Cyberknife to right upper lobe lesion; [2194-5-10] CT torso with 1. Slight interval increase in size of the dominant right upper lobe nodule with adjacent increased soft tissue density surrounding the right upper lobe bronchus, concerning for new adenopathy versus tumor extension. 2. Increase in size of a nodule along the right middle lobe scar, now measuring 6 x 9 mm, previously barely visible. Stable size of multiple other small pulmonary nodules as described above. Asymptomatic. . Past Medical History: - Arthroscopic repair of the right shoulder and right knee, three years ago. - Spine surgery about 20 years ago. - Hypertension, resolved with weight loss after IL2 Social History: Married, has three healthy sons. Does not smoke, drinks only occasionally. Lives in [Location ], [State 1727], where he works as a farmer. His wife is a school principal. Regular Marijuana consumption Family History: Negative for cancer. Physical Exam: VS: 97.4 155/97 72 18 95RA GEN: AOx3, NAD HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No cervical, supraclavicular, or axillary LAD Cards: RR S1/S2 normal. no murmurs/gallops/rubs. Pulm: No dullness to percussion, CTAB no crackles or wheezes Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [Doctor Last Name 515] sign Extremities: wwp, no edema. DPs, PTs 2+. Skin: no rashes or bruising; extensive callus and cracks on hands Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs 2+ BL. sensation intact to LT, cerebellar fxn intact (FTN, HTS). Gait WNL. Romberg normal. Tandem gait with instability to both directions Upon discharge: Stable Pertinent Results: Labs: not reported from OSH (records were not brought to the floor from the ED; I called at 4am and asked for them to be courriered over) . Imaging: not reported from OSH (records were not brought to the floor from the ED; I called at 4am and asked for them to be courriered over) [2194-9-29] CT Head: Expected post-op changes. [2194-9-29] MRI Brain with and without contrast: expected postop changes Brief Hospital Course: ASSESSMENT AND PLAN: 63 yo M with metastatic RCC presenting with HA, ataxia and new cerebellar lesion, likely due to metastatic RCC. . # Brain lesion: - continue Dexamethasone 4mg Q6h (RSS and H2blocker with steroids) - will request neurosurgery consult given mass effect - Q4h neuro exam - review OSH records once available - obtain baseline labs as OSH not available . # Nausea resolved; ? due to brain lesion as well vs stress induced vs other - H2blocker while on high dose steroids . # FEN: Regular diet # PPx: - DVT PPx: encourage ambulation; will neeed to consider pneumoboots; no Hep sq given RCC mets in the brain # Access: PIV # Comm: patient # [Name2 (NI) 7092]: FULL # Dispo: pending above On [9-28] the patient was transferred to the [Hospital Ward Name ] to the neurosurgery service. He remained in the PACU overnight in anticipation of surgery in the morning. On [9-29] he underwent a suboccipital craniotomy and resection of left cerebellar mass. Surgery was without complication and he was extubated and transferred to the ICU post op. CT head was obtained which revealed expected post-op changes. He was kept in the Neuro ICU for monitoring. On [9-30] an MRI was done which showed expected postoperative changes. He was transferred to the regular floor and his diet was advanced. Neurooncology and radiation oncology were consulted and he will followup with Dr. [Last Name (STitle) 724] in Brain tumor clinic. He was seen and evaluated by physical therapy who felt that he was safe to return home. At the time of discharge he is tolerating a regulat diet, ambulating without difficuty, afebrile with stable vital signs. Medications on Admission: none Discharge Medications: 1. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:2 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. sod phos,di & mono-K phos mono 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for muscle spasm. Disp:90 Tablet(s) Refills:0 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:90 Tablet(s) Refills:0 6. dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO every six (6) hours: Take 2 tabs Q6 on [10-1] tabs Q12 hrs on [10-2] and [10-3] then tabe 1 tab Q12 hrs ongoing. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Cerebellar lesion Cerebral edema Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair after your staples are removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in 10 days (from your date of surgery) for removal of your staples. This appointment can be made by calling [Telephone/Fax (1) 1272]. ??????You have an appointment in the Brain [Hospital 341] Clinic on :[2194-10-6] 11:30. The Brain [Hospital 341] Clinic is located on the [Hospital Ward Name 516] of [Hospital1 18], in the [Hospital Ward Name 23] Building, [Location (un) ]. Their phone number is [Telephone/Fax (1) 1844]. Please call if you need to change your appointment, or require additional directions. You will see a rdaition specialist at that time. Provider: [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) 4861], MD Phone:[Telephone/Fax (1) 1844] Date/Time:[2194-10-6] 11:30 [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2194-10-1]	[ "40390", "5859" ]
Admission Date: [2113-1-30] Discharge Date: [2113-2-6] Date of Birth: [2040-3-14] Sex: M Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 11304] Chief Complaint: left renal mass Major Surgical or Invasive Procedure: Robotic left partial nephrectomy- Dr. [Last Name (STitle) 14114] [2113-1-30] History of Present Illness: Mr. [Known lastname 3614] is a 72 year old male with HTN, COPD, CHF, HL, CAD s/p MI with stent placement in [2097], here with post-operative hypoxia. He underwent right partial nephrectomy for a 6 cm renal mass concerning for renal cell carcinoma. Intraoperatively, he received 6 L of IVFs. Post-operatively, he was noted to desat to 80s on 4LNC. . Upon arrival to the [Hospital Unit Name 153], his vitals were RR 20, HR 91, BP 96/55, 95% on 4LNC. The patient reports his breathing is comfortable, though patient is tachypneic. He denies cough, pleuritic chest pain, chest pressure. He reports increased abdominal pain with deep inspiration. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. Past Medical History: HTN Hyperlipidemia CHF, most recent echo with [Last Name (LF) 14115], [First Name3 (LF) ] of 60% in [Month (only) ] by report COPD with moderate obstructive disease on PFTs CAD, s/p MI [17] years ago Type 2 diabetes, insulin dependent Scoliosis Social History: Patient has a 1.5 PPD for 15 years smoking history, but quit 25 years ago. Denies current alcohol use. Patient lives with his daughter who is his health care proxy. [Name (NI) ] is a retired upholsterer. Family History: Patient denies family history of cardiac or pulmonary disease. Physical Exam: Vitals: HR 81, BP 100/60, 96% on 4LNC, General: Alert, oriented, tachypneic HEENT: Sclera anicteric, oropharynx clear Neck: supple, JVP difficult to assess Lungs: coarse breath sounds at right base, but lung exam limited due to patients diffuculty sitting upright CV: distant heart sounds, Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, multiple surgical scars with come tenderness diffusely, bowel sounds present, no rebound tenderness or guarding GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: 137 \| 105 \| 16 / --------------- 121 5.2 \| 24 \| 1.1 \ . \ 11.0 / 14.6 ----- 203 / 33.8 \ Brief Hospital Course: Patient was admitted to Urology after undergoing robotic left partial nephrectomy. No concerning intraoperative events occurred; please see dictated operative note for details. The patient received perioperative antibiotic prophylaxis. The patient was transferred to the floor from the PACU in stable condition. On POD0, pain was well controlled on PCA, hydrated for urine output >30cc/hour, and provided with pneumoboots and incentive spirometry for prophylaxis. However, the patient was noted to have increasing post-operative hypoxia. Intraoperatively, he received 6 L of IVFs and was noted to desat to 80s on 4LNC post-operatively, prompting transfer to the [Hospital Unit Name 153] for interval managment. . The patient's exam and presentation were most consistent with respiratory compromise that was multifactorial and secondary to his known COPD, scoliosis, and splinting from surgery-associated pain. His oxygen saturation and breathing improved with bronchodilator therapy and he was transferred back to the surgical service on POD2. . On POD 3, the patient ambulated, was restarted on home medications, basic metabolic panel and complete blood count were checked, pain control was transitioned from PCA to oral analgesics, diet was advanced as tolerated. On POD5, JP and urethral catheter (foley) were removed without difficulty. The patient passed a void trial with voided volumes greater that post void residuals. The remainder of the hospital course was relatively unremarkable. The patient was discharged in stable condition, eating well, ambulating independently, voiding without difficulty, and with pain control on oral analgesics. On exam, incision was clean, dry, and intact, with no evidence of hematoma collection or infection. The patient was given explicit instructions to follow-up in clinic with Dr. [Last Name (STitle) 3748] in 3 weeks. Medications on Admission: Atenolol 25 mg daily Lipitor 20 mg daily Lasix 20 mg daily Lisinipril 5 mg daily Aspirin 325 mg daily Multivitamin daily Albuterol Atrovent Discharge Medications: 1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for break through pain only (score >4) . Disp:50 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Atenolol 25 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 wheeze, SOB. 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). Disp:30 Capsule, Sust. Release 24 hr(s) Refills:2 6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Capsule(s) 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [Location (un) 8300] VNA Discharge Diagnosis: right renal mass Discharge Condition: Stable Discharge Instructions: -You may shower but do not bathe, swim or immerse your incision. -Do not eat constipating foods for 2-4 weeks, drink plenty of fluids -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthough pain >4. Replace Tylenol with narcotic pain medication. Max daily Tylenol dose is 4gm, note that narcotic pain medication also contains Tylenol (acetaminophen) -Do not drive or drink alcohol while taking narcotics -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication, discontinue if loose stool or diarrhea develops. -Resume all of your home medications, except hold NSAID (aspirin, and ibuprofen containing products such as advil & motrin,) until you see your urologist in follow-up -Call your Urologist's office today to schedule/confirm your follow-up appointment in 3 weeks AND if you have any questions. -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest ER -Call Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 3748] to set up follow-up appointment and if you have any urological questions. [Telephone/Fax (1) 3752] Followup Instructions: Please contact Dr.[Name (NI) 11306] office to arrange/ confirm follow up. Completed by:[2113-2-6]	[ "5180", "496", "V4582", "4280", "4019", "25000", "41401", "412", "2724", "V5867", "V1582" ]
Admission Date: [2150-6-11] Discharge Date: [2150-6-15] Service: SURGERY Allergies: Levofloxacin / Isoniazid Attending:[First Name3 (LF) 371] Chief Complaint: Fall with 5-6 minutes unresponsiveness Major Surgical or Invasive Procedure: None History of Present Illness: 88 yo female presents s/p unwitnessed fall at NH. Nursing reported 5-6 minutes of unresponsiveness after event. No urinary or Fecal incontinence. HRC staff heard a thump and found patient face down on the floor. Some nosebleed, EMS called. Patient was moaning by the time EMS arrived and she was transferred to [Hospital1 18]. Past Medical History: Hx of Falls, HTN, CHF, COPD, Venous Impairment, Afib/RBBB/L Post Hemiblock, Alzheimers, OA, Cataracts, Depression, Recent Hx of Adenovirus URI Tx with Augmentin and Bactrim, + MRSA nasal swab, Hx of PPD + Social History: Lives at [Hospital 100] Rehab, Dependent for ADL's at baseline, + Confusion at basleine, uses a walker Family History: NC Physical Exam: Gen: A&O x 2 HEENT: PERRL, L orbital ecchymosis, Large Hematoma on Left Scalp Resp: Decreased BS on Left CV: Irregular RR Abd: NT/ND Neuro: Cooperative with exam, 5/5 strength in all extremities, Sensation intact peripherally Ext: L UE spinted, fingers warm and well perfused Pertinent Results: [2150-6-11] 05:30AM GLUCOSE-112* UREA N-26* CREAT-0.8 SODIUM-141 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-28 ANION GAP-12 [2150-6-11] 05:49AM LACTATE-1.4 K+-4.1 [2150-6-11] 05:30AM ALT(SGPT)-16 AST(SGOT)-32 LD(LDH)-327* CK(CPK)-37 ALK PHOS-110 AMYLASE-170* TOT BILI-0.3 [2150-6-11] 05:30AM CK-MB-NotDone cTropnT-<0.01 proBNP-989* [2150-6-11] 05:30AM DIGOXIN-0.4* [2150-6-11] 05:30AM WBC-9.8 RBC-4.21 HGB-10.7* HCT-32.8* MCV-78* MCH-25.3* MCHC-32.5 RDW-15.2 Brief Hospital Course: Patient was admitted to TSICU for observation. Pt wrist fracture was splinted in the ED and orthopaedics was consulted on the floor. On HD#2, she was deemed to be appropriate for transfer to the floor, her C-collar was D/C after negative CT and clinical clearance. Geriatrics was consulted and followed along. Pt had an episode on HD#3 of bradycardia into the 50's. Pt. Digoxin D/C and she was restarted on telemetry in the VICU. There was also some concern regarding the patient not taking PO. Pt. passed swallow study on HD#5. In consultation with Geriatrics it was deemed that patient was appropriate for d/c back to rehab with PCP [Last Name (NamePattern4) 702]. Discussed wrist fracture with orthopaedics who would like patient to follow with primary care physician for [Name9 (PRE) 702] of wrist fracture. Medications on Admission: Celexa 20 Digoxin 0.125 Famotidine 20 Furosemide 60 MVI QD Zyprexa 5 KCL 20 Tobradex op oint Tylenol 650 [Hospital1 ] Fosamax 70 qwk Norvasc 5 QD Discharge Medications: 1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:0 4. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:0 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. Disp:15 Tablet, Sublingual(s) Refills:0 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - LTC Discharge Diagnosis: Left Frontal and Temporal Intraparenchymal Hemorrhage Left Frontal Subgaleal hemorrhage Left Distal Radius Fracture Left Ulnar Styloid Fracture Left Lung Consolidation Discharge Condition: Good Discharge Instructions: Return to Emergency Room for: Fever>101.5 Severe headache Dizziness Loss of Consciousness Nausea/Vomiting Followup Instructions: Follow up with your primary care doctor in [12-8] weeks after discharge. Please call to schedule an appointment. Completed by:[2150-6-15]	[ "4280", "496", "42731", "4019", "42789" ]
Admission Date: [2200-10-27] Discharge Date: [2200-10-29] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7333] Chief Complaint: heart block Major Surgical or Invasive Procedure: [10-28] [Company 1543] pacemaker placement, by [Doctor Last Name 13177] for [Doctor Last Name ] History of Present Illness: [Age over 90 ] y/o male with PMH PVD, CAD (sees cardiologist at other hospital but no documented CABG or cath) recurrent falls (2 falls in 2 weeks), who initialyl presented to [Hospital3 ] hospital for workup. [Hospital3 417] felt this was likely a TIA and sent pt home. Pt then followed up with PCP who put on Holter (last tuesday [10-21] for 24 hrs). At 7:55pm during the Holter recording, pt had syncope which corresponds to Holter recording of 3rd degree heart block in [4-10] sec pauses- had 5-7 episodes, per patient. Since wednesday, there have been 2 other episodes where he sits down and gets dizzy/foggy. Holter was recently read and pt told to come to ED. In ED, found to be in 1st degree heart block with LBBB. Initial vitals were 98.5, 71, 143/58, 18, 98%. Denied any chest pain. Trop negative. Cardiology was consulted in the ED and pt was transfered to the CCU for close monitoring. Access- 2 peripherals and vitals on transfer afebrile, HR 65, RR 18, 98% RA, BP 150/56. . In the CCU, pt denies any chest pain or shortness of breath. Vitals BP 181/43, HR 76, 95% on RA, afebrile, NSR. . Pt denies chset pain, no SOB, no fevers, no chills, no abd pain, does report chronic back pain, remainder of ROS negative. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension (unclear, not documenteD) 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: renal stones CAD-no known MI (covering cardiologist will fax cards records here tomorrow AM) PVD cataracts s/p surgery Hiatal hernia. Questionable history of hypertension. The patient was on metoprolol 25 mg b.i.d. given to him either his previous primary M.D. or cardiologist. History of multiple falls. Chronic lower back pain as well as neck pain and some hip discomfort. Mild dementia Failure to thrive prostate surgery? Social History: he lives by himself and his healthcare proxy is his nephew and [Name2 (NI) 802]. He lived by himself until 4 months ago, now in [Hospital 4382] facility. He is independent with ADLs. At baseline, he ambulates with a walker. No ETOH, no tobacco. Went to [Hospital1 ] poly tech, graduated in [2119]. Was an engineer. Family History: Significant for cancer and heart disease, which run in the family. Physical Exam: ADmission Exam: VS: BP 181/43, HR 76, 95% on RA, afebrile, NSR GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8cm. CARDIAC: RRR, [12-11] diastolic murmur, 3rd heart sound LUNGS: no crackles, rhonchi, rhales ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Left: Carotid 2+ Femoral 2+ Pertinent Results: [2200-10-27] cTropnT-<0.01 [2200-10-29] WBC-9.4 Hgb-11.2* Hct-32.4* MCV-99* Plt Ct-276 [10-29] CXR, IMPRESSION: 1. Pacemaker leads in the expected position of the right atrium and right ventricle 2. Unchanged possible right thyroid enlargement causing tracheal deviation. Consider ultrasound for further evaluation. Brief Hospital Course: [Age over 90 ] M with history of CAD (although nothing recorded in OMR) and recent falls admitted for documented high degree heart block on holter monitor. . # RHYTHM: Pt with pauses on Holter concerning for underlying heart block, likely explaining patients recurrent falls. Patient had dual-chamber pacemaker placed [10-28]. At time of discharge, CXR confirmed appropriate lead placement. Implant site without erythema, drainage, hematoma, infection. Will receive 3-day (total) course of post-op antibiotics. . # HTN: Was hypertensive up to the 180s on initial presentation. Controlled with captorpil. . # CAD: OMR reports CAD but pt and family deny. Continued his home regimen of ASA 81. . # Back Pain: Tylenol 1,000 TID standing, per home regimen . # CRI: Cr 1.3, consistent with Cr from 1/[2199]. HAs been in the 1.2-1.4 range since [2198], likely a chronic picture from HTN. Medications on Admission: Tylenol 500mg TID Vit D2 50,000 U once a month multivitamin ASA 81 Lidocaine patch- apply to lower back Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. cephalexin 250 mg Capsule Sig: One (1) Capsule PO four times a day for 3 days. Disp:12 Capsule(s) Refills:0 3. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) patch Topical once a day: apply to lower back. 4. acetaminophen 500 mg Capsule Sig: One (1) Capsule PO three times a day. 5. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 6. Multiple Vitamins Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: Excella Home Care Discharge Diagnosis: Complete Heart Block Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You had complete heart block and needed a pacemaker to help fix the conduction system of your heart. You will need to take antibiotics for 2 days to prevent an infection at the pacer site. No lifting more than 5 pounds for 6 weeks with your left arm, do not reach your left arm over your head for 6 weeks. Please wear the sling at night for one week only. . Medication changes: 1. Start taking Cephalexin, an antibiotic for 3 days to prevent infection at the pacer site. Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [2200-11-5] at 9:30 AM With: DEVICE CLINIC [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage . Name:[First Name11 (Name Pattern1) 488] [Last Name (NamePattern4) 10541],MD Location: [Hospital1 ] HEALTHCARE - [Location (un) 8720] Address: 15 [Doctor Last Name 8721] BROTHERS WAY,[Apartment Address(1) 8722], [Location 8723],[Numeric Identifier 8724] Phone: [Telephone/Fax (1) 8725] The office has been contact[Name (NI) ] for an appointment for next week. You will be called at home with a follow up within the next week. If you dont hear in two business days, please call the above number . Department: CARDIAC SERVICES When: [12-29] at 3:00pm With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "41401", "40390", "5859" ]
Admission Date: [2148-12-18] Discharge Date: [2148-12-26] Service: CSU HISTORY OF PRESENT ILLNESS: Mrs. [Known lastname 1617] is an 80 year old woman transferred from [Hospital6 3872] after a cardiac catheterization revealed three-vessel disease. She is transferred for evaluation for CABG. On transfer, she is pain- free on IV nitroglycerin. She has had angina and shortness of breath times 4-5 years, medically managed. Her last catheterization prior to transfer was in the year [2144]. PAST MEDICAL HISTORY: Past medical history is significant for CAD, hypertension, peripheral vascular disease, diabetes mellitus type 2, obesity, GERD, cholecystectomy, bilateral cataract surgery, nephrolithiasis, osteoarthritis and bilateral total knee replacements. SOCIAL HISTORY: Remote tobacco, no alcohol. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Aspirin 81 daily, Protonix 40 daily, Mevacor 40 daily, Lasix 20 every other day, metformin 500 [Hospital1 ], glyburide 1.25 daily, Exelon 6 [Hospital1 ], enalapril 20 [Hospital1 ], Celebrex 200 daily, quinine sulfate 325 qhs, Lexapro 10 daily, atenolol 50 daily, nitroglycerin at 12 mcg per minute, Mirapex 25 qhs and timolol one drop in the left eye [Hospital1 ]. LABORATORY: Catheterization at [Hospital3 1280] showed left main 40 percent, ostial LAD 80-90 percent, ostial ramus 90 percent, ostial left circumflex 80-90 percent with no ejection fraction, but ejection fraction by echo reported to be normal. Sodium was 136, potassium 5.3, chloride 97, CO2 32, BUN 33, creatinine 1.1, AST 26, ALT 16, alkaline phosphatase 85, cholesterol 154, total protein 7.1, total bilirubin 0.3, albumin 3.8, INR 1.04, PTT 28.8. UA is negative. Chest x-ray - sinus rhythm with a rate of 60. PHYSICAL EXAMINATION: Height is 5' 4". Weight is 197 lb. General - no acute distress. Neurologic - alert and oriented times three, moves all extremities, follows commands, nonfocal exam. HEENT - Pupils are equal, round and reactive to light. Extraocular movements were intact, anicteric. Mucous membranes are moist. Neck is supple with no lymphadenopathy or thyromegaly and no JVD. Respiratory is diminished in the bases and otherwise clear. Cardiovascular - regular rate and rhythm, S1 and S2 with no murmur. Abdomen is obese, soft, nontender with positive bowel sounds and a well- healed right lateral scar. Extremities are warm with no edema and no varicosities. HOSPITAL COURSE: The patient is admitted to the Cardiothoracic Service, placed on heparin and IV nitroglycerin. She is scheduled for carotids and echocardiogram prior to cardiac surgery. On the 12th, in the early morning, the patient had carotid duplex which showed mild plaque of the right RCA with no hemodynamic significance and no significant plaque in the left RCA along with normal vertebrals. She was then brought directly to the Operating Room where she underwent coronary artery bypass grafting times four. Please see the OR report for full details. In summary, she had a CABG times four with a LIMA to the LAD, saphenous vein graft to the ramus, saphenous vein graft to the OM with a sequential graft to the PDA. Her bypass time was 78 minutes with a cross-clamp time of 45 minutes. She tolerated the operation well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient was A-paced at a rate of 80. She had NeoSynephrine at 0.5 mcg/kg/min. and propofol at 20 mcg/kg/min. The patient did well in the immediate postoperative period. Her anesthesia was reversed. She was weaned from the ventilator and when ready to be extubated, it was found that the patient had no cuff leak. Therefore, she remained intubated throughout the night of the operative day. On postoperative day 1, the patient remained hemodynamically stable. Endotracheal cuff was checked again. At that time, she had a significant cuff leak and she was extubated successfully. The patient was also weaned from her NeoSynephrine infusion. Her chest tubes were removed as was her Swan-Ganz catheter. She was begun on beta blockade as well as diuretics. The patient did experience an episode of atrial fibrillation on postop day 1 and therefore was begun on amiodarone as well. On postop day 2, the patient remained in the Cardiothoracic ICU to closely monitor her heart rate and rhythm. She had periodic episodes of atrial fibrillation alternating between sinus rhythm and atrial fibrillation and therefore was begun on an amiodarone drip. The patient continued to have intermittent atrial fibrillation on postoperative day 3, all episodes lasting only a short time. On postoperative day 4, the patient was transferred to the floor for continuing postoperative care and cardiac rehabilitation. At that time, she was in sinus rhythm and was therefore converted to oral amiodarone. Over the next several days, the patient had an uneventful hospital course. Her activity level was increased with the assistance of the nursing staff and physical therapy. She was gently diuresed and on postoperative day 6, it was decided that the patient was stable and ready to be transferred to rehabilitation for continuing postoperative care. At the time of this dictation, the patient's temperature is 99.2, heart rate 65 sinus rhythm, blood pressure 130/40, respiratory rate 18, O2 saturation 98 percent on room air. Weight on the day of discharge is 88.6 kg and preoperatively 90 kg. Lab data reveals a white count of 9.7, hematocrit 30.9, platelets 212, potassium 4.0, BUN 32, creatinine 1.2, magnesium 2.2. Physical examination - in no acute distress. Neurologic - alert and oriented times three and moves all extremities, follows commands, nonfocal exam. Pulmonary - clear to auscultation bilaterally. Cardiac - regular rate and rhythm, S1 and S2 with no murmur. Sternum is stable, incision with Steri-Strips, no erythema or drainage. Abdomen is soft, nontender and nondistended with normoactive bowel sounds. Extremities are warm and well-perfused with no edema. Right leg incision with Steri-Strips clean and dry. The patient's condition at transfer is good. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass grafting times four with a LIMA to the LAD, saphenous vein graft to the ramus, saphenous vein graft to the OM and PDA sequentially. 2. Hypertension. 3. Peripheral vascular disease. 4. Diabetes mellitus type 2. 5. GERD. 6. Cholecystectomy. 7. Obesity. 8. Nephrolithiasis. 9. Osteoarthritis. 10. Bilateral total knee replacements. FOLLOW UP: The patient is to have follow-up with Dr. [First Name (STitle) 1075] 2- 3 weeks after discharge from rehabilitation and follow-up with Dr. [Last Name (STitle) 70] in 6 weeks. DISCHARGE MEDICATIONS: Lopressor 25 mg [Hospital1 ], potassium chloride 20 mEq daily times 10 days and then every other day, Colace 100 mg [Hospital1 ], aspirin 81 mg daily, Percocet 5/325 one to two tabs q4h prn, glyburide 1.25 mg [Hospital1 ], pantoprazole 40 mg daily, Exelon 6 mg [Hospital1 ], Celebrex 200 mg daily, atorvastatin 20 mg daily, amiodarone 400 mg [Hospital1 ] times 1 week, then 400 mg daily times 1 week, then 200 mg daily, timolol one drop [Hospital1 ] and Lasix 20 mg daily times 10 days, then every other day. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5662], [MD Number(1) 5663] Dictated By:[Last Name (NamePattern4) 1718] MEDQUIST36 D: [2148-12-26] 12:21:29 T: [2148-12-26] 13:06:44 Job#: [Job Number 59613]	[ "41401", "42731", "25000", "53081", "4019" ]
Admission Date: [2126-5-16] Discharge Date: [2126-5-21] Service: MEDICINE Allergies: Lisinopril Attending:[First Name3 (LF) 19836] Chief Complaint: DOE, lightheadedness Major Surgical or Invasive Procedure: Colonoscopy Capsule study History of Present Illness: This is a 83 year-old female with a h/o ischemic colitis, MGUS, HTN, AS who presents with SOB, lightheaded, found to have Hct of 19 down from 26. She developed a transfusion reaction vs flash pulmonary edema in the ED and was admitted to MICU for further monitoring. She was briefly on Bipap and her dyspnea/hypoxia resolved. She was diursed 1.2 L (but her breathing improved prior to this). Her hct has been stable after 2U pRBCs. Please see below for more details of her presentation and course. Ms. [Known lastname ] feels well currently, no dyspnea, orthopnea, PND, fevers, chills, cough, LE swelling. . Pt recently had an episode of nonbloody vomiting, felt also more tired, lightheaded and had DOE. Denied any CP, syncope, diaphoresis. She is being closely followed by her PCP, [Name10 (NameIs) ] found to have worsened anemia with Hct from baseline of 30s down to 24 on [2126-5-6]. Her valsartan was held and her PPI was increased to [Hospital1 ]. She underwent EGD on [2126-5-8]. EGD was unremarkable but pt had a granulomatous mass on colonoscopy in [9-/2125] which was initially suspicious for plasma cell neoplasm and led eventually to the diagnosis of MGUS (per last Heme/Onc note from [2126-3-27]). Of note, she has known ischemic colitis with LGIB in [2121] and [7-/2125], treated conservatively. . On day of admission, she was more lightheaded, became diaphoretic while trying to have a BM in the bathroom. Her relatives called 911 and she was brought to the ED. . In the ED, her VS were T97.1, 84, 116/50, 12, 99%RA. She was guaiac positive but takes iron. An EKG was unremarkable. CXR with no acute process. Labs notable for Hct of 19 down from 26 just three days ago. Pt was given 2L IVF and was ordered for 2U PRBC. However, after 60cc of blood, she developed facial redness, diaphoresis, was cool and pale, and was sob with diffuse crackles on exam. She says that she was not at all dyspneic until getting blood. Her BP went down to 83/41 transiently. RR up to high 30s and tachy to 122. She was given IV benadryl, solumderol, and zantac. Repeat CXR showed fluid overload. She was started on BiPAP with improvement of symptoms. She was weaned to NC (satting 100% on 3L) but her admission bed was changed to ICU for closer monitoring. . On arrival in the MICU, she was less SOB, satting well on 2.5L NC. In the MICU she was briefly on BIPAP, SOB resolved with before diuresis. She recieved 2U pRBCs without event, but was diuresed 1.2L with 10mg IV lasix. Transfusion medicine feels that she did not have a blood reaction, but likely flash pulmonary edema. . ROS: The patient denies any fevers, chills, nightsweats, abdominal pain, chest pain, or lower extremity edema. She c/o occasional urinary frequency, dysuria, and constipation. Past Medical History: 1. Hypertension. 2. Hypercholesterolemia. 3. Moderate aortic stenosis. Last echo in [2122] with AoVA 0.8-1.19cm2 4. Gout. 5. Ischemic colitis with LGIB in [2121] and [7-/2125], treated conservatively. 6. Diverticulosis. 7. MGUS (Oncologist Dr. [Last Name (STitle) 410] Social History: Used to drink one cocktail drink a day. Denies any tobacco use. Lives at home with sister. Is functional, does all ADLs herself. Not married. Physical Exam: Vitals: T: 97.6 BP: 100/43 HR: 81 RR: 20 O2Sat: 99% on RA. -1.2L GEN: WDWN elderly female in no acute distress HEENT: EOMI, PERRL, sclera anicteric, MMM, OP Clear NECK: No JVD COR: RRR, 3/6 SEM at USB radiating to both carotids, no G/R, normal S1 S2. pulsus parvus/tardus PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, 2+ DP pulses NEURO: alert, oriented. Moves all 4 extremities. SKIN: No jaundice, cyanosis. No ecchymoses. Brief Hospital Course: Anemia: Black, guaiac positive stools suggestive of UGI source. Baseline Hct in 30s, on admission with hct of 19 ([5-16]) s/p 2 units pRBC in the MICU. Hct stable throughout hospital course at 26-27. On [5-20] colonoscopy with polyps in the descending colon s/p biopsy. She was discharged with capsule endoscopy on [5-21]. She was restarted on her regimen of iron. . Hypoxia: Was thought to be secondary to TRALI versus pulmonary edema from acute blood-transfusion-related volume overload. In the end a diagnosis of TRALI was preferred given the right timing of onset, hypotension and facial flushing. Hypoxia completely resolved since being on the floor. . AS: Moderate AS (AoVA 0.8-1.19cm2) on last echo in [2122]. Repeat ECHO here was unchaged. At baseline she is asymptomatic with AS, though this may have contributed to her SOB/hypoxia here as noted above. She remained stable throughout the rest of her hospitalization. . HTN: She was restarted on her BB and [Last Name (un) ] at discharge and tolerated these well. Medications on Admission: 1. Atenolol 25 mg once a day. 2. Protonix 40 mg [Hospital1 ]. 3. Simvastatin 20 daily. 4. Allopurinol 300 daily. 5. Psyllium daily 6. Iron 160 [Hospital1 ]. 7. (Valsartan 160 daily held for last few days by PCP) Discharge Medications: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Allopurinol Oral 5. Psyllium Oral 6. Iron 160 mg (50 mg Iron) Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 7. Valsartan 160 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Anemia Secondary Hypertension Hyperlipidemia Aortic stenosis Gout Diverticulosis Discharge Condition: hemodynamically stable, stable hct Discharge Instructions: You were admitted with lightheadedness. You were found to have a very low blood count. You had a blood transfusion during this hospitalization. You had an adverse to the blood transfusion and were admitted to the intensive care unit. Your blood counts stabilized following these transfusions. You also had a colonoscopy. You are being discharged with instructions for a capsule endoscopy. You should return the capsule as instructed by the gastroenterologist tomorrow [5-22]. The following medications were changed during this hospitalization: Iron was restarted for your low blood count. Please start the iron following your capsule study. If you have any of the following symptoms, you should call your PCP or return to the emergency room: Chest pain, shortness of breath, lightheadedness, loss of Followup Instructions: We have scheduled an appointment for you with Dr. [Last Name (STitle) 9006] for tomorrow [5-22] at 12:20 PM. Please attend this appointment. You will likely have your blood count monitored then. Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4853], M.D. Phone:[Telephone/Fax (1) 253] Date/Time:[2126-6-5] 10:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 3749], MD Phone:[Telephone/Fax (1) 3241] Date/Time:[2126-6-12] 11:00 Provider: [First Name8 (NamePattern2) ] [Name11 (NameIs) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 250] Date/Time:[2126-6-17] 11:00 [First Name8 (NamePattern2) ] [Name8 (MD) ] MD, [MD Number(3) 19838] Completed by:[2126-6-5]	[ "4241", "2760", "2851", "4019", "2720" ]
Admission Date: [2153-12-20] Discharge Date: [2153-12-28] Date of Birth: [2104-10-27] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 23197] Chief Complaint: Hyponatremia Major Surgical or Invasive Procedure: none History of Present Illness: 49yoF with cryptogenic liver cirrhosis on transplant list, c/b portal hypertension, jaundice, and ascites presents for management of lower extremity edema and hyponatremia. She was seen in clinic by Dr. [Last Name (STitle) 497] on [2153-12-19] for her hyponatremia, hyperkalemia, and inability to decrease her diuretic dose. Despite fluid restriction, her weight increased 3kg to 72kg and she notes increased lower extremity edema. She is admitted for initiation of tolvaptan. Past Medical History: 1. Cryptogenic cirrhosis on the transplant list, decompensated with jaundice, portal hypertension, and ascites. 2. Pancytopenia. Social History: -Tobacco history: None -ETOH: None -Illicit drugs: None -Home: Born in [Country 3594], moved here when she was 5. Single, no children. Lives with family Family History: Mother died at 62, h/o Pulmonary Sarcoid, Htn, and CVA. Father [Name (NI) 23198] hx) Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 97.5, 127/82, 63, 18 GENERAL: Comfortable, appropriate and in good humor. Diffusely Jaundiced HEENT: Sclera icteric. PERRL, EOMI. NECK: Supple with low JVP 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: Distended but Soft, non-tender to palpation. Dullness to percussion over dependent areas but tympanic anteriorly. No HSM or tenderness. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+ [Location (un) ] bilaterally to knees. Pertinent Results: Admission Labs: [2153-12-21] 02:38AM BLOOD WBC-4.0 RBC-3.27* Hgb-11.0* Hct-33.2* MCV-102* MCH-33.7* MCHC-33.2 RDW-14.7 Plt Ct-58* [2153-12-21] 02:38AM BLOOD PT-25.1* PTT-38.5* INR(PT)-2.4* [2153-12-20] 08:20PM BLOOD Glucose-117* UreaN-15 Creat-1.0 Na-117* K-7.0* Cl-84* HCO3-26 AnGap-14 [2153-12-21] 02:38AM BLOOD Glucose-119* UreaN-14 Creat-0.8 Na-119* K-3.9 Cl-84* HCO3-31 AnGap-8 [2153-12-21] 02:38AM BLOOD ALT-110* AST-211* LD(LDH)-251* AlkPhos-273* TotBili-12.3* [2153-12-20] 08:20PM BLOOD Calcium-8.3* Phos-2.4* Mg-2.1 [2153-12-21] 02:38AM BLOOD Albumin-2.2* Calcium-8.3* Phos-2.0* Mg-2.0 Hematology: [2153-12-22] 02:26AM BLOOD Ret Aut-4.0* [2153-12-22] 08:55AM BLOOD calTIBC-152* VitB12-GREATER TH Folate-8.2 Ferritn-1017* TRF-117* Sodium Trend: [2153-12-20] 08:20PM BLOOD Glucose-117* UreaN-15 Creat-1.0 Na-117* K-7.0* Cl-84* HCO3-26 AnGap-14 [2153-12-21] 02:38AM BLOOD Glucose-119* UreaN-14 Creat-0.8 Na-119* K-3.9 Cl-84* HCO3-31 AnGap-8 [2153-12-21] 10:45AM BLOOD UreaN-13 Creat-0.7 Na-117* K-3.9 Cl-83* [2153-12-21] 06:14PM BLOOD UreaN-11 Creat-0.7 Na-117* K-3.8 Cl-84* [2153-12-22] 02:26AM BLOOD Glucose-102* UreaN-12 Creat-0.7 Na-115* K-3.8 Cl-83* HCO3-29 AnGap-7* [2153-12-22] 08:55AM BLOOD UreaN-12 Creat-0.6 Na-112* K-3.8 Cl-80* [2153-12-22] 05:00PM BLOOD UreaN-11 Creat-0.6 Na-110* K-4.0 Cl-78* [2153-12-23] 04:40PM BLOOD UreaN-11 Creat-0.6 Na-110* K-4.3 [2153-12-24] 08:45AM BLOOD Glucose-79 UreaN-13 Creat-0.8 Na-112* K-4.0 Cl-81* HCO3-27 AnGap-8 [2153-12-25] 08:45AM BLOOD Glucose-87 UreaN-13 Creat-0.7 Na-116* K-4.5 Cl-83* HCO3-29 AnGap-9 [2153-12-25] 05:25PM BLOOD UreaN-13 Creat-0.8 Na-118* K-4.2 Cl-83* [2153-12-26] 02:13AM BLOOD UreaN-12 Creat-0.7 Na-118* [2153-12-26] 09:10AM BLOOD Glucose-83 UreaN-13 Creat-0.7 Na-121* K-4.3 Cl-86* HCO3-33* AnGap-6* [2153-12-26] 05:25PM BLOOD UreaN-14 Creat-0.7 Na-121* K-4.2 Cl-89* [2153-12-27] 12:38AM BLOOD Na-122* K-4.7 Cl-89* [2153-12-27] 09:35AM BLOOD Glucose-112* UreaN-16 Creat-0.9 Na-127* K-3.9 Cl-91* HCO3-30 AnGap-10 [2153-12-27] 05:10PM BLOOD Na-121* K-4.5 Cl-89* [2153-12-28] 01:13AM BLOOD Glucose-405* UreaN-15 Creat-0.8 Na-134 K-4.1 Cl-94* HCO3-17* AnGap-27* Imaging: Cxray on [12-27]: Lung volumes are very low, exaggerating mild cardiomegaly and producing pulmonary vascular crowding, but I do not think there is pneumonia or pulmonary edema. Small bilateral pleural effusions could be present, but there is no pneumothorax. Mediastinal appearance is normal for the small thorax. Microbiology: Blood culture ([12-21]): [2153-12-21] 10:45 am BLOOD CULTURE FINAL REPORT [2153-12-27] Blood Culture, Routine (Final [2153-12-27]): NO GROWTH. Brief Hospital Course: 49yoF with cryptogenic cirrhosis on transplant list, c/b ascites, jaundice, portal hypertension who presents with hyponatremia and lower extremity edema and was admitted to start on Tolvaptan. Pt was doing well on the liver floor with the plan for discharge pending sodium level being greater than 130. In the evening of [2153-12-27] pt was then brought to the MICU for hematemesis. She had 3 episodes of vomiting BRB in the floor prior to transfer. Her SBP dropped to the 70s, she was given IV bolus with improvement as she was being transferred. She had known grade 3 varices on EGD done in [2153-5-25]. On arrival to the MICU, she was awake and mentating. Anesthesia was present on arrival and she was urgently intubated for airway protection. Her hematocrit returned at 22 from 33. Due to inadequate peripheral IV access, a trauma CVL was attempted in the LIJ which was unable to be placed due to difficulty threading the wire. The MICU attending then placed a trauma line in the R groin. She received a total of 3 units of PRBCs and 2 FFP prior to EGD. She was started on mass transfusion protocol as well as levophed improving her BP to 120s. Liver attending and fellow were present for EGD. She had an EGD which showed 4 cords of grade III varices were seen starting at 35 cm from the incisors in the Lower third of the esophagus. There were stigmata of recent bleeding with red [Last Name (un) 23199] sign. No active fresh red blood was noted initially. 4 bands were placed over the varices. At which time, fresh red blood was noted coming from the base of the bands. Of note at the time of the endoscopy, the patient's INR was 2.4 and PTT was 111. The endoscope was removed and the band apparatus was removed. A repeat evaluation of the esophagus found that the bleeding had stopped and the 4 bands were in place. 4 bands were successfully placed. Over the next few hours she was without evidence of ongoing hemorrhage. Her Hct returned to 34. At approximately 1am she had large amount of bright red blood from her mouth around her ET tube. Liver was called stat for [Last Name (un) 10045] balloon placement, IR was also notified for urgent angiography/TIPs and surgery was consulted. At this point she had received 10 units of PRBCs, 4 FFP, 2 platelets, ~ 4-5L of IV fluids and 4gm of calcium gluconate. The liver fellow was getting ready for placement of [Last Name (un) ] when she became asystolic and pulseless. Cardiac Code was called. She was started on her 3rd round of mass transfusion with another 5 units of PRBCs, 2FFP and plalets. She was given epi x3, atropine, bicarb, calcium, glucose. She then developed Vtach, and was shocked. CPR was continued for a total of 35 minutes with mainly asystole and PEA. There was a significant amount of blood coming from the ET-tube. Her family was brought into the room and decided to stop CPR. She was then pronounced at 01:55 AM on [2153-12-28]. The family was offered chaplain services and social work. Multiple family members were present and her sister and [Last Name (LF) 802], [Name (NI) ] [Name (NI) ] who is her HCP, did not agree to autopsy. # Hyponatremia/LE edema: Presented for initiation of tolvaptan given refractory hypervolemic hyponatremia. Tolvaptan was started with close monitoring of sodium Q8hours. Per protocol, diuretics were held and the patient was allowed to drink to thirst. Sodium initially did not increase and on [12-22] was found to decrease to 107 at nadir (from 117 on presentation). Tolvaptan dose increased and fluid restriction of 1500cc started. Na increased to 127 at peak. # Cryptogenic cirrhosis c/b jaundice, portal HTN, ascites: Patient was being evaluated for transplant. Her MELD during this admission remained at 26. She was continued home medications. Her LFTs had been slightly trending up reached ALT 142/ AST 259/ Alk Phos 265/ TotBili 14.0 on the day morning of her episode of hemoptsis. # CODE: Full # CONTACT: [Name (NI) ], [Name2 (NI) 802] (to fill out HCP forms) [Name (NI) 23200], [Telephone/Fax (1) 23201]; [Telephone/Fax (1) 23202] Medications on Admission: Furosemide 40 mg daily Nadolol 20 mg daily Spironolactone 25 mg daily Ursodeoxycholic acid 500 mg [Hospital1 ] calcium carbonate-vitamin D3 600-200 mg-unit Tablet [Hospital1 ] ferrous sulfate 325mg daily magnesium 250 mg [Hospital1 ] PRN muscle cramps Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Hemorrhagic shock due to esophageal variceal bleed Crytpogenic cirrhosis Hyponatremia Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None	[ "2761", "2767" ]
Admission Date: [2109-5-27] Discharge Date: [2109-6-8] Date of Birth: [2044-4-8] Sex: F Service: ORTHOPAEDICS Allergies: Codeine / Ciprofloxacin Attending:[First Name3 (LF) 11415] Chief Complaint: wound infection with pus, septic [First Name3 (LF) ] Major Surgical or Invasive Procedure: operative debridement of infected wound x3 History of Present Illness: 65 yo morbidly obese woman with several potentially immunocompromising conditions including diabetes, cirrhosis (attributed to NASH), MGUS, and ulcerative colitis (although evidently not on any chronically immunosuppressive meds for this) who fell from standing [5-11] and sustained a right femur fx; this is particularly noteworthy because she has a prior right hip ORIF as well as bilateral total knee replacements. She underwent ORIF R femur [5-13]; there was extensive hardware implantation given the extent of the fracture. Course at that time was complicated by dysuria treated with TMP/SMX DS x3 days (in addition to peri-op cefazolin); U/A had [12-9] WBC and few bacteria, no accompanying urine culture sent. D/C [5-20] to rehab off antibiotics. . By [5-24] she was manifesting foul-smelling drainage from the recent RLE operative site; by [5-27] she was hypotensive at rehab and was sent back to our ED with a BP 80/30 and lactate 4.3. Code sepsis called, blood culture x1 obtained. Vanc, ceftaz, and flagyl started. She was found to have fluctuance over her eythematous right knee that was draining yellow-green pus. She was taken to the OR [5-28] for I&D of skin, subcutaneous tissue (fat necrosis), and bone, as well as vac placement. Knee arthrotomy was performed without evidence of a septic joint clinically. . Bld cx (2/2 bottles) from admission with E. coli. All three OR swabs growing the same E. coli; [2-22] growing diphtheroids as well. Initially treated with vanc, CTX, flagyl post-op, now just vanc and CTX (day 1 of each is [5-28]). Returned to OR [5-29] for second wash-out, likely to return again [6-2]. 65 yo female s/p ORIF R periprosthetic femur fracture [5-13] who was discharged to rehab on [2109-5-20] and presented to [Hospital1 18] [2109-5-28] with wound infection and sepsis. She is now s/p 2 debridements/VAC for wound infection. Pt admitted to [Hospital1 18] from rehab out of concern from rehab staff for increasing confusion, low grade fever, and yellow drainage from right thigh incision site, as well as concerns for pulmonary edema confirmed by CXR (pt w/o history of CHF) - they had been escalating her aldactone dose to attempt to reverse this. On the day af admission at the rehab she had become hypoxic and tachypnic and was transferred to [Hospital1 18]. In th [Hospital1 18] ED Code sepsis called - her BP had decreased to 79/33, she was given vanco, cefepime, ceftaz as well as levophed, FFP, and vitamin K (INR was 2.9). On [5-28] pt to OR for deep I and D of right leg w/ vac placed for wound infection, flagyl added to vanco/ceftaz regimen, transfused 4 units PRBC for hct 20 (hct 29 on [5-28]) - second I and D in OR on [5-29], on [6-2] closed deep wound and placed superficial vacs. On [5-28] pt extubated, and the [5-27] cultures of blood returned with [2-21] ecoli, wound showed ecoli and diptheroids. ID consulted, suggested ceftriaxone 2 g qd for ecoli(anticipated 6 wk course given multiple artificial joints), with vanco for diptheroids. . Since admission UOP has been trending down to oliguria and creatinine trending up. Fluid boluses with CVP to 20 without success. Lasix doses of 20 mg per trial were given w/o increased output. Aldactone needed to be briefly dc'd given hyperkalemia. Last CXR [6-2] without pulmonary edema, however she has had increasing o2 requirements since that time. Weight had increased from baseline with max 7 kgs above baseline but now back to basline. Volume status has also been complicated by worsening ascites. . On day of transfer to MICU service, transfusion of 2 units ordered for hct of 23. On exam by primary team it was felt that MS [First Name (Titles) ] [Last Name (Titles) 28495], possibly from increased dilaudid overnight but unsure. On transfer medications include ceftriaxone and vancomycin (per dosing), enoxaparin, and aldactone. All others ppx medications. Past Medical History: NASH cirrhosis, NASH c/b portal HTN w/ gII varices, LGIB [2-21] hemorrhoids, HTN, Diabetes type 2, recent E-coli urosepsis ([3-24]), hx of DVT (not in last few months), Ulcerative Colitis, MGUS, Fibromyalgia, OSA, thrombocytopenia, anx/depression, bl total knee replacements, MGUS, BR>1. right hip fracture [2-23] s/p ORIF 2. hx. LGIB secondary to hemorrhoids 3. hx of DVT 4. HTN 5. Presumed NASH Cirrhosis with grade II varices on [9-/2108]- followed by Dr. [Last Name (STitle) 7962] 6. Ulcerative Colitis 7. Fibromyalgia 8. OSA 9. MGUS 10. thrombocytopenia 11. Restless leg syndrome 12. anxiety and depression 13. Diabetes type 2- hgbA1C = 5.4 in [1-/2109] 14. s/p bilateral Total knee replacements Social History: no tob/alc, lived in elderly living alone prior to fall (prior to UTI in [Month (only) ]). has 2 daughters and son. son=HCP. daughter has stolen pain meds from her in past. She lives alone in an apartment complex for the elderly. Elder services on [Location (un) 448] at all time. Housekeeper 3x per week. Home VNA 1/month since mother was doing well. She has three adult children. Her son, [Name (NI) ], is quite responsible and active in her care. He handles all of her finances since [Doctor Last Name 1356]- daughter stole money from her mother. Receives an allowance and is able to balance her finances. [Doctor Last Name 501] and [Doctor Last Name ] do the shopping. Assitance with showering but otherwise able to dress, clean her appt. Her daughter exhibits drug-seeking behavior, with a history of stealing mother's pain medications. She has never smoked, used ETOH or illicit drugs. Her previous work was in the Cafeteria Department at [University/College ] [Location (un) ], as a "checker." At baseline able to walk w/o walker. No recent deficits in memory noted. HCP- [Name (NI) ] [Telephone/Fax (1) 40051] Family History: Her mother and father died from MI: at age 70 and 57, resp. No known cancers. Physical Exam: Tc/Tm 98 76(73-83) 100/52 (93-120/52-66) RR 22 100%2L CVP 17 UOP 277 24 hours I/O at midnight 6L/4L (drain w/ 1.5 L) ABG 7.32/38/106 Confused, knows what town she's from P mildly constricted but reactive and symetric RIJ ([6-4]) unable to determin JVD Chest RRR nl s1s2, no mrg Lungs with soft exp wheeze Abd mildly tender, tense, no g/r, nabs ext right leg with open wound w/ vac 3+ edema to thighs L rad a line Skin without jaundice, marked lymphatic skin loss Pertinent Results: Micro: blood 5/10 neg blood 5/8 ecoli [2-21] wound [5-28] ecoli and dipth urine [5-27] nl . Last cxr [6-2] atelectasis Echo [2106] nl EF, nl LV size, [1-21]+ MR [Last Name (Titles) ] .26% [2109-5-27] 03:00PM PT-28.0* PTT-36.3* INR(PT)-2.9* [2109-5-27] 03:00PM PLT SMR-UNABLE TO PLT COUNT-114* [2109-5-27] 03:00PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-OCCASIONAL MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-NORMAL [2109-5-27] 03:00PM NEUTS-79* BANDS-14* LYMPHS-5* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2109-5-27] 03:00PM WBC-2.6* RBC-2.86* HGB-9.7* HCT-29.2* MCV-102* MCH-33.7* MCHC-33.0 RDW-18.5* [2109-5-27] 03:00PM CRP-152.6* [2109-5-27] 03:00PM CORTISOL-44.7* [2109-5-27] 03:00PM CALCIUM-7.9* PHOSPHATE-2.5* MAGNESIUM-1.6 [2109-5-27] 03:00PM CK-MB-2 cTropnT-<0.01 [2109-5-27] 03:00PM ALT(SGPT)-25 AST(SGOT)-58* CK(CPK)-40 ALK PHOS-180* AMYLASE-31 TOT BILI-4.4* [2109-5-27] 03:00PM GLUCOSE-140* UREA N-29* CREAT-1.3* SODIUM-130* POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-22 ANION GAP-15 [2109-5-27] 03:26PM LACTATE-4.3* K+-4.6 [2109-5-27] 04:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-NEG [2109-5-27] 04:25PM URINE COLOR-Amber APPEAR-Clear SP [Last Name (un) 155]-1.020 [2109-5-27] 05:29PM LACTATE-4.2* [2109-5-27] 06:26PM LACTATE-3.6* [2109-5-27] 08:13PM LACTATE-3.9* [2109-5-27] 08:13PM TYPE-[Last Name (un) ] PO2-48* PCO2-40 PH-7.36 TOTAL CO2-24 BASE XS--2 [2109-5-27] 09:45PM PLT COUNT-149* [2109-5-27] 09:45PM WBC-7.5# RBC-2.53* HGB-8.4* HCT-25.4* MCV-101* MCH-33.4* MCHC-33.2 RDW-18.6* [2109-5-27] 10:02PM freeCa-1.04* [2109-5-27] 10:02PM HGB-6.5* calcHCT-20 O2 SAT-97 [2109-5-27] 10:02PM GLUCOSE-174* LACTATE-4.8* NA+-127* K+-4.5 CL--102 [2109-5-27] 10:02PM TYPE-ART PO2-456* PCO2-36 PH-7.41 TOTAL CO2-24 BASE XS-0 INTUBATED-INTUBATED [2109-5-27] 11:12PM FIBRINOGE-263 [2109-5-27] 11:12PM PT-30.9* INR(PT)-3.3* [2109-5-27] 11:12PM PLT COUNT-141* [2109-5-27] 11:12PM WBC-7.1 RBC-3.41# HGB-11.2# HCT-32.6# MCV-96 MCH-32.8 MCHC-34.4 RDW-19.4* [2109-5-27] 11:12PM CALCIUM-7.9* PHOSPHATE-3.6 MAGNESIUM-1.6 [2109-5-27] 11:12PM GLUCOSE-181* UREA N-28* CREAT-1.2* SODIUM-129* POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-19* ANION GAP-15 [2109-5-27] 11:23PM freeCa-1.16 [2109-5-27] 11:23PM LACTATE-4.7* [2109-5-27] 11:23PM TYPE-ART PO2-243* PCO2-43 PH-7.30* TOTAL CO2-22 BASE XS- ---------- [6-6] Echo: CLINICAL INDICATION: 65-year-old woman with known NASH and increasing liver function tests. The liver is small and very coarse in echotexture and is surrounded by a large volume of ascites. There is also a right pleural effusion. No focal liver lesions are identified, nor is there evidence of biliary dilatation. The patient is status post cholecystectomy. Color flow and pulse Doppler evaluation of the liver shows virtually no flow in the left and right portal veins and only minimal flow in the main portal vein of approximately 5 cm/second. The hepatic veins are all visualized and patent. The inferior vena cava also is fully patent. Increased arterial flow is seen throughout the liver. Both kidneys are seen to be normal in size measuring 10.5 cm in length on the right and 10.1 cm on the left. There are no signs of hydronephrosis, renal stones, or masses. The spleen is upper normal to mildly enlarged measuring approximately 12 cm in length. CONCLUSION: Small cirrhotic-appearing liver with marked ascites and a right pleural effusion noted. Near occlusion of the portal flow with increased arterial flow, and normal hepatic venous drainage. There are no focal liver lesions seen. ------------------ [2109-6-6] Echo: Conclusions: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60-70%). Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. 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. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is no pericardial effusion. Compared with the findings of the prior report (images unavailable for review) of [2106-12-10], probably no major change. [2109-6-8] EKG \Sinus rhythm Modest nonspecific pre-cordial/anterior T wave changes Prolonged Q-Tc interval - clinical correlation is suggested Since previous tracing of [2108-5-27], no significant change Brief Hospital Course: . ------------- 65 F history of dm2, nash cirrhosis, UC, mgus, obesity, p/w septic [Date Range ] on [5-28] from infected wound after orif [5-13] for femur frx, now s/p debridement x 3, HD stable off pressors, transferred to MICU from the surgical service with ARF, confusion and sepsis . # Hypotension/[Name (NI) 21020] - pt was originally in OR for washout of right knee w/ debridement. In OR, pt. intubated and was requring neosynephrine (new for her). Post Op, pt. was extubated successfuly, but pt. continued to have low blood pressures and was requiring pressors to maintain MAP goal > 60. On exam, pt. warm, so distributive [Name (NI) ] is likely. Possible that pt. has adrenal insufficiency. Also possible that pt. is becoming septic - increasing WBC, but afebrile. Patient was transferred to the MICU with a presumed diagnosis of sepsis on [2109-6-6]. Patient was first bolused to maintain BP (as pt. is losing fluid from multiple places, including continues oozing of liters of serosang fluid from multiple places). Due to the patient's body habitus, it was extremely difficult to obtain accurate BP measurements, especially once the patient's A-line stopped functioning correctly. On [2109-6-8], patient suddenly dropped her blood pressure into the systolic of 70s, with worsening of already poor mental status. Patient was DNR/DNI per family, so no repeated attempts at intubation were made. No CPR was performed. The patient's blood pressure continued to drift down despite use of pressors. Multiple attempts at central line placement by both MICU and anesthesia staff placement were attempted, however failed due to the patient's body habitus. The patient's O2 sats drifted below 70% despite max O2 support (aside from intubation). The patient lost all brainstem reflexes. At that point, family was called, the patient was made CMO, placed on morphine for comfort and expired shortly thereafter. . # Leg excision site wound infection: Pt. s/p washout/debridement in OR yesterday w/ no overt wound infection. Pt. afebrile, but w/ increased white count. VAC in place, ortho was following the wound. . # Confusion: likely due to sepsis/hypoxic encephalopathy sustained during surgery. Overuse of pain medications on the surgery service might have also contributed. Pain meds were minimized, and infectious workup was in process. Since patient also developed renal failure, uremia was contributing to patient's mental status changes. . # ARF: Cr. 1.0 on [6-3], trending up gradually to 2.4 on [6-4], [Month/Year (2) ] (<0.1) on [6-5] suggests pre-renal, though hepatorenal in consideration given cirrhosis. Also c proteinuria prot/cr 1.2, glomerular process? Not improving with hydration. Renal was consulted, workup was initiated, renal was planning to start octreotide/midodrine. On ultrasound, pt. w/ no hydronephrosis or stones. . # NASH cirrhosis: Renal u/s showed a cirrhotic liver w/ portal vein thrombosis. There was also some ascites noted arond the liver. GI/Liver was consulted in seeting of increased t. bili 4.2(b/l [2-22]) INR 1.6 (b/l 1.5-3) and U/S findings. Hep B/C negative, AMA ANCA negative, pt has missed several outpt appointments and has not seen her hepatologist, [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Last Name (NamePattern1) ] since the initial visit [2108-8-24]. Liver service was following the patient. Nadolol was held given low BP. . Medications on Admission: Meds at rehab Coumadin dosed by INR (usual 1 mg), Ativan 0.5 [Hospital1 ], Oxycontin 20 mg po BID, albuterol, vitamin D 400, colace/senna, protonix 40 qd, aldactone 25 qd, nadolol 20 qd, fosamax 70 q sunday, Spironolactone 25 mg, Calcium Carbonate 500 mg, Citalopram 60 mg, Nadolol 20 mg, Oxycodone 20 mg Q12H, Pantoprazole 40 mg, Oxycodone 5-15 mg q4 hours Discharge Disposition: Expired Discharge Diagnosis: Sepsis Delirium Multi-system Organ failure Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 2235] MD, [MD Number(3) 11417] Completed by:[2109-7-18]	[ "99592", "5849", "2875", "4280", "51881", "2851", "4019", "49390", "32723", "25000", "53081" ]
Admission Date: [2197-7-7] Discharge Date: [2197-7-27] Date of Birth: [2143-12-26] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 8850] Chief Complaint: Altered mental status. Major Surgical or Invasive Procedure: High-dose methotrexate, rituximab, and Whole brain irradiation. History of Present Illness: [Known firstname ] [Known lastname 33754] is a 53-year-old right-handed woman with a history of CNS lymphoma involving the basal ganglia, left subfrontal white matter, and corpus callosum with some associated edema and mass effect, s/p 2 cycles of induction high-dose methotrexate, and s/p 1 cycle of high-dose methotrexate and rituximab. She was initially admitted for scheduled high-dose methotrexate and rituximab dosing and transferred to the ICU with acute mental status decline. During her recent hospitalization from [2197-6-26] to [2197-7-4] for third induction cycle of high-dose methotrexate, she develop mental status changes. It was due to cerebral edema and encephalopathy developed 2 days after high-dose methotrexate. Head CT showed midline shift with subfalcine and uncal herniation in the setting of tumor progression. She was started on high-dose steroids and rituximab with some improvement in mental status. She was discharged on dexamethasone. On re-admission on [2197-7-7] for a scheduled cycle of methotrexate and rituximab, her examination was notable for an alert metnal status, poor language fluency and comprehension, equal pupils, right lower facial droop, 3/5 strength in the right upper extremity, 1-2/5 in the right lower extremity, absent ankle jerk, upgoing right toe, and impaired pain sensation on the right side of body. Overnight, the patient was noted to have declining mental status with minimal responsiveness, and no purposeful movements. But responded to pain. MRI was read as revealing no change in her intracranial mass, surrounding edema or mass effect/midline shift; though her primary neuro-oncologist did think there was some progression with mild worsening of midline shift. She received dexamethasone (increased from 6 mg IV q6h to 10 mg IV q6h), mannitol and emergent external beam whole brain cranial irradiation. Past Medical History: - CNS lymphoma involving the basal ganglia, corpus callosum and left subfrontal region. Had non-diagnostic brain biopsy on [2197-4-26]. Second brain biopsy confirmed primary CNS lymphoma on [2197-6-2]. S/p 4 induction cycles of high-dose methotrexate initiated on [2197-6-5]. Also receiving rituximab since cycle 3 when she did not appear to be responding to methotrexate alone. - PICC-associated right upper extremity DVT, diagnosed on [2197-6-18] and had PICC removal. - Prior gram positive bacteremia - Hypertension - Hyperlipidemia - s/p oophorectomy Social History: She lives with husband. She worked as special education teacher. She has no tobacco, alcohol, or illicit drug use. Family History: Non-contributory. But she has one mentally retarded daughter and a helthy son. Physical Exam: ADMISSION EXAMINATION ([2197-7-7]) VITAL SIGNS: Temperature is 98.6 F axillary, pulse is 85, blood pressure is 161/92, respiratory rate is 11, and oxygen saturation is 98% in room air, and weight is 85.7 kg. GENERAL: Responsing to painful stimuli only. HEENT: PERRL approximately 3.5mm to 2mm. Likely right lower facial droop. Poor visualization of the fundus. CARDIOVASCULAR: RRR, normal S1 and S2, and no M/R/G. PULMONARY: Clear to auscultation bilaterally. ABDOMEN: No tenderness in the left upper quadrant. No rebound or guarding. EXTREMITIES: Left upper extremity with diffuse ecchymoses in the area of removed Port-a-cath. NEUROLOGICAL EXAMINATION: Responding to sternal rub only. Does say 'Okay' in response to sternal rub. No responding to nailbed pressure in the bilateral upper extremities. No doll's eyes. Right lower facial droop. Unable to assess remainder of CN's. Tongue appears midline. RUE in contracted posture. Bilateral upper extremities with contraction in response to movement. No moving any extremities in response to command. Bilateral lower extremities without movement. Unable to elicit patellar or ankle jerk reflexes bilaterally. Appears to have upgoing left great toe though difficult to assess. NEUROLOGICAL EXAMINATION AT THE TIME OF DISCHARGE ([2197-7-27]): Neurological Examination: Her Karnofsky Performance Score is 50. She is awaker, alert, and able to follow commands. She can speak in full sentences. She is not upset today at all. Cranial Nerve Examination: Her pupils are equal and reactive to light, 4 mm to 2 mm bilaterally. Extraocular movements are full. She has blink to threat bilaterally. Her right lower facial droop is improving. Hearing is grossly intact. Tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: She can lift her right upper extremity against gravity. She can move the toes in her right foot. The left upper has 4/5 strength but her proximal left lower extremity is weak at 3/5. Her reflexes are 0. Her toes are mute. Sensory examination is notable to grimace when pain stimuli are applied to the extremities. She cannot walk. Pertinent Results: [2197-7-7]: Na 138, K 3.4, Cl 102, bicarb 28, BUN/Cr 11/0.3, glucose 115, Ca 9.8, Mg 2.1, Phos 2.9, WBC 5.5, Hct 28.0, platelets 152. ALT 54, AST 12, LDH 417, T Bili 0.8. INR 1.2, PTT 42.6 MTX 5.3 [2197-7-8]: Imaging: MR [Name13 (STitle) 430] ([2197-7-8]): Prelim report with no change in size of the mass surrounding edema, ventricular size and periventricular edema compared to the previous MRI of [2197-7-1]. MR [Name13 (STitle) 430] ([2197-7-1]): Again a large enhancing mass is identified in the left basal ganglia region with mass effect on the left lateral ventricle. Compared to the prior study, the enhancing component of the brain and the lesion in the corpus callosum and also in the left subfrontal region has decreased. However, the mass in the left basal ganglia may have slightly increased in size, now measures 4 x 3 cm compared to 2 x 3.5 cm on the previous study. There is persistent dilatation of the ventricles with dilation of both temporal horns indicative of hydrocephalus. Periventricular edema is also identified. Extensive edema in the left frontal lobe is seen which might not have significantly changed since the previous study. There continued to be uncal herniation on the left and extension of edema into the left side of the midbrain and pons. No other areas of abnormal enhancement identified. There is mild midline shift from the left to the right. IMPRESSION: Since the previous MRI examination, the component of the tumor seen in the basal ganglia may have slightly increased in size but the enhancing lesions in the corpus callosum and left subfrontal region have decreased. Edema is unchanged and midline shift and mass effect is also unchanged. The ventricular size is unchanged with dilated temporal horns and signs of transependymal flow of CSF and periventricular edema. Chest X-Ray ([2197-7-7]): New left-sided PICC line positioned in the left brachiocephalic vein. New increased density in the left base, which may be secondary to film technique MRI Head on [2197-7-26] with improvement in above lesions. Brief Hospital Course: 1. Altered Mental Status: Patient was found unresponsive on hospital day 1 after scheduled methotrexate and rituximab treatment. She was transferred to ICU from [2197-7-9] to [2197-7-14]. Altered mental status was likely secondary to progression of intracranial mass/edema. MRI obtained on transfer on [2197-7-8] showed no interval development of acute ischemia or hemorrhage, but there was evidence of midline shift. ELetrolytes were within normal limits. EEG was negative for status epilepticus. Patient was continued on pulse dose steroids and mannitol, and Keppra for seizure prophylaxis. Whole brain external beam radiation was started given midline shift. Repeat head CT on [2197-7-14] showed decreased midline shift and edema, and neurologic examination (right-sided weakness and facial droop) improved on transfer back to floor. On the floor, the patient did well from a neurological standpoint. She was more alert and oriented than before. The patient continued her regimen of radiation, completing radiation therapy on [2197-7-27]. The patient's methotrexate took longer to clear secondary to third spacing of fluid. The steroids taper was begun and patient was discharged on dexamethasone 4 mg daily, to be tapered further by neuro-oncologist with a follow-up visit in 2 weeks. 2. Abdominal Pain (noted on transfer to floor): Possibly secondary to diverticular microperforation with spontaneous resealing by omentum. CT scan showed bowel dilatation and gas in the portal system. Surgery consult recomendeded a conservative approach with antibiotics of antibioticsmonitoring the patient's good clinical status, normal hemodynamics, and absence of leukocytosis. She was started on a course of piperacillin-Tazobactam on [2197-7-15] with an intended course of 14 days, last day on [2197-7-29]. Pain medications were held and given only after a thorough clinical examination for peritoneal signs. The patient's vital signs remained stable and no peritoneal findings were noted. The patient was treated with a soaps enema, subsequent to which her lactate trended down. The patient's diet (grounded solids with thininned liquids) after she was cleared by speach and swallow. A KUB after she diet was resumed was unremarkable for bowel dilatation or abnormal [Last Name (un) ] pattern. 3. CNS Lymphoma: s/p 3 cycles of high-dose methotrexate combined with rituximab and receiving cranial irradiation c/b acute encephalopathy. Patient was continued on sodium bicarbonate per methotrexate protocol, and completed course of radiation. 4. Hypertension: Patient's systolic blood pressure reached a peak of 190-200, secondary to increased intracranial pressure, and recovered with mannitol infusion to SBP 150s on transfer. Initially the metoprolol was held as it would mask the monitoring of ICP elevation. After manitol was discontinued, metoprolol was reinitiated with adequate control. 5. Right Upper Extremity Deep Vein Thrombosis: PICC-associated clot extending to subclavian was noted on prior admission [2197-6-18], with PICC discontinued; patient was continued on anticoagulation with enoxoparin. It was stopped temporarily due to fall in hematocrit, but this remained stable at 24. Patient was discharged on Heparin S.C. 5,000u TID. 6. Depression with Psychotic Features: Patient reports seeing her mother in the room. She was started on haloperidol for psychosis and agitation. She will need to continue haloperidol 0.5 mg PO BID standing, together with Celexa. Her mood and hallucination features improved. Medications on Admission: Home Medications: - Enoxaparin 90 mg SC Q12H - Dexamethasone 6 mg IV Q6H - Levetiracetam 1000 mg IV BID - Trimethoprim-Sulfamethoxazole 80-400 mg/5 mL Intravenous Q24H - Pantoprazole 40 mg Daily - Metoprolol Tartrate 2.5 mg IV Twice daily - Lactulose 30 ML 3 times a day - Senna 8.6 mg Daily as needed - Docusate Sodium 100 mg 2 times a day - Multivitamin 1 tab po daily Discharge Medications: 1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [Hospital1 ] (2 times a day) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 4. Piperacillin-Tazobactam 4.5 gram Recon Soln Sig: One (1) Intravenous every eight (8) hours for 2 days: To complete 14-day course with last day on [2197-7-29]. 5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime) as needed for insomnia. 8. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for agitation. 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 12. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Levetiracetam 500 mg/5 mL Solution Sig: One (1) Intravenous Q12H (every 12 hours). 14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 15. Morphine Sulfate 2-4 mg IV Q4H:PRN 16. Lorazepam 0.5-1 mg IV Q4H:PRN 17. Haloperidol 0.5 mg IV BID:PRN if unable to take PO 18. Dexamethasone 4 mg IV DAILY 19. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [Location (un) ] Manor - [Location (un) ] Discharge Diagnosis: CNS Lymphoma Encephalopathy Bowel ischemia Discharge Condition: Stable Discharge Instructions: You were admited for a planned chemotherapy for your lymphoma. During your hospitalization you were found to have increasing somlonence from swelling in your brain and required transfer to the intensive care unit, as well as medication to help decreased the swelling in your brain. You tolerated this treatment well and you were transfered back to the floor. You also were complaining of abdominal pain for which we gave you antibiotics. We were able to complete the scheduled chemotherapy and also radiation treatment. Please return to the emergency department if you experience headaches, nausea, vomiting, abdominal pain, fever, chills, looses or absent stools or any other symptom that concerns you. Followup Instructions: Provider: [First Name11 (Name Pattern1) 640] [Last Name (NamePattern4) 4861], MD Phone:[Telephone/Fax (1) 1844] Date/Time:[2197-8-14] 1:00	[ "4019" ]
Admission Date: [2105-9-11] Discharge Date: [2105-10-21] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4691] Chief Complaint: Abdominal pain and distention Major Surgical or Invasive Procedure: [2105-9-17]: Lysis of adhesions, small-bowel resection. [2105-10-5]: Right cephalic PICC. [2105-10-14]: G-J tube placed by IR. [2105-10-15]: Bedside tracheostomy. History of Present Illness: 88 M history of colon cancer s/p colectomy and end colostomy ~20 years ago presents with 1 day history of abdominal pain and distention. He reports having gradual onset abdominal pain which started this morning. He has had ~10 bouts of non-bloody, non-bilious emesis. He has had minimal output from his ostomy for "a few days". He presented to [Hospital3 ] and a CT abdomen performed demonstrated a partial small bowel obstruction in the mid-abdomen. He denies any history of obstructions or similar symptoms. He denies fevers, chills, night sweats, syncope, chest pain. Past Medical History: PMH: history of colon cancer s/p open colectomy and end colostomy ~20 years ago PSH: colectomy with end colostomy ~20 years ago, knee replacement, shoulder surgery (rotator cuff) Social History: Lives with wife [Name (NI) ] tobacco No ETOH Family History: non contributory Physical Exam: VS: 98.0 94 150/96 16 96% RA Gen: NAD, AOx3 CVS: reg Pulm: no resp distress Abd: Softly distended TTP throughout, mainly epigastric region LE: no CCE Pertinent Results: [2105-9-11] 01:20AM WBC-10.8 RBC-4.74 HGB-14.9 HCT-43.4 MCV-92 MCH-31.5 MCHC-34.4 RDW-13.1 [2105-9-11] 01:20AM NEUTS-90.2* LYMPHS-6.0* MONOS-3.6 EOS-0.2 BASOS-0.2 [2105-9-11] 01:20AM PLT COUNT-194 [2105-9-11] 01:20AM GLUCOSE-142* UREA N-17 CREAT-1.0 SODIUM-137 POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-27 ANION GAP-17 [2105-9-11] KUB showed: 1. Dilated small bowel loops containing residual oral contrast and air-fluid levels, which in the right clinical circumstances could be reflective of small-bowel obstruction. 2. Residual contrast filling the right collecting system suggestive of partial or full obstruction of the renal right collecting system. 3. Nasogastric tube looped above the diaphragm, likely in the patient's hiatal hernia. [2105-9-13] KUB showed: In comparison with the study of [9-11], the contrast material from the right renal collecting system has cleared. There is still mild dilatation of small bowel loops containing some residual oral contrast from a previous CT scan and demonstrating air-fluid levels on the decubitus view. In the appropriate clinical setting, these findings could be consistent with small bowel obstruction. [2105-9-16] KUB showed: There are several air-filled minimally dilated loops of small bowel seen particularly in the right abdomen. It appears that the contrast seen in the small bowel on the prior studies has advanced to the colon. There are several air-fluid levels seen within the small bowel on the upright image. This has the appearance of persistent small bowel obstruction. The nasogastric tube has been removed. [2105-9-24] CT chest/abdomen/pelvis showed: 1. New ground glass opacities and small foci of consolidation, most severe in the right upper lobe, is concerning for evolving aspiration pneumonia given large hiatal hernia and recent history of emesis. Differential diagnosis does includes asymmetric pulmonary edema if the patient has underlying mitral valvular disease. 2. Mild anasarca and mild fluid overload with minimal interlobular smooth septal thickening. 3. Small amount of pneumoperitoneum consistent with recent exploratory laparotomy. 4. Small bilateral effusions with associated atelectasis. Mild cardiomegaly. [2105-9-27] CXR showed: Consolidation in the right lung has spread from the juxtahilar right upper lobe to much of the right lower lung, accompanied by increasing moderate right pleural effusion. Left lower lobe atelectasis persists. Pleural surfaces are heavily calcified. Heart size is enlarged but difficult to assess because of adjacent pleural and parenchymal abnormalities. No pneumothorax. Left PICC line ends in the mid SVC. [2105-10-1] KUB showed: 1. Residual oral contrast is seen within the colon to the rectum without evidence of distention. This reflects a prolonged transit time, but no evidence of obstruction. 2. Air-filled loops of small bowel without evidence of obstruction, improved compared to the prior. 3. No other significant change compared to the prior study. [2105-10-5] Video swallow showed: Frank aspiration with appropriate cough response with nectar consistency. [2105-10-9] CTA chest showed: 1. Acute pulmonary embolism involving a right upper lobe apical segmental branch. 2. New left upper lobe airspace consolidation and worsening right upper lobe airspace consolidation that is concerning for multifocal spread of infection. Superimposed mild interstitial pulmonary edema. 3. Stable prominent mediastinal lymph nodes and left hilar lymph nodes, likely reactive in nature. 4. Several foci of intraperitoneal free air, newly apparent since post-surgical CT from [2105-9-24]. 5. Calcified pleural plaques indicative of prior asbestos exposure. 6. Findings compatible with tracheobronchomalacia. [2105-10-10] CT abdomen/pelvis showed: 1. Loop of bowel containing air and oral contrast may be trapped between the right lobe of the liver and the right thoracic wall, although it does contain new oral contrast since the CT chest performed several hours prior. There is fluid around the dome of the liver and around this loop of bowel. 2. Two locules of air at the dome of the liver. Although no definite evidence for perforation is present, it is not excluded. The locules of air may represent residual air from abdominal surgery, although this surgery occurred several weeks prior, which would be unusual. 3. Moderate right and small left pleural effusions. 4. Extensive airspace opacities in the lungs concerning for infection. 5. Nasogastric tube looped on itself within a hiatal hernia with the tip extending superiorly into the esophagus. 6. Parastomal hernia but no bowel obstruction. 7. Pleural plaques. [2105-10-16] CT head showed: No acute large vascular territory infarct, shift of midline structures or mass effect is present. The ventricles and sulci are normal in size and configuration. There is diffuse bihemispheric left greater than right periventricular and subcortical white matter hypoattenuation, consistent with small vessel ischemic disease. However, no loss of [Doctor Last Name 352]-white differentiation is noted. There is calcific atherosclerosis of the vertebral arteries and both carotid arteries. The orbits are unremarkable. The visible mastoid air cells and paranasal sinuses are well aerated. Brief Hospital Course: Mr. [Known lastname ] was evaluated by the ACS service in the Emergency Room and admitted to the hospital for conservative treatment of his partial small bowel obstruction with IV hydration, gastric decompression with a nasogastric tube and serial exams. He was seen by the Urology service initially as he had a ureteral stone noted incidentally on his Abd CT that was done at [Hospital1 ] [Location (un) 620]. He had no pain and no elevation of his creatinine therefore this incidental finding would be worked up if it did not pass on its own. He did have some low urine output which responded to IV fluids but that was secondary to low intravascular volume as opposed to renal failure from an obstructing stone. His [Last Name 16423] problem was that of his bowel obstruction. His NG tube was replaced due to persistent vomiting and eventually his abdomen was soft however his ostomy was not active. After waiting 6 days for resolution he was taken to the Operating Room on [2105-9-17] for an exploratory laparotomy, lysis of adhesions and a small bowel resection. He tolerated the procedure well and returned to the PACU in stable condition. His pain was controlled with a PCA. A PICC line was placed on [2105-9-18] for hyperalimentation as he continued to be NPO. By post op day #5 he developed anasarca and was treated with IV Lasix and 25% Albumin. He continued to have minimal output and air from his ostomy. On post op day #7 he developed a fever of 101.6 and emesis. A nasogastric tube was replaced and he had a Ct scan of the chest and abdomen revealing a new right upper lobe pneumonia. His WBC eventually rose to 15. Urine and blood cultures were negative and he was placed on Vancomycin and Zosyn. He underwent vigorous pulmonary toilet including chest PT incentive spirometry and nebulizer treatments. His initial chest xray revealed a right upper lobe infiltrate but over time he devaloped multilobar infiltrates with a component of fluid volume overload. He was given a ten day course of antibiotics for his physical and xray findings and all of his cultures including sputum were negative. His bowel functioning remained minimal and he remained on TPN. He had his ostomy digitalized and eventually had an enema which helped to increase output. He began clear liquids on post op day 15 as his ileus seemed to resolve. Unfortunately he became tachypneic, desaturated and was tachycardic to 120 BPM one day later and he also had a temp spike to 101.6. His chest xray showed the same multilobar infiltrates along with bilateral effusions and fluid overload. He improved with vigorous diuresis and was eventually placed on daily lasix. After his bowel function returned he was evaluated on multiple occasions by the Speech and Swallow service as he was deconditioned and had some episodes of aspiration. He eventually was able to take ground solids and nectar thick liquids without aspirating. On [2105-9-27], zosyn was changed to cefepime for pneumonia. On [2105-10-4], he was transfused 2 u PRBC for acute post-op anemia with hct of 21.9. His hct responded appropriately. He became febrile on [2105-10-4], and all antibiotics were stopped and PICC was pulled with tip sent for culture. Blood cultures and line tip culture up to [2105-10-4] ultimately showed no growth. On [2105-10-9], CTA chest was obtained for poor respirations, finding acute pulmonary embolism, and the patient was started on a heparin gtt. On [2105-10-10], the patient suffered respiratory decompensation and was transferred to the ICU. BAL cultures showed MRSA and yeast. Pleural effusion was drained for 900 mL and grew bacteroides fragilis. The patient was started on vancomycin and meropenem. A perihepatic abscess was found and a drain was placed by IR. The fluid grew MRSA and bacteroides fragilis. Infectious disease did not recommend anti-fungal antibiotics. On serial CXR, the pneumonia and pleural effusion progressively improved. Due to aspiration risk, on [2105-10-14], a G-J tube was placed by IR. On [2105-10-15], due to failure to wean off mechanical ventilation, the patient underwent bedside tracheostomy. The patient was continued on heparin gtt and started on warfarin for PE. From a physical therapy standpoint he was able to walk with a rolling walker 2-3 times a day despite his lengthy illness. When the perihepatic abscess drain ceased to produce fluid, it was withdrawn. At the time of discharge on [2105-10-21], the patient's ventilatory dependence was weaned to CPAP on PEEP 5. He was receiving vancomycin (most recent course started on [2105-10-9]) and meropenem (most recent course started on [2105-10-10]) for pneumonia and peri-hepatic abscess. Antibiotic requirements should be reassessed after 4 weeks of antibiotics. Medications on Admission: Vitamin A, Vitamin C Discharge Medications: 1. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: Nine Hundred (900) units/hour Intravenous continuous gtt: Titrate heparin gtt to PTT 60-80 while INR <2. 2. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): Check daily INR. Titrate warfarin dose until INR [2-18]. 3. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for fever or pain. 5. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous Q 24H (Every 24 Hours): Check vancomycin trough before 4th dose. Titrate vancomycin dose to trough 15-20. 6. meropenem 1 gram Recon Soln Sig: One (1) g Intravenous Q12H (every 12 hours). 7. pantoprazole 40 mg Recon Soln Sig: Forty (40) mg Intravenous every twenty-four(24) hours. Discharge Disposition: Extended Care Facility: [Hospital3 105] Northeast - [Location (un) 1110] Discharge Diagnosis: Small bowel obstruction Pneumonia Post-op ileus Pulmonary embolism Failure to wean off ventilator 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 acute care surgery service for small bowel obstruction. Please call your doctor or go to the emergency department if: You experience new chest pain, pressure, squeezing or tightness. You develop new or worsening cough, shortness of breath, or wheeze. You are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. Your pain is not improving within 12 hours or is not under control within 24 hours. Your pain worsens or changes location. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. You develop any concerning symptoms. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please get plenty of rest, continue to work with physical therapy, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Incision Care: Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until cleared by your surgeon. You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. G-J tube 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). You may shower and wash the drain site gently with warm, soapy water. 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 tube securely to your body to prevent pulling or dislocation. Warfarin (Coumadin): What is this medicine used for? This medicine is used to thin the blood so that clots will not form. How does it work? Warfarin changes the body's clotting system. It thins the blood to prevent clots from forming. What you should contact your healthcare provider [Name Initial (PRE) ]: Signs of a life-threatening reaction. These include wheezing; chest tightness; fever; itching; bad cough; blue skin color; fits; or swelling of face, lips, tongue, or throat, severe dizziness or passing out, falls or accidents, especially if you hit your head. Talk with healthcare provider even if you feel fine, significant change in thinking clearly and logically, severe headache, severe back pain, severe belly pain, black, tarry, or bloody stools, blood in the urine, nosebleeds, coughing up blood, vomiting blood, unusual bruising or bleeding, severe menstrual bleedin, or rash. Call your doctor if you are unable to eat for several days, for whatever reason. Also call if you have stomach problems, vomiting, or diarrhea that lasts more than 1 day. These problems could affect your Coumadin/warfarin dosage. Coumadin (Warfarin) and diet: Certain foods and beverages can impair the effect of warfarin. For this reason, it's important to pay attention to what you eat while taking this medication. Until recently, doctors advised [Name5 (PTitle) ] taking warfarin to avoid foods high in vitamin K. This is because large amounts of vitamin K can counteract the benefits of warfarin. However, recent research shows that rather than eliminating vitamin K from your diet, it is more important to be consistent in your dietary vitamin K intake. These foods contain vitamin K: Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli, Cabbage, [Location (un) 2831] sprouts, Green onions, Asparagus, Cauliflower, Peas, Lettuce, Spinach, Turnip, collard, and mustard greens, Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver. Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins, Soybeans and Cashews. Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage but it does not mean you must avoid all alcohol. Serious problems can occur with alcohol and Coumadin??????/warfarin when you drink more than 2 drinks a day or when you change your usual pattern. Binge drinking is not good for you. Be careful on special occasions or holidays, and drink only what you usually would on any regular day of the week. Monitoring: The doctor decides how much Coumadin??????/warfarin you need by testing your blood. The test measures how fast your blood is clotting and lets the doctor know if your dosage should change. If your blood test is too high, you might be at risk for bleeding problems. If it is too low, you might be at risk for forming clots. Your doctor has decided on a range on the blood test that is right for you. The blood test used for monitoring is called an INR. Use of Other medications: When Coumadin/warfarin is taken with other medicines it can change the way other medicines work. Other medicines can also change the way Coumadin/warfarin works. It is very important to talk with your doctor about all of the other medicines that you are taking, including over-the-counter medicines, antibiotics, vitamins, or herbal products. Followup Instructions: Please call [Telephone/Fax (1) 600] to schedule a follow-up appointment in the Acute Care Surgery Clinic in [3-19] weeks. Please follow up with your PCP. Completed by:[2105-10-21]	[ "486", "2851", "5119" ]
Admission Date: [2109-4-15] Discharge Date: [2109-4-23] Date of Birth: [2027-5-17] Sex: M Service: CARDIOTHORACIC Allergies: Hydromorphone / Penicillins Attending:[First Name3 (LF) 4679] Chief Complaint: esophageal cancer Major Surgical or Invasive Procedure: [2109-4-15]: Laparoscopic esophagectomy, jejunostomy; esophagoscopy History of Present Illness: 81 year old gentleman had a perforated appendicitis for which he had a ?ileocecectomy done middle of last year. Scans done when recovering from that picked up an esophageal cancer. At that time since he was recovering from the laparotomy and a knee replacement done just prior to the laparotomy it was decided to give him chemoradiation. He completed this 2 months ago. EGD on [2109-2-8] showed a residual lesion positive for malignancy hence he was referred here for further management. Past Medical History: Pulmonary embolism, DVT , IVC filter, Ac perforated appendicitis treated with ?Ileocecectomy.; R AKA traumatic many years ago; L knee surgery; L groin hernia. Depression, ADHD Social History: Married lives with wife. [Name (NI) 1139] 40 pack-year. Quit 10 years ago. ETOH none Occupation:Was in retail Family History: Mother: DM Siblings: Sister throat cancer Offspring: Barretts esophagus [2-28] Physical Exam: VS: T; 98.1 HR 80 SR BP: 115/70 Sats: 97% RA WT: 67.5 kg General: 81 year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRR normal S1,S2 no murmur Resp: decreased breath sounds throughout. no crackles or wheezes GI: benign, bowel sounds positive. J-tube site clean, no erythema or discharge Extr: Left lower extremity warm. no edema DP 2+ Incision: Right Vats site clean, dry intact. no erythema. right inferior incision site with fluid collection, no discharge or erythema. abdominal incisions sites clean, dry intact no erythema Neuro: awake, alert oriented Pertinent Results: [2109-4-23] WBC-5.1 RBC-3.79* Hgb-12.9* Hct-36.4 Plt Ct-267 [2109-4-22] WBC-4.7 RBC-3.65* Hgb-11.8* Hct-35.0 Plt Ct-232 [2109-4-15] WBC-5.5 RBC-3.46* Hgb-11.5* Hct-33.2 Plt Ct-143* [2109-4-23] Glucose-130* UreaN-29* Creat-0.7 Na-142 K-4.5 Cl-107 HCO3-29 [2109-4-22] Glucose-115* UreaN-28* Creat-0.6 Na-137 K-4.3 Cl-104 HCO3-26 [2109-4-15] Glucose-138* UreaN-21* Creat-0.6 Na-138 K-4.0 Cl-106 HCO3-26 [2109-4-23] Calcium-9.0 Phos-3.0 Mg-2.2 CXR [2109-4-23]; there is little change in the appearance of the moderate right apical pneumothorax with loculated areas of air and fluid at the right base laterally. Bilateral basilar atelectasis is again seen with continued left pleural effusion. The right paramediastinal opacification appears slightly more prominent, consistent with hematoma or fluid. No evidence of acute focal pneumonia. There is an air-fluid level in the retrocardiac region that could reflect substantial hiatal hernia. [2109-4-22]: The mild-to-moderate right apical pneumothorax is stable since [2109-4-21]. Bilateral pleural effusions are mild-to-moderate in size. Bilateral lower lobe atelectasis has slightly worsened since [2109-4-21]. Stable right paramediastinal density is suggestive of a postoperative fluid or blood. The cardiac size is normal. Orally ingested barium outlines the neoesophagus on the lateral radiograph. IMPRESSION: 1. Bilateral lower lobe atelectasis with slight interval worsening since [2109-4-21]. 2. Stable bilateral moderately large pleural effusion. 3. Stable right paramediastinal hematoma/fluid collection. Esophagus [2109-4-22]: Thin barium passes freely through the esophagogastric anastomosis and there is no evidence of a leak. Barium also passes freely through the pylorus. Limited views of the stomach are unremarkable. An IVC filter is noted. Bilateral emphysema is present. IMPRESSION: No evidence of anastomotic leak or obstruction. Brief Hospital Course: Mr. [Known lastname 5749] is a 81 year-old male who was admitted [2109-4-15] following Minimally-invasive [First Name9 (NamePattern2) 12351] [Doctor Last Name ] esophagectomy. Buttressing of intrathoracic anastomosis with thymic fat. Laparoscopic jejunostomy. Esophagogastroduodenoscopy. He was extubated in the operating room, transfer to the TSICU for close monitoring with a right chest-tube, JP drain, NGT and Bupivacaine Epidural managed by the acute pain service. While in the TSICU he responded to fluid boluses for hypotension. Aggressive pulmonary toilet and nebs were continued. He transfer to the floor on [2109-4-17]. Respiratory: incentive spirometer, nebs and ambulation he titrated off oxygen with saturations of Chest-tube with minimal drainage was removed [2109-3-25]. Chest-films: serial chest films showed bilateral atelectasis and bilateral pleural effusions. Card: hemodynamically stable sinus rhythm 80-90's blood pressure GI: Bowel regime with good effect. NGT removed 03/ Nutrition: He was seen by nutrition. Jevity full strength was started [2109-4-16] increased to his goal rate of 75 ml/hr continuous or 100 ml/hr x 18, via the J-tube. On [2109-3-25] he was started on a full liquid diet following esophagus study which was negative for anastomotic leak. Renal: He was gently diuresed. His renal function normal with good urine output. Electrolytes were replete as needed. Foley removed [2109-4-22]. Endocrine: Fingerstick blood sugars were < 150. Pain: Roxicet via J-tube was started on [2109-4-17]. The Epidural was removed on [2109-4-22]. Wound: right VATs posterior inferior incision with fluid collection likely a seroma. Disposition: he was followed by physical therapy who worked with him and was able to ambulate him with his right lower extremity prothesis. He continued to make steady progress and was discharged to [Hospital3 4103] Rehab on [2109-4-23]. He will follow-up with Dr. [First Name (STitle) ] as an outpatient. Medications on Admission: Effexor XR 150 mg [Hospital1 ], PrimiDone 50 mg [Hospital1 ], zantac 150 mg [Hospital1 ] Discharge Medications: 1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 2. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. 3. primidone 50 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Effexor XR 150 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO twice a day. 5. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Discharge Disposition: Extended Care Facility: Newbridge on the [Doctor Last Name ] - [Location (un) 1411] Discharge Diagnosis: Pulmonary embolism, DVT , IVC filter Depression ADHD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires right lower extremity protheses Discharge Instructions: Call Dr.[Name (NI) 5067] office [Telephone/Fax (1) 2348] if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough or chest pain -Incision develops drainage -Chest tube site remove dressing and cover site with a bandaid -Increased or difficulty swallowing -Increased abdominal pain -Nausea (take antinausea medication) or vomiting -Daily weights. Keep a log Acitivity: -Shower daily. Wash incision with mild soap & water rinse, pat dry -No lifting greater than 10 pounds. Pain -Take acetaminophen -Roxicet via J-tube. Followup Instructions: Follow-up with Dr. [First Name (STitle) ] [0-0-] Date/Time:[2109-5-7] 10:00 on the [Hospital Ward Name 516] [Hospital Ward Name 23] Clinical Center [Location (un) 24] Chest X-Ray [Location (un) 861] Radiology 30 minutes before your appointment Completed by:[2109-4-24]	[ "32723" ]
Admission Date: [2143-7-14] Discharge Date: [2143-8-13] Date of Birth: [2087-7-8] Sex: M Service: ORTHOPAEDICS Allergies: Simvastatin / Pravastatin / nuts,peanuts,walnuts / Wheat Flour / Nifedipine Attending:[First Name3 (LF) 64] Chief Complaint: Right hip pain Major Surgical or Invasive Procedure: Postoperative hematoma within right gluteus medius s/p I&D and evacuation of hematoma on [2143-7-17] by Dr. [Last Name (STitle) 5322] Septic right total hip arthroplasty s/p I&D, explant of all components, cement spacer placement, and wound vac placement on [2143-7-24] by Dr. [Last Name (STitle) ] Multiple I&D and vac changes for septic right total hip arthroplasty on [2143-7-25], [2143-7-27], [2143-7-30] by Dr. [Last Name (STitle) ] I&D, antibiotic spacer exchange and wound closure [2143-8-1] by Dr. [Last Name (STitle) ] History of Present Illness: Briefly, patient is a 56 yo M who underwent primary right THA with Dr. [Last Name (STitle) ] on [2143-6-26]. He initially did well but was seen in the ER with right hip pain on [2143-7-5]. Xrays showed hardware in good position and he was admitted for pain control and PT. His pain resolved with medications and returned to baseline so no further imaging or intervention was performed. However on [2143-7-14], he felt inceasing pain in the right hip and had to take more oxycodone and tizanidine in setting of right foot drop, and was admitted to the Medicine service for worsening right hip pain. Past Medical History: -OA of knees and hips -low back pain from car accident -rotator cuff injury in b/l arms in [2140] and [2141] -HTN -hyperlipidemia -obstructive sleep apnea -L foot cyst -colonic polyps -CAD (microvascular dz) with h/o atypical cp, s/p cath with no intervention -depression/anxiety -DM 2 -GERD -obesity s/p lap band (lost 60lbs) -anemia PSH: -R HTA on [2143-6-26] -laparoscopic adjustable gastric band [2142-4-2] -R knee arthroscopies x2 -abdominal hernia repair 3 years ago -parathyroid surgery on [5-/2143] -L hip pins put in when 14 years ago -carpal tunnel repair on L hand Social History: Patient is a pastor. He is happily married with a supportive family. Denies cigarettes and reports rare EtOH. Family History: Noncontributory. Physical Exam: ADMISSION PHYSICAL EXAM VS - 98.7, 158/86, 84, 22, 100%RA GENERAL - appears uncomfortable, but in NAD HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no LD LUNGS - Lungs are clear to ausculatation bilaterally, moving air well and symmetrically, resp unlabored, no accessory muscle use HEART - RRR, without murmurs, rubs or gallops ABDOMEN - NABS, obese, soft/NT/ND, no rebound/guarding EXTREMITIES - WWP, 2+ PT pulses. R hip scar with surgical staples, some induration, slight erythema and tender to palpation, but no pus or warmth. Tenderness to palpation throughout leg but in particular R hip, calf, and ankle. Unable to move joint due to pain, but able to wiggle toes. No noticable increased in swelling in R leg compared to L. Knee flexion and extension normal. Sensation to soft touch intact NEURO - awake, A&Ox3, CNs II-XII grossly intact DISCHARGE PHYSICAL EXAM ************* Alert, oriented, NAD Hemodynamically stable and pain well-controlled Ambulating with a walker, voiding independently Tolerating a regular diet Nonlabored breathing, RRR Abdomen soft NT/ND Left lower extremity: Hip incision clean, dry, and intact Positive GS/FHL/peroneals, no TA/[Last Name (un) 938] SILT T/S/S, decreased DP/SP 2+ DP pulse, WWP Pertinent Results: IMAGING: [2143-7-14] ULTRASOUND OF SURGICAL SCAR IMPRESSION: No drainable fluid collection deep to the recent surgical incision along the right lateral hip. [2143-7-14] R LEG ULTRASOUND IMPRESSION: No evidence of right lower extremity DVT. [2143-7-14] R HIP XRAY IMPRESSION: Stable postoperative changes. No acute fracture or dislocation. [2143-7-15] CT PELVIS AND THIGH 1. Large hematoma centered within the right gluteus medius extending inferiorly into the posterolateral aspect of the proximal right lower extremity. 2. No CT evidence for underlying soft tissue mass within the effected musculature, however follow contrast enhanced MR examination would provide further imaging evaluation if clinically warranted. 3. No drainable subcutaneous fluid collection. 4. No retroperitoneal hematoma. 5. Status post right total hip arthroplasty. Surgical hardware intact with no evidence for hardware loosening / failure. 6. Status post pinning of a left femoral neck fracture, surgical pins intact. 7. Heterotopic ossification versus myositis ossificans anteromedial to the right hip. 8. Small left [Hospital Ward Name 4675] cyst. [2143-7-14*] 09:37AM BLOOD WBC-8.5 RBC-2.82 Hgb-7.7* Hct-24.7* MCV-88 MCH-27.1 MCHC-31.0 RDW-17.2* Plt Ct-795* [2143-7-15] 05:55AM BLOOD WBC-8.0 RBC-2.61* Hgb-7.1* Hct-23.0* MCV-88 MCH-27.1 MCHC-30.9* RDW-17.8* Plt Ct-692* [2143-7-15] 06:50PM BLOOD Hct-22.8* [2143-7-15] 11:08PM BLOOD Hct-22.5* [2143-7-16] 06:20AM BLOOD WBC-7.6 RBC-2.57* Hgb-6.7* Hct-22.5* MCV-88 MCH-26.2* MCHC-29.9* RDW-18.1* Plt Ct-621* [2143-7-17] 03:05AM BLOOD Hct-25.3* [2143-7-17] 01:28PM BLOOD WBC-10.1 RBC-3.11* Hgb-8.7# Hct-27.4 MCV-88 MCH-28.0 MCHC-31.8 RDW-16.9* Plt Ct-512* [2143-7-18] 06:10AM BLOOD WBC-8.3 RBC-2.78* Hgb-7.7* Hct-23.9* MCV-86 MCH-27.7 MCHC-32.3 RDW-17.9* Plt Ct-452* [2143-7-19] 06:05AM BLOOD WBC-7.8 RBC-2.72* Hgb-7.8* Hct-23.8* MCV-87 MCH-28.8 MCHC-32.9 RDW-17.6* Plt Ct-397 [2143-7-20] 06:30AM BLOOD WBC-7.4 RBC-2.91* Hgb-8.3* Hct-25.7* MCV-88 MCH-28.5 MCHC-32.4 RDW-16.8* Plt Ct-408 [2143-7-21] 07:35AM BLOOD WBC-7.8 RBC-2.60* Hgb-7.3* Hct-22.9* MCV-88 MCH-28.0 MCHC-31.9 RDW-17.7* Plt Ct-327 [2143-7-22] 05:35AM BLOOD WBC-7.1 RBC-2.52* Hgb-7.1* Hct-22.3* MCV-88 MCH-28.2 MCHC-31.9 RDW-17.5* Plt Ct-317 [2143-7-23] 05:01AM BLOOD WBC-7.4 RBC-2.73* Hgb-7.7* Hct-23.9* MCV-87 MCH-28.1 MCHC-32.1 RDW-16.6* Plt Ct-342 [2143-7-24] 06:05AM BLOOD WBC-10.3 RBC-2.85* Hgb-8.2* Hct-24.9* MCV-87 MCH-28.7 MCHC-32.9 RDW-16.9* Plt Ct-387 [2143-7-24] 07:20PM BLOOD WBC-10.7 RBC-3.16* Hgb-9.0* Hct-27.8* MCV-88 MCH-28.5 MCHC-32.4 RDW-17.2* Plt Ct-377 [2143-7-24] 07:20PM BLOOD WBC-10.7 RBC-3.16* Hgb-9.0* Hct-27.8* MCV-88 MCH-28.5 MCHC-32.4 RDW-17.2* Plt Ct-377 [2143-7-24] 10:04PM BLOOD WBC-14.5* RBC-3.39* Hgb-9.6* Hct-30.4* MCV-90 MCH-28.2 MCHC-31.5 RDW-16.7* Plt Ct-329 [2143-7-25] 07:20AM BLOOD WBC-8.0 RBC-2.26# Hgb-6.8# Hct-20.3# MCV-90 MCH-30.0 MCHC-33.3 RDW-16.2 Plt Ct-277 [2143-7-25] 04:22PM BLOOD WBC-11.6* RBC-2.36* Hgb-7.3* Hct-21.5* MCV-91 MCH-30.8 MCHC-33.8 RDW-15.8* Plt Ct-232 [2143-7-25] 11:43PM BLOOD Hct-21.6* [2143-7-26] 09:13AM BLOOD WBC-9.1 RBC-3.00# Hgb-8.9 Hct-26.6* MCV-88 MCH-29.6 MCHC-33.4 RDW-15.7* Plt Ct-227 [2143-7-26] 11:48PM BLOOD WBC-6.7 RBC-2.84* Hgb-8.5* Hct-25.1* MCV-89 MCH-29.8 MCHC-33.6 RDW-15.7* Plt Ct-256 [2143-7-27] 11:52AM BLOOD WBC-9.3 RBC-2.97* Hgb-8.8* Hct-27.0* MCV-91 MCH-29.6 MCHC-32.5 RDW-15.6* Plt Ct-336 [2143-7-28] 01:30AM BLOOD WBC-7.9 RBC-2.71* Hgb-8.1* Hct-24.3* MCV-90 MCH-29.7 MCHC-33.2 RDW-15.8* Plt Ct-336 [2143-7-29] 08:53AM BLOOD WBC-6.3 RBC-2.86* Hgb-8.4* Hct-25.7* MCV-90 MCH-29.3 MCHC-32.7 RDW-15.7* Plt Ct-489* [2143-7-30] 05:54AM BLOOD WBC-7.1 RBC-3.04* Hgb-8.8* Hct-27.4* MCV-90 MCH-28.9 MCHC-32.2 RDW-15.9* Plt Ct-574* [2143-7-30] 06:19PM BLOOD WBC-8.2 RBC-3.26* Hgb-9.4* Hct-30.0* MCV-92 MCH-28.8 MCHC-31.2 RDW-15.7* Plt Ct-764* [2143-7-31] 12:00PM BLOOD WBC-8.4 RBC-3.02* Hgb-8.9* Hct-27.5* MCV-91 MCH-29.4 MCHC-32.3 RDW-15.8* Plt Ct-817* [2143-8-2] 06:18AM BLOOD WBC-7.9 RBC-2.85* Hgb-8.1* Hct-26.0* MCV-91 MCH-28.3 MCHC-31.0 RDW-15.4 Plt Ct-724* [2143-8-3] 05:20AM BLOOD WBC-6.6 RBC-2.70* Hgb-7.8* Hct-24.7* MCV-92 MCH-28.8 MCHC-31.4 RDW-15.4 Plt Ct-786* [2143-8-4] 06:20AM BLOOD WBC-7.7 RBC-3.00* Hgb-8.7* Hct-27.0* MCV-90 MCH-29.1 MCHC-32.3 RDW-15.8* Plt Ct-853* [2143-8-5] 06:15AM BLOOD WBC-8.4 RBC-3.00* Hgb-8.7* Hct-27.0* MCV-90 MCH-29.1 MCHC-32.5 RDW-16.2* Plt Ct-767* [2143-8-6] 09:25AM BLOOD WBC-6.7 RBC-3.03* Hgb-8.7* Hct-27.3* MCV-90 MCH-28.7 MCHC-31.9 RDW-16.2* Plt Ct-683* [2143-8-12] 10:55AM BLOOD WBC-4.7 RBC-3.18* Hgb-9.3* Hct-28.6* MCV-90 MCH-29.2 MCHC-32.4 RDW-15.8* Plt Ct-397 [2143-7-14] 09:37AM BLOOD Neuts-76.2* Lymphs-16.7* Monos-4.7 Eos-2.2 Baso-0.2 [2143-7-16] 06:20AM BLOOD Neuts-63.8 Lymphs-26.0 Monos-7.5 Eos-2.5 Baso-0.2 [2143-7-23] 05:01AM BLOOD Neuts-67 Bands-0 Lymphs-26 Monos-5 Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0 [2143-8-3] 05:20AM BLOOD Neuts-76.1* Lymphs-16.8* Monos-5.6 Eos-1.3 Baso-0.2 [2143-7-15] 05:55AM BLOOD ESR-59* [2143-7-18] 06:10AM BLOOD ESR-60* [2143-7-23] 05:01AM BLOOD ESR-98* [2143-7-30] 06:19PM BLOOD ESR-91* [2143-8-4] 06:20AM BLOOD ESR-83* [2143-7-14] 09:37AM BLOOD Glucose-118* UreaN-15 Creat-1.1 Na-140 K-4.9 Cl-105 HCO3-23 AnGap-17 [2143-7-15] 05:55AM BLOOD Glucose-107* UreaN-13 Creat-1.1 Na-141 K-4.5 Cl-106 HCO3-25 AnGap-15 [2143-7-16] 06:20AM BLOOD Glucose-148* UreaN-16 Creat-1.0 Na-138 K-4.6 Cl-105 HCO3-25 AnGap-13 [2143-7-17] 03:05AM BLOOD Glucose-125* UreaN-11 Creat-0.9 Na-142 K-4.2 Cl-107 HCO3-25 AnGap-14 [2143-7-17] 01:28PM BLOOD Glucose-184* UreaN-12 Creat-1.2 Na-140 K-4.7 Cl-107 HCO3-28 AnGap-10 [2143-7-18] 06:10AM BLOOD Glucose-128* UreaN-10 Creat-1.0 Na-140 K-4.2 Cl-107 HCO3-26 AnGap-11 [2143-7-19] 06:05AM BLOOD Glucose-189* UreaN-13 Creat-1.1 Na-140 K-4.2 Cl-106 HCO3-26 AnGap-12 [2143-7-20] 06:30AM BLOOD Glucose-220* UreaN-9 Creat-0.9 Na-142 K-4.2 Cl-108 HCO3-25 AnGap-13 [2143-7-21] 07:35AM BLOOD Glucose-178* UreaN-8 Creat-0.9 Na-141 K-3.8 Cl-107 HCO3-25 AnGap-13 [2143-7-22] 05:35AM BLOOD Glucose-195* UreaN-10 Creat-1.1 Na-138 K-3.8 Cl-105 HCO3-24 AnGap-13 [2143-7-23] 05:01AM BLOOD Glucose-199* UreaN-8 Creat-0.9 Na-137 K-3.7 Cl-105 HCO3-25 AnGap-11 [2143-7-24] 10:04PM BLOOD Glucose-166* UreaN-10 Creat-1.1 Na-141 K-4.2 Cl-108 HCO3-22 AnGap-15 [2143-7-25] 07:20AM BLOOD Glucose-223* UreaN-15 Creat-1.7* Na-135 K-4.2 Cl-104 HCO3-24 AnGap-11 [2143-7-25] 04:22PM BLOOD Glucose-154* UreaN-16 Creat-1.8* Na-137 K-3.9 Cl-106 HCO3-23 AnGap-12 [2143-7-25] 11:43PM BLOOD Glucose-120* UreaN-11 Creat-1.3* Na-142 K-3.5 Cl-114* HCO3-20* AnGap-12 [2143-7-26] 09:13AM BLOOD Glucose-167* UreaN-11 Creat-1.1 Na-139 K-4.2 Cl-107 HCO3-24 AnGap-12 [2143-7-26] 11:48PM BLOOD Glucose-162* UreaN-11 Creat-1.0 Na-137 K-4.3 Cl-106 HCO3-25 AnGap-10 [2143-7-27] 11:52AM BLOOD Glucose-160* UreaN-8 Creat-0.8 Na-140 K-4.3 Cl-107 HCO3-25 AnGap-12 [2143-7-28] 01:30AM BLOOD Glucose-143* UreaN-8 Creat-0.9 Na-137 K-4.6 Cl-103 HCO3-28 AnGap-11 [2143-7-30] 05:54AM BLOOD Glucose-131* UreaN-8 Creat-0.8 Na-141 K-4.6 Cl-106 [2143-7-31] 12:00PM BLOOD Glucose-143* UreaN-10 Creat-1.0 Na-139 K-4.9 Cl-102 HCO3-28 AnGap-14 [2143-8-2] 06:18AM BLOOD Glucose-191* UreaN-10 Creat-0.9 Na-138 K-5.2* Cl-105 HCO3-29 AnGap-9 [2143-8-6] 09:25AM BLOOD Glucose-116* UreaN-14 Creat-0.7 Na-143 K-3.9 Cl-113* HCO3-24 AnGap-10 [2143-8-12] 10:55AM BLOOD Glucose-184* UreaN-16 Creat-0.8 Na-140 K-4.5 Cl-107 HCO3-26 AnGap-12 [2143-7-15] 05:55AM BLOOD CRP-36.7* [2143-7-18] 06:10AM BLOOD CRP-66.4* [2143-7-23] 05:01AM BLOOD CRP-114.5* [2143-7-30] 06:19PM BLOOD CRP-41.6* [2143-8-4] 06:20AM BLOOD CRP-18.6* TISSUE Cx: Time Taken Not Noted Log-In Date/Time: [2143-7-17] 12:27 pm TISSUE Site: HIP RIGHT HIP HEMATOMA. GRAM STAIN (Final [2143-7-17]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [2143-7-21]): Reported to and read back by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] [2143-7-18] 12:00N. STAPH AUREUS COAG +. RARE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. Rifampin should not be used alone for therapy. RIFAMPIN REQUESTED BY DR.[First Name (STitle) ] ,APARA #[Numeric Identifier 26977] [2143-7-20]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Final [2143-7-21]): NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final [2143-7-18]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. FUNGAL CULTURE (Final [2143-7-30]): NO FUNGUS ISOLATED. [2143-7-25] 2:55 pm TISSUE RIGHT HIP DEEP TISSUE #2. FINAL REPORT [2143-7-31] GRAM STAIN (Final [2143-7-25]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [2143-7-31]): PROTEUS MIRABILIS. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 353-5633K [2143-7-24]. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 16437]. SPARSE GROWTH. Fluconazole REQUESTED BY DR. [Last Name (STitle) ] #[Numeric Identifier 61848] . SENT TO [Hospital1 4534] FOR SENSITIVITIES [2143-7-31]. Refer to sendout/miscellaneous reporting for results. ANAEROBIC CULTURE (Final [2143-7-29]): NO ANAEROBES ISOLATED. [2143-7-24] 5:00 pm TISSUE Site: HIP RT HIP GRANULATION. FINAL REPORT [2143-8-12] GRAM STAIN (Final [2143-7-24]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. SMEAR REVIEWED; RESULTS CONFIRMED. TISSUE (Final [2143-7-27]): Reported to and read back by DR [Last Name (STitle) ] [2143-7-25] AT 11:10AM. PROTEUS MIRABILIS. MODERATE GROWTH. Piperacillin/Tazobactam sensitivity testing performed by [First Name8 (NamePattern2) 3077] [Last Name (NamePattern1) 3060]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS \| AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ANAEROBIC CULTURE (Final [2143-7-28]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Final [2143-8-12]): NO FUNGUS ISOLATED. [2143-7-30] 4:30 pm TISSUE Site: HIP RIGHT HIP # 1. FINAL REPORT [2143-8-5] GRAM STAIN (Final [2143-7-30]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [2143-8-2]): NO GROWTH. ANAEROBIC CULTURE (Final [2143-8-5]): NO GROWTH. [2143-8-1] 4:55 pm TISSUE Site: HIP RIGHT HIP #3. GRAM STAIN (Final [2143-8-1]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [2143-8-4]): NO GROWTH. ANAEROBIC CULTURE (Final [2143-8-7]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Brief Hospital Course: The patient was initially admitted to the Medicine service for worsening right hip pain. A CT was performed showing a hematoma in the right gluteal region. The patient also developed parasthesias and weakness in the sciatic distribution with a true right foot drop. At that point he was transferred to the Ortho service with a symptomatic postoperative hematoma. He was taken to the OR by Dr. [Last Name (STitle) 5322] for evacuation of the hematoma on [2143-7-17] at which time cultures were sent. These cultures ultimately grew MSSA and the patient was started on Nafcillin and taken back to the OR for I&D, hardware removal, ABX spacer, and wound VAC on [2143-7-24]. These cultures showed proteus in the tissue and yeast in the fluid so ID recommended switching from nafcillin to cefepime with initiation of micofungin. Following further speciation micofungin discontinued & started on Voriconazole. After sensitivities returned on yeast, voriconazole changed to fluconazole. He was found to be bleeding from the wound and required serial transfusions. Postoperatively his VAC failed and due to persistent bleeding so he was taken back to the OR on [2143-7-25] for repeat I&D and VAC placement. He continued to require multiple transfusions and resuscitation and ultimately was transferred to the Trauma ICU, with transfer to floor following stabilization. Patient underwent repeat I&D on [2143-7-30] and interval repeat I&D, antibiotic spacer exchange & wound closure on [2143-8-2]. ************* The patient was admitted to the orthopaedic surgery service and was taken to the operating room on multiple occasions for the procedures described above. Please see separately dictated operative reports for details. In general the patient tolerated the procedures well but had significant blood loss and ultimately required multiple transfusions and ICU monitoring. He received antibiotics as directed by the ID team. Hospital course was remarkable for the following: 1. ID consult: MSSA growing from [2143-7-17] OR tissue specimens. Initially ID recommended nafcillin 2g IV q4h x 6 weeks. However, at the time of hardware removal on [2143-7-24], OR tissue specimens grew proteus and OR fluid specimens grew yeast. The patient was switched to cefepime 2grams Q12H and voriconazole and finally switch to fluconazole . 2. PICC placement [2143-7-22] 3. Neuro consult for presumed sciatic compression injury and new foot drop 4. Chronic pain consult for pain management 5. Post op blood loss anemia: Transfused 1 unit PRBCs on [2143-7-22] for Hct 22.3. Transfused 4units PRBCs on [2143-7-24] for Hct of 24.9. Transfused 6 units PRBC and 4 units FFP on [2143-7-25] for Hct 20.3. Transferred to the Trauma ICU for serial Hct checks and further resuscitative management. 6. Calf pain: [2143-7-22] RLE US shows no DVT, but evidence of superficial thrombophlebitis. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity with posterior precautions and bilateral upper extremity support. Mr [Known lastname 1356] is discharged to rehab in stable condition. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Acetaminophen 650 mg PO Q6H standing dose 2. Acetaminophen-Caff-Butalbital [11-26*] TAB PO Q6H:PRN headache 3. Aspirin 81 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Enoxaparin Sodium 40 mg SC Q 24H 6. Ferrous Sulfate 325 mg PO DAILY 7. Fluticasone Propionate NASAL 1 SPRY NU DAILY 8. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY 9. Lisinopril 20 mg PO DAILY hold for SBP < 110, HR < 60 10. OxycoDONE (Immediate Release) 5-15 mg PO Q4H:PRN Pain hold for sedation 11. Senna 1 TAB PO BID 12. fenofibrate NF* 160 mg Oral daily 13. MetFORMIN XR (Glucophage XR) 1500 mg PO QPM Do Not Crush 14. Metoprolol Succinate XL 25 mg PO DAILY hold for SBP < 110, HR < 60 15. testosterone cypionate NF 200 mg/mL Injection every 2 weeks 16. Vitamin D 50,000 UNIT PO 1X/WEEK ([Doctor First Name ]) 17. Tizanidine 4-8 mg PO HS:PRN pain, spasm Discharge Medications: 1. Acetaminophen 650 mg PO Q6H standing dose 2. Acetaminophen-Caff-Butalbital [11-26] TAB PO Q6H:PRN headache 3. Docusate Sodium 100 mg PO BID 4. Ferrous Sulfate 325 mg PO DAILY 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY 6. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY 7. Lisinopril 20 mg PO DAILY hold for SBP < 110, HR < 60 8. MetFORMIN XR (Glucophage XR) 1500 mg PO QPM Do Not Crush 9. Metoprolol Succinate XL 25 mg PO DAILY hold for SBP < 110, HR < 60 10. Senna 1 TAB PO BID 11. Tizanidine 4-8 mg PO HS:PRN pain, spasm 12. Vitamin D 50,000 UNIT PO 1X/WEEK ([Doctor First Name ]) 13. fenofibrate NF 160 mg Oral daily 14. testosterone cypionate NF 200 mg/mL Injection every 2 weeks 15. Aspirin 81 mg PO DAILY 16. Outpatient Lab Work Check CBC/diff, ESR/CRP, BMP, LFTs - Check weekly and fax results to ([Telephone/Fax (1) 4591] 17. Aluminum-Magnesium Hydrox.-Simethicone 15-30 ml PO Q6H:PRN Dyspepsia 18. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 19. Calcium Carbonate 500 mg PO TID calcium repletion 20. Diazepam 10 mg PO Q6H:PRN pain please encourage more PRN use if needed, patient only taken 1 tab today and 1 tab yesterday per pharmacy 21. DiphenhydrAMINE 12.5-50 mg PO/IV Q6H:PRN Insomnia/Pruritis 22. Gabapentin 600 mg PO Q6H 23. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin 24. Milk of Magnesia 30 ml PO BID:PRN Constipation 25. Multivitamins 1 CAP PO DAILY 26. Nortriptyline 25 mg PO HS 27. CefePIME 2 g IV Q8H 28. Morphine Sulfate IR 15-30 mg PO Q4H:PRN pain 29. Morphine SR (MS Contin) 30 mg PO Q12H RX morphine 30 mg 1 capsule(s) by mouth every twelve (12) hours Disp #60 Capsule Refills:0 30. Lidocaine 5% Patch 1 PTCH TD DAILY 31. Fluconazole 400 mg PO Q24H 32. Enoxaparin Sodium 40 mg SC DAILY stop date is [2143-9-2]. Discharge Disposition: Extended Care Facility: [Hospital1 ] State Discharge Diagnosis: Right hip osteoarthritis s/p total hip arthroplasty [2143-6-26] Postoperative hematoma within right gluteus medius s/p I&D and evacuation of hematoma on [2143-7-17] by Dr. [Last Name (STitle) 5322] Septic right total hip arthroplasty s/p I&D, explant of all components, cement spacer placement, and wound vac placement on [2143-7-24] by Dr. [Last Name (STitle) ] Multiple I&D and vac changes for septic right total hip arthroplasty on [2143-7-25], [2143-7-27], [2143-7-30], [2143-8-1] by Dr. [Last Name (STitle) ] 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: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please keep your wounds clean. You may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) weeks. No dressing is needed if wound continues to be non-draining. Any stitches that need to be removed will be taken out at your follow-up visit. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for four (4) weeks to help prevent deep vein thrombosis (blood clots). If you were taking aspirin prior to your surgery, it is OK to continue at your previous dose while taking this medication. [Male First Name (un) ] STOCKINGS x 6 WEEKS. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Sutures will be removed at yoru follow-up visit. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks, PICC line assessment, IV infusions. Weekly labs - CBC/diff, Chem 7, LFTs and send to ID RNs at [Telephone/Fax (1) 93513]. 12. ACTIVITY: Weight bearing as tolerated on the operative extremity. No strenuous exercise or heavy lifting until follow up appointment. Mobilize frequently. Physical Therapy: WBAT Mobilize Treatments Frequency: dry, sterile dressing changes daily and as needed for drainage wound checks ice TEDs staple removal will be at first follow up appt.* Followup Instructions: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 12567] [Name12 (NameIs) ], MD (Neurology) Phone:[Telephone/Fax (1) 1844] Date/Time:[2143-8-12] 4:00 - PLEASE CALL TO RESCHEDULE THIS APPT FOR END OF [Month (only) ] OR EARLY [Month (only) ] Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 23870], MD Phone:[Telephone/Fax (1) 457] Date/Time:[2143-9-4] 11:00 Provider: [First Name11 (Name Pattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 3260], [MD Number(3) 3261]:[Telephone/Fax (1) 1228] Date/Time:[2143-8-23] 3:20 - YOU WILL SEE DR [Last Name (STitle) ] DURING THIS APPT Completed by:[2143-8-13**]	[ "2851", "32723", "53081", "41401", "2724", "V1582" ]
Admission Date: [2120-2-12] Discharge Date: [2147-11-16] Date of Birth: Sex: M Service: ADDENDUM: This is an Addendum to the Discharge Summary originally dictated on [2147-9-19]. The patient was discharged on [2147-11-16]. As of the last dictation: On [2147-9-30] the patient had right-sided weakness, right facial droop, and a seizure and was transferred to the Coronary Care Unit on pressors. A magnetic resonance imaging scan of the head showed a left parietal cerebrovascular accident. The patient remained in the Intensive Care Unit on pressors for two to three days. His blood pressure came up to the 100 to 110 range after being down to the 80 range. He was started on valproic acid and Dilantin, and once therapeutic was transferred back to the regular floor. The patient was eventually transferred back to [Hospital Ward Name 121] Five where he remained stable; although, he continued to have leakage from his flap site. He eventually was taken back to the operating room on [2147-10-24] for the leakage of this wound. He had an omental flap harvest, and retroperitoneal tunnel, and wound debridement, and new flap placement. At that point, the patient had a ventricular drain placed. The patient was then admitted to the Surgical Intensive Care Unit where he remained for five days with a ventricular drain in place. The ventricular drain was clamped and removed on [2147-10-30]. Also, while the patient was in the Intensive Care Unit, he had developed an ileus and was seen by the Gastroenterology Service with a nasogastric tube in place for decompression. He had positive flatus on the 13th. His abdomen was soft, protruding, and his incision was mildly erythematous. His diet was advanced to clears, and the ileus resolved. The patient was also followed by the Infectious Disease Service and was on vancomycin and ciprofloxacin for intravenous antibiotic coverage. The patient continued to have episodes of tachy-brady but continued to be asymptomatic. It was determined that the patient would most likely need a pacemaker at a later time after the infection was cleared and the patient was off intravenous antibiotics. The patient was then transferred to the floor on [2147-10-30] where he remained stable. He had an episode of atrial tachycardia and atrial fibrillation on [11-4]. The patient was transferred to the Cardiology floor and was successfully cardioverted. The patient currently remains in sinus bradycardia in the 50s to 60s with some episodes of a heart rate down into the 40s. The electrophysiology attending saw the patient and cleared the patient to be off telemetry. The patient was to follow up with her in one month. The patient's heart rate was stable for the last 48 hours off telemetry. The patient's blood pressure runs in the low 90s to 100s; which is his baseline. The [Location (un) 1661]-[Location (un) 1662] drain was removed on [2147-11-13]. The patient's incision was clean, dry, and intact. The staples to be removed per the Plastic Surgery Service in followup. MEDICATIONS ON DISCHARGE: (The patient's medications at the time of discharge included) 1. Decadron 40 mg by mouth once per week (on Friday). 2. Hydromorphone 2 mg to 8 mg by mouth q.4-6h. as needed (for pain). 3. Colace 100 mg by mouth twice per day. 4. Ciprofloxacin 500 mg by mouth q.12h. 5. Methadone 10 mg by mouth twice per day. 6. Fentanyl patch 75-mcg patch topically q.72h. 7. Dilantin 100 mg by mouth three times per day. 8. Vancomycin 1250 mg intravenously q.12h. 9. Divalproex sodium 750 mg by mouth twice per day. 10. Lansoprazole 30 mg by mouth once per day. 11. Thalidomide 200 mg by mouth once per day (the patient takes this on vacations). 12. Lovenox 60 mg subcutaneously q.12h. 13. Gabapentin 900 mg by mouth three times per day. 14. Tylenol 650 mg by mouth q.4h. as needed. CONDITION AT DISCHARGE: The patient's condition on discharge was stable. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with Dr. [First Name8 (NamePattern2) ] [Name (STitle) 1327] in one month. 2. The patient was instructed to follow up with Plastic Surgery Service in two to three weeks. [Name6 (MD) 1339] [Last Name (NamePattern4) 1340], M.D. [MD Number(1) 1341] Dictated By:[Last Name (NamePattern1) 1479] MEDQUIST36 D: [2147-11-14] 10:35 T: [2147-11-14] 10:36 JOB#: [Job Number 46417]	[ "0389" ]
Admission Date: [2184-3-2] Discharge Date: [2184-3-12] Date of Birth: [2112-3-16] Sex: F Service: NEUROLOGY Allergies: Sulfa(Sulfonamide Antibiotics) Attending:[First Name3 (LF) 5831] Chief Complaint: Called by Emergency Department to evaluate for confusion, subsequent seizure activity. Major Surgical or Invasive Procedure: intubation, extubation History of Present Illness: Ms. [Known lastname ] is intubated and sedated; history obtained from husband. Ms. [Known lastname ] is a 71 y/o woman with PMH significant for HTN, HLD and femur fx s/p surgery ([2183-9-16]) who was brought to ED with receptive language difficulties and who subsequently had GTC seizure while in ED triage; she was intubated for airway protection. According to her husband, she was last seen well at 2:55 PM today. She went into another room to check email and she came out at 3 PM saying that the email was not working and that she closed it. However, when her husband went to check on it, it was still open. He was then asking her questions, but she was not responding appropriately. For example, he asked her what day is it and her response was "this is ridiculous." She never answered any questions correctly. He notes that her speech itself was articulate (she was saying intelligible words, though unclear if she ever reached true fluency); it was just that the things she was saying was not relevant to what was being discussed. Her husband also said that she appeared confused. EMS was called and she was brought to [Hospital1 18], while at triage, she had GTC seizure and subsequent extenor posturing noted in all extremities by ED. She received Ativan 2 mg per EMS and was intubated by the ED for airway protection; Etomidate and Succinylcholine was used for intubation. Code Stroke was called because of her speech changes prior to the seizure. Past Medical History: -HTN -HLD -Ulcerative colitis - per PCP/GI doc, trivial 15-30 cm of colitis in distal sigmoid sparing rectum. Pathology showed mild IBD. PCP/GI doc does not consider this UC. -Femur fracture s/p rod + pins ([9-/2183]) -viral tongue lesion (dx 1 month ago) - s/p biopsy and ~4 wks abx -left cheeck skin cancer s/p topical/surgical removal - unclear if basal cell vs melanoma. PCP [Name Initial (PRE) 72520]'t recall melanoma hx but does not have in records. Derm: Dr. [Last Name (STitle) 11487] at [Hospital1 ] Screening tests (per PCP/GI Dr. [Last Name (STitle) 110284] - Pt often refused. - last colonoscopy [2181] - focal ischemia, no polyps - mammogram [2174] - no abnl - prev CXR [2170] Social History: She lives with her husband. She had been in rehab in CT for her femur fx in [9-/2183] and subsequently living with daughter in CT for further rehab; moved back with her husband 1 week ago. Family History: Unable to obtain from patient Physical Exam: At admission: Vitals: T: 97 P: 84 R: 16 BP: 131/93 SaO2: 100% NRB (subsequently intubated) General: intubated, sedated HEENT: NC/AT, no scleral icterus noted, MMM, there is blood on her tongue Neck: Supple Pulmonary: anterior lung fieds cta b/l Cardiac: RRR, S1S2 Abdomen: soft, nondistended, +BS Extremities: warm, well perfused Neurologic: NIH Stroke Scale score was: >20 (patient had just been intubated with paralytics prior to assessment; so unable to obtain accurate NIHSS) Neurologic Exam: she is intubated and sedated. No eye opening. No commands. [Year (4 digits) 2994] 5-->3 mm. Eyes in midline. Unable to elicit Doll's eyes. Unable to elicit corneals. + cough. She was having intermittent pronation of UE b/l and adduction of LE b/l. No purposeful spontaneous movements. No withdrawal or grimmace to noxious stimuli. Unable to elicit any reflexes. Extensor plantar response b/l. PHYSICAL EXAM AT DISCHARGE: VS: 98.6, 130/70's, 70's, 18, 98% on RA GEN: elderly woman sitting in bed, tearful HEENT: OP clear, no tenderness at mouth when made to bite down on tongue depressor CV: RRR PULM: CTAB ABD: soft, NT, ND EXT: trace edema . NEURO EXAM: MS - patient intermittently tearful, sometimes refusing to answer questions, but essentially cooperative CN - L NLF flattening and mild R facial droop, EOMI, [Name (NI) 2994] MOTOR - pt moving all four extremities, not cooperative with formal strength exam SENSORY - intact to light touch throughout GAIT - able to walk without assistance, narrow based gait Pertinent Results: [2184-3-2] 04:34PM WBC-14.0* RBC-4.54 HGB-12.4 HCT-41.2 MCV-91 MCH-27.2 MCHC-30.1* RDW-15.0 [2184-3-2] 04:34PM PLT COUNT-385 [2184-3-2] 04:34PM PT-11.0 PTT-30.6 INR(PT)-1.0 [2184-3-2] 04:34PM UREA N-11 [2184-3-2] 04:35PM GLUCOSE-116* NA+-139 K+-4.8 CL--99 TCO2-24 [2184-3-2] 04:37PM CREAT-0.6 [2184-3-2] 05:56PM TYPE-ART RATES-14/8 TIDAL VOL-450 PEEP-5 O2-100 PO2-231* PCO2-48* PH-7.37 TOTAL CO2-29 BASE XS-2 AADO2-436 REQ O2-75 -ASSIST/CON INTUBATED-INTUBATED [2184-3-3] 02:03AM BLOOD ALT-10 AST-20 AlkPhos-88 TotBili-0.4 [2184-3-3] 02:03AM BLOOD Albumin-3.6 Calcium-8.4 Phos-3.7 Mg-1.9 CXR - portable: FINDINGS: There is pulmonary vasculature indistinctness compatible mild pulmonary edema. Cardiomediastinal silhouette is at the upper limits of normal. There is no evidence of pneumothorax or pleural effusions. Endotracheal tube tip is 4.5 cm from the carina, in standard position, and an enteric tube tip is in the stomach. IMPRESSION: Mild pulmonary edema. Standard positioning of the endotracheal and NG tubes. CTA Head and Neck: CT HEAD: A 15 x 15 mm measuring, fairly sharply demarcated area of hypoattenuation is identified in the left parietotemporal junction. This extends to the cortex and is wedge-shaped. The focus is associated with reduced blood flow and volume on perfusion imaging, but no increase in transit time. This combination of findings suggests that this likely represents a subacute infarct. There is no associated hemorrhagic transformation or mass effect. The cerebral sulci, ventricles, and extra-axial CSF-containing spaces have normal size and configuration. There is no shift of the midline structures. Otherwise, the [Doctor Last Name 352]-white matter differentiation is well preserved and there is no evidence of additional ischemic infarct. Confluent scattered periventricular white matter low attenuation likely represents a sequela of small vessel ischemic disease. The visualized paranasal sinuses and mastoid air cells are clear. PERFUSION IMAGING: As detailed above, the area of hypoattenuation is associated with reduced blood volume and flow, with no increase in transit time, suggesting subacute infarct. CTA OF HEAD: The intracranial internal carotid, vertebrobasilar and anterior, middle, and posterior cerebral arteries are patent with normal contrast enhancement and branching pattern. There is no evidence of stenosis, occlusion, aneurysm, or arteriovenous malformation. CTA OF THE NECK: The origins of the common carotid and vertebral arteries are patent without significant stenosis. The common, internal and external carotid arteries are normal in appearance. There is no evidence of hemodynamically significant stenosis or dissection. The cervical portions of the vertebral arteries demonstrate normal contrast opacification. Note is made of bilateral atelectatic changes in the dorsal basal aspects of the lung apices. IMPRESSION: Hypodense focus at the left parietotemporal junction with reduced blood flow and volume and no increase in transit time. While the CT presentation is compatible with subacute infarct, the more recently obtained MRI suggestes intracranial abcess or neoplasm. CTA of the head and neck is normal. MRI/MRV Brain with contrast: FINDINGS: There is a 10 x 10 mm ring enhancing lesion in the left parietotemporal junction with markedly slow diffusion. The focus has an enhancing leptomeningeal tail projecting toward the dura. There is moderate perilesional vasogenic edema and no evidence of hemorrhage. Mass effect is mild. The [Doctor Last Name 352]-white matter differentiation is otherwise well preserved and there is no evidence of additional enhancing foci. Scattered or confluent periventricular, deep white matter, and subcortical FLAIR/T2 white matter abnormalities are in keeping with sequela of small vessel ischemic disease. The ventricles, cerebral sulci, and extra-axial CSF-containing spaces have age-appropriate size and configuration. Bilateral T2 hyperintense cystic lesions in the atria likely represent xantogranulomas. Flow voids of the major intracranial arteries are preserved. MRV HEAD: When judged from contrast enhancend images, the left transverse and sigmoid sinus is patent. However, flow related MRV and high signal on T2 suggested abnormally slow flow which in unclear in etiology. IMPRESSION: 1. Ring enhancing lesion with slow diffusion in the left parietotemporal junction. Giving the imaging features, the lesion is most compatible with intracranial abcess; however, neoplasm such as solitary metastasis, GBM is nonot excluded. 2. Slow flow in left transverse and sigmoid sinus without evidence of thrombosis. CT HEAD [2184-3-7]: IMPRESSION: Known left parietal rim-enhancing lesion and the surrounding vasogenic edema have progressed since the prior study. These findings, in the context of those on MRI, remain highly concerning for an abscess. Dedicated multi- and single-voxel MR spectroscopy may be helpful in further characterization of this process. CT HEAD [2184-3-8]: IMPRESSION: Status post stereotactic biopsy of left parietal lobe lesion, with expected small air-fluid level and minimal hemorrhage at the surgical site. TTE [2184-3-9]: Conclusions The left atrium is mildly dilated. The right atrium is moderately dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF 65%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. Flow acceleration along the axis of left ventricular outflow is seen (2.4 m/sec). This is may be in part due to an obstructive subaortic fibromuscular shelf (although mild valvular aortic stenosis may be present) The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. No vegetations seen TEE [2184-3-9]: Conclusions No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 30 cm from the incisors. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([11-17]+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No echocardiographic evidence of endocarditis. Mild to moderate mitral regurgitation. CT HEAD [2184-3-11]: IMPRESSION: Status post drainage of left parietal abscess with expected postoperative changes and no significant hemorrhage. Brief Hospital Course: Mrs. [Known lastname ] is a 71 y/o woman with PMHx significant for HTN, HLD and femur fx s/p surgery ([2183-9-16]) who was brought to ED with receptive language difficulties and who subsequently had GTC seizure while in ED triage; she was intubated for airway protection. Neurological exam on sedation was limited but nonfocal. Inital CT imaging was not conclusive. There was a left temporo-occipital hypodensity with no flow limitiation noted on CTA, and decreased blood volume in this location, with no evidence of increased MTT on CTP. Given inconclusivity of CT data and as she was still in time window for tpa, she underwent STAT MRI. This showed a ring-enhancing mass lesion and a possible venous infarct with diminished flow in left transverse sinus. The initial most likely diagnosis was felt to be a metastatic lesion, however the possibility of abscess was also brought up. # NEURO: Patient was able to be extubated the morning after admission and the sedation weaned. Repeat neurological exam off sedation showed difficulty with naming and some commands. She was put on keppra 1 gram [Hospital1 ] for seizure prophylaxis that was then increased to 1250mg [Hospital1 ]. She underwent a CT torso to look for malignancy and this was negative. She then had an LP which showed 2 WBCs, with negative cytology. She then underwent a brain biopsy, but on biopsy frank pus was aspirated, so the abscess was drained. The fluid culture of her abscess showed mixed anaeorobic growth, with fusobacterium species. She was started on CTX, vancomycin and flagyl while awaiting the above Cx retults. She was started on celexa 20mg QD as her hospital course was c/b depression and emotional outbursts. Eventually she was narrowed to just CTX and flagyl and was able to be sent home with a PICC line for the CTX and oral flagyl. On discharge, patient was intermittently tearful, and reporting that she didn't want to leave the hospital, then changing her mind and requesting to leave the hospital. Given her emotional lability, we wanted to ensure that there was no change in her head CT. She had a NCHCT, which showed expected post-surgical changes but no bleeding or increased edema. Eventually, with the help of her family, she decided that she would prefer to complete her treatment at home. # ID: Patient was put on antibiotics as above. Her HIV was negative, TEE was negative for vegetations. She had a panorex that did not show any abscesses. Her brain abscess grew out fusobacterium as above, that was felt to likely have been from her mouth infection that she had previously on her last admission to rehab. # CVS: Pt has HTN, so we continued her home metoprolol and statin. # PULM: pt was extubated on the morning of [3-3], and had no further pulmonary issues. PENDING RESULTS: None TRANSITIONAL CARE ISSUES: Patient and family were told that if her sx change at all or she worsens or changes she should come to the ED for a CT scan to ensure there is no bleeding or increased swelling of her lesion. Medications on Admission: -Metoprolol 50 mg [Hospital1 ] -Simvastatin 10 mg qhs Discharge Medications: 1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. levetiracetam 500 mg Tablet Sig: 2.5 Tablets PO BID (2 times a day) for 2 weeks. Disp:75 Tablet(s) Refills:0 4. ondansetron HCl 4 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for nausea. Disp:180 Tablet(s) Refills:0 5. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. Disp:120 Capsule(s) Refills:0 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. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig: Two (2) grams Intravenous Q24H (every 24 hours): Infectious Disease will determine the date of your final dose. Disp:30 doses Refills:1 8. Outpatient Lab Work CBC with differential, BMP, LFTs, ESR and CRP QWeekly until Infectious Disease determines this can stop. All laboratory results should be faxed to the Infectious Disease R.N.s at ([Telephone/Fax (1) 4591]. All questions regarding outpatient parenteral antibiotics should be directed to the Infectious Disease R.N.s at ([Telephone/Fax (1) 21403] or to the on-call ID fellow when the clinic is closed. ICD-9 Code is 324.00 for brain abscess. 9. oxycodone 5 mg Tablet Sig: 0.5 mg PO every six (6) hours as needed for pain for 3 days. Disp:12 tablets Refills:0 10. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:14 Tablet(s) Refills:0 11. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day: This Rx has been called into your mail order pharmacy. 12. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours: This Rx has been called into your mail order pharmacy. 13. Keppra 500 mg Tablet Sig: 2.5 Tablets PO twice a day: This Rx has been called into your mail order pharmacy. 14. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 2 weeks. Disp:21 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Company 25282] Home Infusion Discharge Diagnosis: Seizure Brain Abscess Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname ], You were seen in the hospital for language difficulties and a seizure. You were found to have had a brain abscess that was causing your symptoms and you were treated with antibiotics. You will need to be continued on antibiotics for at least one month. We made the following changes to your medications: 1) We STARTED you on KEPPRA 1250mg twice a day. 2) We STARTED you on CITALOPRAM 20mg once a day. 3) We STARTED you on FLAGYL 500mg every 8 hours. Infectious Disease will determine when to stop this medication. 4) We STARTED you on CEFTRIAXONE 2 grams once every 24 hours through your PICC line. Infectious Disease will determine when to stop this medication. 5) We STARTED you on ZOFRAN 8mg every 8 hours as needed for nausea while taking flagyl. 6) We STARTED you on LOPERAMIDE 2mg four times a day as needed for diarrhea while you are taking flagyl. 7) We STARTED you on OXYCODONE 2.5mg every 6 hours as needed for pain from your PICC line. This will decrease over the next [12-19] days and you will no longer need this medication. Of note, your longer term medications (keppra, flagyl and celexa have been called into your mail order pharmacy - confirmation # [Telephone/Fax (5) 110285]), and you have been written for a 14 day course of them in addition to make sure you get them on discharge from the hospital. Please continue to take your other medications as previously prescribed. If you experience any of the below listed Danger Signs, please contact your doctor or go to the nearest Emergency Room. It was a pleasure taking care of you on this hospitalization. Please follow these seizure safety guidelines: SEIZURE SAFETY ________________________________________________________________ The following tips will help you to make your home and surroundings as safe as possible during or following a seizure. Some people with epilepsy will not need to make any of these changes. Use this list to balance your safety with the way you want to live your life. Make sure that everyone in your family and in your home knows: - what to expect when you have a seizure - correct seizure first aid - first aid for choking - when it is (and isn't) necessary to call for emergency help Avoid things that are known to increase the risk of a seizure: - forgetting to take medications - not getting enough sleep - drinking a lot of alcohol - using illegal drugs In the kitchen: - As much as possible, cook and use electrical appliances only when someone else is in the house. - Use a microwave if possible. - Use the back burners of the stove. Turn handles of pans toward the back of the stove. - Avoid carrying hot pans; serve hot food and liquids directly from the stove onto plates. - Use pre-cut foods or use a blender or food processor to limit the need for sharp knives. - Wear rubber gloves when handling knives or washing dishes or glasses in the sink. - Use plastic cups, dishes, and containers rather than breakable glass. In the living room: - Avoid open fires. - Avoid trailing wires and clutter on the floor. - Lay a soft, easy-to-clean carpet. - Put safety glass in windows and doors. - Pad sharp corners of tables and other furniture, and buy furniture with rounded corners. - Avoid smoking or lighting fires when you're by yourself. - Try to avoid climbing up on chairs or ladders, especially when alone. - If you wander during seizures, make sure that outside doors are securely locked and put safety gates at the top of steep stairs. In the bedroom: - Choose a wide, low bed. - Avoid top bunks. - Place a soft carpet on the floor. In the bathroom: - Unless you live on your own, tell a family member or [Name2 (NI) 8317] before you take a bath or shower. - Hang the bathroom door so it opens outward, so it can be opened if you have a seizure and fall against it. - Don't lock the bathroom door. Hang an "Occupied" sign on the outside handle instead. - Set the water temperature low so you won't be hurt if you have a seizure while the water is running. - Showers are generally safer than baths. Consider using a hand- held shower nozzle. - If taking a bath, keep the water shallow and make sure you turn off the tap before getting in. - Put non-skid strips in the tub. - Avoid using electrical appliances in the bathroom or near water. - Use shatterproof glass for mirrors. At work: - Consider telling your co-workers that you have epilepsy and the correct first aid for seizures. - Climb only as high as you can fall without injuring yourself. - When working around machinery, make sure that safety features are in place, and consider wearing protective clothing. - Try to keep consistent work hours so you don't have to go a long time without sleep. - Try to limit your exposure to flashing lights if this can trigger your seizures. Out and about: - Carry only as many medications with you as you will need, and 2 spare doses. - Wear a medical alert bracelet to let emergency workers and others know that you have epilepsy. - Stand well back from the road when waiting for the bus and away from the platform edge when taking the subway. - If you wander during a seizure, take a friend along. - Don't let fear of a seizure keep you at home. Sports: - Use common sense to decide which sports are reasonable. - Exercise on soft surfaces. - Wear a life vest when you are close to water. - Avoid swimming alone. Make sure someone with you can swim well enough to help you if you need it. - Wear head protection when playing contact sports or when there is a risk of falling. - When riding a bicycle or rollerblading, wear a helmet, knee pads, and elbow pads. Avoid high traffic areas; ride or skate on side roads or bike paths. Driving: - You may not drive in [State 350] unless you have been seizure- free for at least 6 months. - Always wear a seatbelt. Parenting: - Childproof your home as much as possible. - If you are nursing a baby, sit on the floor or bed with your back supported so the baby will not fall far if you should lose consciousness. - Feed the baby while he or she is seated in an infant seat. - Dress, change, and sponge bathe the baby on the floor. - Move the baby around in a stroller or small crib. - Keep a young baby in a playpen when you are alone, and a toddler in an indoor play yard, or childproof one room and use safety gates at the doors. - When out of the house, use a bungee-type cord or restraint harness so your child cannot wander away if you have a seizure that affects your awareness. - Explain your seizures to your child when he or she is old enough to understand. Followup Instructions: You are to see NEUROSURGERY for your staple removal on [3-16] at 1:45pm on the [Location (un) 470] of the [Hospital Unit Name ] at [Hospital1 18]. If you have any questions, please contact the office at [Telephone/Fax (1) 3231]. Department: INFECTIOUS DISEASE When: TUESDAY [2184-3-30] at 11:15 AM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 456], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: INFECTIOUS DISEASE When: THURSDAY [2184-4-15] at 11:00 AM With: [Name6 (MD) ] [Name8 (MD) 32437], MD [Telephone/Fax (1) 457] Building: LM [Hospital Ward Name ] Bldg ([Last Name (NamePattern1) ]) [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: NEUROLOGY When: MONDAY [2184-6-28] at 4:30 PM With: DRS. [Name5 (PTitle) 43] & [Doctor Last Name 2336] [Telephone/Fax (1) 44] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 858] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "4019", "2724" ]
Admission Date: [2147-4-24] Discharge Date: [2147-4-27] 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: abdominal pain, hypotension, fever Major Surgical or Invasive Procedure: peritoneal dialysis History of Present Illness: 49 yo female with metastatic colon cancer on chemotherapy and s/p renal transplant on peritoneal dialysis was admitted from the ED with fever to 10 and hypotension to 80. Patient reports that 2 days ago ([2147-4-22]) she awoke with pain in her left lower quadrant, which she describes as a "hurting" pain, no radiations, worse with touching and movement, and with no known relievers. Associated symptoms include the following: - nausea - vomiting: nonbloody, nonbilious - [2-19] stools per day: loose, nonbloody, watery but mixed with stool - inability to tolerate solid or liquid POs - an episode of shaking chills on Saturday [2147-4-22] - productive cough with nonbloody but yellow-colored sputum She otherwise denies dysuria, back pain, headache, or neck pain. She also reports that she has had difficulty tolerating her oral medications the last 2-3 days. Of note, patient was previously admitted to the MICU in [2-24] after being hypotensive in the IR suite. Her hypotension was thought most likely secondary to hypovolemia given that her symptoms improved rapidly with fluid resuscitation alone. Upon admission to the ED, vital signs were 98.4, HR 124, BP 133/102 and follow-up BP 86/64, and 100% RA. While in the ED, her blood pressure declined to as low as 80/49. She received 2.3L NS, tylenol 650mg PR, zofran 2mg x 1, vancomycin 1 g x 1, and ceftriaxone 1g x 1. Past Medical History: 1. Metastatic Colon Cancer Patient initially presented with bowel obstruction in [2143] and underwent resection, which revealed a stage III colon adenocarcinoma with lymphovascular, venous, and perineural invasion. She underwent treatment with FOLFOX. Then in [Month (only) 216] [2146], she was undergoing evaluation for a third renal transplant, when she was found to have a mass on CXR. Follow-up PET scan demonstrated FDG-avid right upper lobe mass and left adrenal gland. Pathology was consistent with metastatic colon adenocarcinoma. She underwent 3 cycles of capecitabine and oxaliplatin. her course has been complicated by hypotension and patient was recommended to increase her salt intake. 2. ESRD Patient is now s/p two failed renal transplants (first transplant from sister in [2118] and second transplant in [2140]) and has restarted peritoneal dialysis in late [2146]/early [2147]. Now undergoes peritoneal dialysis 3 times per day 3. s/p stroke in 8/98 with no residual deficit 4. Hyperlipidemia 5. Dyspepsia 6. SLE Diagnosed as a teenager and was maintained on chronic steroids 7. Osteoporosis 8. Mitral Regurgitation Social History: Home: lives alone in [Location (un) 3844] Occupation: was employed until [1-24] as a file clerk at a local hospital EtOH: denies Drugs: denies Tobacco: denies Family History: Multiple relatives with cancer, including GM with stomach cancer and grandfather with unknown type of cancer. Physical Exam: T 98.8 / HR 100 / BP 97/67 / RR 23 / Pulse ox 99% RA Gen: resting comfortably in bed, tired appearing but in no acute distress HEENT: Clear OP, dry mucous membranes, mild right-sided facial droop with flattening of the right nasolabial fold NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: + BS, soft, tender to soft palpation in LLQ with positive guarding and rebound. PD catheter insertion site clean and without evidence of drainage or discharge EXT: trace edema. 2+ DP pulses BL SKIN: No lesions NEURO: A&Ox3. Appropriate. Preserved sensation throughout. [5-22] strength throughout. Normal coordination. Gait assessment deferred. slight right-sided facial droop with flattening of nasolabial fold PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [2147-4-24] CT ABDOMEN/PELVIS: IMPRESSION: 1. New evidence of thickened bowel loop in the left lower quadrant, which has a broad differential and may be due to low albumin or compression from other adjacent structures, or even serosal implants. 2. No significant change in the pelvic mass size. 3. Mild enlargement in the left adrenal lesion. 4. Moderate ascites and free fluid in the pelvis. [2147-4-25] CXR: No free subdiaphragmatic gas or appreciable intestinal distention in the upper abdomen is present. Lung volumes are low, previous pulmonary vascular engorgement has improved. Right juxtahilar mass has been growing since [2147-1-17]. Lungs are otherwise grossly clear. Heart size top normal. Mediastinal vascular engorgement improved. = = = = = = = = = = ================================================================ laboratory results on admission: URINE: COLOR-Brown APPEAR-Cloudy SP [Last Name (un) 155]-1.015 BLOOD-LG NITRITE-POS PROTEIN->300 GLUCOSE-250 KETONE-40 BILIRUBIN-LG UROBILNGN->8 PH-9.0* LEUK-LG RBC-0-2 WBC-[12-7]* BACTERIA-MANY YEAST-NONE EPI-[3-22] AMORPH-FEW ASCITES WBC-21* RBC-9* POLYS-7* LYMPHS-39* MONOS-0 MESOTHELI-1* MACROPHAG-53* blood: GLUCOSE-82 UREA N-42* CREAT-8.0* SODIUM-141 POTASSIUM-3.3 CHLORIDE-101 TOTAL CO2-26 ANION GAP-17 ALT(SGPT)-30 AST(SGOT)-57* ALK PHOS-102 TOT BILI-0.9 CALCIUM-6.1* PHOSPHATE-2.9 MAGNESIUM-1.4* PT-14.9* PTT-27.3 INR(PT)-1.3* LACTATE-1.6 K+-3.2* UREA N-41* CREAT-7.8# SODIUM-139 POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-28 ANION GAP-16 estGFR-Using this PHOSPHATE-3.0 MAGNESIUM-1.6 WBC-29.1# RBC-3.31* HGB-9.8* HCT-30.1* MCV-91 MCH-29.8 MCHC-32.7 RDW-15.5 NEUTS-93* BANDS-2 LYMPHS-4* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 PLT COUNT-232 GRAN CT-[Numeric Identifier ]* Stool: FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA Brief Hospital Course: 49 yo female with history of metastatic colon adenocarcinoma, SLE, ESRD on peritoneal dialysis s/p 2 failed transplants, and history of previous stroke was admitted to the [Hospital Unit Name 153] with sepsis secondary to c.diff colitis. She was treated with oral Vancomycin and metronidazole IV. Her diarrhea improved over the course and so did her hemodynamic instability. She did not require pressor therapy during the course of her ICU stay and was transferred to the floor with stable vital signs. Her diet was advanced to regular without intolerance. IV Flagyl was discontinued and she received prescription for oral vancomycin to finish a total course of 2 weeks. With regard to her ESRD, she was followed by renal inpatient service and continued on PD per protocol. Given her immunosuppressed state and the complete failure of her renal graft, decision was made by renal service that she should discontinue Sirolimus given risk/benefit profile. She should continue with low dose prednisone with Bactrim prophylaxis. For her continues hypokalemia she was instructed to add 8 mEq KCL to her PD bags which she uses every 8 hours. Her SLE was stable and not active. Metastatic Colon Adenocarcinoma: s/p adjuvant therapy with folfox in [2143] s/p irinotecan X2 doses, dc'd d/t intractable diarrhea. On CapOX every 21 days Xeloda 500 mg [Hospital1 ] D1-D14 and oxaliplatin every 21 days now s/p C4 (D1: [2147-4-17]) Will hold further chemotherapy until full resolution of infection. Medications on Admission: 1. Prednisone 5mg PO daily 2. Compazine 10mg PO q8h prn 3. Sirolimus 2mg PO daily 4. Bactrim 400-80 qMWF 5. Tylenol prn 6. Aspirin 81mg PO daily 7. Calcium Carbonate Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 12 days: last day to take this medication [2147-5-8]. Disp:48 Capsule(s) Refills:0 6. Potassium Chloride 2 mEq/mL Syringe Sig: Four (4) ml (of 2mEq/ml Syringe) Intravenous Q 8H (Every 8 Hours): TO BE INJECTED INTO DIALYSIS BAG (4 SYRINGES EVERY 8 HOURS) - NO FOR INTRAVENOUSE OR ORAL USE!!! . Disp:360 ml (of 2mEq/ml Syringe) Refills:6 7. Needle (Disp) 18 G 18 x 1 [1-18] Needle Sig: Four (4) NEEDLE Miscellaneous once a day. Disp:360 Refills:5 8. Compazine 10 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for nausea. Discharge Disposition: Home Discharge Diagnosis: C diff colitis end stage renal disease colon cancer systemic lupus Discharge Condition: Good, no diarrhea, good po intake Discharge Instructions: You were admitted to the intesive care unit as you had severe infectiouse diarrhea caused by clostridium difficile. You were treated with an antibiotic which you have to continue takintg as instructed. It is very important to follow this instructions and call your doctor or come to emergency department if you experience any recurrence of diarrhea or loose stools after finishing your course of antibiotic. YOU SHOULD NOT CONTINUE TAKING SIROLUIMUS as discussed with your kidney doctors. You also should call your doctor or 911 if you have any abdominal pain, bloody stools, nausea vomiting or any other health concer Followup Instructions: Provider: [Name10 (NameIs) ] FELT, RN Phone:[Telephone/Fax (1) 22] Date/Time:[2147-5-1] 8:30 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 593], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2147-5-10] 9:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 26384], MD Phone:[Telephone/Fax (1) 22] Date/Time:[2147-5-10] 9:00	[ "5849", "42789", "4240", "2724" ]
Admission Date: [2128-5-20] Discharge Date: [2128-5-23] Date of Birth: [2055-1-4] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 7333] Chief Complaint: Pleuritic chest and scapular pain Major Surgical or Invasive Procedure: Pericardial drain placement Lead revision History of Present Illness: 73M w/ h/o CAD s/p PCI to RCA, PAF on coumadin, s/p CVA, ischemic CMP (EF 45-50%), complete heart block s/p PPM with recent pacemaker wire exchange on [2128-5-5] transferred from [Hospital ] with pericardial effusion and concern for tamponade for pericardiocentesis and drain placement. . Patient underwent RV lead exchange on [2128-5-5] after lead was found to be malfunctioning on interrogation after 2 weeks of sending abnormal signals to device clinic. Patient was asymptomatic. [Company 1543] Fidelis pace-sense-lead was replaced with pace-sense-defibrillating lead. Procedure was notable for pre-procedure hypertension (166/55) and INR of 3.0 on [5-3]; there was concern for potential bleed and pressure was applied post exchange. After brief admission to [Hospital Ward Name 121] 3, patient was discharged on 7 days of keflex to follow up with device clinic in [Location (un) ] in 1 week. . Per daughter, patient was in good health until [5-17], when started grabbing his scapulae and gesturing in pain (has expressive aphasia at baseline). She noticed his movements were slower than usual, he was weak and tired. Also noticed pleuritic chest pain, SOB w/ exertion, but no F/C, dizziness or syncope. Symptoms progressed and on day of admission patient went to outpatient cardiologist's office where was referred for chest CT at [Hospital3 ] hospital. Chest CT showed no acute aortic disease but a pericardial effusion and he was transferred to [Hospital1 18] for further evaluation. . Vital signs on arrival were: T97.6 HR56 BP110/70 RR18 O2 sat 100% 3L. Bedside TTE confirmed moderate pericardial effusion w/ RV diastolic collapse suggestive of tamponade physiology; he was urgently takent to the cath lab for pericardiocentesis, draining about 1L of dark fluid c/w old blood. He remained hemodynamically stable throughout the procedure, awake and alert. Initial labs were notable for INR 3.6, WBC 10.6, HCT 29.6 (39.4 on [5-3]), and Cr 2.0 (1.3 on [5-3]). . In the CCU, patient denied SOB and chest discomfort. . On review of systems, s/he denies any prior history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. 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 paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: [2111] PTCA/stenting of the RCA -PACING/ICD: Complete heart block s/p [2113] pacemaker implant, s/p [Hospital1 ]-V ICD upgrade [2120] with wire replacment [2128-5-5] 3. OTHER PAST MEDICAL HISTORY: Ischemic Cardiomyopathy (EF 45-50%) Congestive Heart failure Carotid Endarterectomy Paroxysmal Atrial Fibrillation CVA [2117] (residual aphasia and right leg weakness) Social History: Lives with his daughter [Name (NI) 1022] in [Location (un) 701], MA. Widower. Tobacco: Denies; quit 25-30 years, appx 15 pack year history ETOH: 5 beers per day Illicits: Denies. Family History: Father with history of CHF, brother s/p CABG. Physical Exam: ON ADMISSION: GENERAL: Well nourished elderly male in NAD, expressive aphasia. 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: Supple with JVP of 8 cm. CARDIAC: Distant heart sounds, RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Bibasilar crackles; No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Active BS. EXTREMITIES: No c/c/e. SKIN: Slight edema of subcutaneous tissue around pacer pocket, no erythema, fluctuance, or TTP. No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: RADIAL 2+ PT 2+ ; Left: RADIAL 2+ PT 2+ Neuro: expressive aphasia; 5/5 strength in b/l UE's; 5-/5 strength in RLE, 5/5 strength in LLE; CNII-[Doctor First Name 81] tested and grossly intact. Pertinent Results: ADMISSION LABS: [2128-5-20] 04:15PM WBC-10.4# RBC-3.26# HGB-10.3# HCT-29.9* MCV-92 MCH-31.5 MCHC-34.4 RDW-14.0 [2128-5-20] 04:15PM NEUTS-79.3* LYMPHS-12.9* MONOS-4.8 EOS-2.3 BASOS-0.7 [2128-5-20] 04:15PM PLT COUNT-229 [2128-5-20] 04:15PM PT-35.7* PTT-30.8 INR(PT)-3.6* [2128-5-20] 04:15PM GLUCOSE-141* UREA N-36* CREAT-2.0* SODIUM-135 POTASSIUM-5.4* CHLORIDE-104 TOTAL CO2-23 ANION GAP-13 [2128-5-20] 05:30PM OTHER BODY FLUID TOT PROT-5.4 GLUCOSE-68 LD(LDH)-716 AMYLASE-41 ALBUMIN-3.9 [2128-5-20] 05:30PM OTHER BODY FLUID WBC-6000* HCT-35* POLYS-74* LYMPHS-21* MONOS-1* EOS-3* BASOS-1* [2128-5-20] 08:24PM HCT-28.7* [2128-5-20] 08:24PM DIGOXIN-1.9 STUDIES: [5-20] TTE: The left ventricular cavity is unusually small. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is unusually small. There is no aortic valve stenosis. No aortic regurgitation is seen. There is a moderate sized pericardial effusion. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. IMPRESSION: Moderate sized circumferential pericardial effusion with evidence of tamponade physiology. There is more fluid present posteriorly. There is approximately 0.9cm of fluid present over the right ventricular free wall and apex. Compared to the study of [2128-5-5], the pericardial effusion and tamponade physiology are new. Regional wall motion cannot be adequately assessed on the current study but overall ejection fraction has increased. [5-20] TTE: There is a trivial/physiologic pericardial effusion visualized in focused views. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [2128-5-20], the pericardial effusion is now much smaller. [5-20] EKG: A-V paced rhythm. Reason for cycling variability uncertain. Since the previous tracing of [2128-5-6] the QRS width is now wider and therefore more fully ventricular paced. [5-22] TTE: Very small pericardial effusion without echocardiographic evidence of tamponade. Abnormal septal motion. Moderate tricuspid regurgitation. Compared with the prior study (images reviewed) of [2128-5-20]. The previously seen moderate sized pericardial effusion has markedly diminished in size. Right ventricular diastolic collapse is no longer seen. The biventricular cavity sizes have increased. Abnormal septal motion persists. Moderate tricuspid regurgitation is now present and was not previously commented upon. [5-22] CXR: Abandoned leads are seen on the right. Left-sided pacemaker is noted. It is difficult to ascertain the exact location of the leads. Heart is moderately enlarged but decreased in size compared to the prior examination. There is retrocardiac opacity likely representing atelectasis and a small left sided effusion. There is also a small right-sided effusion with basilar atelectasis. IMPRESSION: Mild decrease in size of cardiac contour following drainage of pericardial effusion. [5-23] TTE (PRELIM READ): Very small pericardial effusion with preferential deposition of fluid near the right ventricular apex, upwards of 1.7 centimeters in dimension, locally. No echocardiographic evidence of pericardial tamponade. Compared with the prior study (images reviewed) of [2128-5-22], the overall very small pericardial effusion appears similar in size, however the aspect which is preferentially present near the right ventricular apex may have increased in size (from 1.5 centimeters to 1.7 centimeters), however this change may also be secondary to the more acute angle of the 4 chamber views on the current study, accentuating the severity of the fluid collection. DISCHARGE LABS: 140 106 19 ------------<84 4.4 28 1.3 Ca: 8.4 Mg: 2.6 P: 3.0 Dig: 0.8 MCV 92 7.0> 9.2< 257 26.5 PT: 15.5 PTT: 25.9 INR: 1.4 Brief Hospital Course: 73 year old man w/ h/o CAD s/p PCI to RCA, PAF on coumadin, s/p CVA, ischemic CMP (EF 45-50%), complete heart block s/p PPM with recent pacemaker wire exchange on [2128-5-5] presenting from OSH in pericardial tamponade, now s/p pericardiocentesis and drain placement. . # Pericardial tamponade: Patient with several days of symptoms suggestive of pericarditis and was found to have moderate pericardial effusion on CT chest. On echo at [Hospital1 18] found to have tamponade physiology and taken for urgent drainage with removal of 1 L blood (fluid w/ hct of 35, WBC 6000 c/w blood and has had 10 point hct drop since [5-3]). The bleed was attributed to likely RV perforation in the setting of the patient's recent lead replacement. He was monitored closely in house and when drain output decreased to less than 100 cc/day on [5-22], the pericardial drain was removed. Hematocrit remained stable and the patient remained hemodynamically stable throughout hospitalization. Repeat echo showed stable very small pericardial effusion on preliminary read on the day of discharge. He was discharged to follow up with Dr. [Last Name (STitle) ]. FOR OUTPATIENT F/U: - Repeat TTE +/- hct to assess pericardial fluid reaccumulation . # Abnormal pacing: Pt w/ pacemaker placed for complete heart block with recent RV lead replacement due to abnormal functioning. Pacer was interrogated by EP prior to arrival in CCU and per report was not showing signs of RV pacing. Patient was taken for lead replacement, with improved functioning of the pacer on EP re-interrogation. INR was reversed with 2 units FFP and vitamin K for the procedure and coumadin was held. His coumadin was restarted on discharge and patient was instructed to check INR on [5-25] and follow up with his PCP for dosing. He was discharged to complete a weeks course of keflex for prophylaxis and asked to schedule an appt with Dr. [Last Name (STitle) ] and the device clinic for follow up. FOR OUTPATIENT F/U: - Device clinic for pacemaker/ICD interrogation . # Paroxysmal AF: Patient with PAF, remained paced during this admission. CHADS2 score of 5. On coumadin, INR was 3.6 on admission. His INR was reversed w/ 2 units FFP and vitamin K for the pacemaker lead revsion as above. His coumadin was held and restarted on [5-22] at a dose of 6 mg. On the day of discharge, his INR was 1.4- he was instructed to take 6 mg for the next two days, check his INR on [5-25] and follow up with his PCP for further dosing information. His digoxin was held initially given his renal failure and a level of 1.9 on admission. It was restarted at 0.125 mg daily (half of his previous dose) and the patient as instructed to have his PCP check the level in the coming week. He was continued on his home carvedilol. FOR OUTPATIENT F/U: - INR CHECK - DIGOXIN LEVEL CHECK . # Ischemic cardiomyopathy: EF>55% on echo today, was 45-50% on prior echo. Patient appeared euvolemic on exam. He was continued on his home carvedilol, but his lasix and lisinopril were held given his pericardial bleed and tamponade. These were restarted on discharge. Digoxin was held and redosed as above. . # Acute kidney injury: Patient with creatinine of 2.0, up from prior of 1.3 on [5-3]. Likely pre-renal in setting of pericardial bleed. Digoxin, lasix and lisinopril were held as above and restarted on discharge (digoxin at half of previous dose). His creatinine had trended down to 1.3 by the time of discharge. . # Anemia: Patient's baseline around 39.4 on [5-3] prior to procedure. Had a 10 point hct drop in setting of pericardial bleed. After admission, patient's hematocrit remained stable- he did not require any pRBC transfusions. He will f/u with Dr. [Last Name (STitle) ] for monitoring of the pericardial effusion as above. . # CAD: Last cath in [2117] showed mild-moderate left main disease. Has had numerous MI's per daughter. [Name (NI) ] remained chest pain free throughout hospitalization. He was medically managed with statin, carvedilol and aspirin. Home lisinopril was held and restarted on discharge. . # Hypertension: Remained normotensive during hospitalization. Patient's home lisinopril was held in the setting of his pericardial bleed, but he was discharged back on it. . CODE: Patient's code status on admission was DNR/DNI. This was reversed for his lead replacement. . COMM: [First Name4 (NamePattern1) 1022] [Last Name (NamePattern1) 410] (daughter and HCP) [Telephone/Fax (1) 111265] cell. . Pending on Discharge: [5-23] TTE: Final read Medications on Admission: CARVEDILOL 12.5 mg [Hospital1 ] DIGOXIN 250 mcg qd FUROSEMIDE 20 mg qd LISINOPRIL 40 mg qd SIMVASTATIN 40 mg qd WARFARIN 6mg - 6mg - 4mg (alternates daily) ASPIRIN 81 mg qd Discharge Medications: 1. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 6 days. Disp:24 Capsule(s) Refills:0 7. warfarin 2 mg Tablet Sig: ASDIR Tablet PO Once Daily at 4 PM: Take 3 pills tonight and tomorrow night ( a total of 6mg both nights ). Have your INR checked on [2128-5-25] and then take coumadin as advised by your PCP. 8. digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Pericardial effusion with cardiac tamponade SECONDARY DIAGNOSIS: Ischemic Cardiomyopathy (EF 45-50%) Paroxysmal Atrial Fibrillation Complete heart block s/p pacemaker placement Hypertension Dyslipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 111266], You were transferred to [Hospital1 18] from another hospital after you were found to have fluid around the heart, likely as a result of your recent procedure. We needed to place a drain to remove the fluid and revise the leads to your heart. Repeat echocardiograms showed no reaccumulation of the fluid. The following changes have been made to your medications: 1. CHANGE digoxin 250mcg daily to 125mcg daily. Have your doctor check a digoxin level at your appointment within the next [12-28] weeks. 2. START cephalexin 500mg Q6H for another 6 days (for a total of a one week course) in the setting of your procedure 3. Take 6mg coumadin tonight and tomorrow night to help get your INR (coumadin level) up. Have your INR checked on [2128-5-25]. It was pleasure taking care of you. We wish you a speedy recovery. Followup Instructions: Please make an appointment to follow up with Dr. [Last Name (STitle) ] at [Telephone/Fax (1) 250] within the next 1-2 weeks. You will also likely need an appointment in the device clinic, which you can make when you call Dr.[Name (NI) 29750] office. Please have Dr. [Last Name (STitle) 7047] remember to check a digoxin level this week since we changed your dose. Dr.[Name (NI) 9654] phone number is [Telephone/Fax (1) 108247]. You also need your INR checked (your coumadin level) this week. Ideally, you could have these labs checked on Tuesday, [2128-5-25]. Completed by:[2128-5-23]	[ "5849", "41401", "42731", "4019", "2724", "2859", "412", "V4582", "V1582", "V5861" ]
Admission Date: [2109-7-15] Discharge Date: [2109-7-28] Date of Birth: [2060-7-6] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [2109-7-15] Aortic Valve Replacement utilizing a 19mm St. [Male First Name (un) 923] mechanical valve. Mitral Valve Replacement utilizing a [Street Address(2) 17009]. [Male First Name (un) 923] mechanical valve History of Present Illness: This is a 48yo female with rheumatic heart disease. She is followed by Dr. [Last Name (STitle) ] who has obtained serial echocardiograms. Most recent echo in [2109-3-23] revealed severe AS with a peak gradient of 70 mmHg and [Location (un) 109] of 0.6cm2. There was 2+ AI, 4+ MR, and 2+ TR. She had normal LV function. Cardiac cath in [2109-6-22] showed normal coronary arteries, severe aortic stenosis, moderate mitral mixed stenosis and regurgitation and normal LV function. Given echo evidence of worsening valvular disease, she was referred for surgical intervention. Prior to admission, her symptoms included dyspnea on exertion and decreased exercise tolerance. Past Medical History: Rheumatic Heart Disease Aortic Stenosis, Aortic Insufficiency Mitral Stenosis, Mitral Insufficeincy s/p Ovarian Cyst Removal s/p Cesarean Social History: Denied tobacco and ETOH. Currently lives with her husband. [Name (NI) 1403] in finance. Family History: Denied premature CAD Physical Exam: Vitals: BP 130-150/60-70, HR 77, RR 16, General: well developed female in no acute distress HEENT: oropharynx benign, PERRL Neck: supple, no JVD, transmitted murmur in carotid regions Heart: regular rate, normal s1s2, [3-28] holosystolic murmur with [3-28] diastolic murmur Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: [2109-7-23] 06:40AM BLOOD WBC-8.3 RBC-3.93* Hgb-12.5 Hct-34.7* MCV-89 MCH-31.9 MCHC-36.1* RDW-12.8 Plt Ct-276# [2109-7-23] 06:40AM BLOOD Glucose-120* UreaN-17 Creat-1.0 Na-137 K-3.8 Cl-94* HCO3-32 AnGap-15 [2109-7-28] 05:12AM BLOOD PT-23.8* PTT-88.7* INR(PT)-2.4* Brief Hospital Course: On the day of admission, Dr. [Last Name (STitle) 1290] performed aortic and mitral valve replacments utilizing St. [Male First Name (un) 923] mechanical heart valves. Surgery was uncomplicated and she was brought to the CSRU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated. She had brief episodes of paroxysmal atrial fibrillation. Amiodarone was intiated with successful conversion back to normal sinus rhythm. Her CSRU course was otherwise uneventful and she transferred to the SDU on postoperative day one. She tolerated Amiodarone and low dose beta blockade. She remained in a normal sinus rhythm without further episodes of atrial fibrillation. Warfarin therapy was initiated and dosed for a goal INR between 3.0 - 3.5. She was slow to anticoagulate and temporarily required Heparin due to a subtherapeutic prothrombin time. Her postoperative course was otherwise uneventful and she was discharged to home on postoperative day 13. Her INR at the time of discharge was 2.4 with a dose of 5mg daily. She has been increasing appropriately over the past several days. Her INR will be checked by the VNA tomorrow [7-29] and called in to the office of Dr. [First Name (STitle) ], her PCP, [Name10 (NameIs) 1023] will follow her in the future. Medications on Admission: Calcium, Vitamin D Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. Disp:45 Tablet(s) Refills:0 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 5. Warfarin 2 mg Tablet Sig: 2.5 Tablets PO qpm: Take as directed by MD. Daily dose may vary according to INR. Disp:75 Tablet(s) Refills:2 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Outpatient Lab Work INR Please call results to the office of Dr. [First Name (STitle) ] [Telephone/Fax (1) 12372] Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Reumatic heart disease, aortic stenosis, mixed mitral stenosis and regurgitation - s/p aortic and mitral valve replacements utilizing St. [Male First Name (un) 923] mechanical heart valves Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Cardiac surgeon, Dr. [Last Name (STitle) 1290] in [3-27] weeks - call for appt. Local PCP, [Last Name (NamePattern4) ]. [First Name (STitle) ] in [1-25] weeks - call for appt. Local cardiologist, Dr. [Last Name (STitle) ] in [1-25] weeks - call for appt.	[ "42731" ]
Admission Date: [2126-9-15] Discharge Date: [2126-10-8] Date of Birth: [2098-1-26] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2234] Chief Complaint: sickle cell crisis Major Surgical or Invasive Procedure: intubation, right internal jugular catheter placement, right femoral line placement History of Present Illness: Pt is a 28 yr old female with hx of sickle cell disease with multiple past admissions to [Hospital6 ] hospital for sickle cell crisis. She was transferred from [Hospital3 ] Emergency Department to [Hospital1 18] for management of sickle cell crisis. The patient was most recently hospitalized in [8-9] for this as well as for pneumonia. She was treated with ceftaz and vancomycin while there, then discharged on azithromycin and levofloxacin. The patient was in her usual state of health (per her boyfriend's report) until the evening prior to admission. At that point she began having body pains similar to her other flares, and took her prescribed morphine. He also noted that she has shaking chills and a new cough. Throughout the nicht she became progressively more sleepy to the point that this morning he could not arouse her and he called for an ambulance. At [Hospital6 ] she was confused and combative. She was intubated there and rec'd approx 7L NS boluses. She was given folate, Zosyn (4.5gms), Ceftriaxone 1mg IV, and Zithromax 500mg. CXR was performed and showed a dense opacity in the right hemithorax in the mid-lung extending to the right lower lobe. Also with some patch basilar opacity of the L lung suggestive of at least RLL pneumonia. Also there, HCT found to be 13.6. . In [Hospital Unit Name 153], femoral line placed first for immediate access, 2L NS given as well as two units PRBCs. Blood bank contact[Name (NI) ] and coordinated care. Pheresis catheter placed over femoral line, R IJ placed for access. Pheresis performed exchanging 8u red blood cells. Pt started on levophed to maintain blood pressure. Past Medical History: Sickle cell anemia - HbSS . PSurgH:s/p CCY for cholecystitis [2117] Social History: She is living with her boyfriend and her 4-year old daughter. [Name (NI) ] is not the father of her daughter, but they plan on marrying. She works in daycare. Family History: NC Physical Exam: Vitals: T: 97.8 P: 123 BP: 125/64 R: 11 SaO2: 99% on FiO2 0.50 General: Sedated, intubated on ventilator HEENT: NC/AT, PERRL, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated, R IJ in place Pulmonary: Anterior exam, decreased BS on R lung base, L clear Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, + bowel sounds, no masses, no guarding Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Skin: no rashes or lesions noted. Pertinent Results: Na 136, K 4.7, Cl 109, HCO3 16, BUN 36, Creat 3.4, Gluc 158, Ca 6.1, Mg 1.6, Phos 5.2 . ABG: 7.15/53/157, Lactate 2.0, free Ca 0.92 . ALT 238, AST 648, AP 87, LDH 3540, TBili 8.0, DBili 3.4, Alb 2.6, Haptoglobin < 20 . WBC 21.7, Hbg 5.1, HCT 13.1, Plt 129, MCV 93 . EKG: pending Brief Hospital Course: Pt is a 28 yo female with sickle cell disease presenting with severe anemia, hypotension, and renal failure in the setting of a sickle cell crisis. . PLEASE NOTE DETAILS of ICU course limited as ICU team did not update discharge summary: 1.) Sickle cell crisis/Pneumonia/ARDS?Multi organ system failure/Acute Renal Failure : Blood bank saw pt upon admission and exchange transfusion was performed with 8u PRBCs with appropriate bump in CRIT to 31. She received antibiotics at OSH as above, folate, and IVFs. Central access was obtained. ?inciting event/infection - hx recent pneumonia and cough. Also vomiting at home. Intubated at OSH. Initialy concern for sepsis given hypotension, but pressures have stabilized with fluids and off of pressors. Intubated at OSH. Extubated [9-16] but then witnessed apsiration adn re-intubated. Initially broad spectrum antibiotics. Prolonged ICU stay/intubation [Date range (1) 75108] from pneumonia, aspiration pneumonia and with cardiogenic/non-cardiolgenic pulm edema s/p aggressive fluid rescucitation. Gradually diruesed and vent weaning. Extubated on [10-1]. Heme/onc followed throughout. Exahange transfusions as above. Acute renal failure: Creatinine elevated upon admission >3, good urine output. Improvement with IVFs; extensive hemolysis with strain on kidneys. Gradually trended back to normal with rescucitation. . Transferred to floor on [2126-10-4]: Pain medications gradually titrated. Creatinine returned to baseline. +blood on u/a=patient reports menstruating. Crit stable, afebrile. hemolytic indices down, abx course completed. Discharged with heme follow up. also needs outpatient U/A when not menstruating. #) Communication: contact boyfriend: ([Telephone/Fax (1) 75109], mother [Name (NI) ] - ([Telephone/Fax (1) 75110] or ([Telephone/Fax (1) 75111]. Medications on Admission: Hydroxyurea 1000mg daily Folate 1mg daily MSIR 30mg po 14-6hrs prn pain Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:90 Tablet(s) Refills:2 2. Hydroxyurea 1,000 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1. Acute chest syndrome, resolved 2. Sickle cell crisis, resolved 3. ARDS, resolved 4. Community acquired pneumonia, resolved 5. Bacteremia, resolved 6. Prolonged ventilation wean Discharge Condition: Ambulating, taking good PO, no further pain. Discharge Instructions: Please contact your primary care physician or hematologist if you develop any pain, especially in your chest, or have fevers or have trouble breathing. Take all medications as prescribed. We have re-started your hydroxyurea. You should take it at the dose you were taking previously. Be sure also to take the folic acid. You must follow up as below. We have scheduled you for an appointmnet with Dr. [Last Name (STitle) 21136] which you absolutely must keep. You should also call [Telephone/Fax (1) 8497] to schedule an appointment with a new primary care doctor. This is essential. You will need to have your blood pressure checked as it was high here and you also need a repeat urinalysis to make sure the blood in your urine goes away. Followup Instructions: You have an appointment with Dr. [Last Name (STitle) 21136] on Thursday [10-10] at 1:30 PM at [Hospital3 328], [Location (un) 448]. Please call Dr. [Last Name (STitle) 21136] at [Telephone/Fax (1) 75112] to confirm this appointment. We have contact[Name (NI) ] him about your admission. Call [Hospital3 328] Primary care doctors [Last Name (NamePattern4) ] [Telephone/Fax (1) 8497] to schedule an appointmnet with a new primary care doctor. When you see the doctor they should check your blood pressure and they should repeat a urinalysis to make sure you have no more blood in your urine.	[ "5849", "5070", "2762", "2875" ]
Admission Date: [2195-4-12] Discharge Date: [2195-4-17] Date of Birth: [2129-11-25] Sex: M Service: CARDIAC MEDICINE CHIEF COMPLAINT: ICD firing. HISTORY OF PRESENT ILLNESS: This is a 65-year-old gentleman, with a history of CD, status post a VT arrest, and PTCA of the LAD in [2186], who presents with ICD firing several times over last night. The patient had instances of the ICD firing about 2 weeks ago without any preceding symptoms. He was seen at [Hospital3 68] where he was observed for about four days and then released. He had been feeling well until the night before admission when, at about 2:00 am, he began to feel nauseous and then the ICD fired. He did not have preceding chest pain, shortness of breath, palpitations, lightheadedness, or diaphoresis. The ICD fired a second time, and he was seen again at [Hospital3 68]. He was observed overnight and then discharged. When the ICD fired again that next day, he called 911 and was brought to [Hospital1 18]. He was noted to be in recurrent V-tach and was shocked multiple times by the ICD. RECENT REVIEW OF SYSTEMS: Notable only for diarrhea for the last several days. PAST MEDICAL HISTORY: 1. CAD, status post anterior MI. 2. Prostate cancer, on chemotherapy, last dose 3 weeks ago. 3. Type 2 diabetes x 4 years with the complication of neuropathy. 4. ?History of atrial fibrillation. 5. Hypertension. 6. Hyperlipidemia. MEDICATIONS: 1. Hydralazine 25 mg. 2. Isosorbide 10 mg tid. 3. Metoprolol 50 [Hospital1 ]. 4. Gemfibrozil 600 [Hospital1 ]. 5. Warfarin alternating doses of 2 and 4 mg qd. 6. Furosemide. 7. Aspirin 325 qd 8. Glipizide 5 [Hospital1 ]. 9. Potassium 20 qd. 10.Neurontin 100 tid. 11.Amiodarone 200 qd. ALLERGIES: NKDA. SOCIAL HISTORY: Has smoked about 1-1/2 packs a day for the past 60 years. Denies alcohol or IVDU. Lives with his wife. PHYSICAL EXAM: Vitals on arrival were temperature 98.7, blood pressure 100/60, heart rate 68, respiratory rate 18, 100% on 3 liters. This was an obese gentleman, sitting at 60%, in no apparent distress. He was alert and oriented x 3. He had dry mucous membranes. Pupils were equal and reactive with anicteric sclerae. Neck was supple. It was difficult to assess JVP secondary to habitus. He had very distant heart sounds, but usually regular rate with occasional premature beats. Lungs had decreased breath sounds in the right lower lobe and crackles noted in the left lower lobe. Abdomen was soft, nontender, nondistended, with positive bowel sounds. He had 1+ pitting edema bilaterally to the knees with stasis dermatitis noted. LABS AND STUDIES: EKG showed sinus with AV delay, questionable right bundle branch pattern with left anterior fascicular block. Left axis deviation. Inverted T waves were noted in AVL. Q waves in V1, V2, with poor R wave progression. On rhythm strips taken during events, he was noted to have a wide complex regular tachycardia at a rate of approximately 250, that after shock responded by changing into an irregular more narrow complex tachycardia (AF). Initial CBC showed a white count of 8.1, hematocrit 34.4, platelet count 180. He had a PT of 16.6, PTT 22, INR 1.8. Chem-7 showed a sodium of 140, potassium 3.8, chloride 104, CO2 24, BUN 15, creatinine 0.8, glucose 170. He had a calcium of 9.2, mag 2.0, phos 3.4. Initial set of enzymes showed a CK of 26, troponin-T less than 0.01. Previous cath performed in [2186-4-12] showed a 100% RCA lesion, LAD of 100% that was PTCA'd, EF 25%, with apical and anterolateral akinesis. HOSPITAL COURSE: The patient was admitted to cardiac medicine on telemetry. He was scheduled for an ICD pacer interrogation by EP. His enzymes were followed to rule out MI. On the evening of admission, [4-12], the patient experienced multiple runs of V-tach with the rate in the 200s. He was shocked by his ICD multiple times. His vital signs were initially stable, other than the rhythm of VT. He was given 150 mg IV amiodarone, 5 mg IV metoprolol x 2, 2 gm of magnesium, 40 mEq of KCL, and 0.5 mg of versed. After receiving these medications, the patient's blood pressure decreased to the 70s/40s. He was given a bolus of fluids, after which he increased to 90/60. The EKG showed no ischemic changes. However, he was transferred to the ICU for further monitoring and continuation of the amiodarone GTT. He had a femoral line placement at that time. He was monitored in the ICU until [4-13]. At this point, he was determined stable enough to return to the floor. He underwent a VT ablation procedure by electrophysiology on [4-14]. Overnight, on the [4-15], the patient developed intermittent AFIB with rates into the 120s-130s, and a blood pressure, systolic, in the 90s/70s. He received IV beta blocker and converted back into normal sinus rhythm with a rate in the 80s. He had no chest pain or shortness of breath during this episode. In the early morning hours of [4-16], he developed rapid AFIB again with rates into the 140s. He was given IV diltiazem which decreased his systolic pressure from the 90s to 60s. At that point, he was given multiple small normal saline boluses to increase his pressure. He also received some IV Lopressor, as well as PO Lopressor. Given his recurrent episodes of AFIB with rapid ventricular response, he was taken to the EP Lab for a synchronous cardioversion on the morning of the 4. He received 1 shock of 200 joules and converted to normal sinus rhythm with a rate in the mid-80s. He was changed to an amiodarone rate of 400 [Hospital1 ], his beta blocker was increased to tid dosing of 37.5 metoprolol, a low dose ACE inhibitor was added at 6.25 tid, and digoxin qd of 0.125 was added as well. The patient remained stable status post cardioversion, and by the [4-17], on hospital day #6, he was feeling well with stable heart rate and blood pressure. His INR was noted to be therapeutic between 2 and 3. The patient was evaluated by physical therapy and determined that he did not need home services. It was decided that he was prepared for discharge with a 4-week follow-up with Device Clinic and [Doctor Last Name 1911] in cardiology. DISCHARGE CONDITION: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Ventricular tachycardia. 3. Atrial fibrillation with rapid ventricular response. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg qd. 2. Gabapentin 100 mg q 8 h. 3. Gemfibrozil 600 mg [Hospital1 ]. 4. Lasix 20 mg qd. 5. Glipizide 5 mg [Hospital1 ]. 6. Metoprolol 37.5 mg tid. 7. Amiodarone 400 mg [Hospital1 ] for the first 2 weeks post discharge, with instructions to the patient to decrease to 400 mg qd thereafter until seen in [Hospital ] Clinic. 8. Digoxin 0.125 qd. 9. Captopril 6.25 tid. 10.Warfarin 2.5 qd. FOLLOW-UP: The patient is scheduled to be seen in Device Clinic and by Dr. [Last Name (STitle) 1911] on [5-11]. He was instructed to continue his Coumadin blood draws as he had been prior to his admission to the hospital. [First Name4 (NamePattern1) 610] [Last Name (NamePattern1) ], M.D. [MD Number(1) 3812] Dictated By:[Last Name (NamePattern1) 10454] MEDQUIST36 D: [2195-4-17] 12:21 T: [2195-4-17] 12:25 JOB#: [Job Number 10455]	[ "41401", "V4582", "42731", "2724", "4019", "412" ]
Unit No: [Numeric Identifier 69392] Admission Date: [2198-8-31] Discharge Date: [2198-10-13] Date of Birth: [2198-8-31] Sex: F Service: NEO HISTORY: Baby Girl [Known lastname 953], twin 1, is a newborn 31 and [3-20] week infant admitted to the NICU with prematurity and respiratory distress. At the moment of discharge, she is 42 days old, corrected gestational age 37 and [3-20]. She was born at 5:00 a.m. on [2198-8-31], a 1625 gram product of 31 and [3-20] week twin gestational pregnancy to a 37 year old gravida III, para 0 to 2 mother with [Name (NI) 37516] [2198-10-31]. Prenatal labs included blood group O positive antibody negative, RPR nonreactive, rubella immune, HBS antigen negative and GBS unknown. Pregnancy was induced. Pregnancy was uncomplicated until early on the morning of admission when mother presented with contractions, abdominal pain and vaginal bleeding. Variable decelerations were noted and with persistent abdominal pain, she was taken for a cesarean section delivery due to concerns of abruption. She was given 1 dose of betamethasone shortly before delivery and she received no intrapartum antibiotics. She otherwise had no other sepsis risk factors. At delivery, twin 1 emerged with moderate tone and respiratory effort. She responded well to stimulation and oxygen. Apgars were 8 and 9 and the infant was brought to the NICU on facial CPAP. Moderate respiratory distress was noted and the infant was initiated on nasal CPAP. PHYSICAL EXAMINATION: On physical exam on admission, weight 1625 grams which is 50th percentile, head circumference is 29.5 cm which is 50th to 75th percentile and length is 39 cm which is 25th percentile. Temperature 97.6, heart rate 160, respiratory rate 50, blood pressure 58/26 with a mean of 36. She was on CPAP of 6 with 30% of oxygen saturating in mid 90s. Active preterm infant responsive to exam, vigorous with moderate respiratory distress. Skin warm and dry, pink, no rash. HEENT: Fontanelle soft and flat, palate intact, red reflex positive bilaterally. Ears and nares normal. Neck supple. Chest: Coarse, moderate aeration, moderate retractions. Cardiac: Regular rate and rhythm, no murmur. Femoral pulses symmetrical 2+. Abdomen soft, no hepatosplenomegaly, no masses, quiet bowel sounds, 3 vessel cord. GU exam normal female genitalia, anus patent. Extremities, hips and back normal. Tone and activity appropriate. Intact Moro and grasp. Her admission dipstick was 54. CBC on admission with white blood cell count 10.2, 16 neutrophils, no bands, 70 polys, 6 monos, hematocrit was 43, platelets 265,000. HOSPITAL COURSE: By system: Respiratory: On admission, the infant was placed on nasal CPAP. In the next 24 hours due to worsening respiratory distress, she was electively intubated. Surfactant was given x2 over the next 24 hours. She was extubated on day of life 2 and placed on nasal CPAP. She weaned off nasal CPAP to room air by day of life 3. She remained in room air since then. Due to apnea of prematurity, she was started on caffeine on day of life 1. She remained on caffeine until day of life 16 and it was discontinued on [9-16]. She had several episodes of apnea of bradycardia so was discontinued off caffeine. She remained spell free since [10-4]. Cardiovascular: No issue with blood pressure in the first 24 hours. She was noticed to have murmur consistent with PDA. It was confirmed by echo on [9-3]. She was treated with total of 2 course of indomethacin starting [9-3], and her follow- up echo on [10-8], showed no PDA. She remained without murmur since then. FEN/GI: She was kept NPO in the first 24 hours. PN was initiated on admission. Trophic feeds were started on day of life 1 but due to concern of PDA, they were discontinued. She remained NPO until [9-8]. Her feeds were slowly advanced and she was at full feeds [9-13]. Her PN was discontinued on [9-12]. She remained on p.o. PG feeds and slowly advanced to full p.o. feeds and at full p.o. feeds since [10-7]. She developed hyperbilirubinemia with a peak bilirubin at 7 by day of life 4. She was treated with phototherapy at that time and phototherapy was discontinued on [9-8]. Her bilirubin level was followed and the last one was done on [9-15], and it was 4.3. Hematology: There were no blood product transfusions through her hospital stay. Infectious disease: She was treated with ampicillin and gentamicin for first 48 hours. Her blood cultures remained negative and antibiotics were discontinued. She remained infectious disease free since then. Neurology: Normal neurological exam through hospital stay. She was followed with series of head ultrasound; the last head ultrasound on [2198-10-2], was within normal limits. Newborn hearing screen passed on [2198-10-7]. Last newborn screen was sent on [2198-9-21], and was within normal limits. Passed car seat test on [10-12]. Ophthalmology: Was followed for ROP by Dr. [Last Name (STitle) ]. The last eye exam was done on [10-9], and both eyes mature with follow-up recommended at age of 9 months. Psychosocial: [Hospital1 18] social work involved with family. The contact social worker can be reached. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: Discharged home with parents. PRIMARY PEDIATRICIAN: Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], [Location (un) ] Medicine, phone number [Telephone/Fax (1) 69393]. DISCHARGE INSTRUCTIONS: 1. Feeds at discharge p.o. ad lib with breast milk supplemented with [Doctor Last Name ] 24. 2. Car seat passed. 3. State newborn screen [2198-9-21], within normal limits. 4. Hepatitis B vaccine was given on [2198-9-28]. 5. Medication at discharge: Ferrous sulfate 0.4 cc p.o. once a day. 6. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] for infants who meet any of the following 3 criteria: Born at less than 32 weeks, 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 sibling, and 3 with chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. FOLLOW UP: A follow-up appointment recommended with ophthalmology in 9 months. DISCHARGE DIAGNOSES: 1. Prematurity. 2. Respiratory distress. 3. Rule out sepsis. 4. Patent ductus arteriosus, treated with Indocin. 5. Retinopathy of prematurity. [Name6 (MD) ] [Last Name (NamePattern4) ], MD [MD Number(1) 37201] Dictated By:[Name8 (MD) 69367] MEDQUIST36 D: [2198-10-12] 15:36:25 T: [2198-10-13] 13:00:46 Job#: [Job Number 69394]	[ "7742", "V053", "V290" ]
Admission Date: [2161-4-22] Discharge Date: [2161-5-1] Service: MEDICINE Allergies: Aspirin / Phenobarbital / Meperidine / Penicillins / Codeine / Levofloxacin Attending:[First Name3 (LF) 898] Chief Complaint: cough Major Surgical or Invasive Procedure: none History of Present Illness: [Age over 90 ] yo woman who presented to [Hospital1 18] on [2161-4-22] with cough and decreased mental status. In the ED, she had an episode of emesis, found to be hypertensive, hypoxic to 60s, diuresised, given Levofloxacin, and started on nitro drip. Of note, CXR in ED was without pneumonia though subsequent to the episode of emesis, CXR's with opacity. On arrival to the MICU pt was hypotensive and bradycardic, resolution on hypotension with titration off of the nitro drip. . In the MICU pt was diagnosed with aspiration pneumonia and treated with levofloxacin and flagyl. On her second night in the MICU she had an episode of staring consistent with seizure activity. Neurology was consulted, felt that episode was likely seizure and recommended discontinuing Levofloxacin and flagyl which decrease seizure threshold, titrating up [Name (NI) ] (pt on this at home), and prn ativan for future spells. Since that episode there was no further seizure. . In review of medical history leading up to admission, pt hospitalized at [Hospital1 18] in [3-2] with shortness of breath but no evidence of pneumonia or CHF and was discharged to rehab. She was diagnosed with a UTI at rehab and completed a course of treatment. On [2161-4-10], she was discharged from rehab to home. Several days prior to admission, the patient noted dysuria and her VNA checked a UA that, by report, was consistent with a UTI as well. As a result, the patient's PCP placed her on Cipro for which she received one dose prior to presentation. On day of admission her niece noted that the patient overnight had increased coughing and ?shortness of breath. The niece was afraid she might have aspirated (she had not been eating at the time). The patient denied any chest pain. She did, however, develop a productive-sounding cough with no sputum. Of note, the niece noted that the patient also may have had difficulty swallowing full tablets recently. . On the day of admission, the patient then complained of nausea with mild, diffuse abdominal pain. She had no fevers or chills at home. One of her home health aides had been sick but did not come to work recently (1 week ago). . In addition, the patient's niece notes that she has had a change in her mental status on the day prior to presentation. At baseline, she is interactive with a microphone and headset (hard of hearing) but today, her mental status is depressed and she is not very interactive. . Currently pt complains only of cough. Denies fever, chest pain, abdominal pain. [Name8 (MD) ] RN in ICU no diarhea, pt had wone BM in past 24 hours. Past Medical History: 1. S/P right cerebellar infarct 2. Macular degeneration resulting in legal blindness 3. Hypertension 4. Osteoarthritis 5. History of chorioretinitis 6. Diastolic heart failure. Echo [10/2160] with normal EF, E/A ratio 0.4. 7. S/P appendectomy complicated by peritonitis and urosepsis 8. H/O seizures- "Staring spells" complicated by fall in [7-28]. 9. RLQ Ventral Hernia seen on CT [9-29] 10. Presbyacusis with severe hearing impairment 11. Right bundle branch block 12. Ventral hernia. 13. ? Squamous cell cancer on face s/p excision 14. Duodenitis, gastritis 15. Appendectomy as child. Social History: The patient is a retired [Hospital1 18] nursing. She previously worked in the [Hospital Ward Name 121] building. She currently lives in a two-family house in [Location 1268] with her niece living upstairs. She does not cook nor independently cleans and bathes herself. She receives assistance from a home health aide who visits 3 times a week and she also has an assistant who stays with her from [9-29] pm. She is otherwise monitored by her niece by a baby monitor. She denies tobacco, alcohol, and drug use. She ambulates with a walker at baseline. She only recently got out of rehab 10 days ago. She has been admitted to the hospital several times in the last few months. Her niece works in the department of medicine at [Hospital1 18]. . Family History: Mother deceased from MI. Father died secondary to influenza infection. Physical Exam: Tc = 98.0 P= 80 BP= 125/45 RR=18 O2=100%RA . Gen: speaking easily HEENT:PERRLA, bilateral erythematous macules on face s/p excision of malignant skin disease Heart: Regularly irregular rhythm, Grade II/VI holosystolic murmur Lungs: Rhonchi in mid lung fields, mild crackles at bases Abdomen: Ventral hernia - reducible. discomfort on deep palpation of LLQ, active bowel sounds. No rebound/guarding/hepatosplenomegaly Ext: No C/C/E, +2 d. pedis bilaterally Neuro: awake and alert but could not cooperate due to difficulty hearing, mae Pertinent Results: Micro: UA negative, all cultures negative . Results/Images: . CXR: right peri-hilar opacity . KUB ([4-22]): no obstruction . Echo [2160-11-5]: 1. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF> 55%). Regional left ventricular wall motion is normal. 2. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. . EKG: Rate 101, sinus tachycardia. RBBB with normal axis. No acute ST/TW changes. . RUQ ultrasound: no CBD dilation, nl liver Brief Hospital Course: Impression: [Age over 90 ] yo F with h/o prior stroke, HTN, CHF EF > 55%, admitted with ?chf, aspiration pneumonia, change in mental status, now all resolving. . 1. Hypoxia: multifactorial. Aspiration right middle lobe PNA and possible flash PE were likely culprits. She was initially treated with levofloxacin and flagyl but given seizure activity (see below), this was changed to IV clindamycin. Patient clinically improved on this medication and was changed to PO augmentin several days prior to her discharge. Her last day of augmentin (to complete a 14 day total antibiotic course is [2161-5-4]). Of note, DFA was negative for influenza. Sputum culture was also unrevealing. At the time of discharge, patient is on low flow oxygen with daily improvement. Sputum production has lessened. . 2. aspiration: treated for pneumonia as above. Had speech and swallow evaluation twice during hospitalization and was felt safe for thin liquids. GERD thought to be a large component of her aspiration so high dose PPI with lansoprazole liquid [Hospital1 ] was started. Scopolamine patch also helped secretions somewhat. She was on aspiration precautions with head of bed at >30 degrees at all times. Speech pathology recommended crushing all meds. . 2. Leukocytosis. Nausea, vomiting, abdominal pain initially in ED were nonspecific. KUB did not show obstruction. LFTs were unrevealing. RUS did not show any evidence of acute cholangitis. PNA remains most likely etiology. Resolved. . 3. Low UO - Patient was found to have low UO at the start of her admission. Ulytes showed FeNa 0.4%, Osm 516, she was given IVF boluses and her output improved. No active issues upon discharge. . 4. Absence seizure - patient has h/o of seizures that appears to have previously occured in a setting of her stroke, appears to have had an episode AM on [4-23] -> ativan 0.5 IV x 1, appears to have stopped the spell. Neurology service was consulted and recommended switching levoquin to other antibiotics. Her [Month/Year (2) 74959] was also increased to 300 mg PO BID. EEG [4-24]- showed only mild encephalopathy and no epileptiform features. Levaquin was added to her allergy list since it seemed to lower her seizure threshold. . 5. CHF, EF >55% : no evidence of vol overload on exam. given 80 mg Iv lasix in ED with good UO. Patient appears to be dry after the lasix with low UO. She received several IVF boluses while in the unit and tolerated themm well. Patient UO improved and she was restarted on her home dose of Lasix 20 mg QD as she appeared euvolemic. . 6. HTN: HTN urgency while in ED [2-26] aggitation. Also did not recieve home meds today. Patient was subsequently started on nitro gtt and became hypotensive. She was controlled with her home dose of Lopressor 12.5 mg PO BID and imdur 30. Imdur was stopped since this cannot be crushed. BP's stable off this medication. . 7. Mental status : ddx infection vs medication related, less likely new stroke or repetitive seizure. Patient was easily reoriented and remained at her baseline once the ativan given in ED wore off. She did have an episode of unresponsiveness in ICU that was attributed to complex partial seizure that resolved with 0.5 mg ativan x 1. At time of discharge, patient's mental status continues to improve. She is alert, oriented x 3 and conversant, appropriate. She is very hard of hearing. . 8. hard of hearing: uses microphone/headphones to chat. . 10. Code - The patient has a signed DNR form. Her HCP is formally her son but is being transferred by his attorney to include his wife, [Name (NI) ], as well. Her number is [Telephone/Fax (1) 97617]. She works at [Hospital1 18] and can be reached during the day at [Numeric Identifier 97618]. Medications on Admission: Aspirin 81 mg PO QD Oxcarbazepine 150 mg PO BID Lopressor 12.5 mg PO BID Imdur 30 mg PO QD Lasix 20 mg PO QD Prevacid Trazadone 25 mg PO QHS prn Kdur 20 meq PO QD Cipro x 1 ([4-21]) Colace . Medications in MICU: . Metronidazole 500 tid Pantoprazole 40 qd Metoprolol 12.5 [Hospital1 ] Heparin 500u tid Isosorbide mononitrate 30 qd Furosemide 20 qd Ceftriaxone 1 gm IV q12 Oxycarbazepine 300 mg po bid Discharge Medications: 1. Docusate Sodium 100 mg Capsule [Hospital1 ]: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day) as needed. 3. Heparin (Porcine) 5,000 unit/mL Solution [Hospital1 ]: 5000 (5000) units Injection TID (3 times a day). 4. Ipratropium Bromide 0.02 % Solution [Hospital1 ]: One (1) neb Inhalation Q6H (every 6 hours) as needed. 5. Albuterol Sulfate 0.083 % Solution [Hospital1 ]: One (1) neb Inhalation Q6H (every 6 hours) as needed. 6. Metoprolol Tartrate 25 mg Tablet [Hospital1 ]: 0.5 Tablet PO BID (2 times a day). 7. Oxcarbazepine 300 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 9. Acetaminophen 325 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 10. Miconazole Nitrate 2 % Powder [Last Name (STitle) ]: One (1) Appl Topical [Hospital1 ] (2 times a day) for 7 days: for candidal infection of groin. . 11. Lasix 20 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. 12. Trazodone 50 mg Tablet [Hospital1 ]: [1-26] Tablet PO once a day as needed for insomnia. 13. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for Reconstitution [Month/Day (2) ]: Five Hundred (500) mg PO Q12H (every 12 hours) for 4 days. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - Acute Rehab Discharge Diagnosis: aspiration pneumonia resolved somnolence abscence seizure Discharge Condition: stable Discharge Instructions: Take all medications as directed. Followup Instructions: Follow up with your primary care doctor within one week of discharge from rehab. Completed by:[2161-5-1]	[ "5070", "4280", "2767", "4019", "53081", "2859" ]
Admission Date: [2111-10-13] Discharge Date: [2111-10-19] Date of Birth: [2048-5-26] Sex: M Service: MEDICINE Allergies: Zestril Attending:[Doctor First Name 2080] Chief Complaint: Ventricular tachycardia Major Surgical or Invasive Procedure: [2111-10-13] - Cardiac Catheterization History of Present Illness: The patient is a 63M with ALS, HIV on HAART with undetectable VL (per pt), hepatitis C, recent diagnosis of esophageal adenocarcinoma admitted to [Hospital 2725] Hospital from home on [10-10] with left sided weakness, slurred speach, and altered mental status. He was evaluated by [Month/Year (2) ], head CT negative, head MRI/MRA with old small vessel disease with no acute infarction. [Month/Year (2) 878] thought may have been TIA or possibly worsening of ALS. He was felt to be close to baseline and discharge planning started. Then on the evening of [10-12] when eating a [Location (un) 6002], telemetry alarmed for 2 minute episode of ventricular tachycardia per report (rhythm strip not included in OSH records). RN responded and found patient with mouth full of food, cleared airway, patient started taking shallow breaths, was diaphoretic and complained on non-specific pain. There were no compressions or shocks administered as he spontaneously converted to SR. EKG after the event reported to have ST elevation V1-V4. He informed the ICU team that was having chest pain on transfer. He was started on amiodarone (150mg load and 1mg gtt), heparin (4000u bolus and gtt), lopressor 5mg IV, aspirin 325mg once, lasix 40IV. He was placed on BIPAP with ABG 7.29/71/209 on 100%FiO2. There is documentation that labs showed troponin of 0.5, lactate of 5.3. Blood cultures obtained. He was started on vancomycin, zosyn, and azithromycin for presumed aspiration pneumonia. He was transferred to [Hospital1 18] for further management. . At [Hospital1 18], he reports that he feels at his baseline health. He denies chest pain, shortness of breath, slurred speech, diplopia. He does not recall the events of the previous night. . 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, hemoptysis, black stools or red stools. 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, syncope or presyncope. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Hypertension 2. CARDIAC HISTORY: 3. OTHER PAST MEDICAL HISTORY: -ALS diagnosed [2110], some diaphragmatic weakness, requires BiPAP at night on occuasion, followed by Dr. [Last Name (STitle) 88848] at [Hospital1 ] -HIV diagnosed [2091]. CD4 count is 568 and viral load has been undetectable on HAART therapy. -Hepatitis C with no history of treatment. -Hypertension -L2 compression fracture -GERD -PUD with GI bleed -Status post PEG placement [2110] but takes nutrition PO Social History: - Married, lives w/ son and grandson - Previously worked in electronics, on disability - Tobacco history: no current smoking, 60 pack year hx - ETOH: denies - Illicit drugs: denies current IVDA Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: PHYSICAL EXAMINATION: VS: BP:126/78 GENERAL: African American male, Oriented x3. Mood appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 6 cm. 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. Decreased BS bibasilarly ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: LABS ON ADMISSION: [2111-10-13] 09:50AM BLOOD WBC-6.6 RBC-3.95* Hgb-11.8* Hct-38.0* MCV-96 MCH-29.8 MCHC-30.9* RDW-12.1 Plt Ct-219 [2111-10-13] 09:50AM BLOOD PT-11.3 PTT-80.9* INR(PT)-1.0 [2111-10-14] 04:00PM BLOOD WBC-7.2 RBC-4.36* Hgb-13.3* Hct-41.1 MCV-94 MCH-30.5 MCHC-32.3 RDW-12.7 Plt Ct-257 [2111-10-14] 04:00PM BLOOD Neuts-74.0* Lymphs-18.5 Monos-5.7 Eos-1.4 Baso-0.5 [2111-10-14] 04:00PM BLOOD WBC-7.2 Lymph-19 Abs [Last Name (un) ]-1368 CD3%-71 Abs CD3-969 CD4%-38 Abs CD4-515 CD8%-32 Abs CD8-439 CD4/CD8-1.2 [2111-10-13] 09:50AM BLOOD Glucose-71 UreaN-13 Creat-0.8 Na-143 K-4.0 Cl-102 HCO3-36* AnGap-9 [2111-10-13] 09:50AM BLOOD ALT-33 AST-58* LD(LDH)-248 CK(CPK)-450* AlkPhos-83 TotBili-0.4 [2111-10-13] 09:50AM BLOOD Albumin-3.5 Calcium-8.3* Phos-4.1 Mg-2.0 . CARDIAC BIOMARKERS: [2111-10-13] 09:50AM BLOOD CK(CPK)-450* CK-MB-13* MB Indx-2.9 cTropnT-0.12* [2111-10-13] 06:50PM BLOOD CK(CPK)-442* CK-MB-12* MB Indx-2.7 cTropnT-0.16* [2111-10-14] 04:00PM BLOOD CK(CPK)-590* CK-MB-16* MB Indx-2.7 cTropnT-0.10* [2111-10-16] 06:00AM BLOOD CK(CPK)-267 CK-MB-10 MB Indx-3.7 cTropnT-0.09* . URINALYSIS: [2111-10-14] 11:05AM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.020 [2111-10-14] 11:05AM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG [2111-10-14] 11:05AM URINE RBC-20* WBC-1 Bacteri-NONE Yeast-NONE Epi-0 [2111-10-14] 11:05AM URINE Mucous-RARE . LABS ON DISCHARGE: [2111-10-18] 06:00AM BLOOD WBC-4.2 RBC-4.12* Hgb-12.5* Hct-41.3 MCV-100* MCH-30.4 MCHC-30.3* RDW-12.0 Plt Ct-241 [2111-10-18] 06:00AM BLOOD Glucose-84 UreaN-12 Creat-0.7 Na-140 K-4.2 Cl-101 HCO3-32 AnGap-11 [2111-10-18] 06:00AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.0 . MICROBIOLOGY: [2111-10-14] 11:05 am URINE CULTURE (Final [2111-10-15]): NO GROWTH. [2111-10-14] 4:00 pm BLOOD CULTURE (Preliminary): NO GROWTH TO DATE. [2111-10-15] 6:55 am BLOOD CULTURE (Preliminary): NO GROWTH TO DATE. . IMAGING / STUDIES: # Portable TTE ([2111-10-13] at 11:45:20 AM): There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is moderate to severe regional left ventricular systolic dysfunction with inferior/inferolateral akinesis. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size is normal. with mild global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . # Cardiac Cath ([2111-10-13]): * Not Signed Out * COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated no angiographically significant epicardial coronary artery disease. the LMCA, LAD, LCx, and RCA were without angiographically apparent flow-limiting stenosis. 2. Limited resting hemodynamics revealed systemic arterial normotension. FINAL DIAGNOSIS: 1. No angiographically apparent epicardial coronary artery disease. 2. Systemic arterial normotension. . # CT HEAD W/O CONTRAST ([2111-10-19] at 2:55 AM): FINDINGS: There is no evidence infarction, hemorrhage, mass effect, edema, or shift of normally midline structures. Ventricles and sulci are prominent, suggestive of parenchymal involution. Periventricular white matter hypoattenuation about the frontal horns likely represent small vessel ischemic disease. Suprasellar and basilar cisterns are patent. There is polypoid mucosal disease within the right maxillary and sphenoid sinuses. Remainder of paranasal sinuses and mastoid air cells are well aerated. There is no evidence of fracture. Globes and soft tissues are within normal limits. IMPRESSION: 1. No evidence of hemorrhage or fracture. 2. Moderate cerebral parenchymal involution and small vessel ischemic disease. 3. Right maxillary and sphenoid sinus disease. . Brief Hospital Course: Primary Reason for Hospitalization: =================================== 63M with ALS, HIV on HAART with undetectable VL (per pt), hepatitis C (written in records, antibody positive, reported by primary care physician as not having hepatitis), recent diagnosis of esophageal adenocarcinoma admitted to [Hospital 2725] Hospital and transferred to [Hospital1 18] following presumed episode of ventricular tachycardia. . ACTIVE ISSUES: =============== # WIDE COMPLEX TACHYCARDIA - Patient presented without a known history of coronary artery disease with largely preserved EF on most recent available echocardiogram from his outside hospital. He was presumed to have sustained wide complex tachycardia with an episode of unresponsiveness at the outside hospital. He did not receive shocks or resuscitation at that time. It is difficult to determine the sequence of events leading to the patient's event. It was possible that it was a primary ischemic cardiac event. It is also possible that it was a non-cardiac event such as respiratory arrest due to obstructed airway, from a food bolus. Regardless, the patient had anterior EKG changes and an elevated Troponin indicating myocardial infarction likely in the LAD territory versus myocarditis. His cardiac cath ([10-13]) showed no evidence of significant coronary disease, however. He also had a 2D-Echo on [10-13] which showed moderate to severe regional left ventricular systolic dysfunction with inferior/inferolateral akinesis with an LVEF of 30%. We trended his cardiac biomarkers to improvement (peak Troponin of 0.16, CK-MB peak at 16). We empirically heparinized him given concern for coronary ischemic prior to his cardiac catheterization, but this was discontinued. We maintained him on Aspirin 325 mg PO daily. We also restarted his ACEI (Lisinopril) and titrated this to a dose of 40 mg PO daily for better blood pressure control. We also uptitrated his beta-blocker to 75 mg by mouth three times daily with good effect, given some tachycardia and hypertension. We also considered placement of an ICD given his inferior or inferolateral hypokinesis and presumed V.tach event, but this must be weighed against life expectancy given his esophageal adenocarcinoma and progressive ALS diagnosis. He was not started on any anti-arrhythmics and had no further issues with dysrrhythmia. His electrolytes were optimized and he was monitored via telemetry. . # ASPIRATION - The patient presented with a mild oxygen requirement and decreased breath sounds at bases with CXR showing bibasilar haziness concerning for aspiration pneumonitis. Held antibiotics on admission. He remained afebrile and without leukocytosis. We did start utilizing his PEG tube this admission and speech and swallow evaluation noted the need for thin liquids and soft-moist consistency diet given his risk of aspiration. . # Acute Encephalopathy ?????? He began to develop agitation in the evenings with some delirium noted on HOD#2. Although he intermittently remained alert and oriented to time, place and location, his wife noted that this is not atypical for him during prior hospitalizations. She notes that in the past he has needed benzodiazepines and other sedating medications. We provided aggressive reorientation, avoided deliriogenic medication. An infectious work-up showed a reassuring urinalysis and his urine and blood cultures were reassuring; a CXR was reassuring. We also dosed low dose Seroquel in the evenings for agitation with some benefit. His mental status improved on the regular medical floor after transfer from the ICU to his prior baseline. . # FALL - He had a likely mechanical fall in the setting of his ALS and trying to use the bathroom by himself on the evening of [2111-10-18]. Head CT was negative for fracture or intracranial bleeding. No other injuries were sustained. . # HYPERTENSION - Evidence of elevated systolic pressures even when not agitated. Titrated up Metoprolol and Lisinopril to improved pressures. . CHRONIC ISSUES: =============== # HIV - apparently stable disease: We sent repeat CD4 count which was 515 and HIV-1 viral load which was undetectable. This will be followed as an outpatient. We continued his HAART medications: Truvada, Efavirenz, Raltegravir. . # ALS - stable disease without current issues; we continued Rilutek. . # ESOPHAGEAL ADENOCARCINOMA - seen by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD (Thoracic Surgery) in [8-/2111] who said he was non-operative and could benefit from radiation; Dr. [Last Name (STitle) ] from Heme-Onc saw him as well - patient not likely chemoradiation therapy candidate given other co-morbidities and patient disinterest in aggressive therapy; will need repeat endoscopy and EUS in [2-18] months for re-evaluation of disease progression. . # CHRONIC SYSTOLIC HEART FAILURE (EF 30%): Nonischemic cardiomyopathy given clean coronaries. Unclear etiology. Patient clinically euvolemic. - Metoprolol increased to 75 TID - Lisinopril increased to 40mg daily - Outpatient cardiology follow-up . # GERD - We continued his Omeprazole without issue. . # VITAMIN D DEFICIENCY - We continued Ergocalciferol dosing. . TRANSITION OF CARE ISSUES: =========================== 1. Blood culture final reports pending at discharge. 2. Followup with PCP, [Name10 (NameIs) 878], and Cardiology scheduled. Medications on Admission: - aspirin 81mg daily - lisinopril 20mg daily - cyclobenzapine 5mg [Hospital1 ] - Efavirenz 600mg QHS - Raltegravir 400mg [Hospital1 ] - Truvada daily - Rilutek 50mg [Hospital1 ] - omeprazole 20mg daily - neurontin 900mg TID - metoprolol 50mg [Hospital1 ] - ergocalciterol 5000mg weekly - percocet 1 tab Q4 PRN Discharge Medications: 1. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. riluzole 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 12. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 13. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 15. cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 16. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [Location (un) 44563] Nursing and Rehabilitation Center - [Hospital1 10478] Discharge Diagnosis: Primary Diagnoses: 1. Wide complex tachycardia 2. Aspiration pneumonitis 3. Systolic heart failure (left systolic dysfunction) . Secondary Diagnoses: 1. Human Immunodeficiency Infection (HIV) 2. Amyotrophic Lateral Sclerosis (ALS) 3. Hypertension 4. Reflux esophagitis, GERD 5. Vitamin D deficiency 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: Patient Discharge Instructions: . You were admitted to the Cardiac Intensive Care Unit (CCU) at [Hospital1 69] on CC7 regarding management of a presumed atypical heart rhythm. You had a cardiac catheterization which showed no evidence of significant coronary disease. You also had an echocardiogram (heart ultrasound) which showed a low ejection fracture and some heart failure. Your medications were optimized and your rhythm remained stable. You did have some issues with agitation and delirium, which was attributed to your intensive care unit stay. You were transferred to the regular medical floor and your mental status improved. You were discharged to a rehab facility in stable condition. . Please call your doctor or go to the emergency department if: * You experience new chest pain, pressure, squeezing or tightness. * You develop new or worsening cough, shortness of breath, or wheezing. * You are vomiting and cannot keep down fluids, or your medications. * If you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include: dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit, or have a bowel movement. * You experience burning when you urinate, have blood in your urine, or experience an unusual discharge. * Your pain is not improving within 12 hours or is not under control within 24 hours. * Your pain worsens or changes location. * You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. * You develop any other concerning symptoms. . CHANGES IN YOUR MEDICATION RECONCILIATION: . * Upon admission, we ADDED: INCREASED: Metoprolol from 50 mg by mouth twice daily to 75 mg three times daily INCREASED: Lisinopril from 20 to 40 mg by mouth daily STARTED: Senna 8.6 mg 1 tab by mouth twice daily and Colace 100 mg by mouth twice daily for constipation STARTED: Lactulose 30 mL by mouth every 8 hours as needed for constipation STARTED: Acetaminophen 650 mg by mouth every 6 hours as needed for pain or fever DECREASED: Neurontin from 900 mg to 300 mg by mouth three times daily . * The following medications were DISCONTINUED on admission and you should NOT resume: DISCONTINUED: Percocet . * You should continue all of your other home medications as prescribed, unless otherwise directed above. Followup Instructions: Name: [Last Name (LF) 88849],[First Name3 (LF) ] H Address: [Doctor Last Name ]. NORTH, [Hospital1 ],[Numeric Identifier 77339] Phone: [Telephone/Fax (1) 88850] We are working on a follow up appointment with your primary care physician for your hospitalization. It is recommended you follow up within 2 weeks of discharge. The office will contact you at home with the appointment information. If you have not heard within 2 business days or have any questions or concerns please call the office. Name: NP[First Name8 (NamePattern2) ] [Last Name (NamePattern1) 51236] Location: [Hospital ] MEDICAL CENTER Department: Cardiology Address: [Doctor Last Name ], [Hospital1 ],[Numeric Identifier 88851] Phone: [Telephone/Fax (1) 88852] Appointment: Thursday [2111-10-29] 2:00pm This is a follow up appointment of your hospitalization. You will be reconnected with your primary cardiologist Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] after this visit. Name: Dr. [First Name8 (NamePattern2) 4884] [Last Name (NamePattern1) 88848] Location: [Hospital ] MEDICAL CENTER Department: [Hospital 878] Address: [Doctor Last Name ] North, [Hospital1 ],[Numeric Identifier 88851] Phone: [Telephone/Fax (1) 88853] Appointment: Friday [2110-12-4] 11:00am *The office may call you with a sooner appointment. Any questions call the office.	[ "5070", "25000", "4019", "4280", "53081" ]
Admission Date: [2111-11-30] Discharge Date: [2111-12-12] Date of Birth: [2048-6-14] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: atrial fibrillation Major Surgical or Invasive Procedure: Maze procedure via bilateral mini-thoracotmomies [2111-12-2] History of Present Illness: This 63 year old white male developed atrial fibrillation 8 years ago. He was successfully converted to sinus rhythm. His paroxysmal fibrillation has become chronic, having been cardioverted three times this year, with persistent dysrhythmia now. He has been on Coumadin for this. The Coumadin was discontinued four days ago and he was admitted for Heparin therapy as a bridge peroperatively. A cardiac MRI has been performed to delineate his pulmonary vein anatomy previously. Past Medical History: Hypercholesterolemia s/p partial gastrectomy for peptic ulcer disease gastric reflux chronic brochitis s/p left shoulder surgery s/p hip surgery hypertension paroxysmal atrial fibrillation s/p transurethral prostatectomy Social History: Exsmoker, stopped a year ago. Social ETOH use. Lives alone. Is a retired maintenance worker. Family History: Father died of MI age 57, had MI previously. Physical Exam: At discharge: AVSS Gen: [Male First Name (un) 4746] in NAD HEENT: NC/AT, PERLA, EOMI, oropharynx benign Neck: supple, FROM, no lymphadenopathy Lungs: Clear to A+P, bilat. thorocotomy incisions healing well CV: IRRR without R/G/M Abd: soft, nontender without masses or hepatosplenomegaly Ext: bilat. LE edema Neuro: non focal Pulses: 1+=bilat throughout Pertinent Results: [2111-12-12] 07:15AM BLOOD WBC-8.7 RBC-4.28* Hgb-9.7* Hct-31.8* MCV-74* MCH-22.7* MCHC-30.6* RDW-16.6* Plt Ct-328 [2111-12-12] 07:15AM BLOOD PT-20.1* INR(PT)-1.9* [2111-12-12] 07:15AM BLOOD Glucose-96 UreaN-21* Creat-1.2 Na-136 K-3.7 Cl-96 HCO3-31 AnGap-13 [2111-12-10] 04:00AM BLOOD ALT-93* AST-48* LD(LDH)-258* AlkPhos-127* Amylase-49 TotBili-0.7 [Known lastname 78926],[Known firstname ] [Medical Record Number 78927] M 63 [2048-6-14] Radiology Report CHEST (PA & LAT) Study Date of [2111-12-10] 9:44 AM [Last Name (LF) ],[First Name7 (NamePattern1) 177] [Initial (NamePattern1) ] [Last Name (NamePattern4) 5204] FA6A [2111-12-10] SCHED CHEST (PA & LAT) Clip # [Clip Number (Radiology) 78928] Reason: r/o inf, eff Preliminary Report !! PFI !! Small bilateral pleural effusions are greater on the right side. Bilateral discoid mid-lung atelectases are larger on the right. Mild cardiomegaly is unchanged. DR. [First Name (STitle) 3901] [Initials (NamePattern4) ] [Last Name (NamePattern4) 3902] PFI entered: [Doctor First Name ] [2111-12-10] 10:34 AM Imaging Lab Brief Hospital Course: Heparin was begun after admission. On [12-2] he went to the operating room where bilateral thoracoscopic Mazes with ligation of the left atrial appendage was performed. Marcaine infusion pumps and bulb drains where placed bilaterally. He remained stable and was extubated easily and transferred to the floor on POD 1.He was atrially paced, Sotalol was resumed. His underlying rhythm was sinus bradycardia, however, he returned to AF on POD2. His chest drains were removed on POD4. AF persisted, Sotalol was discontinued and dofetilide was begun. DCSCV was planned and anticoagulation was continued. He spontaneously converted to sinus rhythm on [12-9]. He was prepared for discharge. Dofetilide was continued as was diuresis. Arrangement were made for Coumadin monitoring as he was on preoperatively. Medications, instruction and precautions were discussed with him prior to discharge. On the day of discharge his Lopressor was increased and he was given an extra dose of 12.5 mg. He was discharged to rehab on POD#10 in stable condition. Medications on Admission: Coumadin 5mg m/w/f:2.5mg t/th/s/s Prilosec 20mg/D Zocor 20mg/D Tricor 145mg/D Xalantan Ophth. Diovan 80mg/D Sotalol 80mg [Hospital1 ] ASA 81mg/D Lasix 80mg/D KCl 20 mg/D Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Metoprolol Tartrate Oral 4. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 6. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Dofetilide 500 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 13. Coumadin 4 mg Tablet Sig: One (1) Tablet PO at bedtime: Titrate for INR of [3-14].5. 14. Latanoprost 0.005 % Drops Sig: One (1) Ophthalmic at bedtime: Both eyes. 15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 16. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 17. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed. Discharge Disposition: Extended Care Facility: [Location (un) 6598] ManorExtended Care Facility Discharge Diagnosis: s/p bilateral thoracoscopic Maze procedures with ligation of left atrial appendage Atrial fibrillation hypercholesterolemia Gastric reflux peptic ulcer disease s/p hemigastrectomy chronic brochititis s/p cholecystectomy hypertension s/p transurethral resection prostatectomy s/p herniorraphies s/p shoulder surgery s/p right hip surgery glaucoma Discharge Condition: good Discharge Instructions: No driving for 4 weeks and off all narcotics. No lifting more than 10 pounds for 10 weeks. Shower daily, no baths or swimming. No creams, lotions or powders to incisions. Report any weight gain greater than 2 pounds a day or 5 pounds a week. Report any redness of, or drainage from incisions. Take all medications as directed. Followup Instructions: Dr.[Last Name (STitle) 914] in 4 weeks ([Telephone/Fax (1) 170]) Dr [Last Name (STitle) 3003] in 1 week ([Telephone/Fax (1) 14916]) call for appointments Dr. [Last Name (STitle) ] in 4 weeks. Completed by:[2111-12-12]	[ "42731", "9971", "496", "4019", "2720", "53081", "V5861", "V1582" ]
Admission Date: [2171-9-16] Discharge Date: [2171-9-21] Date of Birth: [2107-7-15] Sex: F Service: ORTHOPAEDICS Allergies: Paper Tape / Augmentin / Penicillins Attending:[First Name3 (LF) 3190] Chief Complaint: Back and leg pain Major Surgical or Invasive Procedure: Anterior T11-L5 fusion / Posterior instrumentation and fusion T4-L5 History of Present Illness: Ms. [Known lastname 78304] has a long history of back and leg pain from her scoliosis. She has attempted conservative therapy and has failed. She now presents for surgical intervention. Past Medical History: Scoliosis Asthma Hyperlipidemia Hypothyroid Social History: Denies Family History: N/C Physical Exam: A&O X 3; NAD RRR CTA B Abd soft NT/ND BUE- good strength at deltoid, biceps, triceps, wrist flexion/extension, finger flexion/extension and intrinics; sensation intact C5-T1 dermatomes; - [Doctor Last Name 937], reflexes symmetric at biceps, triceps and brachioradialis BLE- good strength at hip flexion/extension, knee flexion/extension, ankle dorsiflexion and plantar flexion, [Last Name (un) 938]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes symmetric at quads and Achilles Pertinent Results: [2171-9-20] 06:15AM BLOOD WBC-11.6* RBC-3.67# Hgb-10.6# Hct-30.9# MCV-84 MCH-28.9 MCHC-34.3 RDW-15.8 Plt Ct-108* [2171-9-19] 06:10AM BLOOD WBC-9.7 RBC-2.78* Hgb-7.8* Hct-23.1* MCV-83 MCH-28.2 MCHC-34.0 RDW-16.0* Plt Ct-106* [2171-9-18] 12:52AM BLOOD WBC-9.5 RBC-3.17* Hgb-9.1* Hct-25.8* MCV-81* MCH-28.6 MCHC-35.2* RDW-15.1 Plt Ct-122* [2171-9-17] 04:23PM BLOOD WBC-6.6 RBC-2.92* Hgb-8.2* Hct-24.0* MCV-82 MCH-28.0 MCHC-34.2 RDW-15.0 Plt Ct-129* [2171-9-17] 02:45PM BLOOD WBC-6.8 RBC-2.99* Hgb-8.6* Hct-25.1* MCV-84 MCH-28.7 MCHC-34.2 RDW-14.7 Plt Ct-150 [2171-9-17] 10:35AM BLOOD WBC-7.7 RBC-3.32* Hgb-9.3* Hct-27.1* MCV-82 MCH-27.9# MCHC-34.2 RDW-15.3 Plt Ct-132* [2171-9-20] 06:15AM BLOOD Plt Ct-108* [2171-9-19] 06:10AM BLOOD Plt Ct-106* [2171-9-20] 06:15AM BLOOD Glucose-84 UreaN-7 Creat-0.5 Na-138 K-3.4 Cl-101 HCO3-31 AnGap-9 [2171-9-19] 06:10AM BLOOD Glucose-83 UreaN-9 Creat-0.4 Na-140 K-3.4 Cl-106 HCO3-28 AnGap-9 [2171-9-17] 04:23PM BLOOD Glucose-153* UreaN-9 Creat-0.6 Na-140 K-3.9 Cl-110* HCO3-25 AnGap-9 [2171-9-17] 06:20AM BLOOD Glucose-121* UreaN-9 Creat-0.6 Na-139 K-3.9 Cl-110* HCO3-23 AnGap-10 [2171-9-20] 06:15AM BLOOD Calcium-7.6* Phos-2.4* Mg-1.6 [2171-9-18] 12:52AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.9 [2171-9-17] 02:45PM BLOOD Calcium-9.8 Brief Hospital Course: Ms. [Known lastname 78304] was admitted to the [Hospital1 18] Spine Surgery Service on [2171-9-16] and taken to the Operating Room for an T10-L5 anterior fusion through a thoracotomy. Please refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. She had a chest tube placed and during her thoracotomy. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were given per standard protocol. Initial postop pain was controlled with a PCA. On HD#2 ([2171-9-17]) she returned to the operating room for a scheduled T4-L5 decompression with PSIF as part of a staged 2-part procedure. Please refer to the dictated operative note for further details. The second surgery was also without complication and the patient was transferred to the T/SICU in stable condition for large blood loss. Postoperative HCT was 23. She was transfused multiple units of PRBCs, platelets, and plasma. A bupivicaine epidural pain catheter placed at the time of the posterior surgery remained in place until the following day when it was removed. She was kept NPO until bowel function returned then diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. She was placed on around the clock tylenol due to hypotension after taking opioid pain relievers. Foley and chest tube were removed on POD#3 from the second procedure. There was no pneumothorax after chest tube removal. She was fitted with a TLSO brace to be worn when out of bed. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: Advair 250/50 [Hospital1 ] ASA 81 mg PO Daily HCTZ 25 mg PO Daily Klor-con 20 meq [Hospital1 ] Levothyroxine 88 mg PO Daily Lipitor 40 mg PO Daily Protonix 40 mg PO BID Zetia 10 mg PO Daily Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 6. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) INH IH [Hospital1 ] Inhalation [Hospital1 ] (2 times a day). 10. Potassium Chloride 20 mEq Packet Sig: One (1) PO BID (2 times a day). 11. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital3 7665] Discharge Diagnosis: Scoliosis Acute post-op blood loss anemia Hypotension Discharge Condition: Good Discharge Instructions: You have undergone the following operation: ANTERIOR/POSTERIOR thoracolumbar Decompression With Fusion Immediately after the operation: -Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. oLimit any kind of lifting. -Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. -Brace: You have been given a brace. This brace is to be worn when you are walking. You may take it off when sitting in a chair or while lying in bed. -Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. -You should resume taking your normal home medications. No NSAIDs. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [Hospital Ward Name 23] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Activity: Out of bed w/ assist TLSO for ambulation; may be out of bed to chair without. Treatments Frequency: Please continue to inspect the wounds for signs of infection Followup Instructions: Please follow up with Dr. [Last Name (STitle) 363] in his clinic in 10 days. Call [Telephone/Fax (1) ] for an appointment.	[ "2851", "4019", "2449", "53081", "2724" ]
Admission Date: [2182-11-26] Discharge Date: [2182-11-29] Date of Birth: [2099-10-5] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1257] Chief Complaint: hyponatremia Major Surgical or Invasive Procedure: none History of Present Illness: 83-year-old woman with history of CAD (s/p CABGx2 '[79]) and DM2 presented to [Hospital1 ] with confusion x 1 week and weakness x 4 weeks. The patient has experienced weakness with an 8-lb weight loss since [2182-7-7]. Three weeks ago she had a few episodes of nonbloody diarrhea, presented to [Hospital1 ] a few weeks ago for work-up, which was reportedly unrevealing. She was then diagnosed with an asymptomatic UTI, treated with antibiotics, during that admission. The diarrhea resolved after the discontinuation of stool softeners and she was discharged home. For the past week, according to her son, she was confused intermittently. She reports having poor PO intake for the past few weeks. Patient talked to her PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 6051], on the phone the day of admission and reportedly had some confused speech. She presented to [Hospital1 ] ED and was found to have Na 110 and transferred to [Hospital1 18] after getting 250 ml of NS then 3% NaCl IVF at 29 cc/hr. . In ED, T 98.0, BP 156/67, HR 66, RR 20, O2 sat 99%. Renal was consulted and recommended 3% NaCl at 15 ml/hr with q4h Na checks. . ROS: The patient reports 8-lb weight loss. Denies any fevers, chills, nausea, vomiting, abdominal pain, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity oedema, cough, urinary frequency, urgency, dysuria, lightheadedness, vision changes, headache, rash or skin changes. Past Medical History: CAD: s/p CABG (LIMA to LAD, SVG to PDA) in [2179] DM2 Hyperlipidemia Diverticulosis Anemia Osteoporosis Renal caluli PUD Kyphosis Social History: quit smoking in [2173] after 120 pack years. No EtOH or drug use. Lives by self after husband died 9 years ago. Grown-up children in the area. Family History: Mother, sisters and brothers all with [Name (NI) 5290] Physical Exam: Vitals: T: BP: HR: RR: O2Sat: GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R 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. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [2182-11-26] 07:30PM BLOOD WBC-6.1 RBC-3.92* Hgb-11.9* Hct-33.0* MCV-84 MCH-30.3 MCHC-36.0* RDW-13.4 Plt Ct-238# [2182-11-26] 07:30PM BLOOD Neuts-67.9 Lymphs-27.5 Monos-3.8 Eos-0.6 Baso-0.2 [2182-11-26] 07:30PM BLOOD PT-13.2 PTT-36.4* INR(PT)-1.1 [2182-11-26] 07:30PM BLOOD Glucose-133* UreaN-11 Creat-0.6 Na-115* K-4.3 Cl-86* HCO3-23 AnGap-10 [2182-11-26] 11:33PM BLOOD Glucose-111* UreaN-9 Creat-0.6 Na-115* K-4.3 Cl-85* HCO3-24 AnGap-10 [2182-11-27] 03:23AM BLOOD Glucose-91 UreaN-9 Creat-0.6 Na-121* K-4.5 Cl-91* HCO3-25 AnGap-10 [2182-11-27] 08:02AM BLOOD Na-124* [2182-11-27] 03:23AM BLOOD ALT-26 AST-32 AlkPhos-49 TotBili-0.7 [2182-11-26] 07:30PM BLOOD Osmolal-242* [2182-11-26] 11:33PM BLOOD TSH-2.7 [2182-11-27] 08:02AM BLOOD Cortsol-18.4 . CXR: FINDINGS: In comparison with the study of [2179-9-8], there is again evidence of intact sternal sutures and the patient has undergone a previous CABG procedure. No evidence of vascular congestion, pleural effusion, or acute pneumonia. Brief Hospital Course: Summary by problem: 83-year-old woman with history of CAD (s/p CABGx2 in [2179]) and DM type 2 presented to OSH with confusion, weakness, 8-lb weight loss, nonbloody diarrhea, poor PO intake, and hyponatremia. She was recently trated with Celexa for depression. She was transferred to [Hospital1 18] ICU for hyponatremia and sodium level of 110. She was initially treated with 250 ml of NS and then 3% NaCl IVF at 29 cc/hr (hypertonic 3% saline). She received the latter for approx 4 hours and her Na rose from 110 to 115 in 5 hours. Her sodium rose the following morning to 121. She was then maintained on normal saline and free water restriction. She was then transferred out of the ICU to the medical floor. She was placed Off IV fluids on PO fluid restriction only. Sodium has been within normal levels for the last 3 days. However, she was noted to continue to have problems with cognition and gait. Her confusion and disorientation have resolved. She had no illusions, delusions, or hallucination. She had no focal neurological defects. . . # Hyponatremia: Cortisol and TSH levels were normal. A CT Chest was obtained to look for possible pulmonary malignancy (pulmonary causes of SIADH). It showed no evidence of any mass. Hyponatremia resolved on conservative management. We avoided the use of SSRI which could be responsible for her hyponatremia. . . #Cognitive impairment with gait abnormality with DDX of Delirium, frontal dementia, or normal pressure hydrocephalus. She was evaluated by Gerontology. She may need brain MRI if symptoms progress. However, most of her symptoms can be explained by depression and her OSH CT head was unremarkable. The geriatrics service questioned the diagnosis of [Last Name (un) 309] body or frontal lobe dementia. They recommended out patient follow up with neuropsychiatry. We avoided the initiation of new antidepressants in the hospital as we need to monitor their effects on her. This can be done in the out patient. . . # Diarrhea: resolved last 48 hours. Weight loss: may be related to underlying depression or see above. . . # CAD: History of 2-vessel CABG in [2179]. She was restarted on aspirin. Both carvedilol and Valsartan were restarted later as SBP was initially in 90s. . . # DM2: Oral hypoglycemics were held initially and she was maintained on an insulin sliding scale. Then we restarted Glyburide and placed Metformin on hold secondary to significant GI symptoms. . . # FEN: diabetic, free water restriction. . . # Code: DNR/DNI. . . Diso: to Rehab . . [First Name4 (NamePattern1) ] [Name8 (MD) ], M.D. . . . total discharge time 56 minutes Medications on Admission: alendronate ASA 81 mg qday calcium MVI atorvastatin 20 mg daily Fe valsartan 320mg daily omeprazole 20mg daily carvedilol 6.25 - 1.5 tabs [Hospital1 ] glyburide 5mg po bid ezetimibe 10mg daily metformin 500mg daily Discharge Medications: 1. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every Monday). 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [Hospital3 15644] Healthcare Center Discharge Diagnosis: Hyponatremia Depression Discharge Condition: good Discharge Instructions: stop metformin because of low appetite and diarrhea. Fluid restriction of 1200 ML daily. Stop Celexa monitor Sodium level twice weekly for 2 weeks and then, if levels are stable, once weekly for 1 month. Followup Instructions: PCP: [Name10 (NameIs) ],[First Name3 (LF) ] C. [Telephone/Fax (1) 25493]. Follow up with geriatrics and/or neuropsychiartry.	[ "V4581", "25000", "2859", "2724", "3051" ]
Admission Date: [2180-9-27] Discharge Date: [2180-10-2] Date of Birth: [2113-10-18] Sex: M Service: CARDIOTHORACIC Allergies: No Drug Allergy Information on File Attending:[First Name3 (LF) 1267] Chief Complaint: History of coronary artery disease s/p previous surgical intervention now requiring redo of CABG Major Surgical or Invasive Procedure: CABG x2 History of Present Illness: The patient is a 66-year man who is 24 yearsstatus post coronary artery bypass grafting x3. He recentlydeveloped a positive stress test and shortness of breath. Catheterization showed severe three-vessel disease. There was a patent circumflex bypass graft but all other grafts were occluded. Ejection fraction was 50%. Past Medical History: CAD Hypercholesterolemia HTN BPH h/o basal cell carcinoma on R ear s/p removal h/o SBO [2159] s/p CABG x3 in [2157] s/p TURP in [2180] s/p CCY/appendectomy [2156] Social History: Retired radiochemist. Quit smoking in the [2155]'s. +h/o 36 pack-years tobacco. Social ETOH. Denies drug use. Family History: Mother diet of MI at the age of 62 Physical Exam: Awake and alert in NAD EOMI, PERRLA, anicteric Neck supple, no JVD, no bruit Lungs CTA b/l RRR, NL S1 and S2 Abd soft, NT/ND, NABS EXT: L saphenous incision well-healed. Pertinent Results: [2180-9-27] 01:50PM BLOOD WBC-7.2 RBC-2.75# Hgb-8.6# Hct-23.7# MCV-86 MCH-31.4 MCHC-36.5 RDW-12.8 Plt Ct-67# [2180-9-27] 01:50PM BLOOD PT-20.8 PTT-150* INR(PT)-2.9 [2180-9-27] 01:50PM BLOOD Plt Smr-VERY LOW Plt Ct-67# [2180-9-27] 03:19PM BLOOD UreaN-14 Creat-0.8 Cl-110 HCO3-23 [2180-9-28] 02:03AM BLOOD Glucose-135* UreaN-15 Creat-0.8 Na-137 K-4.5 Cl-106 HCO3-23 AnGap-13 Brief Hospital Course: The patient was taken to the operating room on [2180-9-27]. The patient tolerated the procedure well and without complication. Please see operative note for full details. He was transferred to the CSRU immediately post-op. He was extubated that night. The central line and chest tubes were removed on post-op day #2. He was transferred to the floor. The remainder of the post-operative course was unremarkable. The patient was ambulated and cleared by physical therapy. The supplemental oxygen was weaned. The patient was discharged home on post-op day #5 in stable condition. Medications on Admission: Tenormin 25mg PO BID Vasotec 5mg PO BID Zocor 10mg PO QD ASA 81mg PO QD Proscar 5mg PO QD Uroxotrol 10mg PO QD Isosorbide 10mg QD Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:2 2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours). Disp:60 Packet(s) Refills:2 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:60 Capsule(s) Refills:2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 30 doses. Disp:30 Tablet(s) Refills:0 5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day): Hold Tenormin while taking this medicine. Disp:90 Tablet(s) Refills:2 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Enalapril Maleate 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. Proscar 5 mg Tablet Sig: One (1) Tablet PO once a day. 10. UROXATRAL 10 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Discharge Disposition: Home With Service Facility: [Location (un) 2203] VNA Discharge Diagnosis: Coronary artery disease Hypercholesterolemia Hypertension BPH h/o SBO h/o basal cell carcinoma s/p CABG x3 in [2157] Discharge Condition: Stable Discharge Instructions: Shower daily, wash incision with mild soap and water and pat dry. No lotions, creams, powders, or baths. No lifting more than 10 pounds or driving until folloup with surgeon. Call with temperature more than 101.4, redness or drainage from incision, or weight gain more than 2 pounds in one day or five in one week. Followup Instructions: Provider: [Name10 (NameIs) ],[Name11 (NameIs) 1112] [Name Initial (NameIs) ]. [Telephone/Fax (1) 170] Call to schedule appointment Please follow up with Drs. [Last Name (STitle) 35852] and [Name5 (PTitle) 64002] when you return to [State 760].	[ "41401", "42731", "2724", "4019" ]
Admission Date: [2179-6-9] Discharge Date: [2179-6-16] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1267] Chief Complaint: NSTEMI Major Surgical or Invasive Procedure: [2179-6-10] CABG x 1 with Ligation of LAD aneurysm (SVG to LAD) History of Present Illness: 85 yo F p/w chest pain [6-8]. Ruled in for MI.Cardiac cath showed 99% LAD with aneursym, she was started on heparin and transferred for further management. Past Medical History: PMH: HTN, cholelithiasis, DJD, ? valvular disease on past ECHO PSH: partial colectomy for benign mass ~[2163], c-spine surgery [2173], prior abdominal incisional hernia, hysterectomy at 35 y/o Social History: rare etoh no tobacco lives alone Family History: brother with premature CAD sister with sudden cardiac death Physical Exam: HR 73 RR 20 BP 140/70 NAD Lungs CTAB Heart RRR, no murmur Abdomen benign Extrem warm, no edema 63" 149# Pertinent Results: [2179-6-16] 06:10AM BLOOD Hct-33.2* [2179-6-15] 05:15AM BLOOD Hct-28.8* [2179-6-14] 05:40AM BLOOD WBC-11.4* RBC-3.20* Hgb-10.1* Hct-30.0* MCV-94 MCH-31.5 MCHC-33.5 RDW-13.7 Plt Ct-257 [2179-6-15] 05:15AM BLOOD PT-11.5 INR(PT)-1.0 [2179-6-16] 06:10AM BLOOD UreaN-16 Creat-0.9 K-4.3 [2179-6-15] 05:15AM BLOOD UreaN-20 Creat-0.7 K-4.4 CHEST (PA & LAT) [2179-6-13] 10:09 AM CHEST (PA & LAT) Reason: interval change [Hospital 93] MEDICAL CONDITION: 85 year old woman with POD 3 CABG REASON FOR THIS EXAMINATION: interval change PA AND LATERAL CHEST ON [2179-6-13] AT 1008 INDICATION: Postop CABG. COMPARISON: [2179-6-10]. FINDINGS: Since the prior study, lines and tubes have been removed. There are bilateral effusions, left greater than right with some atelectatic changes at the bases. The upper lungs are clear, and the pulmonary vasculature is within normal limits. There is no pneumothorax. IMPRESSION: Good radiographic progression after CABG. Bilateral effusions. [Hospital1 18] ECHOCARDIOGRAPHY REPORT [Known lastname 78463], [Known firstname ] [Hospital1 18] [Numeric Identifier 78464] (Complete) Done [2179-6-10] at 8:50:26 AM FINAL Referring Physician [Name9 (PRE) ] Information [Name9 (PRE) ], [First Name3 (LF) 1112] W. [Hospital Unit Name 927] [Location (un) 86], [Numeric Identifier 718] Status: Inpatient DOB: [2093-9-1] Age (years): 85 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: cabg ICD-9 Codes: 786.05, 786.51, 799.02, 440.0, 424.0 Test Information Date/Time: [2179-6-10] at 08:50 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 #: 2008AW1-: Machine: aw3 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.3 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.4 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.5 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 45% to 50% >= 55% Aorta - Ascending: 3.5 cm <= 3.4 cm Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets. Trace AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Mild [1+] 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: The heart is rotated which limits windows. Also, baseline frequent ventricular ectopy continues. No spontaneous echo contrast is seen in the left atrial appendage. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: The patient is AV-Paced, on NTG infusion. Good biventicular systolic fxn. 1+ MR, trace AI. Aorta intact. Brief Hospital Course: She was started on a lidocaine drip drip for ventricular ectopy. She was started on cipro for a UTI. She was taken to the operating room on [2179-6-10] where she underwent a CABG x 1 and ligation of LAD aneurysm. She was transferred to the ICU in critical but stable condition. She was given 48 hours of vancomycin as she was in the hospital preoperatively. She was extubated postop. Lidocaine was dc'd. She was transferred to the floor on POD #1. She did well postoperatively, chest tubes and wires were dc'd without incident. Gently diuresed toward her preop weight and beta blockade titrated for ectopy and short [Last Name (un) 24048] of atrial fibrillation. Ready for discharge to rehab on POD #6. Medications on Admission: ASA325', diovan 160', HCTZ 12.5', cartia 240 XT' on transfer: IV heparin, ASA 325 mg, lopressor 25 mg [Hospital1 ] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:30 Capsule(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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:50 Tablet(s) Refills:0 7. Valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Tablet(s) 10. 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. Discharge Disposition: Extended Care Facility: [Last Name (un) 6978] House of [Location (un) 5871] Discharge Diagnosis: Coronary Artery Disease s/p CABG MI postop A fib Hypertension cholelithiasis DJD Discharge Condition: stable Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower daily washing incision, pat dry: no tub bathing or swimming Report any weight gain greater than 2 pounds in 24 hours or 5 pounds in 1 week No creams, powder or lotion on incisions No driving for 1 month No lifting > 10 pounds for 10 weeks Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] in 4 weeks call for an appointment [Telephone/Fax (1) 170] Follow-up with Dr. [Last Name (STitle) 75891] (PCP [Name Initial (PRE) ] [Name Initial (NameIs) 37361]) in 2 weeks Follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] (Cards - [Location (un) 37361]) in 2 weeks Completed by:[2179-6-16]	[ "5990", "9971", "41401", "4019", "42731" ]
Admission Date: [2178-9-22] Discharge Date: [2178-10-3] Date of Birth: [2114-8-14] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 1505] Chief Complaint: aortic stenosis/coronary artery disease Major Surgical or Invasive Procedure: Aortic Valve replacement (25mm St. [Male First Name (un) 923] tissue), coronary artery bypass grafts x3(LIMA-LAD,SVG-dg,svg-pda) on [2178-9-28] History of Present Illness: This 64 year old male underwent catheterization at [Hospital3 ] recently, after a positive stress test. He has known coronary disease, having undergone percutaneous intervention in the past. He has had subsequent dyspnea on exertion which has recently worsened. Catheterization revealed significant coronary disease and aortic stenosis with preserved LV function. He was admitted now for elective operation. Past Medical History: Aortic stenosis, obesity, HTN, OSA/CPAP, high cholesterol, previous cath showing 3 V CAD s/p PTCA [2174], left ankle surgery [36]'s Social History: Mr. [Known lastname ] [Known lastname ] lives with his wife. [Name (NI) ] is a manufacturing engineer. He smoked in the past, but quit 30 years ago. He drinks less than one drink per week. Family History: Hi father died at age 78 of an unknown cause and his mother died at age 82 of congestive heart failure. Physical Exam: Physical Exam Pulse:76 Resp:16 O2 sat: 99% RA B/P Right:130/78 Left: Height: 71 inches Weight: 285# General:AAOx3 in 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 [x] grade II/VI SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Obese Extremities: Warm [x], well-perfused [x] Edema - none Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right:2+ Left:2+ DP Right:2+ Left:2+ PT [Name (NI) 167]:2+ Left:2+ Radial Right:2+ Left:2+ Carotid Bruit Right/Left:transmitted murmur Pertinent Results: [2178-9-22] 11:44PM BLOOD WBC-6.3 RBC-4.58* Hgb-13.9* Hct-40.7 MCV-89 MCH-30.4 MCHC-34.2 RDW-13.1 Plt Ct-181 [2178-9-22] 11:44PM BLOOD Glucose-116* UreaN-16 Creat-0.9 Na-144 K-3.7 Cl-106 HCO3-30 AnGap-12 Conclusions PREBYPASS: Normal systolic funciton with LVEF > 55% with no segmental wall motion abnormalities. The left atrium is mildly dilated. No mass/thrombus is seen in the left atrium or left atrial appendage. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. Aortic valve area is 1.0-1.5 by planimetry, unable to do continuity equation (not able to get good deep TG lax CWD profile).The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Essentially: moderate AS in large man (bsa = 2.45) for CABG NO PFO, normal coronary sinus. Lateral mitral annular tissue Doppler e' = 11 cm/sec. Normal appearing transmitral and pulmonary venous pwd flow profiles. POSTBYPASS: Normal functioning bioprosthetic AV. No AI, No AS. RV with transient dysfunction immediate post pump, impropved with time. Otherwise no change. Electronically signed by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 16164], MD, Interpreting physician [Last Name (NamePattern4) ] [2178-9-28] 12:32 [2178-10-3] 06:40AM BLOOD WBC-5.8 RBC-2.79* Hgb-8.5* Hct-24.7* MCV-88 MCH-30.6 MCHC-34.6 RDW-13.6 Plt Ct-187 [2178-10-3] 06:40AM BLOOD UreaN-22* Creat-0.9 Na-141 K-4.1 Cl-104 Brief Hospital Course: Following admission the usual preoperative workup was undertaken. Dental extraction of # 19 was performed on [9-25]. On [9-28] he was returned to the Operating Room where aortic valve replacement and coronary bypass grafting was undertaken. See operative note for details. He weaned from bypass in stable condition on Neosynepherine and propofol. He weaned from the ventilator eaily and required another 24 hours to wean the pressor. He was transferred to the floor on POD 2. Physical Therapy was consulted for strength and mobility. CTs and temporary pacing wires were removed according to protocol without incident. Beta blockade and diuresis was started when he was hemodynamically stable and adjusted appropriately. Discharge was planned for POD#4 but developed fever to 101. He was pan cultured. WBC was normal. CXR showed atelectasis. He was afebrile for the ensuing 24 period and was cleared for discharge to home on POD# 5. All follow-up appointments were advised. Medications on Admission: ASA 81 daily Fish oil 1200 mg with a meal daily Lisinopril 10 mg daily Zocor 80 daily Medications on transfer: Lisinopril 10 daily, Lipitor 40 daily, Toprol XL 25 mg daily, ASA 81 daily Discharge Medications: 1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 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 for pain, fever. 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:65 Tablet(s) Refills:0 6. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day). Disp:15 Tablet(s) Refills:2 7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: care centrix/ [Hospital3 ] care Discharge Diagnosis: Aortic stenosis coronary artery disease s/p aortic alve replacement s/p coronary artery bypass grafting hypertension obstructive sleep apnea obesity hypercholesterolemia s/p coronary angioplasty Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with percocet Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema 1+ lower extremity edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours Followup Instructions: You are scheduled for the following appointments Surgeon: Dr.[Last Name (STitle) ] ([Telephone/Fax (1) 170]) on [2178-11-4] 1:00pm in the [Hospital ] Medical office building [Last Name (NamePattern1) ]. [Hospital Unit Name ] Please call to schedule appointments with: Primary Care/Cardiologist: Dr. [Last Name (STitle) 29070] ([Telephone/Fax (1) 37284]in [3-17] 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:[2178-10-3]	[ "4241", "5180", "41401", "4019", "32723", "2720", "V4582" ]
Admission Date: [2104-1-20] Discharge Date: [2104-2-19] Date of Birth: [2104-1-20] Sex: F Service: Neonatology HISTORY OF PRESENT ILLNESS: Patient is the 1175 gram-product of a 32-5/7 week twin gestation born to a 22-year-old primiparous mother. This was twin #2 born by spontaneous vaginal delivery. It was an uncomplicated pregnancy until the mother presented to [Hospital3 ] with PPROM and increased blood pressure. The mother was treated with magnesium sulfate, betamethasone, and antibiotics. After transferred to [Hospital1 ] [Name (NI) ], mother progressed to spontaneous vaginal delivery. Patient did well in the delivery room with Apgars of 7 and 8. She required blow-by O2. PHYSICAL EXAM ON ADMISSION: Showed a pink, active, and nondysmorphic infant. Skin was without lesions. Cardiovascular exam showed a normal S1, S2 without murmurs. Pulses were 2+ and equal bilaterally without delay. Lung exam shows sparse crackles bilaterally. Abdomen was benign. Genitalia showed a normal female. Neurologic exam was nonfocal and age appropriate. HOSPITAL COURSE BY SYSTEMS: 1. Respiratory: The patient remained in room air throughout her hospital stay. She had several desaturation episodes in the initial days of her hospitalization, but has not had significant apnea and bradycardia. She was not treated with caffeine or methylxanthine. There is no murmur noted throughout her hospital stay. 2. Fluids, electrolytes, and nutrition: Patient was initially treated with IV fluids and rapidly progressed on p.o. feedings. By the end of the first week, she was on 150/kg of breast milk or premature formula. Currently, she was taking in adlib amounts of breast milk supplemented with NeoSure powder 4 calories/ounce. Her weight was 1895 grams on the day prior to discharge. This is 45 grams from the previous day. 3. Hematologic: CBC on admission showed hematocrit of 59.6 with a white count of 11.7 and 221,000 platelets. She has not required transfusion during her hospital stay. Her hematocrit has not been repeated. 4. Gastrointestinal: Patient was treated with phototherapy during the first week of life. Her maximum bilirubin was 6.5/0.4. Phototherapy was discontinued on [2104-1-28] with subsequent resolution of jaundice. 5. Infectious diseases: CBC on admission showed a well controlled of 11.7 with 41 polys and 1 band. Patient was treated with ampicillin and gentamicin for 48 hour rule out of antibiotics. Patient remained clinically stable after discontinuation of antibiotics. 6. Neurological: Patient had a normal head ultrasound examination on [1-28]. An eye exam on [2-11] showed immature retina in zone 3 bilaterally. A followup was suggested for three weeks. 7. Routine healthcare maintenance: Patient has passed the hearing test on [2-7]. Car seat test ................ Patient received a newborn screening test and no abnormalities have been reported from [Location (un) 511] Regional Newborn Screening Program at this point. There were no Synagis risk factors noted in this infant born at greater than 32 weeks. DISCHARGE DIAGNOSES: 1. Small for gestational age premature infant. 2. Twin gestation. 3. Hyperbilirubinemia. 4. Rule out sepsis. DISCHARGE DISPOSITION: Patient is being discharged home with her parents. FOLLOW-UP APPOINTMENT: Follow-up appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Hospital3 ] Pediatrics, is to be arranged four days following discharge. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 36142], M.D. [MD Number(1) 36143] Dictated By:[Last Name (NamePattern1) 37102] MEDQUIST36 D: [2104-2-18] 10:28 T: [2104-2-18] 10:30 JOB#: [Job Number 52569]	[ "7742" ]
Admission Date: [2142-5-21] Discharge Date: [2142-5-29] Service: MEDICINE Allergies: Valium Attending:[First Name3 (LF) 3556] Chief Complaint: mixed respiratory failure Major Surgical or Invasive Procedure: intubation History of Present Illness: [Age over 90 ]yo man with h/o Parkinson's disease, multiple prior admissions for aspiration pneumonia most recently [2142-4-23], who presents again from [Hospital 100] Rehab after the staff there had "trouble waking him up" this AM, and found him to be in mixed respiratory failure. On the prior admit, the pt was diagnosed with a LLL pna and treated with vancomycin/zosyn. Per his wife, the patient was doing relatively well last week, still in the MACU at [Hospital 100] Rehab since his recent discharge from [Hospital1 18] but with a plan to transition to the regular floor soon. His ABG on [2142-5-16] was 7.34/69/55 on room air, which is close to his baseline pCO2. On Saturday 2d PTA, the pt's wife noted that he was congested more than baseline, initially unable to cough, but then improved after neb treatments with the production of brown-pink secretions. He had hyperglycemia to FS 223, which per wife he has never had before (no h/o DM). By Saturday night though he was doing well, less congested and speaking clearly. Then, Sunday AM, he was congested again and though he received nebs he was not able to cough out the secretions. Per the Pulmonologist note from Sunday PM, he was then found to be poorly arousable, with RR 30, shallow breathing, lungs clear, O2 sat 90% on pulse oximeter. ABG performed, 7.20/107/44, O2 sat 68% on ABG, presumably on room air though unclear. BIPAP was written for (IPAP 16, EPAP 3), though it is not clear if this was started. He was shortly thereafter intubated after the Pulmonologist confirmed his Full Code status with the pt's wife. After intubation, it was noted that he had copious thick yellow secretions in his trachea, which were felt to be the culprit causing obstruction and hypercarbia/hypoxemia. With suctioning his breathing improved, and he was transferred to [Hospital1 18] for further work up. The patient remained awake the whole time. He was noted to have a temp of 100.4F this AM. . Upon arrival to the [Hospital1 18] ED, he appeared to be in no respiratory distress. His initial ABG was 7.34/67/315. He was found to be febrile to 100.4F, with HR 60s-70s, SBPs ranged 60s-80s. His CXR was concerning to the ED staff for RUL/RLL processes (though appears to have only persistent LLL , and he was given CTX, Vanc, and Flagyl out of concern for nosocomial vs. aspiration pna. His urine was leuk esterase (+) on UA, culture pending. Blood cultures were also sent. He received 1L NS for hypotension, and subsequently his pressures were still low so he was started on a dopamine drip via a newly-placed RIJ (per report, sterile placement via ultrasound in the ER). He also had a 18G PIV placed, and has a PICC line from [Hospital ] Rehab that is of unclear age or indication (felt to be from prior need for IV abx). His ECG was notable for Q-wave in V1, ST elevations laterally, concerning for ischemia. TnT 0.10, CK 22, MB not done. Lact 0.6. He was given ASA 325mg PR. His wife confirmed that he is full code. Past Medical History: 1. h/o aspiration PNA - Tx with levo, unasyn, vanco/zosyn in the past 2. h/o aspiration s/p swallow eval with swallowing difficulty, s/p [Hospital 282] placement on [10-9] 3. Parkinson's 4. Osteoporosis 5. T11/12 compression fx 6. LLE osteomyelelitis as a child/Chronic osteomyelitis, quiescent. 7. granulomatous liver disease 8. LUE rotator cuff tear 9. Prostate cancer s/p orchiectomy in [2126] 10. s/p laminectomy L4-5 11. Cataracts s/p surgery [46]. Glaucoma 13. Hypertension Social History: The patient has a sixty-pack-year history of tobacco. He quit in [12/2098]. He lives in a NH for the past 2 years. He is a retired history professor. He reports no alcohol intake. Family History: Non-contributory Physical Exam: PE: VS: T 97 HR 77 BP 124/96 RR 14 O2 100% on vent VENT: AC 550 x14 FIO2 of 50/PEEP 5 GEN: sedated, intubated HEENT: NC/AT, MMM, ET tube in place NECK: supple, no LAD; RIJ presep cath in place without bleeding/hematoma LUNGS: coarse throughout, decreased BS at L base HEART: RR, with 3/6 systolic murmur at the LL-sternal border. ABDOMEN: +b/s, soft, [Last Name (LF) ], [First Name3 (LF) ] in place without erythema or discharge EXTREMITIES: 1+ pitting edema bilat. Ext warm. PICC in R upper arm, PIV in R forearm Pertinent Results: Upon admission: [2142-5-21] 5.3 >-------<205 30.5 133 \| 99 \| 29 \| ---------------<134 4.8 \| 32 \| 0.6\| Lactate: 0.6 Cardiac enzymes negative. Cultures: [2142-5-22] 1:36 am SPUTUM Source: Endotracheal. FINAL REPORT [2142-5-24] GRAM STAIN (Final [2142-5-22]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Final [2142-5-24]): RARE GROWTH OROPHARYNGEAL FLORA. YEAST. SPARSE GROWTH. [2142-5-21] 10:45 am URINE Site: CLEAN CATCH FINAL REPORT [2142-5-22] URINE CULTURE (Final [2142-5-22]): YEAST. 10,000-100,000 ORGANISMS/ML.. [2142-5-21] Blood: Negative Studies: [2142-5-21] 10:22 EKG: NSR at 65 with freq PACs, LAD, normal intervals, Q in II/III/aVF, poor R-wave progression, 0.5mm ST elev in I,aVL,V1-V3, TWI in III. C/t prior ECG [2142-5-2], Q waves old, poor R-wave prog old, ST elev new. . [2142-5-21] CXR: INDICATIONS: [Age over 90 ]-year-old man with Parkinson's disease, pneumonia, and left effusion, intubated. CHEST, AP SUPINE: Comparison is made to [2142-5-2]. The patient is now intubated. The endotracheal tube terminates approximately 4 cm above the carina near the thoracic inlet. The lung volumes are low. The cardiac and mediastinal contours are similar. Markedly calcified subcarinal lymphadenopathy is again noted. There is persistent left lower lobe opacity with an effusion, as well as a new mild congestive heart failure or pulmonary venous hypertension. IMPRESSION: 1. Status post endotracheal intubation. 2. Persistent left lower lobe opacity. 3. Mild congestive heart failure or fluid overload. . [2142-5-21] AXR: Single supine AP: Part of the left hemipelvis is not included in the study. The study is also centered around the pelvis rather than including the whole abdomen. The visualized portion of the abdominal cavity demonstrate normal bowel gas pattern with stool noted within the ascending colon and sigmoid colon. The bone and soft tissues structures are unremarkable. IMPRESSION: No acute abdominal pathology is identified. No evidence of obstruction or free intra-abdominal air is noted. . [2142-5-26] CXR: Worsening right lower lobe opacity, suspicious for pneumonia. Brief Hospital Course: [Age over 90 ] yo M with h/o aspiration PNA, swallowing difficulty, parkinsons, who p/w acute hypercarbic respiratory failure. [Age over 90 3553] followed by stress EKG negative for ischemia. Patient extubated [2142-5-27] and is planned to transition to [Hospital 100] Rehab [2142-5-29]. . 1. Respiratory Failure: mixed hypercarbia and hypoxemia likely from mucus plugging in setting of poor reserve from underlying restrictive lung disease and LLL pna. He has a history of hypercarbia possibly due to neuromuscular weakness of respiratory muscles due to Parkinsons. CTA neg for PE. . During his stay the patient has an 8 day antibiotic treatment for nosocomial PNA with ceftaz and vancomycin as he was found to have gram positive cocci in pairs in his sputum. He continued on his albuterol and ipratroprium nebulizers on nasal cannula. A neurology consult on [2142-5-28] suggested that the patient should see neuromuscular in follow up and a decision can be made at that time whether any further EMG studies are needed but no further eval at this time with regards to investigating a neuromuscular source of his hypercarbia. In addition the patient had transient pulmonary edema that improved with lasix admiinstration. . While in house, the patient was given an overnight trial of BIPAP as the patient is chronically hypercarbic with weak respiratory muscles secondary to Parkinson's disease. While he did not tolerate the procedure well we believe that he may benefit from a repeated trial when he is healthier 2-3 months discharge. . 2. Parkinsons: The patient was continued on his home regimen of Parkisons medication including cabidopa/levidopa and mirapex while in house . 3. Glaucoma: The patient was continued on his home regimen of drops. . 4. Hypertension: Controlled with lisinopril 20 and lasix as needed. . 5. Osteoporosis: Osteoporosis drugs were held during this admission. The patient should be reevaulated for possibly re-starting an anti-osteoporosis regimen as an outpatient. . 6. Chest pain: The patient described chest pain but had a negative EKG. It improved during his hospital stay and a spontaneous breathing trial followed by stress EKG to evaluate for ischemia was negative. Medications on Admission: -Insulin SS q6h prn -Ipratropium nebs q6h -Lisinopril 10mg qday -MVI qday -Hydrocodone-Acetaminophen 1 TAB PO Q6H:PRN -Senna 2 TAB PO QHS -Fexofenadine 60 mg PO BID -Fluticasone Propionate NASAL 1 SPRY NU [Hospital1 ] -Entacapone 200 mg Q 5Am, 8AM, 11Am, 2PM, 5PM, 8PM, 11PM -Pramipexole 0.125 mg Q 5AM, 8AM, 11AM, 2PM, 5PM, 8PM -Pramipexole 0.1875 mg @ 11PM qday -Carbidopa-Levodopa (25-100) 2 TAB PO Q5AM, 8AM, 11AM, 2PM, 5PM, 8PM, 11PM -Docusate Sodium (Liquid) 100 mg PO BID -Omeperazole 20mg PO Q24H -Artificial Tears 1 DROP BOTH EYES TID -Chlorhexidine Gluconate 15 ml PO BID -Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS -Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES [Hospital1 ] -Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN -Calcium/Vit D 500mg [Hospital1 ] -Hep 5000 SQ TID Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [Hospital1 ]: One (1) injection Injection TID (3 times a day). 2. Hexavitamin Tablet [Hospital1 ]: One (1) Cap PO DAILY (Daily). 3. Carbidopa-Levodopa 25-100 mg Tablet [Hospital1 ]: Two (2) Tablet PO 7X/D (). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: One (1) Tablet, Delayed Release (E.C.) PO once a day. Tablet, Delayed Release (E.C.)(s) 5. Latanoprost 0.005 % Drops [Hospital1 ]: One (1) Drop Ophthalmic HS (at bedtime). 6. Polyvinyl Alcohol 1.4 % Drops [Hospital1 ]: 1-2 Drops Ophthalmic TID (3 times a day). 7. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: [12-5] PO BID (2 times a day). 8. Lisinopril 20 mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 9. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [Month/Day (2) ]: Two (2) nebs Inhalation Q4H (every 4 hours) as needed. 10. Calcium Carbonate 500 mg Tablet, Chewable [Month/Day (2) ]: One (1) Tablet, Chewable PO BID (2 times a day). 11. Cholecalciferol (Vitamin D3) 400 unit Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 12. Entacapone 200 mg Tablet [Month/Day (2) ]: One (1) Tablet PO 7x/day (). 13. Ipratropium Bromide 0.02 % Solution [Month/Day (2) ]: Two (2) nebs Inhalation Q6H (every 6 hours). 14. Lactulose 10 g/15 mL Syrup [Month/Day (2) ]: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 15. Aspirin 325 mg Tablet [Month/Day (2) ]: One (1) Tablet PO DAILY (Daily). 16. Fluticasone 50 mcg/Actuation Aerosol, Spray [Month/Day (2) ]: One (1) Spray Nasal [Hospital1 ] (2 times a day). 17. Pramipexole 0.125 mg Tablet [Hospital1 ]: One (1) Tablet PO six times per day (). 18. Dorzolamide-Timolol 2-0.5 % Drops [Hospital1 ]: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 19. Senna 8.6 mg Tablet [Hospital1 ]: 1-2 Tablets PO BID (2 times a day). 20. Fexofenadine 60 mg Tablet [Hospital1 ]: One (1) Tablet PO BID (2 times a day). 21. Pramipexole 0.125 mg Tablet [Hospital1 ]: 1.5 Tablets PO qday (). 22. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital3 ] Center Discharge Diagnosis: respiratory failure aspiration pneumonia parkinson's disease anemia chronic respiratory failure Discharge Condition: stable Discharge Instructions: Please take your medications as prescribed. If you develop shortness of breath, fever, or any other concerning symptoms please contact a health care provider [Name Initial (PRE) 2227]. Followup Instructions: Provider: [Name10 (NameIs) 3557] [Name8 (MD) 3558], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2142-6-4] 2:30 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 44] Date/Time:[2142-7-9] 9:30 [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3559] MD, [MD Number(3) 3560] Completed by:[2142-5-29]	[ "5070", "2762", "2859", "4019", "42789" ]
Admission Date: [2160-10-8] Discharge Date: [2160-10-11] Date of Birth: [2094-1-20] Sex: M Service: MEDICINE Allergies: Iodine / Shellfish Attending:[First Name3 (LF) 3984] Chief Complaint: Respiratory Failure Major Surgical or Invasive Procedure: Endotrachial intubation Triple Lumen Central Venous Line Placement Arterial Line Placement Bronchoscopy History of Present Illness: 66 year old gentelman, with DM, CAD, chronic Afib, hiatal hernia, [Last Name (un) ] esophagus with mutliple esophageal dilatations who had robotic prostatectomy for T1C prostate adenocarcinoma on [2160-9-18] at OSH. During the surgery he lost about 150 cc blood however post-op he became anemic and had exp-lap on [9-20] for evacuation of clots and hemostatis. Post-op he developed prolonged ileus for which NG tube placement was difficult [1-23] large hiatal hernia. Ileus eventually resolved. PEG was considered (alb 1.6), however anesthesia at OSH considered him high risk and thought of Dobhoff. After dobhoff was placed unsuccessfully [10-4], he started to have upper airway bleeding requiring intubation. He was on lovenox for DVT prophylaxis, and after 1 dose of coumadin for chronic Afib, INR 2.36). CXR showed stable ARDS [Date range (1) 79119]. He required multiple transfusions during his stay. His last Hct was 24.3 and received 2 units at the time of transfer to [Hospital1 18]. His Last INR 1.44. . His plt dropped from 166 on [9-27] to 40 on [10-7]. Received plt transfusion morning of [10-8] and plt was up to 62. HIT antibodies and SRA test were sent. Heme consult at OSH thought it was most likely due to lovenox which was stopped [10-5]. Also, regarding his 4 blasts on his differentials of count, heme consult at OSH thought it is most likely a leukomoid reaction but could not exclude underlying hematological malignancy. they sent [10-8] flow cytometry that is still pending. . Due to repeat bleed from his upper airway he was rebronched and new ETT was placed. . Post-op he also developed pneumonia for which he was placed on vanc, ceftaz. On [10-6] ID thought there is no active pneumonia anymore, stopped tobra, and recommended completing ceftaz [10-3] days. His bronch cultures from [10-4] are negative so far. . Also post-op, he had Afib with RVR that required IV dilt and esmolol and digoxin. Lung nuclear scan did not show PE. Echo on [9-24] showed EF 55%, Aortic thickening but no stenosis, mikld MR, LAE, normal wall motion. Off dilt IV now. . Nutrition: on TPN for the last 4 days came on PSV, Fio2 60%, TV 650, RR 18, PEEP 8. on propofol for sedation. Past Medical History: HL Afib HTN CAD DM Hypothyroidism Acoustic Neuroma Bell's palsy Hiatal hernia GERD OA Depression Social History: Married with adult children. Lives in [Location 686] Family History: No family h/o hematological malignancy Physical Exam: Admission Phsyical Exam: Vitals: T: 99.8 BP: 134/84 P: 98 irregular R: [12-4] O2: 100% General: intubated, sedated, not responding to voice, sternal rub, resisted opening left eye, moved left eyebrow when name called. Did not follow commands. HEENT: Sclera anicteric, MM relatively dry, oropharynx seems clear, but intubated. Right eye open Neck: supple, JVP not elevated, no LAD, right IJ Lungs: good air entry bilaterally anteriorly and axillary, with faint insp rhonchi bilaterally, no crackles. reduced breath sounds on right side CV: irregular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, no palpable masses or organomegaly. surgical clean wounds with steristrips, echymotic patch at left and right lower quadrant, non-distended, bowel sounds present Ext: 1+ pulses, slight pitting edema bilaterally up to knees, right UE PICC . Ventilator: PS 15 PEEP 8 FiO2 50% TV 800-1000 cc RR 12-15 Pertinent Results: [2160-10-8] 04:12PM BLOOD WBC-14.1* RBC-3.74* Hgb-11.2* Hct-32.3* MCV-86 MCH-29.9 MCHC-34.7 RDW-18.3* Plt Ct-70* [2160-10-8] 04:12PM BLOOD PT-14.7* PTT-36.5* INR(PT)-1.3* [2160-10-9] 02:26PM BLOOD FDP->1280* [2160-10-9] 02:26PM BLOOD Fibrino-345 [2160-10-8] 04:12PM BLOOD Glucose-161* UreaN-50* Creat-1.0 Na-140 K-3.9 Cl-105 HCO3-26 AnGap-13 [2160-10-8] 04:12PM BLOOD ALT-69* AST-88* LD(LDH)-2700* AlkPhos-110 TotBili-1.7* [2160-10-8] 04:12PM BLOOD Albumin-2.3* Calcium-7.1* Phos-3.0 Mg-2.0 [2160-10-9] 02:26PM BLOOD Hapto-170 [2160-10-9] 01:00AM BLOOD TSH-11* [2160-10-9] 01:00AM BLOOD Free T4-0.66* [2160-10-8] 04:32PM BLOOD Lactate-1.6 MICRO [2160-10-11] Blood Culture, Routine-PENDING-NGTD [2160-10-10] CATHETER TIP-IV WOUND CULTURE-PENDING-NGTD [2160-10-10] Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture-PENDING; Respiratory Viral Antigen Screen-PENDING; VIRAL CULTURE: R/O CYTOMEGALOVIRUS-PENDING [2160-10-10] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-PRELIMINARY; POTASSIUM HYDROXIDE PREPARATION-FINAL; Immunoflourescent test for Pneumocystis jirovecii (carinii)-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY; ACID FAST SMEAR-PRELIMINARY; ACID FAST CULTURE-PRELIMINARY [2160-10-10] URINE CULTURE-PENDING-NGTD [2160-10-10] Blood Culture, Routine-PENDING-NGTD [2160-10-10] Blood Culture, Routine-PENDING-NGTD [2160-10-9] URINE CULTURE-PENDING-NGTD [2160-10-9] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-PRELIMINARY [2160-10-8] URINE CULTURE-FINAL-Negative [2160-10-8] Blood Culture, Routine-PENDING-NGTD [2160-10-8] Blood Culture, Routine-PENDING-NGTD IMAGING: CT CHEST, ABD & PELVIS W/O CONTRAST ([2160-10-8]) 1. Heterogeneous but widespread opacities in each lung, predominantly of ground glass attenuation. Major differential considerations include multifocal pneumonia, although other processes could be considered such as heterogeneous involvement with edema, respiratory distress syndrome or even hemorrhage in the appropriate clinical setting. 2. Extensive left lower lobe atelectasis with mucus plugging and hyperdense material, potentially due to aspiration of barium or other hyperdense substance. 3. Large hiatal hernia. 4. Cholelithiasis. 5. Minimal colonic wall thickening, which can probably be explained in the setting of widespread edema. 6. Fluid collections in the pelvis which would be compatible with resolving hematomas. 7. Small nodule in the anterior subcutaneous fat of the right lower quadrant, probably benign, but correlation with physical findings and attention in follow-up is suggested. CT HEAD W/O CONTRAST ([2160-10-8]) 1. No acute intracranial hemorrhage or mass effect . Large area of hypodensity in the right cerebellar hemisphere adjacent to the remote craniotomy, presumably prior insult; correlate with history. If there is continued concern for parenchymal changes and acute infarcs, MRI is more sensitive and can be considered if not contra-indicated. 2. Left mastoid air cells -opacification from fluid/mucosal thickening. TTE ([2160-10-9]) Suboptimal image quality due to body habitus. Overally left ventricular ejection fraction is normal, a focal wall motion abnormality cannot be excluded. The right ventricle is not well seen but is probably normal. No significant valvular abnormality. Mildly elevated pulmonary artery systolic pressure. Dilated thoracic aorta. Brief Hospital Course: Patient was transferred from OSH for further management of his respiratory failure and increasing leukocytosis and blast forms. Upon arrival, the patient was intubated and sedated. A bone marrow biopsy was obtained, the final results of which remain pending. The preliminary read reported dysplasia with approximately 30% blasts. A head CT was performed that showed a large area of hypodensity in the right cerebellar hemisphere adjacent to the remote craniotomy (acoustic neuroma). A MRI of the head was planned to better evaluate the posterior fossa, however it was determined that the patient was too unstable to leave the floor after an episode of tachycardia and tachypneic followed by bradycardia. The patients foley was replaced and began to drain dark bloody urine with clots. It flushed easily, confirming its placement in the bladder. Urology was consulted and felt that a clot from his previous procedure may have been dislodged and that the bladder should be hand irrigated. A renal ultrasound did not reveal hydronephrosis. The following day, the patient's labs continued to be consistent with ARDS/[Doctor Last Name ] and he was placed on ARDSnet protocol ventilation. He had some difficulty tolerating the vent settings, and had to have an increase in his tidal volume transiently. A bronchoscopy was done which revealed bloody fluid in the left lower lobe. The patient had difficulty maintaining his oxygen saturation and appeared dyssynchronous with the vent, even with the higher tidal volumes. It was decided that it order to better ventilate his lungs, he would require the lower tidal volumes and he was paralyzed. During this time, the patient also began to be hypotensive and required pressors. Over the course of the evening, he became increasing acidotic requiring bicarbonate. His conditioned continued to deteriorate and he became anuric. He became asystolic around 710am and it was felt hat CPR was not medically indicated. As the family was [Name (NI) 653], ACLS was initiated as the decision to stop resuscitation was made. Resuscitation was then stopped and the patient was taken off the ventilator. Time of death was 715 am. Medications on Admission: Medications on transfer: insulin sliding scale methylpred. 40 mg q12hr IV furosemide 40 mg IV PRN propofol drip pantoprazole 40 mg IV metochlopramide 10 IV q6hr digoxin 0.125 IV calcium carbonate 500 TID ceftaz 2g iv q8hr to finish on [10-12] TPN Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438]	[ "486", "5849", "2762", "25000", "42731", "2449", "53081", "4019", "2859", "311" ]
Admission Date: [2128-3-19] Discharge Date: [2128-4-2] Date of Birth: [2071-6-8] Sex: M Service: CARDIOTHORACIC Allergies: Codeine Attending:[First Name3 (LF) 1505] Chief Complaint: Cardiac arrest Major Surgical or Invasive Procedure: [2128-3-24] Aortic Valve Replacement(21mm St. [Male First Name (un) 923] Mechanical Valve) and Single Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to the left anterior descending. [2128-3-22] Cardiac catherization History of Present Illness: Mr. [Known lastname 66956] is a 56 yo man who presents as a transfer after sustaining a cardiac arrest during an exercise tolerance test. He reports that at the start of the ETT, he began to get dizzy. This was followed by chest pain and then LOC. Per report, the pt was hypotensive and bradycardic, then had an asystolic arrest. He fell onto the treadmill. CPR was initiated, and the pt had rapid ROSC (3-5 minutes). By the time of EMS arrival, he was awake and alert. Upon arrival to the OSH, he was in atrial fibrillation with RVR. He received a total of 20 mg of IV metoprolol and converted to sinus rhythm. He underwent pan-CT scan, which did not demonstrate any significant injuries. He was transiently on a heparin drip. An echocardiogram reportedly demonstrated [First Name8 (NamePattern2) ] [Location (un) 109] of 0.8 cm2 with a peak gradient of 62 mm Hg and a mean gradient of 41 mmHg. He reports worsening exercise tolerance and progressive exertional angina over the past few months. He had a nose bleed after his arrest today, but has otherwise not had any bleeding events. Past Medical History: Bicuspid aortic valve with severe aortic stenosis Coronary Artery Disease s/p DES to mid-LAD in [2124] Dyslipidemia Social History: Active smoker, smokes 1 ppd, 20+ PY smoking history. Drinks EtOH on weekends, not to excess. Denies drug abuse. Lives with girlfriend. Family History: No family history of early MI, otherwise non-contributory. Physical Exam: VS: 37.2, 84, 109/80, 16, 96% GENERAL: Obese man, NAD, pleasant, appropriate, cooperative HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 6 cm. CARDIAC: III/VI systolic murmur heard best at the RUSB, relatively late peaking, no loss of S2, radiates to clavicle. No audible diastolic murmur. CHEST: tender over anterior L lower rib cage LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Obese, soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: Mild chronic venous stasis changes PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: [2128-3-19] 10:50PM BLOOD WBC-9.0 RBC-3.95* Hgb-13.1* Hct-36.0* MCV-91 MCH-33.2* MCHC-36.4* RDW-13.2 Plt Ct-131* [2128-3-19] 10:50PM BLOOD PT-13.0 PTT-24.5 INR(PT)-1.1 [2128-3-19] 10:50PM BLOOD Glucose-113* UreaN-14 Creat-0.9 Na-136 K-3.9 Cl-103 HCO3-24 AnGap-13 [2128-3-19] 10:50PM BLOOD CK(CPK)-573* [2128-3-19] 10:50PM BLOOD CK-MB-37* MB Indx-6.5* cTropnT-0.67* [2128-3-19] 10:50PM BLOOD Calcium-8.6 Phos-3.3 Mg-1.9 [2128-3-22] 02:45PM BLOOD %HbA1c-5.9 [2128-3-22] Cardiac Cath: 1. Coronary angiography of this left dominant system revealed 1 vessel coronary disease. The LMCA was short and had no angiographically apparent coronary disease. The LAD had a 90% stenosis proximal to the prior Cypher stents. The remainder of the LAD was without angiographically significant disease. The LCX was patent but there was a 30-40% stenosis at the origin of OM1. The RCA was small and without significant disease. 2. Resting hemodynamics revealed mildly elevated right-sided filling pressures and moderately elevated left-sided filling pressures. The RA mean was 21 mm Hg, RVEDP 21 mm Hg, PASP 47 mm Hg with a mean of 33 mm Hg, and a PCWP of 21 mm Hg. The cardiac output was 5.0 and index 2.3 l/min/m2. 3. Left ventriculography was deferred. 4. The aortic valve was not crossed as it was known to be critically stenosed. [2128-3-22] Carotid Ultrasound: Less than 40% stenosis of the bilateral internal carotid arteries. [2128-3-23] Chest CT Scan: 1. Thoracic aorta normal in caliber throughout, without evidence of aneurysm. Aortic diameter measurements are listed above. 2. Multiple noncalcified sub 5 mm pulmonary nodules are seen throughout the lungs. Recommend follow up in one year. 3. Subtle bronchial irregularities, compatible with chronic airway disease. 4. No evidence of acute cardiopulmonary process. Normal cardiac size. Calcified aortic valves. Stent in proximal LAD. Conclusions A patent foramen ovale is present. There is moderate symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Mild to moderate ([12-19]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. PRELIMINARY REPORT Not reviewed/approved by the Attending Anesthesia Physician. POSTBYPASS Patient is on a phenylephrine infusion. A well seated, well functioning mechanical valve seen in the aortic position. No perivalvular leaks. Max grad is 50 mmHg with a mean gradient of 36 mmHg. LV looks underfilled. LV EF is similar at 60%. Aortic contour is smooth after decannulation. Electronically signed by [First Name8 (NamePattern2) 6506] [Name8 (MD) 6507], MD, Interpreting physician [Last Name (NamePattern4) ] [2128-4-1] 10:59 ?????? [2121] CareGroup IS. All rights [2128-4-2] 06:05AM BLOOD WBC-8.0 RBC-3.05* Hgb-9.1* Hct-27.7* MCV-91 MCH-30.0 MCHC-33.0 RDW-13.9 Plt Ct-372 [2128-4-2] 06:05AM BLOOD Plt Ct-372 [2128-4-2] 06:05AM BLOOD PT-32.2* PTT-30.6 INR(PT)-3.3* [2128-4-2] 06:05AM BLOOD Glucose-99 UreaN-17 Creat-1.2 Na-138 K-5.0 Cl-101 HCO3-30 AnGap-12 [2128-3-22] 02:45PM BLOOD ALT-35 AST-28 AlkPhos-60 TotBili-0.7 [2128-4-2] 06:05AM BLOOD Mg-2.1 [2128-3-20] 05:04AM BLOOD CK-MB-25* MB Indx-4.6 cTropnT-0.62* Brief Hospital Course: Mr. [Known lastname 66956] was admitted to the medical ICU. Cardiac biomarkers were initially elevated but improved over several days. He remained stable on medical therapy. On [3-20], he underwent cardiac catheterization whgich revealed AS and LAD disease.Referred to Dr. [First Name (STitle) ] and underwent surgery on [3-24]. Transferred to the CVICU in stable condition on titrated propofol and phenylephrine drips. Extubated the following morning. Went back into A fib and was treated with amiodarone. Chest tubes removed on POD #2.Transferred to floor on POD #4 to begin increasing his activity level. Coumadin anticoagulation started for intermittent A fib. EP consulted and amiodarone discontinued with further titration of beta blockade. Cleared for discharge to home on POD #9. Target INR 2.0-2.5. Coumadin to be followed by Dr. [Last Name (STitle) 29070]. Medications on Admission: Aspirin 81 daily Clopidogrel 75 daily Atorvastatin 40 daily Atenolol 50 daily Omeprazole 20 daily Fish Oil 1000 daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:0 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 3. Outpatient [Name (NI) ] Work PT/INR for coumadin dosing with goal INR 2.5-3.0 for mechanical aortic valve with first draw [4-4] sunday with results to cardiac surgery [Telephone/Fax (1) 170] after that to be followed by Dr [Last Name (STitle) 66588] - office # [Telephone/Fax (1) 37284] fax [Telephone/Fax (1) 66957] with draw tuesday [4-6] with results to Dr [Last Name (STitle) 66588] 4. Warfarin 2 mg Tablet Sig: goal INR 2.5-3.0 Tablets PO once a day: please adjust dose as instructed . Disp:60 Tablet(s) Refills:0 5. Warfarin 5 mg Tablet Sig: goal INR 2.5-3.0 Tablets PO once a day: please adjust dose as instructed . Disp:60 Tablet(s) Refills:0 6. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:60 Tablet(s) Refills:0 9. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day): to bilateral feet . Disp:qs qs Refills:0 10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:60 Tablet Sustained Release 24 hr(s) Refills:0 11. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 12. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 13. Outpatient [Hospital1 ] Work coumadin please take 5 mg on saturday [4-3], VNA will come sunday and check [Month/Year (2) ] - calling the cardiac surgery office for dosing because Dr [Last Name (STitle) 66588] office will be closed Discharge Disposition: Home With Service Facility: All Care VNA of Greater [Location (un) ] Discharge Diagnosis: Coronary artery disease s/p Coronary Artery Bypass Grafting Bicuspid Aortic Valve s/p Aortic valve replacement Atrial Flutter post op Atrial fibrillation preoperative Cardiac Arrest at outside hospital Acute diasystolic heart failure Dyslipidemia Lung Nodules Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Heart monitor for evaluation of rhythm - please press button if feel fast heart rate or at least once a day and call in as instructed PT/INR for coumadin dosing with goal INR 2.5-3.0 for mechanical aortic valve with first draw [4-4] sunday with results to cardiac surgery [Telephone/Fax (1) 170] after that to be followed by Dr [Last Name (STitle) 66588] - office # [Telephone/Fax (1) 37284] fax [Telephone/Fax (1) 66957] Followup Instructions: Please call to schedule appointments Dr. [Last Name (STitle) 29070] in 1 week [Telephone/Fax (1) 37284] Dr. [Last Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] [Doctor Last Name ] of hearts monitor being followed by EP service Dr [Last Name (STitle) ] call holter [Last Name (STitle) ] with questions [Telephone/Fax (1) 3104], to call in daily with [Location (un) 1131] as instructed PT/INR for coumadin dosing with goal INR 2.5-3.0 for mechanical aortic valve with first draw [4-4] sunday with results to cardiac surgery [Telephone/Fax (1) 170] after that to be followed by Dr [Last Name (STitle) 66588] - office # [Telephone/Fax (1) 37284] fax [Telephone/Fax (1) 66957] with draw tuesday [4-6] with results to Dr [Last Name (STitle) 66588] Completed by:[2128-4-13]	[ "4241", "9971", "4280", "41401", "42731", "2724", "V4582", "53081" ]
Admission Date: [2183-3-12] Discharge Date: [2183-3-21] Date of Birth: [2141-5-14] Sex: F Service: CHIEF COMPLAINT: Mrs. [Known lastname 5655] is a 41-year-old woman with a history of systemic lupus erythematosus, hypertension and BOOP, who came to the Emergency Department on [2183-3-12] for cough of two weeks duration and subsequently went into hypoxic respiratory arrest, was intubated, and transferred to the Medical Intensive Care Unit. HISTORY OF PRESENT ILLNESS: Over the two weeks prior to admission, Mrs. [Known lastname 5655] complained of increasing shortness of breath with a cough productive of yellow sputum, flecked with blood. She denied any chills, fever, chest pain or headache. Shortly before admission, she was unable to walk more than eight feet without having to rest and catch her breath. She decided to come to the Emergency Department when she was unable to walk up a flight of stairs without extreme shortness of breath. While at the Emergency Department, Mrs. [Known lastname 5655] got up to go to the bathroom, and on her return to her stretcher experienced a hypertensive crisis with systolic blood pressure in the 190s and a heart rate greater than 140. She became tachypneic, short of breath, confused and pulse oximetry could not be obtained. She continued to be very short of breath on 100% nonrebreather. She was intubated for presumed respiratory failure and transported to the Medical Intensive Care Unit. PAST MEDICAL HISTORY: 1. Systemic lupus erythematosus, diagnosed in [2173] with AWA/ds-DNA/anti-[Doctor Last Name ] positivity. 2. Lupus nephritis - membranoproliferative glomerulonephritis. 3. Hemolytic anemia. 4. Thrombocytopenia. 5. Lupus cerebritis. 6. Lupus peritonitis, [2179-1-6]. 7. Pleuritis. 8. Arthritis. 9. Raynaud's syndrome. 10. BOOP in [2179-9-6]. 11. Hypertension. 12. Salmonella bacteremia in [2182-7-6]. 13. TTP - HUS. 14. Membranous glomerulonephritis with a necrotizing component and focal crescent formations, mixed Type III/V lupus erythematosus. SOCIAL HISTORY: Patient lives in [Location 669] with her brother. She works part time as a tax accountant. She has a negative tobacco history. She stopped drinking alcohol in [2170]. She denies any other drug use. She is not currently sexually active. FAMILY HISTORY: The patient's mother died of lupus at the age of 47. She does not know her father well and is unable to report on his health history. She has seven brothers and sisters. Two of her brothers have alcoholism. One sister has insulin dependent diabetes mellitus. There is no significant family history of cancer, asthma or heart disease. ALLERGIES: Haldol - acute dystonic reaction. Sulfa - hives and shortness of breath. Biaxin. MEDICATIONS ON ARRIVAL AT THE EMERGENCY DEPARTMENT: Lopressor 50 mg b.i.d., Zestril 5 mg q.d., prednisone 5 mg q.d., aspirin 81 mg q.d., Lipitor 20 mg q.d., Prilosec 20 mg q.d., Nephrocaps. REVIEW OF SYSTEMS: Chronic constipation, treated with Colace. Joint pain significantly worse in winter time with Raynaud's. No history of chest pain or palpitations. PHYSICAL EXAM ON ADMISSION TO THE MEDICAL INTENSIVE CARE UNIT: General: intubated, sedated, middle-aged woman. Vital signs: Blood pressure 140/90. Heart rate 130. Temperature 99.1. Head, eyes, ears, nose and throat: pupils equal, round and reactive to light. Sclerae are anicteric. Neck, supple, no LAD. Chest: bilateral breath sounds anteriorly. No wheezing. Coarse bilateral breath sounds throughout. Inspiratory crackles. Cardiovascular: tachycardic rhythm, no murmurs. Abdomen: soft, nontender, nondistended, normal active bowel sounds. Light brown guaiac negative stool. Extremities: warm without edema. Neuro: Babinski downgoing bilaterally. Sedated. Symmetric reflexes. LABORATORIES VALUES ON ADMISSION: White blood cell count 2.6, differential 57 neutrophils, 2 basophils, 25 lymphocytes, 9 macrophages. Hematocrit 28.2, platelets 142,000. MCV 82. Sodium 138, potassium 3.7, chloride 98, bicarbonate 28, BUN 27, creatinine 7.1, glucose 82. Urinalysis: small amount of blood. Greater than 300 protein. 2 red blood cells, 1 white blood cell, 20 epithelial cells. Electrocardiogram, sinus tachycardia. Rate 110, normal axis. TWI, V4 through V6, lead I. HOSPITAL COURSE: While in the Emergency Department, Mrs. [Known lastname 5655] received nitroglycerin paste, Lasix 80 mg intravenous, 500 mg levofloxacin, heparin per protocol, Versed 1-2 mg per hour via IV drip. After intubation in the Emergency Department, Mrs. [Known lastname 5655] received a bedside echocardiogram which showed severe left ventricular systolic functional depression and a small loculated pericardial effusion. Right ventricular diastolic collapse was present consistent with impaired filling and tamponade. A chest x-ray at the time showed congestive heart failure with pulmonary edema, although pneumonia could not be excluded. An electrocardiogram revealed T wave inversions laterally. Mrs. [Known lastname 5655] then underwent CT angiography for pulmonary embolus which was negative; however, the CT showed fluid overload with left and right pleural effusions and pulmonary edema. After intubation and in the Medical Intensive Care Unit, Mrs. [Known lastname 5655] was initially placed on SIMV plus PFs, but was not well sedated and had rapid respiration rate. An arterial blood gas at the time post intubation was 7.18/55/76. The patient was switched to ACV/500/14/FIO2 100% with PEEP of 7.5. Arterial blood gases then was 7.24/56/57. Initial differential diagnosis at the time of admission to the Medical Intensive Care Unit was infectious community- acquired pneumonia versus lupus pneumonitis versus flash pulmonary edema or congestive heart failure. During her stay in the Medical Intensive Care Unit, Mrs. [Known lastname 5655] showed rapid improvement. On [3-12], she was started on Solu-Medrol intravenous 80 mg q. 8 hours, Lasix 40 mg q.d. and levofloxacin 500 mg q.d. By [3-14], Solu-Medrol had been changed to 60 mg intravenous q. 8 hours. By [3-15], to 40 mg intravenous q. 8 hours. She continued with Lasix at 40 mg q.d. and levofloxacin at 500 mg q.d. Mrs. [Known lastname 5655] was extubated on [3-14] with adequate 02 saturation. By [3-15], a chest x-ray showed significant interval improvement of pulmonary edema with an accompanying decrease in the size of her pleural effusions. Mrs. [Known lastname 5655] was then discharged to the Medicine [Hospital1 ] on [3-15]. PHYSICAL EXAMINATION ON ADMISSION TO THE MEDICINE FLOOR: Vital signs, temperature 98.6. Heart rate 105 with a maximum of 117. Blood pressure 142/98 with a maximum systolic blood pressure of 162 and a minimum of 109 in a 24-hour period. Respiratory rate 18 to 20 breaths per minute. 02 saturation 99-100% on two liters 02. General: middle-aged African American woman sitting quietly in bed, applying makeup and talking on the phone while eating. Head, eyes, ears, nose and throat: oropharynx pink, no injection. Cervical range of motion limited by IJ line, right neck. No sinus tenderness. No auricular, submandibular, cervical or clavicular LAD. Pulmonary: rales at the right base and 1/3 up from the base on the left. No dullness on percussion. No accessory muscle use. No wheezes. Cardiovascular: regular rate and rhythm. S1, S2 auscultated. No murmurs, rubs or gallops. Pulses 2+ at carotids and femorals. Palpable pulses at radials and bilateral dorsalis pedis pulses. No jugular venous distention. No carotid or abdominal aortic bruits. Abdomen: soft, no organomegaly, no masses palpated. Right upper quadrant tenderness at palpation with positive [Doctor Last Name 515] sign, positive bowel sounds. Extremities: cool, dry without edema. Dermatology: no visible petechia or other lesions. Lymph: palpable 1 cm x 1 cm lymph node in right axilla. No LAD in left axilla. No inguinal LAD. Neuro: cranial nerves II through XII are grossly intact. Pupils equal, round and reactive to light. Strength: 4+/5 in upper extremities and lower extremities bilaterally. Reflexes: [1-9] in triceps bilaterally, [2-9] in biceps and brachioradialis bilaterally. [2-9] in quadriceps bilaterally, 0/4 in ankle jerks. Downgoing toes Babinski. Sensation: sensation to light touch intact in upper and lower extremities. Cerebellar signs: finger-to-nose and finger tapping within normal limits. MEDICATIONS ON ADMISSION TO MEDICINE FLOOR: Nephrocaps 1 tab po q.d., levofloxacin 250 mg po q.o.d., enteric-coated aspirin 325 mg po q.d., Lopressor 50 mg po b.i.d., Nifedipine 20 mg po t.i.d., Zantac 150 mg po q.d., Solu-Medrol 40 mg intravenous t.i.d., captopril 7.5 mg po b.i.d., Tylenol 650 mg po q. 4-6 hours prn pain, Tums 2 tabs po q.a.c. LABORATORY VALUES ON ADMISSION TO THE MEDICINE FLOOR: White blood cell count 13.7, hematocrit 32, platelets 168,000. MCV 81. RDW 19.0. Sodium 139, potassium 5.2, chloride 99, bicarbonate 20, BUN 60, creatinine 7.1, glucose 125, calcium 8.4, magnesium 2.4, phosphorus 6.0. Cardiac enzymes were cycled through to rule out myocardial infarction. Troponin values went from 4.5 on [3-12] to 1.1 on [3-13] to 0.8 on [3-14]. CK-MB values went from 8 on [3-13] to 9 on [3-14] to 4 on [3-15]. REVIEW BY SYSTEM: 1. Pulmonary. Mrs. [Known lastname 5655] had a series of chest x-rays during her hospitalization. Chest x-ray on [3-14] stated that there was significant interval improvement of the pulmonary edema over previous x-ray the week before. There was also interval decrease in the size of pleural effusions. Overall impression was that there had been interval improvement of pulmonary edema and pleural effusion. Chest x-ray from [3-15] stated that there were newly developed bilateral pleural effusions blunting both costophrenic angles. There was also upper zone redistribution suggesting mild congestive heart failure. The heart size was prominent for the portable examination taken. There was no pneumothorax. During her time in the hospital, Mrs. [Known lastname 5655] had a cough productive of yellow sputum, sometimes tinged with blood, that had resolved by discharge to first clear sputum and then no productive cough and no cough at all by [3-21]. She denied any shortness of breath at rest or exertion at discharge. 2. Cardiovascular. Echocardiography was performed on [2183-3-14]. Overall conclusions were that the left ventricle was mildly hypertrophic with sparing of the septum. The overall left ventricular systolic function was severely depressed. Right ventricular function was good. The aortic leaflets were mildly thickened. The mitral leaflets were mildly thickened. There was a small circumferential pericardial effusion. The pericardium may have been thickened. Compared with a prior study of [2183-3-12], the effusion was somewhat smaller, especially anteriorly and right ventricular collapse was less pronounced. Ejection fraction was estimated to be between 20-25%. Cardiac catheterization was performed on [3-18]. Internal comments were: 1. Coronary angiography of this right dominant system revealed normal coronary arteries. The LM as normal. The left anterior descending and its D1 and D2 branches were all normal. The left circumflex artery and its OM1 and OM2 branches were all normal. The right coronary artery and its AM, R-PDA, R-PL branches were all normal. 2. Hemodynamic measurement revealed mildly elevated PAP (32/19/24 mmHg), highly elevated central aortic pressure (170/98/125 mmHg), and highly elevated left ventricular end-diastolic pressure (27 mmHg). No transaortic gradient was seen. 3. Left ventriculography revealed global hypokinesis and an estimated ejection fraction of 22%. Mitral regurgitation was at least 2+. The final diagnosis was: 1. Coronary arteries are normal. 2. Moderate mitral regurgitation. 3. Severe systolic ventricular dysfunction. Blood pressure. Blood pressure was difficult to control during Mrs. [Known lastname 5655] stay in the hospital. Her systolic blood pressure was persistently greater than 150. It was particularly well-controlled during the catheterization productive. During nitroglycerin drip the systolic blood pressure was in the 120s, but noted to be in the 160s to 170s with discontinuation of the drip. As a consequence of the catheterization procedure, Mrs. [Known lastname 5655] developed a hematoma at her right groin. Her hematocrit dropped from 25-22 within 24 hours following the procedure while serial hematocrits were taken every 2 hours. Her hematocrit stabilized at 22. An ultrasound of the right groin at the time showed the common femoral artery. There was no evidence of pseudoaneurysm or AV fistula. There was no hematoma over the puncture site. 3. Infectious Disease. Blood cultures taken at the time of admission were eventually negative. Urine cultures also taken showed no growth. A sputum culture showed [10-30] PMNs with more than 10 epithelial cells. There were gram positive cocci in pairs and clusters. There was sparse growth of oropharyngeal flora. Legionella urinary antigen was also negative. Levofloxacin was discontinued before discharge. 4. Renal. During her stay in Medical Intensive Care Unit and during her stay on the Medicine floor, Mrs. [Known lastname 5655] underwent dialysis numerous times. During dialysis she consistently received several units of packed red blood cells as well as Epogen. 5. Heme. As mentioned above, Mrs. [Known lastname 5655] received numerous units of packed red blood cells during her hospitalization, as well as Epogen. Iron studies provided the following values: FE: 49 within normal limits. TIBC: 211/ TRF: 162. Haptoglobin: 179. LD: 252. Reticulocyte count on [3-20]: 5.2. Her hematocrit on admission was 28.2. Her hematocrit on discharge was 32. CONDITION ON DISCHARGE: Stable. DIAGNOSES ON DISCHARGE: 1. Systemic lupus erythematosus. 2. Lupus nephritis/membranoproliferative glomerulonephritis with a necrotizing component and focal crescent formations. 3. Hypertension. 4. Congestive heart failure. DISPOSITION: The patient was discharged to home. She was instructed to follow-up with her primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], within one week; as well as to make an appointment with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. The patient refused to allow the House Officer to schedule those appointments and said that she would schedule them herself. [First Name11 (Name Pattern1) 971] [Last Name (NamePattern4) 7425], M.D. [MD Number(1) 7426] Dictated By:[Last Name (NamePattern1) 7427] MEDQUIST36 D: [2183-4-2] 22:26 T: [2183-4-3] 09:17 JOB#: [Job Number 7428]	[ "51881", "486" ]
Admission Date: [2189-7-13] Discharge Date: [2189-8-4] Date of Birth: [2151-5-24] Sex: F Service: GYN/ONC CHIEF COMPLAINT: The patient is a 38-year-old gravida 2, para 2 presenting with a new diagnosis of cervical cancer. HISTORY OF PRESENT ILLNESS: The patient underwent a routine PAP smear which revealed high-grade squamous intraepithelial lesion and subsequently underwent a loop electrosurgical excision procedure on [2189-6-1]. High-grade squamous intraepithelial lesion revealed gland involvement present at the ectocervical and endocervical margins. There was also invasive adenocarcinoma with depth of invasion of 7 mm. There was also adenocarcinoma in situ. The patient was admitted to the hospital and underwent a radical hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy for stage IA2 adenocarcinoma of the cervix. Please see Operative Report for more details of that particular surgery. PAST MEDICAL HISTORY: Past medical history was noncontributory. PAST SURGICAL HISTORY: Appendectomy. ALLERGIES: None. MEDICATIONS ON ADMISSION: Current medications included Triphasil. PAST OBSTETRICAL HISTORY: Vaginal deliveries times two. PAST GYNECOLOGICAL HISTORY: PAP smear as mentioned in the History of Present Illness. Last mammogram was in [2189] and was normal. FAMILY HISTORY: Family history significant for mother with breast cancer at the age of 55, and a father and sister with melanoma. SOCIAL HISTORY: No tobacco. Occasional alcohol. PHYSICAL EXAMINATION ON PRESENTATION: Postoperatively, the patient was doing well without complaints. In general, she was alert and oriented times four, in no apparent distress. Vital signs revealed a temperature of 37.5, pulse was 85 to 115, blood pressure was 110/55, oxygen saturation was 95% to 100% on 3 liters via nasal cannula. Cardiovascular examination revealed a regular rate and rhythm without murmurs. Pulmonary was clear to auscultation bilaterally. The abdomen was soft, normal bowel sounds. The incision was clean, dry, and intact without rebound or guarding. Genitourinary revealed no vaginal bleeding. Extremities revealed no clubbing, cyanosis or edema, nontender. Pneumo boots were in place. HOSPITAL COURSE BY SYSTEM: 1. GYNECOLOGY/ONCOLOGY: The patient was noted to have adenocarcinoma grade II at 1.7 mm at greatest depth of invasion. No lymphvascular invasion was seen. No in situ carcinoma or dysplasia. All margins were free of tumor. No malignancy was identified in lymph nodes. Please see complete pathology report for details. The patient complained of having hot flashes on hospital day three and was subsequently started on Premarin p.o. 2. PULMONARY/CARDIOVASCULAR: On postoperative day one, the patient was transferred from Five South to Twelve [Hospital Ward Name 1827]. It was noted that the patient was requiring oxygen via nasal cannula. The patient had minimal ambulation on the first day secondary to discomfort. Pneumo boots had been placed and were on at all times. On postoperative day four, when trying to wean the patient off of oxygen, it was noted that her saturation dropped to the 70s and 80s. There was high concern for a possible deep venous thrombosis at this time. Prior to this, the patient had a chest x-ray on postoperative day one. This was done as the patient was requiring oxygen as previously mentioned, and the x-ray showed bibasilar atelectasis with patchy air space consolidation. There was no evidence of congestive heart failure, and there was free air under the diaphragm; presumably post surgical. On postoperative day four, secondary to the patient's oxygen requirements and inability to wean off of supplemental oxygen, and an arterial blood gas that was 7.48/38/42/32/6, there was great concern that rather than this being venous that the patient might in fact be in respiratory compromise. A CT angiogram was done, and the patient was noted to have pulmonary emboli in the right lobe and segmental branches to the right lower lobe, and a suggestion of thrombus in the left lower lobe vessels. There was evidence of segmental atelectasis in both lung bases. The patient was immediately started on a heparin drip for a goal of PTT of 60 to 100. The patient was then started on Coumadin on [2189-7-17] to maintain anticoagulation. On [2189-7-20], the patient was noted to have a distended abdomen, and her complaints of abdominal pain had escalated overnight. The heparin drip and Coumadin were discontinued. A STAT hematocrit was sent and was noted to be 19.5 with an INR of 3.5. The patient was assessed to have an abdominal bleed, and an immediate transfusion of 3 units of packed red blood cells was started. The patient's hematocrit stabilized after her 3 units. However, on serial abdominal examinations it was noted that the patient's wound had cellulitis and that her incision was beginning to open up. With the suspicion of hemoperitoneum, the patient was scheduled to have re-exploration for hemoperitoneum. Prior to this, the patient had an inferior vena cava filter placed (please see Interventional Radiology note for said procedure). The patient underwent the procedure on [2189-7-22] for evacuation of 3 liters of hemoperitoneum. The patient received 1 unit of packed red blood cells intraoperatively and 1 unit postoperatively in the Intensive Care Unit. Additionally, the patient had been started on oxacillin for her cellulitis. The patient's follow-up hematocrits remained stable. The patient had tolerated the procedure well and convalesced appropriately. The patient's Coumadin was restarted, and her inferior vena cava filter was discontinued on [2189-7-30]. The patient's Coumadin dose was adjusted between 2.5 and 7.5 to try and obtain an INR between 1.8 and 2.2. 3. GASTROINTESTINAL: The [Hospital 228] hospital stay was rather uncomfortable for the patient as she continued to have nausea and emesis. The patient did not tolerate her p.o. well and also had an aversion to taking pills. Suppositories did in fact help with the patient's nausea and vomiting toward the end of her course. 4. INFECTIOUS DISEASE: On [2189-7-22], the patient was noted to have a urinary tract infection positive for gram-negative rods after the patient had a temperature spike. The patient was started on ceftazidime. Additionally, the patient had been started on oxacillin for wound cellulitis. Intraoperatively, the patient received Flagyl. On [2189-7-26], the patient's Flagyl was discontinued, and the subsequent day the other intravenous antibiotics were discontinued. 5. FLUIDS/ELECTROLYTES/NUTRITION: The patient was started on total parenteral nutrition during the course of her hospital stay after her surgery for the evacuation of hemoperitoneum. The patient was weaned off her total parenteral nutrition on [8-1] until the remainder of her course. The patient tolerated her oral intake toward the end of her stay. Intermittently, the patient's phosphate, magnesium, and potassium were repleted. Electrolytes were checked on a regular basis for nutritional evaluation. DISCHARGE DISPOSITION: The patient was discharged to home on [2189-8-4]. DISCHARGE PLAN: The patient was to follow up with Dr. [First Name (STitle) 1022] as previously scheduled. The patient was also to see her primary care physician to have her INR checked every three days times one week after discharge. At that time, the patient would have seen Dr. [First Name (STitle) 1022] and also her primary care physician for determination of how often the patient was to have her INR checked for a goal between 1.8 and 2.2. DISCHARGE DIAGNOSES: 1. Adenocarcinoma of the cervix, stage IA2. 2. Status post radical hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy; complicated by pulmonary embolus and hemoperitoneum. MEDICATIONS ON DISCHARGE: 1. Coumadin 5 mg p.o. q.h.s. 2. Dilaudid 2 mg to 4 mg p.o. q.6h. 3. Tylenol 650 mg p.o. q.4-6h. as needed. 4. Colace 100 mg p.o. b.i.d. 5. Tagamet 200 mg p.r. q.8h. as needed. 6. Premarin 1.25 mg p.o. q.d. CONDITION AT DISCHARGE: Condition on discharge was stable. [First Name8 (NamePattern2) ] [First Name8 (NamePattern2) ] [Name8 (MD) ], M.D. [MD Number(1) 4871] Dictated By:[Last Name (NamePattern4) 8102] MEDQUIST36 D: [2189-8-19] 13:25 T: [2189-8-25] 19:11 JOB#: [Job Number 41869]	[ "5180" ]
Admission Date: [2188-12-19] Discharge Date: [2188-12-23] Date of Birth: [2109-3-22] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1654] Chief Complaint: Respiratory Failure Major Surgical or Invasive Procedure: intubation laryngoscopy flexible bronchoscopy History of Present Illness: This is a 79 yo M with a past medical history of , who was brought to the [Hospital1 18] ED after being noted to be dyspneic at [Hospital 100] Rehab. In the ED, despite having inspiratory and expiratory stridor and using accessory muscles with increased work of breathing, the patient denied shortness of breath. In evaluation of his airway, there was some concern that he may have epiglottitis. ENT was consulted and although they noted an omega-epiglottis, there was no sign of infection. They recommended 12mg decadron IV Q8h x 3 and bronchoscopy. . He was kept in the ED for several hours, and he began to look tired, with some agitation and the decision was made to intubate him. He was a difficult intubation, and thick secretions were noted in his throat, raising the suspicion that he is unable to clear his airway and that perhaps he had a mucous plug contributing to his increased work of breathing. . Of note, he has had a dry cough for about 3 weeks pta. He had a CXR which was notable for a lack of an acute intrathoracic process. He was afebrile and hemodynamically stable while in the ED. Past Medical History: DM2 asthma dyslipidemia gait disorder vertigo CRI (baseline 1.1-1.3) Mild dementia- ?[Last Name (un) 309] Body Dementia s/p recent mechanical fall s/p CCY s/p hernia repair s/p b/l blepharoplasty Social History: Tob 40 pack yrs, smokes a cigarette now only occasionally ETOH rare IVDA none Pt lives in an [Hospital3 ] facility. He has a daughter who lives in the area. His wife recently died in [Month (only) 359], since that time, patient has been seen several times by his gerontologist for confusion and hallucinations. Family History: non-contributory Physical Exam: VS: Temp: BP: 118/60 HR:79 RR: O2sat 98% on PS 5/5 GEN: sedated, NAD HEENT: Right pupil small and fixed. Left RRL. Right sided fullness in the throat, two small mobile LN's. No thyromegaly. RESP: CTAB no w/r/r CV: RRR (distant) no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm, good pulses NEURO: unable to perform complete neuro exam [2-1] intubation/sedation downgoing Babinski b/l Pertinent Results: [2188-12-19] 09:10PM WBC-7.9 RBC-4.17* HGB-13.4* HCT-40.5 MCV-97 MCH-32.2* MCHC-33.1 RDW-14.4 [2188-12-19] 09:10PM NEUTS-89* BANDS-0 LYMPHS-2* MONOS-6 EOS-0 BASOS-0 ATYPS-3* METAS-0 MYELOS-0 [2188-12-19] 09:10PM GLUCOSE-238* UREA N-30* CREAT-1.1 SODIUM-144 POTASSIUM-3.9 CHLORIDE-110* TOTAL CO2-25 ANION GAP-13 [2188-12-19] 09:10PM CALCIUM-8.7 PHOSPHATE-2.4* MAGNESIUM-2.1 [2188-12-19] 11:13AM TYPE-ART O2-100 PO2-97 PCO2-46* PH-7.40 TOTAL CO2-30 BASE XS-2 AADO2-595 REQ O2-94 INTUBATED-NOT INTUBA [2188-12-19] 10:00AM cTropnT-0.09* . EKG: poor baseline. NSR@ 83. No acute ST-T wave changes. . INITIAL CXR [12-19]: FINDINGS:AP upright portable chest radiograph is obtained. Evaluation somewhat limited by low lung volumes. The lungs are clear bilaterally, demonstrating no evidence of pneumonia or CHF. The cardiomediastinal silhouette is unremarkable. There is no pneumothorax. No evidence of foreign body. Bowel gas pattern appears unremarkable. Visualized osseous structures are intact. Degenerative changes are noted in the spine. IMPRESSION: No acute intrathoracic process. . MRI [12-19] Neck Soft Tissues: FINDINGS: When compared with prior MRI dated [2187-12-5], there is prominence of the epiglottis. Multilevel degenerative changes are again noted in the cervical spine with prominent anterior osteophytes at multiple levels. IMPRESSION: 1. Prominence of the epiglottis. Clinical correlation is advised. 2. Degenerative changes in the cervical spine, not significantly changed from prior study. Brief Hospital Course: . # Respiratory Failure - Chest xray did not show pneumonia, but viral infection was suspected in the setting of cough and thick airway secretions. If exacerbated by dehydration, these could become thick enough to cause difficulty clearing past an enlarged omega-shaped epiglottis which was identified on laryngoscopy. The increased work of breathing could have been caused either by a mucous plug caught at the epiglottis, or a bronchial plug resulting in transient lobar collapse. He underwent bronchoscopy by Interventional Pulmonary which showed thick secretions but no airway lesions. It does not seem that this is a lower airway issue as he did very well on minimal pressure support and was extubated shortly. He received 3 doses of Decadron. He was maintained on chest PT. HOB was elevated at all times and he was maintained on aspiration precautions. He underwent swallow evaluation which showed aspiration with thin liquids and difficulty with regular solids. He should also have strict supervision with eating and reevaluation of swallowing function if shows any sign of aspiration. The possibility of bulbar dysfunction was considered given his neurologic deterioration over the last couple of months. As his respiratory function rapidly returned to [Location 213], neurologic evaluation was deferred to the outpatient setting. On discharge, he was requiring daily Physical Therapy and occasional oral suctioning to assist him in clearing his secretions. He oxygen saturation was 97 to 100% on room air. . # Dementia/Vertigo - Concern over last few months that this patient may have [Last Name (un) 309] body dementia as he has had progressive decline with hallucinations with a history of a gait disorder. Neurologic evaluation deferred as above. He had occasional agitation with redirectability at night which did not require medication. . # DM2 - His Actos and glipizide were initially held in the setting of being NPO. They were restarted when he began taking regular po. He was maintained on [First Name8 (NamePattern2) ] [Doctor First Name ] diet and his fingersticks were under reasonable control. . # Hypernatremia - He developed hypernatremia on the floor, which was thought secondary to hypovolemia from poor po intake after extubation. He was given gentle fluid resuscitation after which his sodium normalized. He should be encouraged to take po (nectar thickened) fluids and have his sodium level rechecked on [2188-12-24]. . Medications on Admission: RISS Vit D colace Zetia Actos tylenol PRN albuterol Dulcolax PRN Milk of Magnesia ASA 81 Ca Carbonate Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Omega-shaped epiglottis Respiratory failure of unclear etiology Hypernatremia Dementia Discharge Condition: good, stable on room air Discharge Instructions: You were admitted with respiratory distress. You were temporarily intubated and placed on ventilator. You were evaluated by ENT who found some edema in your larynx, but no signs of infection. You underwent bronchoscopy and were found to have lots of respiratory secretions that were likely from a viral syndrome. Your chest xray showed no pneumonia. After extubation, you had excellent respiratory status with no oxygen requirement. You were evaluated by the Speech therapists who have modified your diet to prevent aspiration. . Please take all of your medications as prescribed. Please attend all of your follow up appointments. . If you experience difficulty breathing, chest pain, fever, or other concerning symptoms, please call your doctor or go to the ER. Followup Instructions: Please call your primary care doctor, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 24024], to schedule a follow up appointment within the next 1-2 weeks. Please discuss Neurology evaluation with Dr. [Last Name (STitle) ]. Completed by:[2188-12-23]	[ "51881", "2760", "5859", "V1582", "49390", "2724" ]
Admission Date: [2110-8-6] Discharge Date: [2110-8-10] Date of Birth: [2053-4-16] Sex: F Service: NEUROSURGERY Allergies: Dilantin / ibuprofen / phenobarbital Attending:[First Name3 (LF) 1835] Chief Complaint: Left suboccipital mass Major Surgical or Invasive Procedure: [2110-8-6]: Left suboccipital craniotomy and tumor excision History of Present Illness: 56yo woman with PMH of a TBI at age of 16. She recovered fully but developed seizures at the age of 17. She was started on anti-epileptics and was seizure free for greater than 25 years. Last fall she started developing new seizures where she would go into a daze. She was having [9-5] of these a day. The patient was seen at [Hospital1 2177] and evaluated. Imaging revealed an incidental lateral cerebellar meningioma. It was recommended that she follow up with neurosurgery every [4-1] mo for surveillance monitoring. Her insurance had since changed and she presented in [4-7] for evaluation at [Hospital1 18]. Imaging was consistant with a meningioma and it was recommended that she undergo a craniotomy and excision. She electively presents [8-6] to undergo this. Past Medical History: TBI @ age 16 seizures @ age 17 Hypothyroidism Social History: Married, lives with husband. Grown children. Denies tobacco, EtOH or drugs. worked in telecommunications but currently is not working due to the increased seizures. Family History: non-contributory Physical Exam: Pre-Operative Admission Physical Examination AF VSS Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs intact Neck: Supple. Lungs: no adventicious sounds Cardiac: RRR. Abd: Soft, NT Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to finger rub bilaterally. 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 [5-31] throughout. No pronator drift Sensation: Intact to light touch Coordination: normal on finger-nose-finger, rapid alternating movements Discharge Physical Examination: unchanged from admission with following exceptions -Tenderness to palpation of left tragus -Incision clean/dry/intact Pertinent Results: [2110-8-6] Head MRI w/o Contrast: Left posterior fossa extra-axial mass, compatible with a meningioma, is again demonstrated for surgical planning. [2110-8-6] Pathology: pending at time of discharge [2110-8-6] Head CT without Contrast: Status post resection of a left posterior fossa mass, with expected postoperative changes. [2110-8-7] Head MRI w/ and w/o Contrast: Post-surgical changes as above with a possible 14 x 5mm focus of residual tumour, as above, immediately adjacent to the left transverse sinus. [2110-8-8] Abdomen Supine and Erect: Normal bowel gas pattern with no evidence of bowel obstruction. Brief Hospital Course: On [2110-8-6], patient electively underwent a left suboccipital craniotomy and excision of lesion. Surgery was without complication. Upon procedure completion, patient was extubated and transferred to the neuro-ICU in stable condition. She was started on dexamethasone with concomitant prophylaxis. She subsequently underwent a post-operative CT scan that revealed no evidence of acute hemorrhage with post-operative changes. On [2110-8-7], Ms. [Known lastname 67736]' diet was advanced, her Foley catheter removed, and was able to get out of bed. Her blood pressure restrictions were liberalized to systolic BP < 160. Subcutaneous heparin was initiated for DVT prophylaxis. Her pain was well-managed. As patient demonstrated signs of recovery, she was transferred to the floor. On [2110-8-8], patient got out of bed with PT. She complained of constipation and decreased flatulence, a KUB was obtained, which was without abnormality. On [2110-8-9], patient's bowel regimen was escalated with magnesium citrate for continued complaints of constipation. A Decadron taper was initiated. The patient was initiated on ASA 325 in addition to her heparin for DVT prophylaxis. Patient continued to recover. On the morning of [2110-8-10], patient complained of significant ear pain. Neurological examination remained intact. Tenderness of left tragus was noted on examination. As pain was thought to be neurologic in origin, we instituted gabapentin 300 mg tid with good result. An ENT consult was also obtained for evaluation of otitis externa and mastoiditis. The ENT service felt that there was no evidence of infection. As patient's pain was well-controlled and she endorsed bowel mobilization, patient was discharged home to self-care in good condition. She was instructed to continue her home antiepileptics. She is also to continue her gabapentin, dexamethasone taper, pain regimen, aspirin, and bowel regimen. Patient is to follow-up in the Brain [Hospital 341] Clinic in two weeks for evaluation and wound check. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Zolpidem Tartrate 10 mg PO HS:PRN insomnia 2. DiphenhydrAMINE 25 mg PO Q6H:PRN allergic reaction 3. Calcium Carbonate 1500 mg PO BID 4. Vitamin D 200 UNIT PO BID 5. Carbamazepine 200 mg PO ASDIR 3 tabs @ 0800, 2 tabs @ 1100, 2 tabs @ 1800, 2 tabs @ 2200 6. Levothyroxine Sodium 200 mcg PO DAILY 7. Topiramate (Topamax) 200 mg PO BID 8. Acetaminophen 650 mg PO Q6H:PRN fever or pain Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN fever or pain 2. Carbamazepine 200 mg PO ASDIR 3 tabs @ 0800, 2 tabs @ 1100, 2 tabs @ 1800, 2 tabs @ 2200 3. Levothyroxine Sodium 200 mcg PO DAILY 4. Topiramate (Topamax) 200 mg PO BID 5. Aspirin 325 mg PO DAILY for DVT prophylaxis RX aspirin 325 mg 1 tablet(s) by mouth qday Disp #30 Tablet Refills:0 6. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #30 Capsule Refills:0 7. Gabapentin 300 mg PO TID RX gabapentin 300 mg 1 capsule(s) by mouth three times a day Disp #90 Capsule Refills:0 8. Pantoprazole 40 mg PO Q24H RX pantoprazole 40 mg 1 tablet(s) by mouth q24h Disp #30 Tablet Refills:0 9. Senna 1 TAB PO DAILY RX senna 8.6 mg 1 by mouth qday Disp #30 Capsule Refills:0 10. Calcium Carbonate 1500 mg PO BID 11. DiphenhydrAMINE 25 mg PO Q6H:PRN allergic reaction 12. Vitamin D 200 UNIT PO BID 13. Zolpidem Tartrate 10 mg PO HS:PRN insomnia 14. Dexamethasone 1 mg PO ASDIR Duration: 4 Days Please take 1 tablet every 6 hours on [8-11]; 1 tablet every 8 hours on [8-12]; 1 tablet twice a day on [8-13]; 1 tablet once a day on [8-14] Tapered dose - DOWN RX dexamethasone 1 mg 1 tablet(s) by mouth as directed Disp #11 Tablet Refills:0 15. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain RX Oxecta 5 mg [1-27] tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:0 RX oxycodone 5 mg [1-27] capsule(s) by mouth every four (4) hours Disp #30 Capsule Refills:0 Discharge Disposition: Home Discharge Diagnosis: Left posterior fossa meningioma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Craniotomy for Tumor Excision Dr. [Last Name (STitle) 14354] [Name (STitle) ] ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Dressing may be removed on Day 2 after surgery. ?????? You have dissolvable sutures you may wash your hair and get your incision wet day 3 after surgery. You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) & Senna while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Please continue your home anti-seizure medications. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. Followup Instructions: ??????Please schedule an appointment with the Brain [Hospital 341] Clinic for an appointment in the next 2 weeks. The Brain [Hospital 341] Clinic is located on the [Hospital Ward Name 516] of [Hospital1 18], in the [Hospital Ward Name 23] Building, [Location (un) ]. Their phone number is [Telephone/Fax (1) 1844]. Please call if you need to change your appointment, or require additional directions.	[ "2449" ]
Admission Date: [2143-8-20] Discharge Date: [2143-9-13] Date of Birth: [2063-4-7] Sex: F Service: MEDICINE Allergies: Aspirin / Biaxin / Codeine / Bactrim Attending:[First Name3 (LF) 2704] Chief Complaint: initially admitted for 7 days shortness of breath, transferred to CCU for hypotension Major Surgical or Invasive Procedure: Bi Ventricular Pacemaker placement History of Present Illness: This is a 80 yo F CAD s/p CABG, known CHF with EF of 20% presenting with 7 days shortness of breath and weight gain. Patient has had gradual worsening of these symptoms over the week PTA. At baseline she is able to walk the 3 blocks to her church. On day of admission she was unable to walk 5 feet without being short of breath. She weighs herself daily. Her baseline weight is 133lbs and she was at 141 on the day of admission. She has noticed some symmetric mild swelling of her legs similar to other episodes of decompensated CHF. She reports orthopnea. She reports a non-productive cough and sore throat for the last 2 days. She also complained of a few episodes of her typical anginal pain (left back/shoulder pain) that resolved with sublingual nitro and tylenol. . Of note she had a somewhat recent medication ([6-4]) change from bumex (thought to have caused a rash which resolved with steroid treatment) and was changed onto her old regimen of lasix (160 QAM, 80QPM-although at her last cardiology appt here she was stable at 160QAM, 160QPM). . She went to see her PCP [Last Name (NamePattern4) ] [2143-8-20], who found her to be hypoxic to 88% and then sent her to the ED. In the ED CXR showed CHF, BNP was elevated from 4000 to [Numeric Identifier 7987], PE/dissection were ruled out. In addition, she was given 80mg IV lasix, and only put out 350cc (UO) over 8 hours at the ED. She was admitted to the [Hospital1 1516] service overnight for further management. Past Medical History: Coronary Artery Disease: s/p anterioseptal MI in [2125] CABG [2126]/[2127]- LIMA - LAD and SVG - RCA -status post coronary artery bypass graft and aneurysmectomy s/p PCTA in [2134] with stent placed proximal circumflex artery Hypertension Hypothyroidism Diabetes type II x 40 years Chronic Sinusitis Cataract in L eye, scheduled for surgery . Social History: Tobacco: denies Alcohol: denies Living Situation: Primarily Italian-speaking woman who lives by herself on the [Location (un) 1773] of a building (no elevator). Her son and his family live below and one of her grandkids sleeps in her apt everynight. She also has a med alert call bracelet. Patient has 2 sons and one daughter; all who live in relatively close vicinity of her. Family History: Family History: Brother and dad with coronary artery disease. Father had diabetes and cancer (skin?). Physical Exam: Vitals: T: 97.1 P: 67 BP: 80/50 R: 24 SaO2: 99% on 2L General: Awake, alert, NAD. HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, MMM, OP erythematous without exudate Neck: supple, no LAD, no carotid bruits appreciated, + JVD to earlobe sitting at 30 degree Pulmonary: left basilar crackles Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: minimal bilateral edema, 2+ radial, DP and PT pulses b/l. Skin: no rashes or lesions noted. Neurologic: Alert, oriented x 3. Speaks italian primarily. grossly non-focal. . Pertinent Results: Admission Labs: [2143-8-20] WBC-19.5 HGB-10.6 HCT-31.6 PLT 356 [2143-8-20] DIGOXIN-1.2 [2143-8-20] TSH-0.89 [2143-8-20] ALBUMIN-3.6 CALCIUM-7.8 PHOSPHATE-3.7 MAGNESIUM-2.1 [2143-8-20] cTropnT-0.05* [2143-8-20] AST-273 LD-414 CK-33 ALK PHOS-97 TOT BILI-0.3 [2143-8-20] GLUCOSE-96 UREA N-52 CREAT-1.0 SODIUM-135 POTASSIUM-3.5 CHLORIDE- 103 TOTAL CO2-18 ANION GAP-18 [2143-8-20] URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2143-8-20] PT-19.4 PTT-28.9 INR(PT)-1.8 [2143-8-21] Cortsol-29.3 [2143-8-21] WBC-23.3 Hgb-11.8 Hct-35.2 Plt Ct-410 [2143-8-22] WBC-18.4 Hgb-10.5 Hct-30.8 Plt Ct-301 [2143-8-22] Glucose-45* UreaN-64* Creat-1.5* Na-135 K-4.2 Cl-101 HCO3-23 AnGap-15 [2143-8-22] ALT-353 AST-122 LD(LDH)-292 AlkPhos-93 TotBili-0.2 [2143-8-20] BNP-[Numeric Identifier 7987] [2143-8-23] Glucose-111 UreaN-49 Creat-1.1 Na-137 K-4.4 Cl-103 HCO3-23 [2143-8-23] WBC-16.3 Hgb-10.8 Hct-33.1 Plt Ct-307 [2143-8-21] HBsAb-NEGATIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE . Discharge Labs: [2143-9-13]: WBC 11.8, Hct 36.5, Na 138, K 4.1, Cl 93, HCO2 33, BUN 27, Cr 0.9, Mg 2.2 . Micro: URINE CULTURE (Final [2143-8-21]): NO GROWTH. URINE CULTURE (Final [2143-8-22]): NO GROWTH . CXR ([2143-8-22]) IMPRESSION: Mild pulmonary edema. CXR ([2143-8-21]) IMPRESSION: Interval resolution of the probable interstitial edema seen on prior exam. No pneumonia. . CTA ([2143-8-20]) IMPRESSION: 1. No pulmonary embolism or aortic dissection. 2. Moderate congestive heart failure. Redemonstration of marked cardiomegaly, mitral and coronary artery calcifications. . EKG ([2143-8-20]) Sinus rhythm. Intraventricular conduction disturbance. Multiform ventricular premature beats. Compared to the previous tracing of [2143-8-19] ST segments are currently elevated in leads VI and V3-V5. Possible nanterior injury. . TTE [2143-8-22]: 1. The left atrium is markedly dilated. The right atrium is markedly dilated. 2. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis with some preservation of basal lateral and basal inferior wall motion. Overall left ventricular systolic function is severely depressed. 3. The right ventricular cavity is moderately dilated. There is severe global right ventricular free wall hypokinesis. 4. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. Moderate (2+) mitral regurgitation is seen. 6. There is severe pulmonary artery systolic hypertension. . EKG ([2143-8-22]) Sinus rhythm. Intraventricular conduction delay. Left axis deviation. Probable atypical left bundle-branch block. Possible anterior myocardial infarction, age indeterminate. Clinical correlation is suggested. Since the previous tracing of [2143-8-21] no significant change. . ECHO [2143-9-3]: Conclusions: The left atrium is moderately dilated. The right atrium is markedly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. Overall left ventricular systolic function is severely depressed. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Tissue synchronization imaging demonstrates significant left ventricular dyssynchrony with the septal wall contracting 280 ms later than the lateral wall. These findings are c/w significant LV dysnchrony for which the patient may benefit from CRT therapy. The right ventricular cavity is dilated. There is severe global right ventricular free wall hypokinesis. 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. Moderate to severe (3+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is at least moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the findings of the prior study (images reviewed) of [2143-8-22], the mitral regurgitation is increased, and the left ventricular ejection fraction is somewhat higher. . CXR [2143-9-5]: IMPRESSION: 1. Biventricular pacing leads in standard position on this portable projection, but dedicated PA and lateral view would be helpful to confirm appropriate location. No pneumothorax. 2. CHF with interstitial pulmonary edema. . Brief Hospital Course: 80F with h/o DM, CAD s/p cath, who presents with SOB and weight gain x7days. Admitted to CCU for hypotension not relieved with fluids. . 1) Hypotension: On second hospital day, she got all her daily BP medications in the am with additional lasix. She was found to be hypotensive with BP running 70-80/40-50s on [2143-8-21] and triggered on the [Hospital1 1516] service. She had normal mentation, denied feeling SOB or dizzy. She was given 250cc NS bolus x 3, and her SBP went up to 85 (baseline SBP 90-100). Decision was made to transfer her to CCU service for further management of her hypotension overnight. In the CCU, patient was given an additional 500cc bolus of NS with only minimal improvement in blood pressure. All blood pressure meds were held. Patient continued to be without sob, dizziness, and mentating well. Echo was ordered for [2143-8-22] that showed moderate dilation of the right ventricular cavity with severe global right ventricular free wall hypokinesis (a change from prior). TTE continued to show severely depressed systolic function with EF<20% but no other significant change. Given this new, biventricular failure, her [Last Name (un) ] was restarted at a loser dose. BB and other heart failure medications were also restarted. She was re-admitted to the CCU for hypotension and decreased urine output. She was given a medication holiday and responded. Her BP increased and she began to diurese on her own, and become respnsive to lasix. Hypotension was likely a result of biventricular failure and anit-hypertensive medications, as well as intravascular volume depletion. . 2) SOB/CHF: Her shortness of breath likely due to CHF exacerbation. Pt was afebrile and no focal consolidation on imaging or exam to suggest pna. She had a non-productive cough. Pt had poor output to 80mg of IV lasix on [2143-8-20], but repeat dosing on [2143-8-21] had good effect of 350/3 hours. Echo was performed, and digoxin was held initially. After being transferred out of the CCU, she initially responded well to diuresis. However, her urine output progressively decreased despite being put on a lasix drip. She was again transferred to the CCU. While there, her lasix drip was stopped, as well as her CHF medications (metoprolol/valsartan). A repeat ECHO showed an EF of 20%. Her BP improved off of her medications, she was given compression stalkings and she proceeded to mobilize her own fluids. After that, she responded very well to lasix boluses (80mg IV) TID. Near the time of discharge, the patient was switched to Lasix 160mg PO BID, responding well. Her D/C wt was 59kg, with an estimated dry weight of 58kg. She was length of stay negative 19-20L. . Also, EP was consulted given her degree of CHF. She also experienced asymptomatic NSVT during her stay. EP thought she would benefit from PCM +\- ICD. A BiV pacemaker was placed by EP on [2143-9-5] successfully without complications. Her BP responded favorably and post placement check was normal. . 3)Leukocytosis: Upon admission, patient found to have elevated WBC count to 23. She was empirically started on antibiotics. Her cortisol found to be WNL. Patient continued to be afebrile with negative chest xrays. On [2143-8-22], antibiotics were discontinued, and she remained hemodynamically stable and afebrile. Her WBC remained elevated, but decreased from admission between 15-18 to normal. She remained afebrile. . 4) Elevated BUN/Cr: On the 3rd hospital day, patient was noted to have elevated BUN/Cr. It was noted that she had been on high doses of ibuprofen for an undisclosed reason. The ibuprofen was discontinued. Moreover, the patient was on lasix and failing to diurese. She was admitted to the CCU and her BUN/Cr improved by holding her anti-hypertensives. She was transferred to the floor, and once again experienced elevation in her BUN/Cr while on a lasix drip. She was admitted to the CCU a second time. While there, they stopped her BP meds. Her BP improved, as did her BUN/Cr. She then responded to lasix after fluid mobilization with stockings and ambulation. Her transient renal insufficiency was thought secondary to intravascular depletion/pre-renal, as it improved with increased BP and increased renal perfusion. . 5) CAD: Chest pain resolved with sl nitro and tylenol. MI was ruled out and patient to be under medical management. *Importantly, her PCP may wish to consider re-starting her statin, which was discontinued with her elevated liver enzymes.* . 6) Transaminitis: Her elevated LFTs were thought due to drug effect (statin), vs hypoperfusion secondary to hypotension. Her LFTs improved and she remained asymptomatic. . Anticoagulation: The patient was started on warfarin due to her ECHO findings of decreased EF and hypokinesis. Her INR was stable, but her warfarin was stopped upon her second admission to the CCU for BiV pacemaker. She was started instead on aspirin and plavix. She tolerated this well. She tolerated aspirin 81mg without incident, despite previous history of dyspepsia on higher aspirin doses. . Anemia: remained stable in mid 30s. Was consistent with anemia of chronic disease. . Diabetes: Her blood sugars were difficult to control. She was on [Hospital1 ] dosing of Lantus (30units/60units), but had episodes of hypoglycemia. On her second admission to the CCU, her lantus was changed to 25units qAM plus a humalog sliding scale. this regimen was later changed to Lantus 35units qPM, 10 units qAM plus the sliding scale. Her sugars fluctuated in the 200s. Further titration of her insulin will be needed as an outpatient . Hypothyroidism: Stable during admission on home regimen. . Code: She was initially DNI, but later changed her status to FULL CODE once the procedures were explained to her. . Outstanding Issues: 1. She will need close follow up and monitoring of her CHF, particularly with regards to her blood pressure medications (? add spironolactone, statin, titrate beta blocker/acei), diet, and weights. . 2. Her BiV pacemaker will need to be followed by EP. . 3. Her blood sugars were running high throughout admission. She will need further adjustment of her diabetes regimen. . 4. VNA will be following her as an outpatient. . 5. PCP should address sleep habits. Medications on Admission: Levoxyl 125mcg QD DIGOXIN 125 MCG ENTERIC COATED ASA 81MG FUROSEMIDE 160mg QAM, 160QPM Imdur 30 MG QD METOPROLOL 50 MG Spironolactone 25mg QD atorvastatin 20 QHS Lantus 60U QAM 60UQPM Humalog Albuterol PRN Ativan 1mg QHS PRN Ultram 50mg PO BID PRN Tylenol occassionally lactulose 2 TBSP QHS Colace 100mg [Hospital1 ] VitB-12 1000mcg QD Discharge Medications: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:30 Tablet(s) Refills:0 4. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:30 Tablet(s) Refills:0 6. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Furosemide 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Please take at 8AM and 4PM. Disp:120 Tablet(s) Refills:2 9. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:30 Tablet Sustained Release 24HR(s) Refills:2 10. Lantus 100 unit/mL Solution Sig: Thirty Five (35) units Subcutaneous at dinner. Disp:1 vial Refills:2 11. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous in the morning. Disp:1 vial Refills:2 12. Humalog 100 unit/mL Solution Sig: Per scale units Subcutaneous qACHS. Disp:1 vial Refills:2 13. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation every six (6) hours as needed for cough: Take as needed. Disp:1 1 Refills:0 14. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: [1-1] Tablet, Sublinguals Sublingual PRN (as needed) as needed for chest pain: take 1 sublingual nitro for chest pain, if persists can repeat every 5 minutes x2 additional tablets. Call 911 if no relief. Disp:30 Tablet, Sublingual(s) Refills:0 15. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO QPM (once a day (in the evening)). Disp:60 Capsule, Sustained Release(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: Primary: 1. Heart Failure Secondary: 1. Coronary Artery Disease 2. Diabetes Mellitus 3. Hypothyroidism Discharge Condition: Good condition, vital signs stable, discharged to home with services and follow-up arranged. Discharge Instructions: You have been evaluated and treated for shortness of breath. You were found to have an exacerbation of your congestive heart failure (CHF). Your medications were changed; see the list included in your discharge paperwork. Please take all medications as directed and keep all follow-up appointments. . Please weigh yourself every morning, and call your PCP if your weight increases more than 3 lbs. Please limit your sodium intake to 2 grams per day. Do not take in more than 2 liters of fluid per day. . If you develop further shortness of breath, chest pain, nausea/vomiting, lightheadedness/dizziness, or any other symptom that is concerning to you, please call your PCP or go to the nearest hospital emergency department. Followup Instructions: 1. An appointment has been made for you to follow-up with your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 7988] ([Telephone/Fax (1) 6951]), on [9-25] at 8:40AM. . 2. An appointment has been made for you to follow up with Dr. [First Name8 (NamePattern2) 449] [Last Name (NamePattern1) 437] from cardiology on [9-16] at 1 PM ([Telephone/Fax (1) 4451]) . 3. An appointment has been made for you to follow up with the pacemaker device clinic on Thurs, [11-28] at 12:30PM ([Telephone/Fax (1) 59]) , and with Dr. [Last Name (STitle) ] on Thurs, [11-28] at 1:00PM ([Telephone/Fax (1) 2934])	[ "5849", "2767", "V4581", "2449", "4019" ]
Admission Date: [2182-2-5] Discharge Date: [2182-2-6] Date of Birth: Sex: M Service: Neurosurgery HISTORY OF PRESENT ILLNESS: Patient was an 84-year-old man, who had a fall at home after a bad headache with positive loss of consciousness. 911 was called and he was brought to the Emergency Room awake and alert. Initial CAT scan of the head did show a small right subdural hematoma as well as left temporal contusions with ventricular blood. He was scheduled for a MRI of the brain when his mental status deteriorated. Repeat CAT scan of the head showed a larger subdural hematoma on the left side as well as increased contusions in the left temporal region and blood in the fourth ventricle, which was increased. He was emergently taken to the OR for left craniotomy and evacuation of a subdural hematoma. PAST MEDICAL HISTORY: 1. Coronary artery disease status post MI in [2153]. 2. CABG x4 in [2169]. 3. Non-insulin dependent-diabetes mellitus. 4. GERD. 5. Cataracts. 6. Glaucoma. 7. Hypertension. 8. Osteoarthritis. 9. Prostate cancer status post TURP in [2170]. 10. Status post colon resection for adenoma. MEDICATIONS AT TIME OF ADMISSION: 1. Isosorbide. 2. Lasix. 3. Procardia. 4. Naprosyn. 5. Diazepam. 6. Chlorpropamide. SOCIAL HISTORY: He was not a smoker. Did not drink alcohol. ALLERGIES: He has allergies to dye and shellfish. HOSPITAL COURSE: Postoperatively, he remained intubated. His vital signs were stable. His left pupil was nonreactive at 6 mm and the right was 2 mm and nonreactive. He had no corneal reflexes, no gag response or cough. He had bloody drainage from the ventricular drain. He had a poor prognosis. On [2182-2-6] he had a cold caloric test, which was negative, had no response. He continued to be managed in the Intensive Care Unit. With discussion initially with his wife and daughter and later with a nephew, and after much discussion, the family opted to withdraw care. On [2182-2-6] at 3:20 p.m., the patient expired. [Name6 (MD) 742] [Name8 (MD) ], M.D. [MD Number(1) 743] Dictated By:[Last Name (NamePattern1) 5996] MEDQUIST36 D: [2182-4-8] 12:04 T: [2182-4-9] 07:27 JOB#: [Job Number 5997]	[ "25000", "4019", "V4581" ]
Admission Date: [2116-5-30] Discharge Date: [2116-6-14] Date of Birth: [2116-5-30] Sex: M Service: NB HISTORY: Baby [Name (NI) ] [Known lastname ] was the 2.375 kg product of a 35- [2-26] week gestation born to a 23-year-old, G2, P1, now 2, mother. Prenatal screen: O negative, antibody negative, RPR nonreactive, rubella immune, hepatitis surface antigen negative, GBS unknown. Mother receive RhoGAM at 28 weeks. PAST MEDICAL HISTORY FOR MOTHER: Notable for chronic hypertension, tobacco use, Factor V Leiden heterozygosity. FAMILY HISTORY: Negative. SOCIAL HISTORY: Notable for cigarette use but negative for alcohol during pregnancy. Father of baby is involved. This pregnancy complicated by thin lower uterine segment, full fetal survey within normal limits at 16 weeks. Underwent repeat cesarean section under spinal anesthesia. No intrapartum fever or other clinical evidence of chorioamnionitis. Intrapartum antibiotics were given only intraoperatively. Rupture of membranes occurred at delivery yielding clear amniotic fluid. Infant was vigorous at delivery, was orally and nasally suctioned, dried, and a supplemental flow of O2 was administered. Apgars were 8 at one minute and 8 at five minutes. Infant was transferred to the newborn intensive care unit. DISCHARGE EXAM: Active with good tone. Anterior fontanel open and flat. Pink, well perfused. No murmurs auscultated. Comfortable in room air. Breath sounds clear and equal. Tolerating enteral feedings with a soft abdominal exam. Active bowel sounds. Moving all extremities. HISTORY OF HOSPITAL COURSE BY SYSTEM: 1. Respiratory: [Known firstname ] was admitted to the newborn intensive care unit, placed on cannula briefly with progressive grunting, flaring and retracting. Chest x-ray revealing transient tachypnea of the newborn versus respiratory distress syndrome. Infant was placed on CPAP. He remained on CPAP for a total of 72 hours at which time he transitioned to nasal cannula O2. He remained on nasal cannula O2 until [6-6] at which time he transitioned to room air and has been stable in room air since that time. He has not required methylxanthine therapy and he has had no documented episodes of apnea and bradycardia. 2. Cardiovascular: [Known firstname ] has an audible murmur. Cardiac workup was within normal limits. EKG was normal. Chest x- ray showed normal cardiac silhouette, pre and post ductal sats within normal limits and 4 extremity blood pressures within normal limits. Murmur felt to be PPS in quality. 3. Fluids/Electrolytes: Birth weight 2.375 kg, discharge weight is 2390g; discharge head circumference was 32.5 cm, length was 46 cm. Infant was initially started on 80 cc per kilo per day. Enteral feedings were initiated on day of life #3. Full enteral feedings were achieved by day of life #8. He is currently ad lib feeding Similac 24- calorie, taking in adequate amounts. 4. GI/GU: Peak bilirubin was, on day of life #3, 11.8/0.3, responded nicely to phototherapy, and his most recent bilirubin was 8.5/0.3 on [6-6]. 5. Hematology: The patient's blood type is O positive, direct Coombs' negative. Initial hematocrit was 46.8. 6. Infectious disease: CBC and blood culture obtained on admission. CBC was benign. Blood culture remained negative at 48 hours at which time ampicillin and gentamicin were discontinued. Infant is currently receiving Nystatin ointment to a monilial rash in his diaper area. 7. Neuro: Infant has been appropriate for gestational age. 8. Sensory: Hearing screen was performed with automated auditory brainstem responses and the infant passed. CONDITION AT DISCHARGE: Stable. DISCHARGE DISPOSITION: To home. PRIMARY PEDIATRICIAN: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], MD, telephone number ([Telephone/Fax (1) 65233]. CARE RECOMMENDATIONS: Continue ad lib feeding Similac 24- calorie. MEDICATIONS: Not applicable. Car seat position screening was performed for a 90-minute screening and the infant passed. State newborn screen was sent most recently on [6-6]. Initial screening was done on [6-1] with an elevated 17-OHP, with repeat screen requested. IMMUNIZATIONS RECEIVED: Infant received hepatitis B vaccine on [6-9]. DISCHARGE DIAGNOSES: 1. Premature infant born at 35-3/7 weeks. 2. Respiratory distress syndrome. 3. Rule out sepsis with antibiotics. 4. Hyperbilirubinemia. 5. Monilial rash. 6. PPS murmur. Reviewed By: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 53043], MD [MD Number(1) 36250] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2116-6-13] 19:49:20 T: [2116-6-14] 11:21:45 Job#: [Job Number 72893]	[ "7742", "V290", "V053" ]
Admission Date: [2137-3-14] Discharge Date: [2137-3-20] Date of Birth: [2085-10-31] Sex: F Service: SURGERY Allergies: Sulfonamides Attending:[First Name3 (LF) 148] Chief Complaint: Retroperitoneal tumor Major Surgical or Invasive Procedure: 1. Excision of retroperitoneal tumor greater than 10 cm in size. 2. Open cholecystectomy. 3. Vena caval resection and reconstruction with bovine pericardium. History of Present Illness: This is a delightful 51-year-old lady who is totally healthy. A mass was picked up by her PCP in her abdomen. The lady had had many years of vague right back pain, however, no other symptoms were in play. The CAT scan was obtained and there was a huge tumor in the retroperitoneum abutting the pancreas, the liver, the colon and the duodenum as well as the kidney. Endoscopic ultrasound was used to identify this and it was uncertain if this was attached to the GI tract or not. A fine needle aspirate of this was suspicious for malignancy, however, more detail from this could not be ascertained. I met with Ms. [Known lastname 111240] and her family and indicated that she had a malignancy suggestive of either a sarcoma or a lymphoma. Also in play was the possibility of this being a GI stromal tumor arising from the pancreatic and duodenal head. I discussed the rationale for proceeding with a large open exploration and attempted resection of this mass Past Medical History: UC, ^lipids, hypoTH, LBP, osteopenia Social History: No tobacco No EtOH Family History: Colorectal CA - sister Liposarcoma - mother Physical Exam: AVSS GEN: NAD, A+O x3 HEENT: WNL, PERRLA CV; RRR, No M/R/G Pulm: CTAB Abd: no scar, soft/NT, large palpable mass to RUQ Pertinent Results: [2137-3-18] 04:20AM BLOOD WBC-4.9 RBC-3.49* Hgb-9.5* Hct-26.9* MCV-77* MCH-27.1 MCHC-35.2* RDW-13.9 Plt Ct-185 [2137-3-16] 02:03PM BLOOD Hct-23.7* [2137-3-16] 03:40AM BLOOD WBC-8.7 RBC-3.23* Hgb-8.8* Hct-25.4* MCV-79* MCH-27.1 MCHC-34.5 RDW-13.0 Plt Ct-172 [2137-3-15] 02:45AM BLOOD WBC-11.7* RBC-3.79* Hgb-10.1* Hct-29.2* MCV-77* MCH-26.6* MCHC-34.5 RDW-13.0 Plt Ct-232 [2137-3-16] 03:40AM BLOOD PT-14.0* PTT-53.4* INR(PT)-1.2* [2137-3-18] 04:20AM BLOOD Glucose-92 UreaN-9 Creat-0.7 Na-140 K-3.9 Cl-107 HCO3-28 AnGap-9 [2137-3-17] 04:40AM BLOOD Glucose-75 UreaN-11 Creat-0.7 Na-138 K-3.5 Cl-104 HCO3-26 AnGap-12 [2137-3-16] 03:40AM BLOOD ALT-36 AST-77* LD(LDH)-219 AlkPhos-44 Amylase-42 TotBili-0.5 [2137-3-18] 04:20AM BLOOD Calcium-7.9* Phos-1.6* Mg-1.6 . Pathology Examination Name Birthdate Age Sex Pathology # [Hospital1 18] [Known lastname 111241],[Known firstname ] [2085-10-31] 51 Female [Numeric Identifier 111242] [Numeric Identifier 111243] Report to: DR. [Last Name (STitle) ] [Last Name (NamePattern4) ] Gross Description by: DR. [Last Name (STitle) ] [Last Name (NamePattern4) 44437]/dif SPECIMEN SUBMITTED: gall bladder, retroperitoneal tumor, left renal vein. Procedure date Tissue received Report Date Diagnosed by [2137-3-14] [2137-3-14] [2137-3-20] DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]/yc Previous biopsies: [Numeric Identifier 111244] CYTOSPINS FOR IMMUNOHISTOCHEMISTRY, ABDOMINAL MASS FNA, [Numeric Identifier 111245] FNA for immunophenotyping [Numeric Identifier 111246] COLON BXS [-3/3339] GI BX'S, 9. (and more) DIAGNOSIS: 1. Gallbladder, cholecystectomy (A): Gallbladder with no diagnostic abnormalities recognized. 2. Soft tissue and superior vena cava, retroperitoneum, resection (B-N): A. Leiomyosarcoma, conventional type, intermediate grade, involving vein wall. See note. B. Tumor is present at the superior vena cava margin and is within microns from the soft tissue margin. C. One unremarkable lymph node. 3. Renal vein, left, resection (O): Vessel wall with focal involvement by leiomyosarcoma. Note: Immunohistochemical stains show that the tumor cells are strongly positive for desmin and actin, focally positive for cytokeratin cocktail (AE1-3/CAM5.2), and are negative for S-100 protein. Staining for CKIT is equivocal. These findings are in keeping with the above diagnosis. . [2137-3-20] 10:35AM BLOOD Hct-32.2* [2137-3-20] 10:35AM BLOOD PT-14.9* PTT-30.8 INR(PT)-1.3* [2137-3-19] 11:35AM BLOOD Glucose-104 UreaN-6 Creat-0.7 Na-142 K-3.4 Cl-107 HCO3-25 AnGap-13 Brief Hospital Course: This is a 51 year old female with a large retroperitoneal tumor and went to the OR on [2137-3-14] for: 1. Excision of retroperitoneal tumor greater than 10 cm in size. 2. Open cholecystectomy. 3. Vena caval resection and reconstruction with bovine pericardium. She went to the ICU post-op for monitoring. Pain: She had a PCA for pain control. Once tolerating a diet, she was transitioned to PO meds. GI: She had a NGT to LWS. The NGT was removed on POD 2. Her diet was slowly advanced and she was tolerating a regular diet at time of discharge. Abd/Pelvis: Her abdominal incision was C/D/I. She had a left groin incision that was stable with no hematoma and minimal serosang drainage. Heme: Her HCT was stable post-op. She was started on a Heparin gtt on POD 1 per the vascular recs secondary to the Cavoplasty. She had a HCT drop after starting Heparin. She had some oozing from the left groin. She was transfused 2 units blood and her HCT was stable at 26.9. The Heparin drip was stopped. The next day she was started on Aspirin 325mg. On POD 6, she was started on Lovenox with a bridge to Coumadin. Her INR at time of discharge was 1.3. She will remain on Coumadin for 3 months. Medications on Admission: rowasa enema, levoxyl 88', lipitor 10', Ca++/Vit D, folic acid Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:45 Tablet(s) Refills:0 4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 5. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Mesalamine 1,000 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 12. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous [Hospital1 ] (2 times a day) for 5 days. Disp:10 Refills:0 13. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks: Follow-up with your PCP for your next Rx in one week. Your INR on [2137-3-20] was 1.3. Disp:7 Tablet(s) Refills:0 14. Outpatient Lab Work INR check on [2137-3-22], [2137-3-25], [2137-3-27] and fax results to PCP. [Last Name (NamePattern4) ]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 1609]. (f) [Telephone/Fax (1) 111247] (p) [Telephone/Fax (1) 2740] Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Retroperitoneal tumor Post-op Blood Loss Anemia Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Please resume all regular home medications and take any new meds as ordered. You are being discharged on Aspirin, Lovenox and Coumadin. The VNA will assist with Lovenox injections and will check your INR level. Your PCP, [Last Name (NamePattern4) ]. [First Name (STitle) 1609], [First Name3 (LF) ] get the INR results faxed to her and dose your Coumadin accordingly. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to increase activity daily * No heavy lifting (>[9-4] lbs) for 6 weeks. * Monitor your incision for signs of infection * Keep your incision clean and dry. Followup Instructions: You need to follow-up with your PCP for INR monitoring and Coumadin dosing. You will need to get a Rx for Coumadin from your PCP. [Name10 (NameIs) ] to schedule an appointment. Please follow-up with Dr. [Last Name (STitle) ] in 2 weeks. Call [Telephone/Fax (1) 1231] to schedule an appointment. Your staples will be removed at that time. Provider: [Name10 (NameIs) ] [Apartment Address(1) ] (ST-3) GI ROOMS Date/Time:[2137-4-1] 10:30 Provider: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 6925],MD Phone:[Telephone/Fax (1) 463] Date/Time:[2137-4-1] 10:30 Completed by:[2137-3-20]	[ "2851", "2449", "2724" ]
Admission Date: [2165-9-23] Discharge Date: [2165-10-24] Date of Birth: [2101-3-3] Sex: F Service: MEDICINE Allergies: Penicillins / Reglan / Iodine; Iodine Containing / Compazine / Hayfever / Levofloxacin / Vancomycin / Magnesium Sulfate / Dalmane / Acyclovir Analogues / Cefepime Attending:[First Name3 (LF) 3913] Chief Complaint: Night sweats, low-grade fever and abnormal CBC. Major Surgical or Invasive Procedure: Central line placed (Right IJ) Thoracosentesis 750cc (right) Lumbar Puncture Sinus exploration by ENT History of Present Illness: Ms. [Known firstname ] [Known lastname 95142] is a very nice and sweet 64 YO woman with multiple lymphomas s/p 2 autologus stem cell transplant (see below for details) and transfusion-dependent MDS, CHF (EF 30%) who came here initially for night sweats, low-grade fever, abnormal CBC and SOB. She had been having face pain with greenish nasal discharge for the past 3-4 weeks. She saw an ENT who recommended saline spray; there was no improvement. She received Z-pack (unknown date) and then was started on cefpodoxime 7 days ago with improvement of her upper airway symtpoms. Patient states she has been having fever up to 100.8, with chills, there has been production of greenish sputum with cough associated, but has also improved since starting of antibiotics. Patient started loosing 10 lbs within the last couple of moths, but then has gained them back in the last two weeks. She has been on and off her lasix with multiple doses and she decided to stop it 7 days ago. There has been no swelling of her legs. The SOB was getting worse during the 3 days prior to admission. Past Medical History: 1.Summary Hodgkin's lymphoma dx [2144] S/P mantle radiation therapy S/P recurrence in [2147]; large cell non-Hodgkin's lymphoma diagnosed in [2145] S/P chemotherapy S/P recurrence in [2147] S/P first bone marrow transplant in [2147]; S/P second recurrence throat and lung in [2160] S/P chemotherapy between [12/2161] and [3-/2162] S/P second autologous stem cell transplant in 12/[2161]. s/p MDS dx [3-5] now transufsion dependent. 2. LLL anthracotic nodule s/p wedge resection - bronchial metaplasia only, no malignancy identified. 3. Migraines with visual disturbances (? diplopia) 4. Asthma (usually seasonal) 5. Recurrent Shingles 6. s/p resection of LLL, as above 7. Neuropathy [12-29] her chemotherapy 8. Constipation 9. Hemorrhoids 10. Depression 11. CP - diagnosis of myalgias in [1-30] 12. CAD - Cath mid [2164-11-27] - left main stenosis, LCS and RCA disease -- after angiogram sever chest pain- IABP placed and CABG with mitral valve reparir ring [2164-12-13]. rSVG to LAD and OM, second graft to PDA. 13. Hashimoto's disease/subclinical hypothyroidism: on levothyroxine 14: GERD 15 s/p left lower lobe resection in [2157] 17. Pneumonia [2164] 19: Hypogammaglobuliniemia requiring IVIG <br> She was first diagnosed in [2144] when she presented with a right neck mass. She underwent radiation to her mantle and below the diaphram. In [2145], more nodes wer found, and she underwent chemotherapy at that time. In [2147], she underwent high dose chemo with stem cell rescue, which was successful. Her post transplant course was complicated by disseminated Zoster (had for years--treated with acyclovir), encephalitis/ meningitis (?on Bactrim). She also suffered from depression and was started on Prozac during that time. She was doing well until [2157] when she was admitted for work-up of a left lower lobe mass. LN Biopsy revealed an anthracotic node and lung wedge bx showed only patchy areas of scarring and bronchial metaplasia, with no malignancy identified in either tissue. . Around [2161-10-28], she started to feel 'not right'. She presented to her PCP with [Name Initial (PRE) ] sore throat. In mid [Month (only) 404], she had a recurrence of her shingles (treated with Valtrex; recurred on right chest, left neck). She also saw an ENT for her sore throat who saw a mass on her tonsillar pillar. Biopsy revealed findings c/w diffuse large B cell lymphoma with high-grade features, given the proliferation fraction of ~90%. The alternative consideration of an atypical Burkitt was considered less likely given the nuclear pleomorphism and reported bcl-2 positivity. She followed-up with her Oncologist after the biopsy was done and underwent BM bx revealing no marrow involvement. She underwent cycle 1 of ESCHAP 2/17-22/05. Her course was c/b fluid overload, profound nadir and mucositis. She had a PET scan [2-2] showing marked interval decrease in FDG-avid disease within the pulmonary parenchyma and interval resolution of FDG-avid lymph-adenopathy within the neck, mediastinum, and hila. Pt was admitted from [Date range (1) 95143] /05 when she received [Hospital1 ]-R chemo, which she tolerated well. [Date range (3) 95144] - she was admitted for a 2nd autologous stem cell transplant with BEAM chemotherapy. * MDS dx [3-5] Social History: Worked part time as school nurse. Married with 2 grown children. Native of [State 1727]. No smoking. No alcohol. Family History: Mother dx'[Name2 (NI) ] uterine cancer age 35, died alzheimers age 80. Father died COPD age 74. Paternal aunts with breast cancer. Physical Exam: VITAL SIGNS - Temp 97.5 F, Tmax 99.4 F, BP 106/68, HR 92, RR 22, SpO2 95% RA, weight 101 lbs GENERAL - well-appearing woman, no acute distress, A&Ox3 HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - clear to auscultation bilaterally, but slightly decreased vesicular breath sounds in both bases, with increased dullness to percussion, mostly in posterior left and lateral right bases. HEART - RRR, nl S1-S2, S3 present, SEM apex [1-2] 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 [4-1] throughout, sensation grossly intact throughout Pertinent Results: On Admission: [2165-9-23] 01:55PM WBC-2.7* RBC-2.72* HGB-8.1* HCT-23.9* MCV-88 MCH-29.7 MCHC-33.8 RDW-18.8* [2165-9-23] 01:55PM NEUTS-37* BANDS-0 LYMPHS-27 MONOS-20* EOS-0 BASOS-4* ATYPS-0 METAS-3* MYELOS-7* PROMYELO-2* NUC RBCS-11* [2165-9-23] 01:55PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+ SCHISTOCY-1+ ACANTHOCY-1+ [2165-9-23] 01:55PM PLT SMR-VERY LOW PLT COUNT-50* [2165-9-23] 01:55PM GRAN CT-1323* [2165-9-23] 01:55PM ALT(SGPT)-22 AST(SGOT)-32 LD(LDH)-299* CK(CPK)-24* ALK PHOS-352* TOT BILI-2.1* DIR BILI-1.5* INDIR BIL-0.6 [2165-9-23] 01:55PM CALCIUM-9.4 PHOSPHATE-3.2 MAGNESIUM-2.1 URIC ACID-4.8 [2165-9-23] 01:55PM CK-MB-2 cTropnT-<0.01 [2165-9-23] 01:55PM UREA N-25* CREAT-1.1 SODIUM-135 POTASSIUM-5.0 CHLORIDE-101 TOTAL CO2-26 ANION GAP-13 [2165-9-23] 06:49PM TYPE-ART PO2-113* PCO2-34* PH-7.45 TOTAL CO2-24 BASE XS-0 [2165-9-23] 09:00PM DIGOXIN-0.8* [2165-9-23] 09:00PM CK-MB-2 cTropnT-<0.01 proBNP-8667* [2165-9-23] 09:00PM CK(CPK)-71 PITUITARY TSH [2165-10-3] 05:44PM 2.8 Chest CT scan on [2165-9-23] (admission): Bilateral dependent pleural effusions have increased in size, now moderate to large on the right and moderate on the left. No enlarged mediastinal or hilar lymph nodes are identified. Heart is normal in size. Exam was not tailored to evaluate the subdiaphragmatic region, but no substantial changes are identified in the upper abdominal region on this limited assessment with persistent atrophy of the superior pole of the left kidney. Within the lungs, bilateral paramediastinal areas of radiation fibrosis with associated traction bronchiectasis appear unchanged, as well as focal linear scarring adjacent to an apparent wedge resection site in the superior segment of the left lower lobe. Atelectatic changes are present at the lung bases adjacent to the pleural effusions. Additionally, there are new scattered thickened septal lines, predominantly in the lung bases, accompanied by mild bronchovascular thickening. Skeletal structures demonstrate diffusely heterogeneous appearance of the patient's bones, likely related to the history of myelodysplastic syndrome. Asymmetric stranding of the soft tissues throughout the left chest and abdominal wall compared to the right likely reflects asymmetrical anasarca. IMPRESSION: 1. New mild septal and bronchovascular thickening predominantly in the lower lungs, most suggestive of hydrostatic edema in the setting of enlarging pleural effusions and body wall edema. 2. Diffuse heterogeneity of the skeletal structures, likely related to the provided history of myelodysplastic syndrome. Echocardiogram [2165-9-24]: Overall left ventricular systolic function is moderately depressed (LVEF=30 %). The mitral valve leaflets are mildly thickened. A mitral valve annuloplasty ring is present. There is a moderate sized pericardial effusion. The effusion appears loculated and is adjacent to the anterolateral and inferolateral walls of the left ventricle. Compared with the prior study (images reviewed) of [2165-9-17] (outpatient), the pericardial effusion is slightly larger. There are no echocardiographic signs of tamponade. Abdominal Ultrasound ([2165-9-25]): 1. No signs of biliary obstruction. 2. Unchanged cholelithiasis with no secondary findings to suggest acute cholecystitis. 3. Enhancing lesion noted on prior CT suggestive of a hemangioma does not display son[Name (NI) 493] characteristics to support this diagnosis. Differential still includes other benign liver lesions including hepatic adenoma or FNH. If a more definitive diagnosis is needed, a dedicated MRI abdomen with BOPTA contrast would be recommended. MRI of the abdomen [2165-10-2]: There are moderate bilateral pleural effusions, which are also seen on the recent CT. Anasarca is present. There is diffuse hypointensity in the liver, bone marrow, and spleen on the T1- and T2-weighted images, compatible with hemosiderosis. There is a 2- mm probable cyst in the left lobe of the liver on series 1603, image 15, which is probably present on the previous MRI. No suspicious focal liver lesions. No evidence of biliary ductal dilatation. The liver is enlarged measuring 20 cm in length. Spleen is normal in size. Gallbladder is unremarkable. The pancreas, adrenals are unremarkable. There is atrophy in the upper pole of the left kidney with stable 1 cm cyst in the upper pole. This is about 1-2mm larger than on the [1-2] MRI. The atrophy in the upper pole could be due to radiation or stenosis in an accessory renal artery. It is stable. There is very minimal atrophy in the medial upper pole of the right kidney as well, also stable. Sternotomy wires. No bulky adenopathy. Pleural based 1 cm nodule in the right lower lobe is stable since the CT of [2162-2-23]. Multiplanar 2D and 3D reformations delineated the dynamic series with multiple perspectives. IMPRESSION: 1. No focal suspicious lesions in the liver or spleen to suggest candidiasis. 2. Moderate bilateral pleural effusions. 3. Hemosiderosis in the liver and spleen. MRI head [2165-10-2]: There is diffuse mild pachymeningeal enhancement, which is new since the prior MR study of [2165-4-22]. However, this has a relatively smooth appearance, without associated nodularity or mass like appearance. No evidence of leptomeningeal enhancement is noted on the present study. The ventricles and the extra-axial CSF spaces are unremarkable. There are scattered FLAIR hyperintense foci in the cerebral white matter on both sides, without enhancement and not significantly changed. A vague area of enhancement in the left cerebellar hemisphere on the axial spin echo post-contrast images reflects pulsation artifacts and has no correlate on the FLAIR sequences. The MP-RAGE post-contrast images are limited due to motion artifacts. There are no areas of restricted diffusion or negative abnormal susceptibility, to indicate acute infarction or hemorrhage. Bilateral basal ganglial calcifications are noted. There is moderately increased signal in the right maxillary sinus, along with polypoidal mucosal thickening and dense contents centrally as well as in the sphenoid sinus and mild in the ethmoid air cells on both sides, not significantly changed compared to the prior MR study. There are areas of increased signal intensity in the mastoid air cells on both sides, right more than left, reflecting fluid and/or mucosal thickening. IMPRESSION: 1. No abnormal enhancing lesions in the brain parenchyma to suggest toxoplasma intraparenchymal lesions. 2. Diffuse mild pachymeningeal enhancement, which may relate to inflammation, infection, or post-LP, if performed. To correlate clinically, and if necessary with LP results. No evidence of leptomeningeal enhancement. 3. Extensive paranasal sinus disease involving the right maxillary sinus, sphenoid, mild involving the ethmoid air cells, with dense contents. As mentioned before, this can be due to inspissated secretions or fungal etiology, given the new compromised condition. To correlate clinically. Echocardiogram [2165-10-3]: Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate to severe global left ventricular hypokinesis (LVEF = 30 %) with intraventricular mechanical dyssynchrony. There is no ventricular septal defect. Right ventricular chamber size is normal. with depressed free wall contractility. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. A mitral valve annuloplasty ring is present. The mitral annular ring appears well seated and is not obstructing flow. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a small to moderate sized posterior pericardial effusion. There are no echocardiographic signs of tamponade. USG of left arm [2165-10-5]: Grayscale and color Doppler son[Name (NI) ] of the left internal jugular, subclavian, axillary, and brachial veins were obtained. There is normal compressibility and flow, without evidence of DVT. The left cephalic vein was not visualized. CT sinus [2165-10-18]: Worsening paranasal sinus opacification compared to the prior MR of [2165-10-2]. Dense material in the right maxillary and sphenoid sinuses could reflect inspissated secretions, however, underlying fungal infection cannot be excluded, particularly in the setting of an immunocompromised patient. To correlate clinically. CSF Cytology/Pathology: No malignant cells seen. CSF Cultures: Negative Upon discharge: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [2165-10-24] 05:45AM 1.41 3.29 9.8* 28.7* 87 29.7 34.1 16.7* 322 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos Promyel Blasts NRBC Other [2165-10-24] 05:45AM 201 0 76* 0 0 0 4* 0 0 24* RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr Spheroc Ovalocy Target Schisto Burr Stipple Tear Dr [MD Number(4) ] [Name (STitle) ] Bite Acantho Fragmen Ellipto [2165-10-24] 05:45AM NORMAL 1+ 2+ NORMAL 1+ NORMAL 1+ 1+ 1+ RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [2165-10-24] 05:45AM 102 12 0.8 139 3.6 103 30 10 ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili [2165-10-24] 05:45AM 17 25 327* 279* 1.5 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [2165-10-24] 05:45AM 3.5 8.8 3.1 1.4* MISCELLANEOUS HEMATOLOGY Gran Ct QG6PD [2165-10-24] 05:45AM 280* Brief Hospital Course: 64 year-old woman with history of multiple lymphomas (see onc history) and s/p 2 autoSCT now with MDS, sCHF, admitted with low-grade temp, night-swats and of breath. 1. Hypotension - Patient usually has had SBP in the 90's, but was as low as 70 upon admission. Infectious, obstructive and cardiac etiologies were considered. Cardiac and blood pressure medications including spironolactone, lasix and carvedilol were held. Patient had mild-moderate pericardial effusion and was followed by echocardiography. However, there were no signs of tamponade or restrictive physiology. Patient also had negative exntensive infectious work up (see below) and PE was also ruled out. Ms. [Known lastname 95142] required ICU care for invasive monitoring and pressure support. Adrenal insuffiency was ruled out by [Last Name (un) 104] stim and steroid challenge. When patient stopped spiking high-grade temperatures and her intravascular volume was repleted she improved and we were able to re-start spironolactone (25mg QD) and carvedilol (3.125 mg [Hospital1 ]). After work up etiologies considered were unknown infectious etiology, which contributed to systolic heart failure exacerbation. . 2. Fevers - Upon admission patient had fever up to 104 and had altered mental status associated with fevers and/or hypotension. Patient had CXR showing bilateral pleural effusions (R>L) that were tapped and showed a transudate by lights criteria and were negative for infectious agents and malignant cells. Blood cultures, including mycolytics were negative. Toxoplasma titer was IgM positive and IgG negative in the setting of multiple blood transfusions. It was repeated and was negative, so it was considered an artifact. Patient had EBV viral load of 400, which went up to 1000 in teh setting of steroid administration in the ICU and down to 400 afterwards. We are awaiting last value and will need follow up. Patient was negative for HSV-6, CMV, Lyme, Ehrlichia, Histoplasma, Cryptococcus, Aspergillus, Brucella, head sinuses cultures (fungal, viral and bacterial) and stool studies as well. AML was considered as part of the differential and pt had a negative bone marrow bipsy. Patient was evaluated by ENT for sinusitis and pt also had negative LP (WBC 3, normal protein and glucose with negative cultures). Patient was treated on Vanc/Cefepime/Caspo originally and developed severe rash with cefepime. She was then switched to aztreonam and consequently to meropenem. She improved in this regimen. After recovery she was back in the BMT floor and then developed a UTI with VRE, for which she was treated with Daptomycin (Pt on SSRI) for 5 days. She had vaious epiosdes of neutropenic fevers, which were treated with meropnem. She was discharged afebrile >24 hours without antibiotics and was asked to come back if T>=100.4 or any sign of infection or anything else that concerns her. Patient was followed by Dr. [Last Name (STitle) 724]. . 3. Neutropenia: Patient had ANC that dropped rapidly and was thought to be due to valgancyclovir (for ? EBV), which was stopped. However, patient dropped ANC multiple times afterwards. CMV, HSV were negative and HIV is pending (will need follow up). Medications were reviewed multiple occassions and there was no correlation. MDS was postulated as a cause of her cyclic ANC. Patient required treatment with meropenem in various occassions for neutropenic fever. . 4. Sinusitis: MRI showed signs of sinusitis/inflammation as well as CT scan. Patient was cultured by ENT and given 2 week course of antibiotics (meropenem-->doxycicline). Repeat CT shwoed congestion in right maxillary sinus and patient was re-cultured. ED and ENT suggested only symptomatic treatment with normal saline wash. Cultures were negative. . 5. MDS: Patient had a bone marrow finding 1% blasts and other findings compatible with MDS. patient required multiple RBC transfussions as well as HLA-matched platelets to fullful our targets of HCT >25 and PLT >10,000. Patient was discharged with stable HCT of 28.7 and PLT of 32,000 with CBC scheduled for 1 day after discharge. Patient was neutropenic with ANC of 280 and patient was aware of risks. She was given warning signs and symptoms as well as educationr regardind neutropenia and diet and infections. She had 1-5% circulating blasts throughout admission. There is question about MDS causing her ANC to cycle up and down from ~200-800. . 6. CVD: Patient was followed by echocardiogram and her EF was stable from her baseline at 30-35% with moderate to severe left global hypokinesis. NT-proBNP upon admission was 8667. Mild-moderate pericardial effusion. CV medications were stopped due to hypotension. Patient also required fluid ressusitation gaining up to 18 pounds of fluid that were then slowly diuresed. Then patient was re-started on her beta-blocker and dose was slowly increased up to 3.125 mg PO BID. ASA was not continued for low platelet count. Lasix was given PRN to maintain a weight of 101-102 lbs. Patient was given appointment with the [Hospital 1902] clinic and she was tought to weight herself daily and call if >2.9 lb change from her baseline. Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 696] and cardiology were consulted and followed the patient. . 7. Diarrhea: Patient with diarrhea 1 week prior to discharge and was c diff negative x3. However, since she was so fragile and her ANC up and down it was decided to give her a 2 week course of PO vancomycin. She will complete it [2165-10-27]. Upon discharge patient's bowel movements were normal. . 8. Hypothyroidism: Patient's levothyroxine was continued throughout hospitalization at outpatient dose. TSH was 2.8. . 9. Access: Patient had peripherals, but then required right IJ central line. . 10. PPx - -DVT ppx with Pneumoboots, no Heparin given [12-29] low platelets. Then aptient was walking. -Bowel regimen. -Pantoprazole 40mg [Hospital1 ]. . 11. Code - Full code, but no tracheostomy or feeding tube. Medications on Admission: 1. Citalopram 20 mg PO DAILY. 2. Clonazepam 1 mg PO QHS. 3. Clotrimazole 10 mg QID PRN pain. 4. Lorazepam 0.5 mg PO Q6H PRN anxiety. 5. Valacyclovir 500 mg PO DAILY. 6. Magnesium Oxide 400 mg PO BID. 7. Multivitamin PO DAILY. 8. Cetirizine 10 mg PO DAILY. 9. Fluconazole 100 mg PO Q24H. 10. Levothyroxine 75 mcg PO DAILY. 11. Nystatin 100,000 unit/mL Suspension 5 ML PO QID. 12. Nexium 40 mg (E.C.) PO BID. 13. Aspirin 81 mg PO DAILY. 14. Furosemide 40 mg PO BID. 15. Carvedilol 6.25 mg PO BID 16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: PO QD. 17. Calcium Citrate + D 315-200 mg-unit Tablet PO DAILY. 20. Fluticasone-Salmeterol 250-50 mcg/Dose Disk (1) puff Inhalation twice a day. Discharge Medications: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Digoxin 125 mcg Tablet Sig: Half a pill Tablet PO DAILY (Daily). 3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 5. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for insoomnia. 11. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO four times a day for 3 days. Disp:12 Capsule(s) Refills:0 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 13. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 15. Cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day. 16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 17. Lab draw Please do on Fri [2165-10-25] CBC with differential and absolut neutrophil count, chem-7 and fax to Dr. [Last Name (STitle) ] at: ([Telephone/Fax (1) 51492]. Discharge Disposition: Home With Service Facility: Androscoggin VNA Discharge Diagnosis: Primary Diagnosis Neutropenic Fever Bacterial Sinusitis Systolic Heart Failure exacerbation EBV? . Secondary Diagnosis 1.Summary Hodgkin's lymphoma dx [2144] S/P mantle radiation therapy S/P recurrence in [2147]; large cell non-Hodgkin's lymphoma diagnosed in [2145] S/P chemotherapy S/P recurrence in [2147] S/P first bone marrow transplant in [2147]; S/P second recurrence throat and lung in [2160] S/P chemotherapy between [12/2161] and [3-/2162] S/P second autologous stem cell transplant in 12/[2161]. s/p MDS dx [3-5] 2. CAD 3. GERD 4. Depression 5. Hashimoto's disease 6. Hypoglobulinemia Discharge Condition: Stable, tolerating diet, afebrile without antibiotics for more than 24 hours, walking, asymptomatic, diarrhea resolved. Discharge Instructions: You were seen at the [Hospital1 18] for night sweats, fever and changes in your blood work that were concerning for leukemia. A bone marrow biopsy showed similar findings that before, compatible with Myelodysplastic syndrome. Your blood pressure was very low and your fevers very high suggesting sever infection. You required ICU care and a central line to measure pressures and give you fluids and medications to help you with your blood pressure. All the infectious work up was negative, but EBV, which was borderline and we are awaiting the final result. Toxoplasma titer was mildly positive once, but we think it was due to a prior transfusio and subsequent titers were negative. Your echocardiogram was unchanged, but still shows some fluid around your heart. The fluid around your lungs was tapped and shows that most likely it is due to your heart failure. It has been decreasing with Lasix and management of your heart failure. . You had VRE infection in your urine and were treated for it with daptomycin. . Your neutrophil counts have been varying a lot during the hospitalization and during multiple episodes you had neutropenic fever, which is a medical emergency. You received antibiotics and all the work up was negative for infection. It is extremely important that you come back to the hospital if you have a fever (Temp >=100.4) or any sign of infection that concerns you. . You were tested for HIV for your history of multiple transfusions and the change in your cell counts. The result is pending. . You had sinus drainage with facial pain and fever. So ENT saw you twice and observed your sinuses. You also had an MRI and CT of your sinuses. All cultures were negative. There is no need for treatment or follow up with them for now. However, we recommend that you wash your nose with saline twice a day as you normaly used to do. . You will have appointment Monday with Dr. [Last Name (STitle) ] and [Hospital 1902] clinic. YOu have appointment early next year with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 696]. Followup Instructions: Provider: [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Doctor Last Name ] Phone:[Telephone/Fax (1) 62] Date/Time:[2165-10-28] 11:00 Please call tomorrow Dr.[Name (NI) 95145] office for appointment on Monday afternoon. His phone number is: ([Telephone/Fax (1) 3936].	[ "5990", "4280", "2875", "2449" ]
Admission Date: [2181-9-4] Discharge Date: [2181-9-7] Date of Birth: [2104-12-10] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5018] Chief Complaint: coma Major Surgical or Invasive Procedure: none History of Present Illness: 76 y [Hospital 78924] transferred to [Hospital3 ] ED after being found unresponsive at [First Name4 (NamePattern1) 1820] [Last Name (NamePattern1) 731] Rehab/NH. His GCS on arrival to the ED was assessed to be 3 on arrival. According to his wife [Name (NI) 2127] and his daughters, he had fallen 2 days ago at his residence, and had fallen some time at night, although this is unclear. At [Hospital3 9717] ED, he was intubated and sedated (etomidate 20/succ 100/lidocaine 100, then given fentanyl 25/versed 2 at 7 am). He received 50 g mannitol. His daughters [Name (NI) ] [Last Name (NamePattern1) 16229] and [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] were present with their Mother [Name (NI) 2127] [Name (NI) 805]. Past Medical History: 1. [2181-8-22] - Surgeon Dr [Last Name (STitle) ] [Last Name (NamePattern4) 1132] at [Hospital1 3278]: Left ACOM clipped (wide neck) post-op report: 12 mm (unruptured), left sided approach. 2. [3-31] - left carotid artery stent (at the bifurcation) started on ASA and Plavix 3. [3-31] TIA as per [Hospital1 3278] Neurosurgical Resident, and stroke according to the family. 4. CAD: Angioplasty 15-20 y ago 5. "Borderline diabetic" 6. HTN 7. Hyperlipidemia 8. Prostate cancer (3 monthly hormonal treatment at the [Hospital3 ]) Social History: Retired Government worker. Ran a cab company in [Hospital1 8]. Gave up smoking after his angioplasty. Minimal alcohol intake. No IVDA. Lived with his wife [Name (NI) 2127] (cell: [Numeric Identifier 78925]). Family History: Family Hx: Not known (did check with family). ROS: Not known, as Mr [Known lastname 805] was found in a coma. Brief Hospital Course: Patient admitted to ICU and made CMO, then extubated. Passed away on the floor. Autopsy pending. Medications on Admission: N/A Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Subdural hematoma Discharge Condition: Expired Discharge Instructions: None Followup Instructions: Expired [Name6 (MD) 4267] [Last Name (NamePattern4) 4268] MD, [MD Number(3) 5023] Completed by:[2181-9-8]	[ "2724", "4019", "V4582", "41401" ]
Admission Date: [2145-8-23] Discharge Date: [2145-9-7] Date of Birth: [2104-11-11] Sex: F Service: [Company 191] MEDICINE HISTORY OF PRESENT ILLNESS: This is a patient well known to me, she is a 40 year-old Caucasian female with a past medical history significant for C3-C4 quadriplegia, recurrent aspiration pneumonias with a history of MRSA positive sputum with MRSA, chronic pain, anxiety/depression, adrenal insufficiency, and multiple decubitus ulcers colonized by Pseudomonas who now presents with recurrent aspiration pneumonia and hypotension. The patient was recently discharged from the [Hospital1 69] to rehab on a total fourteen day course of Vancomycin for her previous aspiration pneumonia. On [8-22] the patient was found unresponsive with agonal respirations and hypoxia with sats in the 80s after apparently eating popcorn. She was suctioned by the Emergency Department at the time and corn kernels were retrieved. On [8-23] she was intubated without complications for a rigid bronchoscopy. Fragments of popcorn were removed from the left lower lobe rhonchus and copious white secretions were noted to be within the trachea and lungs bilaterally. PAST MEDICAL HISTORY: C3-C4 spinal cord injury after a motor vehicle accident in [2139] with resulting quadriplegia with some upper extremity use. Gastroesophageal reflux disease. Depression. Chronic adrenal insufficiency. Recurrent aspiration pneumonia with a history of MRSA positive sputum. Chronic low back pain. History of left heel osteomyelitis. Anxiety. Chronic anemia. Decubitus ulcers colonized by Pseudomonas. ALLERGIES: Penicillin and sulfa. MEDICATIONS ON ADMISSION: Baclofen 5 mg t.i.d., Oxycodone 5 to 10 mg q 8 hours prn, Prednisone 5 mg q.d., Tylenol prn, Tizanidine 4 mg t.i.d., heparin subQ b.i.d., Albuterol/Atrovent nebulizers prn, Colace 100 mg b.i.d., Clonazepam 1 mg b.i.d., Dulcolax prn, Zoloft 50 mg q.d., Protonix 40 mg q.d., Milk of Magnesia prn, Ambien prn, vitamin C 500 mg b.i.d., zinc 220 mg b.i.d., iron 325 mg q.d., Lactulose 30 cc t.i.d., Neurontin 400 mg t.i.d., Dilaudid 0.5 to 1 mg intravenous q 3 to 4 hours prn, Oxycontin 30 mg b.i.d. SOCIAL HISTORY: The patient apparently smokes five cigarettes per day. She denies any alcohol or intravenous drug use. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.7. Blood pressure 120/60. Pulse 54. Respirations 99% on AC 600 times 12 with a PEEP of 5 and 40% FIO2. In general, she was intubated and sedated at the time and in no acute distress. Her pupils are equal, round and reactive to light. Extraocular movements intact. Oropharynx was clear post intubation. There was no apparent JVD. Neck was supple without any lymphadenopathy. Lungs were with coarse breath sounds bilaterally, but with adequate air movement. There was no wheezing or crackles appreciated. Cardiac examination revealed a normal S1 and S2 with a brady rate. No murmurs, rubs or gallops were appreciated. Abdomen was obese, soft with good bowel sounds. It was noted that she had diffuse tenderness to mild palpation after she was extubated. Her extremities were 1+ pitting edema bilaterally. Her back revealed a stage three sacral decubitus as well as a stage three posterior thoracic decubitus ulcer. There was good granulation tissue and no purulent discharge present. LABORATORIES ON ADMISSION: White blood cell count 9.9 with a differential of 84 neutrophils, 11 lymphocytes, 3 monocytes and 3 eosinophils. Her hematocrit was 36, platelets 208, sodium 150, potassium 3.3, BUN and creatinine of 16 and 0.9. Urinalysis with moderate blood, moderate leukocyte esterase, greater then 50 red blood cells, greater then 30 white blood cells, many bacteria and positive nitrites. Chest x-ray was stable bibasilar consolidations, revealing no change since [8-15]. Electrocardiogram showing sinus brady in the 40s with normal axis, poor R wave progression and no ST changes. [Name6 (MD) 251] [Name8 (MD) ], M.D. [MD Number(1) 1197] Dictated By:[Last Name (NamePattern4) 1198] MEDQUIST36 D: [2145-9-7] 07:53 T: [2145-9-7] 08:52 JOB#: [Job Number 33136]	[ "5070", "5990", "53081", "3051" ]
Admission Date: [2159-1-24] Discharge Date: [2159-2-2] Date of Birth: [2107-8-11] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 78] Chief Complaint: assault/headache Major Surgical or Invasive Procedure: s/p open reduction left zygomatic arch fracture w/[Doctor Last Name 3228] [2159-1-31] History of Present Illness: HPI: (history obtained from patient and from ER physician) 57 year old male presents from an outside hospital. He reportedly was assaulted on Sunday by his girlfriend's husband. [Name (NI) ] went to an OSH where he was found to have a SDH and was discharged. The patient was reportedly assaulted again today by the same person. He went to another hospital and reportedly had a SDH, so he was transferred to [Hospital1 18] for further evaluation. The repeat CT here shows a large intraparenchymal hemorrhage on the left side as well as a SDH. The patient had a headache earlier today but that has since resolved. He has no nausea or vomiting. He has no visual changes, numbness, or tingling anywhere. Past Medical History: PMHx: CAD with stent Social History: Social Hx: lives with girlfriend and her husband; quit smoking 3 days ago but was smoking 1 ppd Recommend change in living situation. Will be discharged with sister. Family History: Family Hx:non-contributory Physical Exam: PHYSICAL EXAM ON ADMISSION: T:98.2 BP:155/85 HR:78 RR:20 O2Sats:96% Gen: WD/WN, comfortable, NAD. The patient is unable to recall all of the events leading up to today, but is able to explain parts of the story. HEENT: Pupils:PERRL EOMs-intact No otorrhea or rhinorrhea. Neck: In cervical collar. No point tenderness. 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 with prompting, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. The patient is somewhat tangential and needs to redirected when giving history. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [4-30] throughout. No pronator drift. Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Pertinent Results: CT head: FINDINGS: There is a large intraparenchymal hemorrhage of the left temporal lobe measuring about 5.1 x 3.1 cm in greatest axial dimension. There is a rim of surrounding hypodensity consistent with edema/infarction. There is associated mass effect with effacement of the left lateral ventricle and shift of the septum pellucidum to the right by approximately 4 mm. These findings are similar to the outside hospital study performed earlier today. Hyperdensity within the left lateral ventricle could possibly indicate intraventricular hemorrhage. Hyperdensity is also noted along the tentorium more prominent on the left concerning for small subdural hematoma. The suprasellar cistern is not effaced. An acute fracture is noted of the left zygomatic arch. The orbits and globes are intact. There is no evidence of retroorbital hematoma. The visualized paranasal sinuses and mastoid air cells remain clear. IMPRESSION: 1. Acute intraparenchymal hemorrhage of the left temporal lobe with associated mass effect causing effacement of the left lateral ventricle and subfalcine herniation to the right by about 4 mm. These findings overall appear similar to the outside hospital study performed earlier today. 2. Small subdural hematoma along the tentorium. 3. Depressed left zygomatic arch fracture. CT c-spine: Preliminary Report !! Wet Read !! No acute bony injury Labs: WBC 9.4 Hgb 15.8 Hct 43.6 Plts 275 PT: 12.7 PTT: 27.7 INR: 1.1 Na:137 Cl:94 BUN:16 Glu:92 K:4.0 CO2:27 Cr:0.9 Lactate:1.5 Brief Hospital Course: Patient was admitted to hospital on [2159-1-24] with a large left IPH and small SDH after being physically assaulted. On [2159-1-24] repeated head CT was stable. On [2159-1-25] CT/CTA stable with no aneurysm. He progressed slowly, mental status and cognition have slowly improved. PT has cleared him to be discharged home; however occupational therapy has found that he still has some cognitive challenges, unable to find rehabilitation placement for cognitive therapy, recommended discharge with family members for monitoring and one of his sister's has aggreed to this. His diet was advanced without any difficulties, and he has been voiding without difficulties. On [2159-1-31] he underwent a open reduction of left zygomatic arch fracture with plastic surgery, for which he would need only PRN follow up. As the fracture was comminuted, he should not put weight on the left side of the face to prevent recurrent fracture. Patient was cleared by PT to be d/c home with sister on [2159-2-2] Medications on Admission: Medications prior to admission: Aspirin 81 mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed: please use as needed for pain or fever. Disp:60 Tablet(s) Refills:0 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 4. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day): Please take the medicine as prescribed until your follow up appointment. You will need to have weekly blood draws for Dilantin level. Disp:120 Capsule(s) Refills:2 5. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily): Please follow up with your PCP for nicotine patch management. Disp:14 Patch 24 hr(s) Refills:2 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: Please do not exceed 4000 mg of Acetaminophen over 24 hour period. Please do not use any ETOH while on percocet, please do not drive or operate machinery while using narcotic pain meds. Please use stool softeners with pain meds. Disp:30 Tablet(s) Refills:0 9. Outpatient Lab Work Weekly Dilantin level Please fax results to Dr. [First Name (STitle) ] [Telephone/Fax (1) 4483] 10. Outpatient Speech/Swallowing Therapy Evaluation and therapy for language and cognitive deficits 11. ASA 81 mg Qday Discharge Disposition: Home with Service Discharge Diagnosis: Large left intraparenchymal hemorrhage, small subdural hemorrhage Discharge Condition: neurologically stable, mild cognitive slowing Discharge Instructions: YOU MUST NOT PUT WEIGHT/LIE ON THE LEFT SIDE OF YOUR FACE TO PREVENT RECURRENCE OF YOUR FACIAL FRACTURE ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication Please follow up with your primary care physician as you will need weekly Dilantin levels drawn (you have been given a prescription for this and can go to any laboratory for this), please have results faxed to Dr. [First Name (STitle) ] (neurosurgery office) [Telephone/Fax (1) 4483]. Followup Instructions: -PLEASE CALL [Telephone/Fax (1) ] TO SCHEDULE AN APPOINTMENT WITH DR.[First Name (STitle) ] TO BE SEEN IN [4-1] WEEKS. -YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST AT THAT TIME -PLEASE FOLLOW UP WITH PLASTIC SERVICES AS NEEDED, PLEASE CALL [Telephone/Fax (1) 6331] IF YOU NEED AN APPOINTMENT. -YOU SHOULD CONTINUE TO TAKE YOUR BABY ASPIRIN 81 mg once daily. YOU SHOULD ALSO FOLLOW-UP WITH YOUR PRIMARY CARE PHYSICIAN REGARDING THE [Name9 (PRE) ] YOU LIKELY SHOULD RESUME TAKING FOR YOUR CARDIAC STENT. Completed by:[2159-2-2]	[ "41401", "V4582" ]
Admission Date: [2140-11-27] Discharge Date: [2140-12-5] Date of Birth: [2061-6-27] Sex: M Service: MEDICINE Allergies: Penicillins / Horse Blood Extract Attending:[First Name3 (LF) 896] Chief Complaint: Hyperglycemia Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname ] is a 79yoM with h/o IDDM, CAD who presents from his [Hospital1 1501] with hyperglycemia. He is followed by Dr. [First Name (STitle) ] at [Last Name (un) ] Diabetes Center, and has had multiple admissions in recent months related to labile blood sugars. Most recent admission from [Date range (3) 25659] for hypoglycemia, and since that time his insulin regimen was changed from 18u [Hospital1 ] of Humalog 75/25 to a humalog sliding scale with meals and 4u Lantus qAM. Per [Hospital1 1501] blood glucose log from this week, his blood sugars have generally been high, frequently >400. This AM his blood sugar was >500 on multiple checks. The staff called Dr. [Last Name (STitle) 10088] at [Last Name (un) ], who was covering for Dr. [First Name (STitle) ] and recommended pt go to ED for further eval. In the ED, initial VS were T 97.9, HR 68, BP 120/68, RR 16, O2sat 98% RA. Labs were notable for FBS 431, AG 17, HCO3 21, +urine ketones. He was started on insulin gtt @ 6u/hr with 6u bolus and IV NS with 20mEqK at 250cc/hr. He was admitted to MICU for continued management on insulin gtt. On arrival to the MICU, he reports feeling well. Endorses labile blood sugars recently, but is uncertain of the cause. Denies HA, lightheadedness/dizziness, visual changes, CP/SOB, abdominal pain, N/V, diarrhea. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Hypertension. CAD s/p NSTEMI [10-2] tx with medical management DMI recently labile blood sugars, on insulin pump in past, followed by [Last Name (un) ] Glaucoma h/o colon adenocarcinoma, resected Social History: Lives at [Location (un) 169] facility. He quit tobacco 38 years ago, but his smoking exposure was very minimal. He drinks wine very seldomly. He is a retired computer scientist. He has 3 children, son [Name (NI) 3979] is HCP, has daughter [Name (NI) ], and another child. Wife died several yrs ago. Family History: Father had a question of coronary artery disease and had a pacemaker and died at the age of 81. His mother died of CA, unknown. Physical Exam: In ICU: General: Pleasant, frail-appearing elderly male in NAD HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema Neuro: AAOx3, CNII-XII grossly intact, no focal deficits On Floor: Vitals: T: 99.5, BP: 132/52, P: 103, R: 20, SaO2: 98% RA General: Pleasant, elderly, cachectic male, no apparent distress, AOx3, days of week backwards HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated CV: Regular rhythm (frequent PACs), tachycardic to 100s, normal S1 + S2, no murmurs, rubs, gallops appreciated Lungs: Left base with crackles Abdomen: soft, non-tender, non-distended, bowel sounds present Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema Neuro: 4+ strength throughout, sensation grossly intact, grossly nonfocal Pertinent Results: [2140-12-5] 07:35AM BLOOD WBC-12.7* RBC-3.48* Hgb-11.1* Hct-33.1* MCV-95 MCH-31.8 MCHC-33.4 RDW-14.1 Plt Ct-514* [2140-12-5] 07:35AM BLOOD Glucose-85 UreaN-21* Creat-0.9 Na-138 K-3.8 Cl-102 HCO3-29 AnGap-11 [2140-11-27] 07:05PM BLOOD CK-MB-3 cTropnT-0.01 [2140-12-5] 07:35AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.8 [2140-11-29] 06:50AM BLOOD TSH-14* [2140-11-27] 01:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG Blood culture and urine cultures negative. MRSA screen positive CXR: Though there is new mild volume loss in the left lower lobe, there is enough irregular consolidation accompanied by a new small left pleural effusion to raise concern for pneumonia, particularly due to aspiration. A smaller region of vague opacity in the right upper lung at the level of the second anterior interspace and third rib is larger than it was in [10-2] and [11-27]. The nature of this abnormality is unclear. Brief Hospital Course: DKA: The patient presented with DKA and was started on an insulin drip and admitted to the ICU. [Last Name (un) ] diabetes consult was called and he was transitioned to SC insulin. He was transferred to the floor where he was found to have a pneumonia. His insulin levels were titrated by [Last Name (un) ]. He will follow up with Dr. [First Name (STitle) ] at [Last Name (un) ]. Pneumonia, aspiratoin: The patient has risk factors for HCAP however on symptoms and CXR it was thought his pneumonia was consistent with aspiration pneumonia. He was treated with levofloxacin and metronidazole. His fevers and white blood cell count improved on this regimen. Encephalopathy: He was confused in the ICU with visual hallucinations. Upon treating his hyperglycemia and infection his mental status improved. It was thought to be most consistent with metabolic encephalopathy. It continued to improve through the hospital course. HTN: Stable and continued on home medications. CAD: Stable and continued on home medications. Glaucoma: Stable and continued on home medications. Code status: DNR/DNI Transitional Issues: f/u CXR for lesion noted on [2140-11-29] titration of insulin regimen complete antibiotic course - monitor mental status Medications on Admission: -ASA 81mg chewable PO daily -Brimonidine 0.15% ophth solution 1 drop to each eye twice daily -Xalatan 0.005% ophth 1 drop each eye qhs -prune juice prn: constipation -Milk of Magnesia 30mL PO daily prn constipation -Dulcolax 10mg PR qhs prn constipation -Plavix 75mg PO daily -Lipitor 80mg PO daily -Metoprolol tartrate 37.5mg PO BID -Albuterol sulfate neb q6hours prn SOB/wheezing -Glucerna [1-24] can PO TID -Lisinopril 2.5mg PO BID -Insulin Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 4. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ml PO once a day as needed for constipation. 5. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO at bedtime as needed for constipation. 6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/wheezing. 10. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 11. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days. 13. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 days. 14. insulin glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous twice a day. 15. insulin lispro 100 unit/mL Solution Sig: as directed Subcutaneous as directed: please see attached insulin sliding scale. Discharge Disposition: Extended Care Facility: [Location (un) 8162]-[Location (un) 8163] Village - [Location (un) ] Discharge Diagnosis: Diabetic ketoacidosis Pneumonia 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 Mr [Known lastname ], You were admitted to the hospital with diabetic ketoacidosis. You were treated in the ICU with an insulin drip and then converted to subcutaneous insulin. You blood sugar levels improved. [Last Name (un) ] Diabetes Center was consulted and helped in titrating your insulin. You were found to have a pneumonia and were treated with antibiotics. You were slightly confused throughout your say which was thought to be due to the pneumonia. This should continue to improve with treatment of your pneumonia. You should continue antibiotics through [2140-12-7]. You were found to have a low functioning thyroid. You were started on a low dose of medication for this called levothyroxine. Followup Instructions: Name: [Last Name (LF) ], [First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] Location: [Last Name (un) ] DIABETES CENTER Address: ONE [Last Name (un) ] PLACE, [Location (un) ],[Numeric Identifier 718] Phone: [Telephone/Fax (1) 3402] When: Monday, [2139-12-13]:00 AM	[ "5070", "41401", "4019", "2449", "412" ]
Admission Date: [2182-4-8] Discharge Date: [2182-4-14] Date of Birth: [2114-9-19] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 165] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2182-4-10] Urgent coronary artery bypass graft x3: Left internal mammary artery to left anterior ascending artery, saphenous vein graft to right coronary and diagonal arteries [2182-4-8] Cardiac cath History of Present Illness: 67 year old male with a history of CAD s/p Cypher stent to RCA [1-5] DES to LCx in [11-9], type 2 diabetes, hypertension and hyperlipidemia. He reports that he has experienced worsening intermittent chest pain with activity for the past 6 months. He is completely pain free at rest. He sought evaluation with his cardiologist and underwent a stress test on [2182-4-3]. The test was stopped due to severe chest discomfort. He developed [2181-6-11] chest pain, onset at 1minute of exercise with severity of chest pain at worst at peak exercise. Chest pain resolved 5 minutes into recovery. There was no arrhythmia during exercise or recovery. There was a blunted BP response to exercise. There was 2mm planar ST depression during exercise in leads II, III, F, V3-V6. EKG changes began at 1:21 minutes of exercise at a heart rate of 102 bpm and persisted for 8 minutes into recovery. The nuclear portion showed a large area of severe stress induced myocardial ischemia in the distribution of RCA coronary artery at a low cardiac workload. Presently he is able to tolerate his ADLs but has curtailed any strenuous activities over the last 6 months. He also notes that his symptoms seemed to have worsened since he underwent the stress test. He was referred for a cardiac catheterization and was found to have 90% ISR of RCA and complex 80% disease of the proximal LAD and septal branch and is now being referred to cardiac surgery for revascularization. Past Medical History: Coronary artery disease s/p Cypher PCI to RCA [1-5] ; s/p Xcience DES to LCx in [11-9] Hypertension Hyperlipidemia Type 2 diabetes Gastroesophageal reflux disease Spinal stenosis Skin CA - on back excision approx 10 years ago; left arm -removed [2151] Appendectomy at age 10 Tonsillectomy at age 5 Social History: Race:Caucasaian Last Dental Exam:edentulous Lives with:wife Occupation:retired Tobacco:quit at the age of 18 ETOH:occasional glass of wine Family History: mother had "heart problems" she died at age 60 and brothers had MI and has CAD Physical Exam: Pulse:69 Resp:18 O2 sat:97/RA B/P Right:129/64 Left:108/81 Height:5'6" Weight:174 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 [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema 0 Varicosities: +1 Neuro: Grossly intact Pulses: Femoral Right: dressing Left: +2 DP Right: +2 Left: +2 PT [Name (NI) 167]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: 0 Left: 0 Pertinent Results: [2182-4-8] Cardiac Cath: 1. Coronary angiography in this right dominant system demonstrated 2 vessel CAD. The LMCA had a 20% distal lesion. The LAD had a 70%-80% angulated stenosis in a tortuous vessel. There was a 70% stenosis in the distal LAD. The Lcx had a 30% ostial lesion with a widely patent stent in OM1. The RCA had a proximal 90% ISR. 2. Limited resting hemodynamics revealed normotension. [2182-4-10] Echo: PRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No spontaneous echo contrast is seen in the body of the right atrium or right atrial appendage. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe regional left ventricular systolic dysfunction with mid to apical inferior and inferosepatal hypokinesis. Overall left ventricular systolic function is mildly depressed (LVEF= 40-50 %). The remaining left ventricular segments contract normally. The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. Prioro to initiation of CPB, RV suddenly became severely hypokinetic with moderate TR. IABP in good position 2-3 cm below the aortic arch POST: 1. Unchanged LV and RV systolci function (Patient on epinephrine infusion) 2. IABP in good position. 3. No other change. Brief Hospital Course: As mentioned in the HPI, Mr. [Known lastname ] has chest pain with a positive stress test. He underwent a cardiac cath on [4-8] which revealed severe two vessel coronary disease. In view of the symptoms and via the fact he had some chest pain, he was kept in the hospital for coronary artery bypass grafting and underwent usual pre-operative work-up. A few hours before he was taken to the operating room on [4-9], he developed chest pain and intra-aortic balloon pump was initially placed before he was taken to the operating room. Following placement of his IABP, he was brought to the operating room where he underwent a urgent coronary artery bypass graft x 3. Please see operative report for surgical details. Following surgery he was transferred to the CIVCU for invasive monitoring in stable condition. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 6 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged in good condition with appropriate follow up instructions. Medications on Admission: AMLODIPINE - (Prescribed by Other Provider) - 5 mg Tablet - once daily GEMFIBROZIL - (Prescribed by Other Provider) - 600 mg Tablet - twice daily GLYBURIDE - (Prescribed by Other Provider) - 5 mg Tablet - twice daily INSULIN GLARGINE [LANTUS SOLOSTAR] - (Prescribed by Other Provider) - 100 unit/mL (3 mL) Insulin Pen - inject 12 units [Last Name (un) ] daily at bedtime INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100 unit/mL Solution - inject 12 units sc once daily at bedtime ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 30 mg Tablet Extended Release 24 hr - once daily LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - once daily METFORMIN - (Prescribed by Other Provider) - 1,000 mg Tablet - twice daily METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg Tablet - twice daily OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - twice daily SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - once every evening Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet, Chewable - once daily BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - (Prescribed by Other Provider) - Strip - use as directed 3-4 times daily LANCETS - (Prescribed by Other Provider) - Dosage uncertain OMEGA 3-DHA-EPA-FISH OIL - (Prescribed by Other Provider) - 1,000 mg (120 mg-180 mg) Capsule - once daily Discharge Medications: 1. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 3. Lantus 100 unit/mL Solution Sig: One (1) 12 units Subcutaneous at bedtime. 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Omega 3 Fish Oil 684-1,200 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 10 days. Disp:60 Capsule(s) Refills:0 12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation for 10 days. Disp:30 Suppository(s) Refills:0 13. furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days. Disp:12 Tablet(s) Refills:0 14. potassium chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 6 days. Disp:12 Packet(s) Refills:0 15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/temp. Disp:30 Tablet(s) Refills:0 16. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain for 10 days: prn for pain. Disp:40 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: vna [Location (un) ] Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x 3 Past medical history: s/p Cypher PCI to RCA [1-5] ; s/p Xcience DES to LCx in [11-9] Hypertension Hyperlipidemia Type 2 diabetes Gastroesophageal reflux disease Spinal stenosis Skin CA - on back excision approx 10 years ago; left arm -removed [2151] Appendectomy at age 10 Tonsillectomy at age 5 Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month 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 should be called by Dr [First Name (STitle) ] [Name (STitle) ] office for a follow appointment. If you do not hear from his office, you should call his office for the appropriate follow up. Department: Surgery Division: Cardiothoracic Surgery Operating Unit: [Hospital1 18] Office Location: W/LMOB 2A Office Phone: ([Telephone/Fax (1) 1504] We were unable to reach your cardiologist. You should see her in two weeks. Please call her and schedule an appointment. Cardiologist: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2920] Please call to schedule appointments with your Primary Care Dr. [First Name (STitle) ] [Name (STitle) ] in [5-7] weeks You have an appointment to come in for a sternal incision check on [Wardname 5010], One of the midlevlers will evaluate your wound. This is scheduled for [4-18] at 1000 hrs Please call cardiac surgery office with any questions or concerns [Telephone/Fax (1) 170]. Answering service will contact on call person during off hours [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 173] Completed by:[2182-4-14]	[ "41401", "25000", "4019", "2724", "V5867", "V4582", "V1582" ]
Admission Date: [2130-4-27] Discharge Date: [2130-7-4] Date of Birth: [2084-6-19] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 552] Chief Complaint: new acute low back pain w/ bilateral leg spasms associated w/ obliterated T4 vertebrae on CT chest Major Surgical or Invasive Procedure: [5-15]: Median Sternotomy for anterior approach T1-T7 fusion. Placement of 3 chest tubes and a lumbar drain. History of Present Illness: 45F w/ multiple medical problems including alcohol abuse, c/b pancreatitis, CRI, DM2 was d/c'd on [2130-4-25] from [Hospital ] hospital after EtOH detoxification since [2130-3-31] and returning for atypical chest pain on [2130-4-22] (negative cardiac workup). One day after she returned to [Hospital1 ] w/ new acute new acute low back pain w/ bilateral leg spasms. Back pain was constant, leg spasms were intermittent and varied b/w sharp and dull and had associated tingling. She also c/o weakness in her arms/shoulders and legs when walking. CTA chest demonstrated destruction of T4 vertebral body. Past Medical History: atypical chest pain, h/o ETOH abuse, hypercoagulopathy secondary to ETOH abuse, depression, DM2, h/o hepatic encephalopathy, CRI, h/o anemia, hepatic cirrhosis, GERD, h/o ETOH pancreatitis Social History: ETOH for 15 yrs w/ at least 3 "heavy" drinks daily, detox on [2130-3-31], Smoked for ~15yrs, quit w/ detox, denies illict/IVDU, married, lives w/ husband, currently unemployed. Family History: non-contributory Physical Exam: On admission: BP: 147/96 HR: 80 RR: 20 O2Sats: 100% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL; EOMI 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. Motor: D B T WE WF IP Q H AT [Last Name (un) 938] G R 5 5 5 5 5 5- 5- 5 5 5 5 L 5 5 5 5 5 5 5- 5 5 5 5 Sensation: Intact to light touch, pinprick bilaterally but decreased below knees bilaterally Reflexes: B T Br Pa Ac Right 2----------> Left 2----------> Rectal exam normal sphincter control, rash at perineum On Discharge: VS: Tm 101.5 P 100-120 BP 120-140/60-90 RR 18 Sat 99/RA GEN alert, confused ENT dry OP CV tacycardia P mildly decreased breath sounds at right base GI soft, mildly tender, non distended EXT warm, no edema NEURO RLE weakness 1-2/5 Pertinent Results: Labs On Admission: [2130-4-26] 09:30PM BLOOD WBC-4.2 RBC-3.22* Hgb-10.9* Hct-31.3* MCV-97 MCH-33.8* MCHC-34.8 RDW-15.5 Plt Ct-81* [2130-4-26] 09:30PM BLOOD Neuts-57 Bands-0 Lymphs-29 Monos-13* Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [2130-4-26] 09:30PM BLOOD Hypochr-1+ Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL [2130-4-26] 09:30PM BLOOD PT-18.3* PTT-32.4 INR(PT)-1.7* [2130-4-27] 09:35AM BLOOD ESR-43* [2130-4-26] 09:30PM BLOOD Glucose-81 UreaN-13 Creat-1.2* Na-132* K-4.0 Cl-98 HCO3-23 AnGap-15 [2130-4-26] 09:30PM BLOOD ALT-71* AST-110* LD(LDH)-408* AlkPhos-140* TotBili-1.8* [2130-4-27] 09:35AM BLOOD Calcium-8.3* Phos-5.6* Mg-1.2* [2130-4-27] 09:35AM BLOOD CRP-7.3* Labs on Discharge ([2130-7-4]): Iron: Pnd Ferritn: Pnd TRF: Pnd 133 95 14 AGap=13 -------------< 105 3.2 28 2.9 D Ca: 8.0 Mg: 1.4 P: 0.7 D WBC: 4.8 PLT: 39 HCT: 20.1 Imaging: CTA Chest [4-26]: IMPRESSION: 1. No central, lobar, or segmental pulmonary embolus. 2. Complete destruction of T4 vertebral body with a soft tissue mass circumferentially involving this level and extending into the central canal as described above. Further evaluation with a dedicated CT and MR should be performed. 3. Ascites. CT T-Spine [4-27]: MPRESSION: Complete destruction of T4 vertebral body with a circumferential soft tissue mass extending into the spinal canal as described above. Evaluation of [Month/Day (4) ] is significantly limited, but appears to be displaced and possibly compressed by this complex. Overall, this could represent consequence of infection such as Potts' disease or neoplastic process. It is unclear if there is concomitant history of trauma. Overall, clinical correlation is recommended. (counting based on L5 from the scout) CXR [4-27]: FINDINGS: The hemidiaphragms are in normal position, there is no pleural effusion. The structure and transparency of the lung parenchyma is unremarkable. No focal parenchymal opacity suggestive of pneumonia, normal size of the cardiac silhouette, normal hilar and mediastinal appearance. MRI C/T/L-Spine [4-27]: FINDINGS: The completely destroyed collapsed T4 vertebral body, with focal kyphotic deformity and increased signal, is visualized with ffacement/discontinuity of the ventral thecal sac, and extension into the spinal canal causing compression on the [Month/Day (4) ]. The outline of the [Month/Day (4) ] is not clearly traceable. Hence, the effect on the [Month/Day (4) ] cannot be adequately assessed. Given the lack of continuity of the [Last Name (LF) ], [First Name3 (LF) 691] injury to the [First Name3 (LF) ] like transection cannot be completely excluded. IMPRESSION: Uninterpretable study, due to marked patient motion artifacts. Please see the CT performed on the same day. There appears to be extension of the collapsed and destroyed T4 vertebral body into the spinal canal, with displacement and compression of the [First Name3 (LF) ]. As the continuity of the [First Name3 (LF) ] cannot be traced, transection of the [First Name3 (LF) ] cannot be completely excluded if there is history related to trauma. EKG [5-1]: Sinus rhythm. There is a late transition with Q waves in the anterior leads consistent with possible prior anterior myocardial infarction. Low voltage in the limb leads. Compared to the previous tracing there is no significant change. Intervals Axes Rate PR QRS QT/QTc P QRS T 71 114 88 426/445 69 0 56 Abdominal Ultrasound [5-2]: More images from this ultrasound examination became available after the original report was dictated. The visualized portion of the pancreatic head and proximal body is normal in contour and echotexture. The distal pancreatic body and tail are obscured by overlying bowel gas. Kidneys are normal in contour and echotexxture without hydronephrosis. Right kidney measures 1.9 cm. Left kidney measures 10.8 cm. Spleen is enlarged. [5-15]: CT of T-Spine: TECHNIQUE: MDCT axially acquired images of the thoracic spine were obtained. No IV contrast was administered. Coronal and sagittal reformats were performed. FINDINGS: There has been interval placement of anterior spinal fusion plate with two screws inserting in the T3 and T5 vertebral bodies. There is persistent kyphosis at this level, improved in appearance compared to the prior exam. Extensive streak artifact from the hardware limits full evaluation, but there appear to be several tiny calcifications within the central canal, decreased in appearance when compared to prior exam. The extent of canal encroachment is difficult to assess with CT. Evaluation of the [Month/Year (2) ] integrity at this level is markedly limited. The remainder the spine is unremarkable. Incidental note is made of left- sided posterior rib fractures, unchanged. Imaged portions of the lung demonstrate a large right pleural effusion with associated atelectasis or consolidation. The patient is intubated. Two metallic wires are identified within the thoracic spinal canal, incompletely imaged. There is a small amount of free fluid surrounding the spleen, incompletely imaged. IMPRESSION: 1. Interval t4 vertebrectomy with placement of the anterior spinal fusion with screws spanning T3 through T5. 2. Right pleural effusion and associated atelectasis/consolidation. 3. Free fluid surrounding the spleen. MRI T-spine [5-18]: FINDINGS: There are post-surgical changes at the T4 and T5 vertebral bodies with overlying susceptibility artifact. There is a focal kyphotic deformity at this level that appears stable when compared to the prior exams. There is packing material posterior to the vertebral body of T4 with severe [Month/Year (2) ] compression, [Month/Year (2) ] edema, and increased T2 signal surrounding the vertebral body at this level consistent with CSF leak or postoperative fluid. There is increased T2 signal within the [Month/Year (2) ] at the T4 and T5 levels. The remainder of the visualized portion of the thoracic [Month/Year (2) ] demonstrates no disc bulge, central canal or neural foraminal stenosis. There is a small right pleural effusion and associated lung consolidation. IMPRESSION: 1. Stable angulation of the spine at T4 after fusion. 2. Spinal [Month/Year (2) ] edema at T4 and T5 bodies with postoperative change including packing material causing severe [Month/Year (2) ] compression at this level. 3. Right pleural effusion with associated atelectasis/consolidation. CT Torso [5-18]: FINDINGS: Since [2130-4-26], diffuse anasarca increased. A recent surgery of the spine was performed for a large T4 mass extending in the spinal canal. Sternotomy was performed with a minimal less than 1 mm AP misalignement between the fragments. Subcutaneous gas collections are new on the right, related to placement of two right chest tubes, one ending at the apex and one at the base. The ETT tip is in the right main stem bronchus. A nasogastric tube ends in the stomach. A right central venous catheter ends in expected position. A right pneumothorax is small. Minimal pneumomediastinum is associated with fat stranding, expected in this recent postop status. Small right pleural effusion is heterogeneous, with dependent denser portions due to clot. The effusion is mostly layering but also loculated, especially along the mediastinal border and at the apex. Pericardial effusion is small. There is no left pleural effusion. Multifocal ground-glass opacities and consolidation are throughout both lungs, not associated with significant septal thickening. The main pulmonary artery measures 3.6 mm wide. 19 mm soft tissue nodularity is new in the anterior chest wall (2:34). Coronary artery calcifications are minimal. Airways are patent to the subsegmental level. The right middle lobe and the right lower lobe are almost completely collapsed. This study was not tailored for subdiaphragmatic evaluation except to note ascites. Recent surgery was performed in the upper thoracic spine. Left tenth and eleventh rib fractures are chronically non-united. A catheter is in the spinal canal. Healed right rib fractures are present. IMPRESSION: 1. ETT tip in the right main stem bronchus. 2. Increase in diffuse anasarca, persistence of ascites, and new right pleural effusion. 3. Heterogeneous right pleural effusion, likely containing some blood, partly layering and partly loculated along the mediastinal border and at the apex. Two chest tubes in place. Small right pneumothorax. 4. Tiny pneumomediastinum and fat stranding of the anterior mediastinum, expected in this recent postoperative period. Subcutaneous gas collections. 5. Multifocal bilateral ground-glass opacities and consolidation, could be multifocal pneumonia, developping ARDS or hemorrhage, given the reported coagulopathy. 6. Small pericardial effusion. 7. Enlargement of pulmonary artery, could be pulmonary hypertension. 8. New soft tissue in the anterior chest wall, probable small hematoma. 9. Recent T4 surgery with metallic hardware, non-united left and healed right rib fractures, not fully evaluated by this study. Port Chest s/p PICC [5-24]: The right PICC line tip is at the level of mid SVC. There is no change in the right basal opacity consistent with a combination of high level of the diaphragm due to ascites and liver enlargement as well as pleural effusion and atelectasis. The right chest tube is in unchanged position. Cardiomediastinal silhouette is unchanged as well as there is no change in minimal left basal opacity, most likely due to atelectasis. LENIS [5-24]: BILATERAL LOWER EXTREMITY ULTRASOUND: The right and left common femoral, superficial femoral and popliteal veins demonstrate normal compressibility, waveforms, augmentation and flow. The calf veins are unremarkable. IMPRESSION: No lower extremity DVT. CXR [5-25]: FINDINGS: A portable upright AP view of the chest was obtained. The cardiomediastinal silhouette is stable in appearance. There is stable elevation of the right hemidiaphragm. There is persistent collapse of the right middle and right lower lobe with a small right pleural effusion. There is a right apical lateral pneumothorax identified, not significantly changed from the prior study. There is increased lucency noted at the right lung base which may represent slight interval increase in the basilar aspect of the right-sided pneumothorax. The right sided chest tube is unchanged in position. The left lung is unchanged. Again noted are median sternotomy wires and spinal fixation hardware. IMPRESSION: Interval increase in right basilar lucency which may represent an increase in the basilar aspect of the right pneumothorax. Persistent collapse of the right middle and right lower lobes with a small stable right pleural effusion. CXR [5-26]: Right chest tube still in place. Right basilar pleural gas collections are unchanged. Complete collapse of the right middle lobe and right lower lobe is unchanged. Right pleural effusion is unchanged, overlying the lower half of the right lung. Small left pleural effusion is unchanged. [2130-6-25] Radiology MR THORACIC SPINE W/O C [Last Name (LF) ],[First Name3 (LF) ] B. 1. New severe compression of T3 with retropulsed fragments resulting in [First Name3 (LF) ] compression. 2. Right posterior mediastinum fluid collection with enlarged loculated right pleural fluid collection. Increased T2 signal within T3 and T5. Findings may be secondary to infection. 3. These findings were discussed with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] by Dr. [Last Name (STitle) ] on [2130-6-26] at 10:00 a.m. [2130-6-25] Radiology CT CHEST W/CONTRAST [Last Name (LF) ],[First Name3 (LF) ] B. [2130-6-25] Radiology CT ABDOMEN W/CONTRAST [Last Name (LF) ],[First Name3 (LF) ] B. [2130-6-25] Radiology CT PELVIS W/CONTRAST [Last Name (LF) ],[First Name3 (LF) ] B. 1. Large right hemothorax which appears more organized and reduced in volume compared to prior CT on [2130-5-27]. Superimposed infection of this hemothorax is not excluded. 2. Right lower lobe collapse with interval partial reexpansion of right upper and middle lobes. 3. Fluid containing tract in the right chest wall at site of prior chest tube placement. 4. Interval wedge compression of the T3 vertebral body with increased soft tissue and calcific/osseous material projecting into the spinal canal causing severe spinal canal stenosis at the level of T4. 5. Evidence of cirrhosis. 6. Mild-to-moderate ascites. 7. No drainable or organized intra-abdominal or pelvic fluid collection. 8. Bilateral femoral head AVN. [2130-6-25] Radiology BILAT LOWER EXT VEINS [Last Name (LF) ],[First Name3 (LF) ] B. No evidence lower extremity DVT. [2130-6-22] Radiology US ABD LIMIT, SINGLE OR [Last Name (LF) 2416],[First Name3 (LF) 2415] V. Approved 1. No evidence of biliary dilatation or cholecystitis. 2. Small ascites. Brief Hospital Course: Ms. [Known lastname ] is a 45 year old woman with a significant history of alcohol abuse and presumed alcoholic cirrhosis who was initially trasnferred from [Hospital ] Hospital to the [Hospital1 18] neurosurgery service on [2130-4-27] with a destructive T4 spinal mass causing [Date Range ] compression and back pain. At the time, she had an essentially intact neurologic exam (except for possibly decreased light touch/pinprick sensation below both knees). The etiology of her spinal mass was unclear (infectious versus neoplastic) and she was started on empiric vancomycin, ceftriaxone, and metronidazole; she did have a single blood culture bottle from admission grow Corynebacterium so ID was consulted and recommended discontinuation of antibiotics and biopsy of her T4 lesion. . On [2130-5-15], she was taken to the OR for vertebrectomy and spinal fusion via an anterior median sternotomy approach. Due to the approach, she had a chest tube placed perioperatively. The surgery was also complicated by a dural tear requiring a dural drain. Post-operatively, she received multiple blood products for her coagulopathy. Her chest tube was initially draining to gravity (rather than to suction) given the dural tear. Her lumbar drain was discontinued on [2130-5-20], however, and the chest tube was able to be placed to suction. She has continued to have high output of blood-tinged pleural fluid from this tube, and one theory has been that her abdominal ascites has simply been migrating to her pleural space. . Of note, the operative pathology/microbiology from her T4 lesion was nondiagnostic. Neurosurgery thought the leasion was likely traumatic with poor healing and there was no strong evidence of infection or malignancy. A sputum culture from [2130-5-20] grew sparse GNRs and she was put on vancomycin and pip/tazo for empiric therapy of VAP. . On [2130-5-22], she was initially extubated but had to be quickly reintubated due to respiratory distress. That same day, she underwent ultrasound-guided paracentesis by IR to assist with her repiratory mechanics in the hopes of facilitating extubation. 5.6 liters of fluid were removed, though it was not sent for laboratory analysis; she did not receive any periprocedure albumin. She also underwent pleurodesis with doxycycline. She was extubated on [2130-5-23] and was sent to the floor (under neurosurgery) on [2130-5-24]. On the floor, she had been requiring only about 2 liters/min of oxygen. She underwent a second doxycycline pleurodesis on [2130-5-25]. . Her renal function began to decline. Initially this was thought to be related to non-oliguric ATN in setting of large volume paracentesis and furosemide treatment. Over time this became more consistent with hepato-renal syndrome. She was started on an octreotide and mididrine and bolused with albumin. . She then was noted on chest x-ray to have "white out" of her right lung in spite of relatively well-compensated pulmonary function (requiring only 2 liters of oxygen by nasal cannula). A chest CT also showed an increase in the size of her right pleural effusion and complete collapse of the right lung. It was thought that she could be having recurrent mucous plugging of the right lung, so she was transferred back to the T-SICU in preparation for a bronchoscopy to try and relieve the obstruction. . During the bronchoscopy, she had secretions (described as purulent) suctioned from her right mainstem bronchus. These secretions were noted to spill over to her left mainstem bronchus, however, and she experienced an acute episode of hypoxia to the 80s with bradycardia to the 30s; she never lost a pulse, by report. She was given 1 mg of atropine with an increase of her heart rate to the 50s. Due to the hypoxia, she was emergently intubated. Suctioning was then completed from both the right and left mainstem bronchi. . Post-procedure, she was noted to be hypotensive with SBPs in the 80s and was started on phenylephrine (in addition to propofol for sedation). A post-intubation CXR demonstrated some improvement in the aeration of her right lung, though still with a right-sided loculated effusion in both the apical and basilar portions of the right lung. A post-procedure ABG was 7.26/44/202 (unclear what her FiO2 was at this time) and her ventilator rate was increased from 14 to 16 (Vt of 500 cc). She was then transferred to the MICU for further care. . In the MICU, she was noted to have a am cortisol at 1.8 and was started on stress dose steroids. Family wanted to pursue HD, so dialysis catheter was placed by IR. She continued to have bleeding from the chest tube sites. She recieved multiple transfusions, FFP, cryo and DDAVP. She underwent a bronchoscopy by thoracics, was given more blood and had more chest tubes placed. Eventually it was felt that instead of having the chest tubes to suction that they be placed on waterseal and allow the bleeding to essentially tamponade itself. Chest tube output decreased. Patient eventually self extubated on [6-3]. She continued to need some blood products and was given more DDAVP and amikar. Over time her transfusion requirement decreased. Her diet was advanced and she was called out to the floor after being stable for over 48 hours. . On the medical floor she was initially stable and her remaining chest tubes were able to be pulled. She slowly began to have mental status changes. These were waxing and [Doctor Last Name 688]. She was found to have positive blood cultures and overnight pulled out her PICC. She was started on Linezolid for VRE. Because of the positive blood cultures her temporary HD cath was pulled. She had a second set of positive blood cultures so a second temporary line had to be put in for HD. Her lactulose was also increased as her mental status was in part due to hepatic encephalopathy. The Liver team was reconsulted and it was determined that she was not currently a candidate for transplant and that she would need supportive care and continued HD. Per liver, consideration for transplant would require that she be stable out of a medical facility for 3 months with abstenence from alcohol and regular visits, that there be no evidence of infection and that any potentially infected hardware be removed. She would also need to be evaluated by transplant psyciatry. . From [Date range (1) 16463], patient had low grade fevers up to 100.4. ID was reconsulted for evaluation of these fevers and recommended a CT scan and serial cultures. CT scan showed enhacement around hemothorax with a small amount of air, concerning for infection. Thoracentesis of hemothorax showed Enterococcus. Further imaging was suggestive of a possible connection between hemothorax and peri-spinal space, and enhancement concerning for a spinal empyema. IR and neurosurgery were consulted about getting a biopsy of this vertebral tissue, but neither service felt that it could be done safely. The decision was made with ID and the family to continue with emperic gram positive coverage for 6 weeks and then reassess. . She developed vague numbness and weakness on [6-25]. Her exam showed progressive lower extremity weakness. A repeat CT showed interval narrowing of spinal canal and MRI showed impingement on [Month/Day (4) ]. Neurosurgery was reconsulted. Her findings were concerning for T3 osteomyelitis and possible connection between epidural space and hemathorax. She was treated with one dose of solumedrol, but managed expectantly for progressive paralysis. As this progression was highly concerning for progressive osteomyelitis. Although this problem would require surgical intervention, she is was felt unlikely to survive a further surgery per neurosugery. . * ACTIVE MEDICAL ISSUES * . # GOALS OF CARE: There were several family meetings with primary team, neurosurgery team and palliative care team with the family regarding goals of care with her family. The most recent team meeting was with the mother, [Name (NI) ], who is the HCP, and sisters [Name (NI) ] and [Name (NI) ]. [Known firstname ] has had an extensive protracted hospital course for >90 days now with multiple complications. She has end stage liver disease, end stage renal disease, a new T3 fracture with [Known firstname ] compression which is inoperable - these medical problems cannot be reversed and will decrease [Known firstname ] life expectancy. In the more immediate setting, we have concerns over an infected pleural effussion and spine but there is no way left to biopsy the spine anymore. Family is very emotionally exhausted and troubled over the impending loss of their loved one. After several family meetings, we have come to the following decision. The most important thing currently for the family is for [Known firstname ] to be closer to home. They agree with DNR/DNI/DNH. They would like dialysis to be continued for now as without it she would likely pass in a few days and they would like more time with her if possible. They agree to only essential medications and essential lab draws. With regards to treatment of pleural effussion and empiric treatment of possible osteo, currently they want antibiotic continued with hopes of giving [Known firstname ] more time with them. They agree with not re-imaging her chest or spine to see if anything is changing. If [Known firstname ], continues to decline on antibiotics, they will consider stopping it entirely. If [Known firstname ] is signficantly better toward the end of the currently projected abx course of 6 weeks, they can consider ID consultation/re-imaging. [Known firstname ] has delirium and varying degrees of clarity into what is going on. She does seem to understand that "she is dying" and is happy about being closer to home. . T4/T3 MASS LESION: Although there was no evidence of infection on pathology of T4 and the new T3 lesion is not amenable to surgery or biopsy according to NSG and IR, this is likely osteomyelitis with a presumably gram positive organism. She has lower extremitiy neurologic symptoms from [Known firstname ] compression caused by this lesion. She is not a candidate for neurosurgery. - antibiotics as below - TSLO for any activity out of bed . INFECTED HEMOTHORAX and BACTEREMIA: Patient found to have enteroccus in hemothorax that may connect with perispinal space. Linazolid may have lowered her cell counts. Antibiotic plan per ID is below. Consider reimaging with CT thorax (with contrast) and T-spine MRI at end of antibiotic course if there has been significant improvement in overall picture. Please see the Goals of Care discussion above. Prescribed Antibiotic Information: Daptomycin 8mg/kg (600mg) IV q48hr. If dose falls on HD day, please give after HD. Duration: minimum of 6 weeks ([Date range (1) 82483]) laboratory monitoring required: Weekly: CBC/diff, chem 7, LFTs, CPK, ESR/CRP 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: MRI of T-spine, 2-3 weeks CT of chest w/ contrast, 2-3 weeks [Hospital ] clinic, 4 weeks . END STAGE RENAL DISEASE: Patient is now HD dependent. - HD per renal, labs as needed. . ALTERED MENTAL STATUS: Patient has delerium likely from hepatic, renal, and bacterial processes as well as underlying alcohol-related dementia. She continues to have intermittant hallucinations. - continue olanzapine as needed. - rifamixin and lactulose titrated to 4 BM/day if desired for further clarity. . ALCOHOL-RELATED CIRRHOSIS: Has been evaluated by liver and not a transplant candidate. Could not consider outpatient evaluation for transplant until [Month (only) 205] when she might be 4-6 months sober and in alcohol rehab. Infectious issues would need to be settled by then as well. . ANEMIA: Iron studies consistant with anemia of chronic disease. . . Medications on Admission: FoLIC Acid 1 mg PO DAILY, Furosemide 40 mg PO DAILY, GlipiZIDE 5 mg PO BID, Lactulose 30 mL PO TID, Nadolol 20 mg PO DAILY, Eplerenone 50 mg PO DAILY, Omeprazole 20 mg PO BID, Sertraline 50 mg PO DAILY, Thiamine 100 mg PO DAILY, traZODONE 50 mg PO HS:PRN, ASA 81mg PO Daily Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 4000-[Numeric Identifier 2249] unit dwell Injection PRN (as needed) as needed for line flush: DIALYSIS NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL NS followed by Heparin as above according to volume per lumen. . 3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day) as needed for confusion: Hold for > 4 bowel movements daily. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: Patient with liver failure. Do not exceed 2gm per day. 5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. Neutra-Phos Sig: Two (2) packets three times a day as needed for phosphate < 2.0. 8. Sodium Phosphate 3 mMole/mL Solution Sig: One (1) dose Intravenous once: 30 mmol / 250 ml NS IV ONCE on arrival. 9. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet, Chewable PO QID (4 times a day) as needed for indigestion. 10. Daptomycin 450 mg IV Q48H On HD days, give dose after HD. 11. Heparin Flush (10 units/ml) 2 mL IV PRN As needed for PICC 12. Ondansetron 4 mg IV Q8H:PRN nausea 13. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. Discharge Disposition: Extended Care Facility: [Hospital3 105] - [Location (un) 1121] - [Location (un) 1456] Discharge Diagnosis: T4 Vertebral Body Distruction Acites Acute Renal Failure Hepatic coagulopathy Respiratory distress Discharge Condition: Stable Discharge Instructions: You were admitted to the [Hospital1 18] with a spinal mass. You had a surgical procedure to remove this tissue. You developed blood in your lungs that became infected. You also had continued degereration of the area in your spine for unclear reasons. This [Last Name ] problem is causing you to have numbness and weekness in your legs. Neurosurgery does not feel that further surgical procedures could help improve this situation. You also have renal and liver failure. You were started on dialysis for your liver failure. You are being treated with antibiotics for the infected blood in your lungs. You may also have an infection in your spine bones, although we are not able to do a biopsy to determine what infection is there. Please call your PCP if you have new or concerning symptoms or have questions about your goals of care. Followup Instructions: Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [First Name (STitle) ] to be seen in [6-28] weeks. Please follow up with infectious disease in [4-24] weeks ([Telephone/Fax (1) 82484] Completed by:[2130-7-9]	[ "5845", "2851", "5180", "5859", "25000", "53081", "40390", "2875" ]
Admission Date: [2122-10-4] Discharge Date: [2122-10-9] Date of Birth: [2045-1-21] Sex: M Service: MEDICINE Allergies: Bactrim / Sulfa (Sulfonamide Antibiotics) / Hayfever Attending:[First Name3 (LF) 905] Chief Complaint: Hematochezia Major Surgical or Invasive Procedure: Colonoscopy with endovascular clipping of angioectasia Colonoscopy Capsule endoscopy History of Present Illness: This is a 77 y.o. male w/ Wegner's diverticulosis, AS, ESRD, and multiple lower GI bleeds who presents with hematochezia. The patient reports his recent medical history was notable for development of some shortness of breath and wheezing over the last few weeks in the setting of a viral illness. He was given ipratroprium by his PCP with good improvement of his symptoms. Then, today the patient awoke at around 7am and felt some discomfort in his lower abdomen and a need to defecate, he expected to pass gas but instead had a large bowel movement with gross blood and clots. He has has multiple similar bowel movements throughout the day. He denies any fevers or chills. Endorses mild lower abdominal pain. No nausea or vomiting. No diarrhea or symptoms preceding this. No presyncope, chest pain, or current SOB. He came into the ED this afternoon with these symptoms. In ED initial vitals: T 98.7, P 75, BP 172/72, RR 18, O2 Sat 100%. He had a right sided EJ placed and a 20 gauge IV. He did not have any bloody bowel movements in the ED. He is being admitted to the ICU due to a history of these bleeds becoming quite fulminant (bled to a Hct of 17 during the previous one). ROS: Negative for fevers, chills, night sweats, or unintentional weight loss. He denies chest pain or SOB. No nausea or vomiting. No hematemesis. He denies melena. No dysuria or hematuria. No rashes or skin changes. Past Medical History: - Wegeners Disease - ESRD on HD from ANCA-positive glomerulonephritis dx [2112] (on HD through left arm fistula for one year) - Gout - Depression - Hyperlipidemia - Glaucoma - h/o Septic thrombophlebitis - h/o Cellulitis of the right upper extremity - h/o Gastrointestinal bleed secondary to NSAID use - h/o Diverticulitis - s/p Left inguinal hernia repair Social History: Retired butcher. Lives with wife and oldest daughter. [Name (NI) ] smoking history. Denies any current alcohol use, or heavy use in the past. No illicit drug use. Family History: Mother with diabetes, kidney disease. 3 brothers with heart disease, one has had MI. Sister with diabetes. No family history of cancer. Physical Exam: VS: T 97.3, HR 90, BP 189/81, RR: 22, O2sat 97% on RA GEN: well appearing gentleman in NAD HEENT: anicteric, MMM, OP without lesions or blood RESP: CTA(B) with no wheezes, rhonchi, or rales, good air movement bilaterally CV: RRR, 3/6 systolic ejection murmur heard best at the left upper sternal border, 2+ DP and radial pulses bilaterally, + fistula in left upper extremity w/ thrill and bruit ABD: Mildly TTP over lower quadrants, hyperactive bowel sounds, soft, no masses or hepatosplenomegaly EXT: no c/c/e, probable popliteal cyst left lower extremity SKIN: no rashes or jaundice appreciated NEURO: AAOx3, moving all extremities equally Pertinent Results: Initial Labs: [2122-10-4] 04:00PM WBC-7.9 RBC-3.18* HGB-9.8* HCT-29.3* MCV-92 MCH-30.7 MCHC-33.4 RDW-16.2* [2122-10-4] 04:00PM NEUTS-77.3* LYMPHS-12.8* MONOS-4.0 EOS-5.7* BASOS-0.3 [2122-10-4] 04:00PM PLT COUNT-236# [2122-10-4] 04:00PM PT-13.5* PTT-27.4 INR(PT)-1.2* [2122-10-4] 04:00PM GLUCOSE-89 UREA N-47* CREAT-6.7# SODIUM-136 POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-29 ANION GAP-15 [2122-10-4] 04:00PM cTropnT-0.10 [2122-10-4] 09:51PM CK-MB-4 cTropnT-0.09* . HCT trend [2122-10-4] 04:00PM Hct-29.3* [2122-10-4] 09:44PM Hct-21.5* [2122-10-5] 02:51AM Hct-26.0* [2122-10-5] 11:36AM Hct-31.9* [2122-10-5] 09:24PM Hct-31.9* [2122-10-6] 04:00AM Hct-30.1* [2122-10-6] 04:35PM Hct-30.5* [2122-10-6] 10:49PM Hct-31.0* [2122-10-7] 03:44AM Hct-31.2* [2122-10-7] 07:45PM Hct-28.2* [2122-10-8] 06:37AM Hct-30.2* [2122-10-9] 06:24AM Hct-28.6* . Discharge Labs: [2122-10-9] 06:24AM BLOOD WBC-6.2 RBC-3.19* Hgb-9.7* Hct-28.6* MCV-90 MCH-30.3 MCHC-33.8 RDW-16.3* Plt Ct-212 [2122-10-9] 06:24AM BLOOD PT-13.5* PTT-25.8 INR(PT)-1.2* [2122-10-9] 06:24AM BLOOD Glucose-95 UreaN-20 Creat-5.9# Na-139 K-3.5 Cl-95 HCO3-33* AnGap-15 [2122-10-9] 06:24AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.7 . Imaging: [2122-10-4] CXR: Moderate left and small right pleural effusion are new. Aside from attendant atelectasis in the left lower lobe, lungs are clear. Heart is normal size. [2122-10-5] Colonscopy: A single medium angioectasia that was not bleeding was seen in the cecum. A gold probe was applied for tissue destruction successfully. One triclip was successfully applied for the purpose of hemostasis. Protruding Lesions Grade 1 internal hemorrhoids were noted. Excavated Lesions Multiple diverticula with medium openings were seen in the sigmoid colon. Other No avms seen in ileum. Impression: Grade 1 internal hemorrhoids. Diverticulosis of the sigmoid colon. Angioectasia in the cecum (thermal therapy, endoclip). No avms seen in ileum. Otherwise normal colonoscopy to cecum and ileum. [2122-10-6] Tagged RBC scan: Active bleeding at a site within the sigmoid colon with activity moving retro- and anterograde. [2122-10-6]: Capsule endoscopy progress report: GI bleeding at the distal ileum, fresh blood seen in thecolon as well. [2122-10-7] Colonoscopy: Diverticulosis of the whole colon, Clip seen in Cecum. Capsule seen in Cecum. Of note, capsule was noted to be in cecum about 16 hours ago. Terminal Ileum could not be intubated despite multiple attempts. Otherwise normal colonoscopy to cecum. [2122-10-7] CXR: The interpretation of this study is limited given the presence of respiratory motion. A small right and moderate left pleural effusions have improved. Cardiomediastinal contours are unchanged. There is no evidence of pneumothorax or new lung abnormalities. Opacity in the left lower lobe is a combination of the pleural effusion and atelectasis. Brief Hospital Course: 77 y.o. man with Wegner's granulomatosis and history of multiple lower GIB's with known AVM's as well as diverticula and internal hemorrhoids presenting with hematochezia. 1. Hematochezia: The patient presented with grossly bloody bowel movements, from lower GI source, likely from angioectasias vs diverticulosis. Initial HCT was 29, which was at/slightly above baseline. The patient was hemodynamically stable. Of note, following admission to the ICU, the patient had a presyncopal event on the way to the bathroom. Vital signs measured following event were within normal limits, but repeat Hct showed decrease to 21.5. Initially resuscitated with 2 units pRBCc with semi-emergent colonoscopy revealing no source of active bleeding. An angioectasia was visualized and clipped, although this was not felt to be the source of bleeding. Following colonoscopy, capsule endoscopy was pursued to r/o bleed from small bowel. On [10-5], patient complained of recurrent hematochezia and tagged RBC scan performed. Tagged RBC scan showed bleeding from sigmoid colon while capsule endoscopy revealed hemorrhage at distal ileum. Given conflicting results of imaging studies, a repeat colonoscopy was performed on [10-7] which showed diverticulosis of the whole colon but no active source of bleeding. The terminal ileum could not be intubated. On [2122-10-7], the patient was felt to be stable for transfer to the general medicine floor. The hematochezia appeared to be self-limited, HCT was stable, and the last bloody bowel movement was the evening of [2122-10-6]. His diet was slowly advanced, and he was tolerating a regular diet prior to discharge. He was initially placed on a PPI, but this was stopped prior to discharge as the etiology of his bleeding was felt to be lower and not upper GI source. Due to unclear etiology of the hematochezia, the patient has been instructed to present to the ED for emergent angio/CTA should the bleeding recur. He was followed by both general surgery and GI during the admission, and will follow up with GI as an outpatient. Total transfusion requirement during hospital admission was 7U pRBC. The patient remained hemodynamically stable through hospital course. 2. Pleural Effusion: The patient was noted to have mild hypoxia with new O2 requirement of 2L NC on day of admission. CXR [2122-10-4] showed new bilateral pleural effusions of unknown etiology. Of note, the patient reported 1-2 weeks of orthopnea and mild dyspnea when climbing stairs prior to admission. Repeat CXR on [2122-10-7] showed improvement in small right and moderate left pleural effusions. The patient's respiratory status improved, and he was satting well on room air prior to discharge. The most likely etiology of the pleural effusions is fluid overload secondary to heart failure. Supporting evidence includes a history of aortic stenosis with suboptimal ejection fraction and improvement of pleural effusions seen on CXR following hemodialysis. Diagnostic thoracentesis was considered but deferred given improvement in effusions and resolution of mild hypoxia. The patient should have repeat CXR in [1-14] weeks following discharge to assess for interval change in pleural effusions. If pleural effusions persist/increase, he may benefit from diagnostic thoracentesis. 3. End Stage Renal Disease: ESRD secondary to ANCA-positive glomerulonephritis diagnosed in [2112]. The patient continued to have dialysis on M/W/F via left arm AVG. He received supplemental IV vitamin D, and was also continued on sevelemer and nephrocaps. 4. HTN: Home dose of valsartan was initially held in setting of acute GI bleeding. Valsartan was restarted prior to discharge once bleeding had resolved and HCT was stable. 5. Hyperlipidemia: Continued home statin. 6. Gout: Continued home allopurinol. 7. Glaucoma: Continued lantaprost drops. 8. Depression: Continued home paroxetine. 9. Probable popliteal cyst: The patient was noted to have a probable popliteal cyst in his left lower extremity during the admission. He denied any pain, and his range of motion in the left knee was not limited. He should follow-up with his PCP for further evaluation. 10. Code Status: The patient was a full code during this admission. Medications on Admission: -Allopurinol 100 mg PO once a day. -Cyanocobalamin 1000 mcg PO DAILY -Paroxetine HCl 20 mg PO DAILY -Simvastatin 20 mg PO QHS -B Complex-Vitamin C-Folic Acid 1 mg PO DAILY -Latanoprost 0.005 % Ophthalmic HS -Valsartan 80 mg PO DAILY -Pantoprazole 40 mg PO Q12H -Sevelamer HCl 1600 mg PO TID W/MEALS -Calcitriol 0.25 mcg PO once a day. Discharge Medications: 1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 6. valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Lower Gastrointestinal Bleeding End Stage Renal Disease Secondary Diagnosis: Hypertension Possible popliteal cyst, left leg 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 Mr. [Known lastname 1005], You were admitted to the hospital beause you had another episode of bleeding from your lower gastrointestinal tract. You had multiple studies done to try to figure out where this bleeding was coming from, but there was no definite answer. As you are aware, the next time this bleeding occurs, you should inform the Emergency Room doctors that [Name5 (PTitle) ] need to go straight to the Interventional Radiology suite for an Angio procedure to figure out where the bleeding is coming from. You were also found to have pleural effusions (small fluid collections at the bottom of your lungs) which do not seem to be affecting your breathing at this time. Your primary care doctor should arrange for you to have another Xray as an outpatient in the next 1-2 weeks to see if the effusions are improving. If not, your primary care doctor [First Name (Titles) ] [Last Name (Titles) ] a procedure to get a sample of that fluid to see what might be causing it. You have a possible cyst behind your left knee that should be evaluated by your primary care doctor next week. The following changes have been made to your medications: - Please STOP your pantoprazole and omeprazole for now The rest of your medications are listed below. Please be sure to keep all of your followup appointments as listed below. Followup Instructions: Please be sure to keep all of your follow-up appointments as listed below. Name: [Last Name (LF) ],[First Name3 (LF) ] F. Location: [Hospital1 ] [First Name (Titles) ] [Last Name (Titles) ] Address: 545A CENTRE ST, [Location (un) ],[Numeric Identifier 6809] Phone: [Telephone/Fax (1) 608] Appt: [10-13] at 1:50pm Department: GASTROENTEROLOGY With: [First Name11 (Name Pattern1) 1730] [Last Name (NamePattern4) 2301], M.D. [Telephone/Fax (1) 463] Building: LM [Hospital Unit Name ] [Location (un) 858] Campus: WEST Best Parking: [Hospital Ward Name ] Garage *Dr.[Name (NI) 13540] office should contact you to make an appointment. Please call [Telephone/Fax (1) 463] to make an appointment if you have not heard from them by early next week.* [Name6 (MD) 251] [Name8 (MD) ] MD [MD Number(1) 910]	[ "2851", "40391", "4280", "4241", "2724", "311" ]
Admission Date: [2127-8-14] Discharge Date: [2127-8-19] Date of Birth: [2066-6-19] Sex: M Service: CSU CHIEF COMPLAINT: A 61-year-old man transferred from an outside hospital after a cardiac cath revealed 2-vessel disease. Transferred to [Hospital ] [Hospital ] [First Name (Titles) ] [Last Name (Titles) ] for coronary artery bypass grafting. HISTORY OF PRESENT ILLNESS: The patient with known CAD, status post PTCA in [2115] and stent in [2121], with recent abnormal exercise tolerance test was referred for cardiac catheterization and then transferred to [Hospital ] [Hospital ] [First Name (Titles) ] [Last Name (Titles) ]. PAST MEDICAL HISTORY: Significant for CAD, hypercholesterolemia, diabetes mellitus type 2, gout, hypertension and hypothyroidism. ALLERGIES: Patient has no known drug allergies. MEDICATIONS ON ADMISSION: Include glyburide 2.5 mg daily, Synthroid 0.1 mg daily, Lipitor 40 mg daily, allopurinol 300 mg daily, atenolol 100 mg daily, lisinopril 20 mg daily. SOCIAL HISTORY: Lives with his wife and sons. [Name (NI) ] works as a [Doctor Last Name 9808] operator. Positive alcohol use (6 to 10 drinks per day). Positive tobacco use (2 packs per day x 45 years). FAMILY HISTORY: Mother died of a MI; otherwise noncontributory. LABORATORY DATA/IMAGING STUDIES: Catheterization performed at [Hospital3 28250] showed the right coronary artery with a 70% to 90% lesion and the LAD with a 90% lesion at D1. The circumflex had no significant disease and a normal EF. A chest x-ray at an outside hospital showed no acute pathology. From [Hospital3 ]: White count of 8.8, hematocrit of 33.9, platelets of 267. PT is 12.6 with an INR of 1.0. Sodium of 130, potassium of 5.0, chloride of 92, CO2 of 28, BUN of 16, creatinine of 0.8. ALT of 25, AST of 28, alkaline phosphatase of 89, total bilirubin of 0.8, albumin is 3.7. UA done at an outside hospital showed 2 white cells with moderate bacteria. Repeat at [Hospital1 ] [Hospital1 ] was negative. EKG was sinus rhythm at a rate of 86, intervals of 0.16, 90 and 34. Q's in II, III and aVF with ST flipped T waves in II, III and aVF. REVIEW OF SYSTEMS: No palpitations, angina, syncope, edema, claudication. Positive diaphoresis with exertion. No COPD, asthma, shortness of breath or dyspnea on exertion. No TIAs, CVAs or seizures. Positive diabetes mellitus and hypothyroidism. No cancer, bleeding, dyscrasias, hematochezia, hematuria, melena. No GERD or gastritis. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature of 98.2, heart rate of 81, blood pressure of 150/80, respiratory rate of 18, O2 saturation of 96% on room air. GENERAL: Lying comfortably in bed. HEENT: Pupils are equally round and reactive to light with extraocular movements intact, anicteric. Mucous membranes are moist. Normal mucosa with no lymphadenopathy or JVD. No bruits. The neck is supple. RESPIRATORY: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm. S1/S2 with no murmurs, rubs or gallops. ABDOMEN: Soft, nontender, nondistended, with normal active bowel sounds and no hepatosplenomegaly. EXTREMITIES: Warm and well perfused with no clubbing, cyanosis or edema and no varicosities. PULSES: Carotids are 2+ with no bruits bilaterally, radials are 2+; femoral on the right is his cath site, the left is 2+ and dorsalis pedis is 1+ bilaterally. HOSPITAL COURSE: The patient's cardiac catheterization films were reviewed, and he was scheduled for coronary artery bypass grafting. On the [5-15] he was brought to the operating room where he underwent where he underwent coronary artery bypass grafting. Please see the OR report for full details. In summary, the patient had a LIMA to the LAD, a saphenous vein graft to diagonal and saphenous vein graft to the RCA. His bypass time was 93 minutes with a cross-clamp time of 78 minutes. He tolerated the operation well and was transferred from the operating room to the cardiothoracic intensive care unit. At the time of transfer, the patient was in sinus rhythm at 89 beats per minute with a mean arterial pressure of 73. He had propofol at 60 mcg/kg/min. The patient did well in the immediate postoperative period. However, he was slow to wake up from his anesthesia and therefore removed intubated throughout the evening of his operative day. On the early morning on postoperative day 1, the patient was weaned from the ventilator and successfully extubated. He remained hemodynamically stable throughout the day. His Swan- Ganz catheter was removed as were his chest tubes, and he was begun on oral beta blockade as well as diuretics. On postoperative day 2, the patient continued to do well. However, he did have some atrial fibrillation and was begun on amiodarone following which he converted to a normal sinus rhythm. Additionally, his hematocrit was noted to be 23.6 and he was transfused with 2 units of packed red blood cells; following which he was transferred to the floor for continuing postoperative care and cardiac rehabilitation. Once on the floor, with the assistance of the nursing staff and physical therapy the patient's activity level was gradually advanced. On postoperative day 3, he was changed to oral amiodarone and his temporary pacing wires were removed. On postoperative day 4, it was decided that the patient was stable and ready to be discharged to home. At the time of this dictation, the patient's physical exam is as follows. Temperature of 97.6, heart rate of 75 (sinus rhythm), blood pressure of 135/71, respiratory rate of 20, O2 saturation of 97% on 1 liter. Weight preoperatively was 76 kilograms. At discharge it is 83.4 kilograms. GENERAL: In no acute distress. NEURO: Alert and oriented, moves all extremities, nonfocal exam. PULMONARY: Clear to auscultation bilaterally. CARDIAC: Regular rate and rhythm. S1/S2 with no murmurs. Sternum is stable. Incision is clean and dry without erythema or drainage. ABDOMEN: Soft, nontender, nondistended with normal active bowel sounds. EXTREMITIES: Warm and well perfused with no edema. Labs with a white count of 10.6, hematocrit of 31.9, platelets of 120. PT of 12.5, PTT of 31.1, INR of 1.0. Sodium of 130, potassium of 4.2, chloride of 96, CO2 of 25, BUN of 18, creatinine of 0.8, glucose of 81. Magnesium of 1.6. DISCHARGE DISPOSITION: The patient is to be discharged home with visiting nurses. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Coronary artery disease; status post coronary artery bypass grafting x 3 with a left internal mammary artery to the left anterior descending, a saphenous vein graft to the distal right coronary artery and saphenous vein graft to the diagonal. 2. Hypercholesterolemia. 3. Hypertension. 4. Diabetes mellitus type 2. 5. Hypothyroidism. 6. Gout. MEDICATIONS ON DISCHARGE: Include Percocet 5/325 1 to 2 tablets q.4-6h. as needed (for pain), aspirin 81 mg daily, Colace 100 mg b.i.d., atorvastatin 40 mg daily, Synthroid 100 mcg daily, Nicotine patch 21 mg daily x 7 days/then 14 mg daily x 2 weeks, Lasix 20 mg daily x 2 weeks, potassium chloride 20 mEq daily x 2 weeks, glyburide 2.5 mg b.i.d., lisinopril 20 mg daily, amiodarone 400 mg daily x 1 weeks/then 200 mg daily, and atenolol 100 mg daily. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(2) 5897] Dictated By:[Last Name (NamePattern4) 1718] MEDQUIST36 D: [2127-8-19] 13:14:43 T: [2127-8-19] 13:52:22 Job#: [Job Number 28251]	[ "41401", "42731", "5180", "25000", "2449", "2720", "4019" ]
Admission Date: [2197-6-4] Discharge Date: [2197-6-6] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 618] Chief Complaint: Inability to understand or speak in a meaningful way. Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: 85 right-handed man, Cantanese-speaking only, with PMH of dyslipidimia, smoker, probable Alzheimer's disease who woke-up today with frontal headache and very significant change in mental status, being innatentive and with illogical speech, found to have acute left temporal-parietal intraparenchymal hemorrhage with mild surrounding edema. On his baseline, patient has short tem memory problems for the past few years (eg. wife says he often forgets what he ate before but he has a good memory for childhood events), he, however, can dress by himself, does not get lost in the streets and he is oriented to time and place. He lives with his wife and his son. Yesterday, he did some gardening work and was well when he went to bed as per his wife. This morning, he woke-up at 5am, his usual time, and complained of frontal headache to his wife. His wife noticed that he was not himself, he did not get his usual morning cup of coffee, he was speaking to himself, he did not respond to her when she asked questions and he was completely incoherent in his speech, illogic. The words he spoke in Cantanese were meaningless, they did not think he had slurred speech. He would say sentences like "I go somewhere" or things they would not understand at all. Daughter and wife reported that they did not find any evidence of weakness, he could hold objects well but his gait was somewhat unsteady, not falling to any side. ROS: Family denied fever, wt loss, appetite changes, cp, palpitations, DOE, sob, cough, wheeze, nausea, vomiting, diarrhea, constipation, abd pain, fecal incont, dysuria, nocturia, urinary incontinence, muscle or joint pain, hot/cold intolerance, polyuria, polydipsia, easy bruising, depression, anxiety, stress, or psychotic sx. Past Medical History: -osteoporosis -no formal diagnosis of Alzheimer's disease, however, he has had for the past few years short term memory problems (eg. wife says he often forgets what he ate before but he has a good memory for childhood events) -Dyslipidimia (not on medications) Social History: Patient is from [Country 651], Cantanese-speaking only, he has been in US for 33 years, retired, used to do yard work, he smokes [5-31] cigarettes/day for 60 years, no alcohol or illicit drug abuse. Patient lives with his wife and his son. Family History: His father had a stroke at 66 yo Physical Exam: Exam: T-97.4 BP-119/63 HR-67 RR-20 100O2Sat Gen: Lying in bed, somewhat agitated HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Neurologic examination: Mental status: Awake and alert, extremely innatentive, could not follow wvent simple commands such as point to the ceiling, not oriented to time or place. He could not say the months of the year, he could not name a watch or thumb. As translated by his daughter, he would say words that have no meaning in Cantanese or "I go somewhere"; "I know". He could not register any word and could not follow commands to write things. No clear evidence of neglect. Cranial Nerves: Pupils equally round and reactive to light, 4 to 3 mm bilaterally. Unable to examine visual fields due to extreme innatention. Extraocular movements intact bilaterally, no nystagmus. Facial movement symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Tongue midline, movements intact Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor. He could move all extremeties symmetrically Mild right pronator drift Patient could hold both legs up for 20s Sensation: He retracted bilaterally to noxious stimuli symmatrically Reflexes: B T Br Pa Pl Right 1 1 1 1 1 Left 1 1 1 1 1 Upgoing toes bilaterally. Coordination: Patient was too innatentive to follow commands such as finger-nose-finger normal, heel to shin normal or RAMs normal. Gait: Narrow based, mildly unsteady, leaning towards either side. Romberg: Negative Pertinent Results: NON-CONTRAST HEAD CT: There is a 2.6 x 2.8 cm (axial plane) hyperdense focus in the left temporal lobe, with surrounding edema associated with a mass effect in the adjacent sulci, consistent with acute intraparenchymal hemorrhage. Minimal adjacent subarachnoid blood is also demonstrated. IMPRESSION: Acute left temporal intraparenchymal hemorrhage with surrounding edema, causing mild mass effect on adjacent sulci, but no herniation or midline shift. CT CHEST w/o contrast: 1. Spiculated left upper lobe nodule that is highly suspicious for lung cancer, undelayed further workup is required. 2. Small left satellite lesion in the caudal aspect of the above-mentioned nodule. 3. Moderate to extensive bilateral emphysema. 4. No lymphadenopathy, no pleural effusion, no adrenal enlargement. MRI/MRA; 1. Stable large left temporal lobar hemorrhage with mild perilesional edema. No findings to suggest underlying hemorrhagic tumor, infarction, or AVM. Although, there is absence of other foci of blooming on susceptibility characteristic of amyloid, this can represent amyloid angiopathy. 2. Stable left supratentorial subdural and subarachnoid hemorrhage. 3. Stable moderate chronic microangiopathic small vessel ischemic changes. Stable mild diffuse parenchymal volume loss. 4. No neurovascular abnormality identified. No evidence for AVM Brief Hospital Course: Mr. [Known lastname ] is a 85 yo Cantonese-speaking RHM with hx dyslipidemia, tobacco use, and probable Alzheimer's, presenting with frontal headache and illogical speech, found to have acute left temporo-parietal intraparenchymal hemorrhage, thought to be most likely secondary to amyloid angiopathy. The patient was admitted to the critical care service and monitored. Patient continued to be have difficulty speaking and comprehending language. A Cantonese interpreter confirmed his speech was still illogical at the time of discharge. However, he would occasionally produce some coherent phrases. He was not oriented to place or time and was not consistently following commands. It was thought his exam may be consistent with a Wernicke's aphasia. However, it is difficult to assess given the language barrier. The patient's strength has remained intact and will continue physical therapy upon discharge home. His LDL was 119. A statin was not started as the etiology of the stroke was likely secondary to amyloid angiopathy. HbA1c was 6.1. Also, a CT chest was performed given a nodule seen on routine CXR at the time of admission. The CT did reveal a spiculated 1.8 x 1.8 cm LUL nodule suspicious for malignancy. The patient's wife reports the patient is known to have a stable lung nodule at baseline. When discussing diagnostic and managment options with the family including possible biopsy and pending biopsy results the possibility of chemotherapy and/or radiation, the family wished to defer an aggressive workup at this time given the patient's recent stroke and current mental status. It was explained that this workup could be completed as an outpatient and the patient's PCP, [Last Name (NamePattern4) ]. [First Name (STitle) ], was notified of the CT chest results. The patient will follow up with his PCP [Last Name (NamePattern4) ] [11-25] weeks and with Dr. [Last Name (STitle) ] (neurology) in 1 month. Medications on Admission: -calcium vit D 500mg [Hospital1 ] -alendronate sodium 70mg Discharge Medications: 1. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 2. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. Discharge Disposition: Home With Service Facility: [Location (un) 86] VNA Discharge Diagnosis: 1) Left temporal intraparenchymal hemorrhage, likely secondary to amyloid angiopathy. 2) Lung nodule concerning for malignancy. Further evaluation to be scheduled as an outpatient Discharge Condition: Not oriented to time or place. Difficulty following commands. Occasional comprehensible phrases in Cantonese. Moving all extremities against gravity. Discharge Instructions: Patient to be discharged home with home physical therapy and follow up with Dr. [Last Name (STitle) ] (neurology) and Dr. [First Name (STitle) ] (PCP). Return to the Emergency Department immediately for any new weakness or numbness or changes in mental status. Also, as discussed, the cat scan of your chest showed a 1.8 cm x 1.8 cm nodule in your left upper lobe of your lung that is concerning for malignancy. You should discuss this with Dr. [First Name (STitle) ] and if this nodule is new (or larger) compared to any prior imaging studies, a thorough evaluation should be completed as an outpatient. Followup Instructions: Neurology; Provider: [Name10 (NameIs) ] [Name11 (NameIs) ], [Name Initial (NameIs) ].D. Phone:[Telephone/Fax (1) 2574] Date/Time:[2197-7-18] 3:30 [Hospital1 18], [Hospital Ward Name 23] [Location (un) ]. Dr. [First Name (STitle) ] (PCP); [Telephone/Fax (1) 12372] [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632]	[ "3051", "2724" ]
Admission Date: [2200-10-1] Discharge Date: [2200-10-8] Date of Birth: [2132-5-30] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1835] Chief Complaint: recurrent palate abscess, headache Major Surgical or Invasive Procedure: Formal Cerebral angiogram via the right groin. History of Present Illness: 68F with recurrent palate abscess. The initial episode occurred in [10-14] after pt had pain and swelling of her palate after dental work. She had the lesion drained at that time resulting in complete resolution of swelling and symptoms. Her symptoms recurred with dental work in [1-15]. The lesion was again drained and treated with penicillin with complete resolution of signs and symptoms. Her symptoms returned again last week which also included a fever. She had her lesion lanced and was treated with clindamycin. The following morning she woke with a mouthful of blood, which ceased after compression. It was noted then that the patient was complaining of headache. She had vomited twice and a head CT showed diffuse frontal subarachnoid hemorrhage and enlarged pituitary. Past Medical History: OSA - requiring CPAP at 8 cm HTN - on norvasc, metoprolol and lisinopril MI - in the [2175]. Bilateral cataract operations Chronic bronchitis CVA [1-15] Goiter Partial hysterectomy Social History: 90 pack years, has quit. No alcohol. Used to work as a nurse. Lives alone, sister is upstairs. Never married, no kids. Retired RN. Family History: Mother had a stroke in her 70s. Physical Exam: Exam: Gen:pleasant woman lying in bed NAD HEENT:No Carotid bruits, neck supple, R hard palate bleed CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect Orientation: oriented to person, place, and date Attention: able to due serial substractions Recall: [3-13] at 5 minutes Language: fluent with good comprehension and repetition; naming intact. No dysarthria or paraphasic errors No apraxia, no neglect [Location (un) ] intact Cranial Nerves: I: not tested II: Pupils equally round and reactive to light, 3 to 2 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 finger rub bilaterally. IX, X: Palatal elevation symmetrical [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations, intact movements Motor: Normal bulk and tone bilaterally No tremor No pronator drift Sensation: Intact to light touch. Right 2 2 2 2 2 Left 2 2 2 2 2 Toes were downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements normal, heel to shin also normal Gait was not assessed this time. Pertinent Results: [2200-10-7] 05:55PM BLOOD WBC-11.8* RBC-3.66* Hgb-12.2 Hct-35.7* MCV-97 MCH-33.3* MCHC-34.2 RDW-13.7 Plt Ct-393 [2200-10-1] 12:45PM BLOOD WBC-9.6 RBC-3.87* Hgb-12.5 Hct-37.8 MCV-98 MCH-32.3* MCHC-33.0 RDW-12.7 Plt Ct-332 [2200-10-7] 05:55PM BLOOD Plt Ct-393 [2200-10-6] 03:12AM BLOOD PT-13.5* PTT-21.6* INR(PT)-1.2 [2200-10-1] 12:45PM BLOOD Plt Ct-332 [2200-10-1] 12:45PM BLOOD PT-21.7* PTT-30.2 INR(PT)-3.4 [2200-10-8] 06:25AM BLOOD Glucose-95 UreaN-11 Creat-0.6 Na-134 K-4.0 Cl-100 HCO3-26 AnGap-12 [2200-10-1] 12:45PM BLOOD Glucose-115* UreaN-16 Creat-0.8 Na-135 K-5.2* Cl-98 HCO3-22 AnGap-20 [2200-10-8] 06:25AM BLOOD Calcium-9.7 Phos-3.5 Mg-1.9 [2200-10-2] 03:07AM BLOOD Calcium-10.4* Phos-3.7 Mg-1.7 [2200-10-7] 03:04AM BLOOD Phenyto-6.1* [2200-10-3] 02:53AM BLOOD Phenyto-6.1* [2200-10-4] 03:31AM BLOOD Type-ART pO2-100 pCO2-45 pH-7.46* calHCO3-33* Base XS-6 [2200-10-1] Head CT: 1. Subarachnoid hemorrhage in the distribution of the anterior cerebral artery. 2. No evidence of hydrocephalus or shift of normally midline structures or mass effect. 3. Right maxillary sinus opacification, which may be related to right hard palate abnormality. Would recommend dedicated facial bone scan with contrast if clinically indicated to further evaluate this lesion. [2200-10-2] head CT: 1. Unchanged subarachnoid hemorrhage in the distribution of the anterior cerebral arteries. 2. Small hyperdensity in the right trigone consistent with small amount of intraventricular hematoma. 3. Right maxillary sinus opacification of unclear etiology. Recommend dedicated facial bone scan with contrast if clinically indicated to further evaluate this lesion. [2200-10-3] Head CT: IMPRESSION: No significant interval change in subarachnoid hemorrhage and likely small intraventricular hemorrhage compared to study of one day prior. [2200-10-3] EKG: Sinus rhythm. Diffuse non-specific ST-T wave changes. Compared to the previous tracing of [2200-1-30] the rate has increased. [2200-10-3] CXR: IMPRESSION: Mild congestive heart failure with cardiomegaly and small bilateral pleural effusion. Bibasilar patchy atelectasis. [2200-10-4] Head CT: IMPRESSION: Stable appearance of subarachnoid and intraventricular hemorrhage. [2200-10-6] cerebral angiogram: IMPRESSION: No evidence of intracranial aneurysm or arterial vascular malformation. No cause for subarachnoid hemorrhage identified. The left anterior cerebral artery territory was supplied by the right anterior cerebral artery by way of the anterior communicating artery. Again seen is a small infundibulum at the origin of the right posterior communicating artery. Brief Hospital Course: 68F with SAH on CT s/p palate abscess drainage. She was admitted to the neuro ICU for qhr checks. Her INR was reversed with FFP, platelets and vitamin K. She was given Nimodipine to maintain her SBP between 100 and 130. She was given dilantin as seizure prophylaxis. Her repeat head CT's during her hospital course showed that the hemorrhage was stable in appearance. Her clindamycin was continued for a course of total 7 days. ENT was consulted for her palate abscess. They recommended follow-up with Dr. [Last Name (STitle) 99691] in 2 weeks. On HD6 pt received a cerebral angiogram that showed no evidence of aneurysm. She was transferred to the floor on HD7. PT and OT were consulted and recommended rehab secondary to poor functional status. She was discharged to rehab in stable condition on [2200-10-8]. Medications on Admission: ALBUTEROL 17 GM--Two puffs up to four times a day as needed AMBIEN 5 mg--1 tablet(s) by mouth at bedtime as needed for insomnia ASA 81 MG--One tablet every day COLACE 100MG--One tablet twice a day - tid, as needed COUMADIN 1MG--one tablet(s) by mouth once a day COUMADIN 5MG--one tablet(s) by mouth once a day DETROL LA 4MG--Take one by mouth every day FLUOXETINE HCL 40 mg--1 capsule(s) by mouth once a day HYDROCHLOROTHIAZIDE 25 MG--Take one by mouth every day LISINOPRIL 40 mg--1 tablet(s) by mouth once a day LOPRESSOR 50 mg--1 (one) tablet(s) by mouth twice a day LOVASTATIN 20 mg--1 tablet(s) by mouth once a day ULTRAM 50MG--One tablet tid, prn, pain Discharge Medications: 1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Acetaminophen-Caff-Butalbital [Medical Record Number 3668] mg Tablet Sig: [1-12] Tablets PO Q4-6H (every 4 to 6 hours) as needed. 12. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 13. Labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Potassium & Sodium Phosphates [Telephone/Fax (3) 4228] mg Packet Sig: Two (2) Packet PO ONCE (once) for 1 doses. 15. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 16. HydrALAZINE HCl 20 mg IV Q6H PRN SBP>150 hold for SBP<110 give for SBP>150 Discharge Disposition: Extended Care Facility: [Hospital6 85] - [Location (un) 86] Discharge Diagnosis: S/P subarrachnoid hemorrhage - No aneurysm identified on angiogram. Discharge Condition: neurologically stable - awake alert oriented. Follows commands. speech clear - requires balance and mobility training. Discharge Instructions: please call Dr [Last Name (STitle) ] for any mental status changes, neurological deterioration - if you cannot reach him - please go to the nearest emergency room. Followup Instructions: Provider: [Name10 (NameIs) 9977] Where: [Hospital6 29] RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2200-10-28] 10:45 Provider: [First Name11 (Name Pattern1) 569] [Last Name (NamePattern4) 12637], M.D. Where: [Hospital6 29] [Hospital3 249] Phone:[Telephone/Fax (1) 250] Date/Time:[2201-1-2] 11:00 Provider: [First Name4 (NamePattern1) 8990] [Last Name (NamePattern1) ], MD Where: [Hospital6 29] MEDICAL SPECIALTIES Phone:[Telephone/Fax (1) 1803] Date/Time:[2201-3-13] 11:30 Provider: [Name10 (NameIs) ] up with Dr. [Last Name (STitle) ] in one month - Neurology call for appointment [Telephone/Fax (1) 2574]. Provider: [Last Name (NamePattern4) ]. [Last Name (STitle) 66323] in 2 weeks - ENT [Telephone/Fax (1) 41] for follow up of palate abcess..possible MRI for follow up of palate and thyroid. Completed by:[2200-10-8]	[ "4019", "412" ]
Admission Date: [2157-12-28] Discharge Date: [2158-1-1] Date of Birth: [2098-8-12] Sex: F Service: NEUROSURGERY ADMITTING DIAGNOSIS: Middle cerebellar artery stenosis. HISTORY OF PRESENT ILLNESS: This is a 59 year old female with a history of reversible neurologic deficit, right sided weakness in [2157-3-16]. She has a past history of risk factors She underwent an angiogram in [2157-10-16], which showed a 70% left M1 middle cerebral stenosis and a minimal stenotic disease of the right middle cerebral artery and a 30% stenosis of the right anterior cerebral artery and an occluded left external carotid artery. She also underwent an angiogram and successful angioplasty of the left M1 segment on the day of admission by Dr. [Last Name (STitle) 1132]. PAST MEDICAL HISTORY: 1. Above mentioned transient ischemic attacks. 2. History of hypertension. 3. History of hypercholesterolemia. 4. History of severe atherosclerosis of the cerebral arteries. PAST SURGICAL HISTORY: 1. Tonsillectomy and adenoidectomy as a child. 2. Appendectomy. 3. Tubal ligation. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She denies use of tobacco and drinks one alcoholic beverage per day. LABORATORY DATA: On admission, white blood cell count 6.7, hematocrit 33.6, platelet count 205,000. Chem7 was within normal limits. MEDICATIONS ON ADMISSION: 1. Coumadin. 2. Labetalol. 3. Wellbutrin. 4. Plavix. 5. Aspirin. 6. Lescol. 7. Univasc. 8. At the time of admission, she had already been started on Heparin intravenous infusion and was continued on her Plavix and Aspirin. PHYSICAL EXAMINATION: On physical examination at the time of admission, she was awake and alert and oriented to time, place, and person in no active distress and no acute distress. The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Neurologic examination was nonfocal. Strength was [3-20] in all extremities. Cranial nerves II through XII are grossly intact. Cardiovascular - regular rate and rhythm without murmurs, rubs or gallops. The chest was clear to auscultation bilaterally. Extremities were without cyanosis, clubbing or edema. The abdominal examination was unremarkable and nontender with normoactive bowel sounds. HOSPITAL COURSE: Due to clinical findings, the patient had been taken to the angiography suite at the time of admission to the hospital where she underwent a cerebral diagnostic angiogram and an endovascular angioplasty of the left M1 segment. The patient tolerated the procedure well, was admitted to the Neurologic Intensive Care Unit postoperatively where the initial full history and physical examination note was obtained. Postoperative angiogram check showed her to be afebrile with stable blood pressure and vital signs, awake, alert and oriented times three and repeating test phrases, naming all objects appropriately and following all commands. She also was moving all extremities with full strength and there was no drift and smile was equal. Tongue was midline and she was considered neurologically stable. The remainder of her postangioplasty course was essentially unremarkable and she was maintained in the Intensive Care Unit for approximately the first 48 hours of her hospital admission and subsequently transferred to the floor on [2157-12-31]. Her intravenous Heparin was discontinued and she was maintained on Lovenox during the remainder of her hospitalization and discharged home on Aspirin and Plavix. She was instructed to follow-up with Dr. [Last Name (STitle) 1132] in the clinic in approximately one to two weeks time and to call his office for an appointment for follow-up. CONDITION ON DISCHARGE: Stable and improved. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 1133] Dictated By:[Name8 (MD) 5474] MEDQUIST36 D: [2158-1-1] 11:25 T: [2158-1-2] 19:20 JOB#: [Job Number 43477]	[ "2720", "4019" ]
Admission Date: [2142-2-1] Discharge Date: [2142-2-8] Date of Birth: [2057-2-22] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[First Name3 (LF) 3556] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: CVL Placement x4 PICC line placement ([2142-2-6]) History of Present Illness: 84 yo male with vascular dementia vs Alzheimer's, HL, DM II, CVA with right temporoparietal bleed who presents to the ED with AMS. At [Hospital3 ] he was reported to have AMS and SBPs in the 80s. Per his wife he was increasingly lethargic at the nursing home. For the last 3-4 days he would not open his mouth to eat and "went down [Doctor Last Name ] quickly." He was changed to a soft diet and was pouching his food. Prior to that time he was chewing normally. He had poor PO intake for multiple months and especially the last 3 weeks. He's had at least a 25 lb weight loss since [Month (only) 216] per his wife. Wife says he used to weight 200 lbs and now he weighs 158. Prior to [Month (only) 205] was walking at home with a cane and he stopped walking in the middle of [Month (only) 216]. At baseline does not have comprehensible speech. Per his wife he also had 4 UTIs in [Month (only) 359]. . In the ED, initial vs were: T 98.5, HR 124, BP 124/76, RR 16, SpO2 96% on unknown amount of oxygen. In the ED the patient was initially minimally responsive and non verbal. He was found to have a UTI with >1000 WBC and few bacteria for which he received Ciprofloxacin. He also had hypernatremia to 160 and received 1L of NS and then a second liter of NS with 40 of potassium since he was hypokalemic to 2.3. His mental status improved while in the ED and he became more alert but remained not oriented and non comprehensible. He initially was not hypotensive in the ED but became hypotensive to SBP of 80s prior to transfer and an IJ was placed. His lactate 2.2. His Trop was 0.05 and his EKG was notable for new septal q waves. He was given Aspirin 600 mg PR. His INR was 1.8. HCT was 29 (recent baseline 37). His left eye was notable for erythema and tearing which is chronic. He had a pressure ulcer on his left heel. . On arrival to the ICU, vitals were T axillary 100.4, BP 103/52 (dropped pressures to 80s soon after arrival with MAPs in 50s), RR 31, SpO2 92% on 50% shovel mask. Labs were notable for stable lactate (2.3), troponin increasing to 0.14 (from 0.05), K 4.4, bicarb improved from 16 to 21, creatinine to 2.3 (from 1.2), HCT up from 29 in ED to 39, WBC up to 14 from 8.6. He was originally groaning but opened his eyes more and became more interactive during the first hour. . Review of systems: Unable to obtain given AMS. Past Medical History: -Dementia, vascular vs. Alzheimer's -Hypercholesterolemia for which he takes Crestor. -Diabetes type 2, followed by Dr. [Last Name (STitle) 3845] [Name (STitle) ]: right temporoparietal bleed [2130], with gait abnl, impairment in attention and executive functioning -Obstructive sleep apnea. Does not tolerate CPAP -Weight loss. -Polydypsia -Melanoma. right thigh in [2115]. -SCC on left cheek -baseline neuro exam in [2139] oriented to self only, poor attn, left hemineglect and hemianopsia, increase tone throughout, hyperesthesia from calf to toe Social History: Mr. [Known lastname ] was born and raised in [Location (un) 669]. He then moved to [Location (un) ] after marrying his wife. [Name (NI) ] has two sons. [Name (NI) ] ran an appliance business for many years until his stroke. He did not smoke nor does he drink alcohol. He cannot transfer out of bed on his own anymore. Speech does not make sense at baseline. Family History: Mother died at age 67 of breast cancer, father died at age 69 of CAD. Father had first MI in his 50s. Physical Exam: Physical Exam On Admission: Vitals: T axillary 100.4, BP 103/52 (dropped pressures to 80s soon after arrival with maps in 50s), RR 31, SpO2 92% on 50% shovel mask. General: Groaning and initially not opening his eyes. Knows his wife's name. Otherwise speaking nonsense. HEENT: extremely dry mucus membranes, erythema of left eye Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, systolic murmur Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: ulcer on left heel, 1+ DP pulses, extremities warm, no clubbing, cyanosis or edema Neuro: oriented to self and wife's name, otherwise speaking nonsense, able to move all extremities, pupils equal and reactive, shoulder shrug intact, symmetric palate raise, CN XII intact. Brisk 3+ UE reflexes R>L, patellar reflexes +3 . Physical Exam On Discharge: General: NAD, reclining in bed HEENT: mucus membranes moist, erythema of left eye Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, systolic murmur Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: ulcer on left heel, 1+ DP pulses, extremities warm, no clubbing, cyanosis or edema Neuro: oriented to self, otherwise speaking non sense, able to move all extremities, pupils equal and reactive, shoulder shrug intact, symmetric palate raise, CN XII intact. Pertinent Results: Admission Labs: [2142-2-1] 06:35PM BLOOD WBC-8.6 RBC-3.06# Hgb-9.4# Hct-29.4* MCV-96 MCH-30.6 MCHC-31.9 RDW-14.0 Plt Ct-141* [2142-2-1] 06:35PM BLOOD PT-19.6* PTT-37.4* INR(PT)-1.8* [2142-2-1] 06:35PM BLOOD Glucose-174* UreaN-43* Creat-1.2 Na-160* K-2.3* Cl-134* HCO3-16* AnGap-12 [2142-2-1] 06:35PM BLOOD cTropnT-0.05* [2142-2-1] 06:50PM BLOOD Lactate-2.2* Discharge Labs: [2142-2-8] 05:16AM BLOOD WBC-14.7* RBC-3.56* Hgb-10.5* Hct-31.4* MCV-88 MCH-29.3 MCHC-33.3 RDW-14.7 Plt Ct-197 [2142-2-7] 04:25AM BLOOD Neuts-90.6* Lymphs-6.5* Monos-2.4 Eos-0.3 Baso-0.1 [2142-2-7] 04:25AM BLOOD PT-13.7* PTT-25.6 INR(PT)-1.2* [2142-2-8] 05:16AM BLOOD Glucose-158* UreaN-18 Creat-1.0 Na-140 K-3.4 Cl-111* HCO3-21* AnGap-11 [2142-2-8] 05:16AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.0 Brief Hospital Course: 84 yo male with vascular dementia vs Alzheimer's, HL, DM II, CVA with right temporoparietal bleed who presents to the ED with AMS in the setting of poor PO intake and was found to have hypernatremia, UTI, acute renal failure and hypotension. Hypernatremia treated with IV fluids D5W and NS and gradually resolved over first 3 days. UTI treated with vancomycin and meropenem with subsequent decrease in urinary WBCs. Urine culture only showed Diphtheroids, felt likely contaminant. Renal failure resolved gradually and serum creatinine normalized to baseline. Mental status gradually improved to baseline by around hospital day 3. Hypotension proved largely treatment resistant. Patient was ~16.5 L positive in fluid balance for total hospital stay but presented severely dehydrated with ~7 L free water deficit. Developed mild respiratory distress with pulmonary edema that responded to Lasix/albumin. Nevertheless continued to require IV pressor support. Trial of hydrocortisone for possible relative AI was not effective. Ultimately, given severity of patient's underlying dementia and inability to wean pressor support, family meeting was held and decision was made to make Mr. [Known lastname ] [Last Name (Titles) 3225]. . Management by problem: # Shock: Intermittently hypotensive, likely reflective of sepsis. He was minimally responsive to IV fluids and pressors. He was placed on a Norepinephrine drip and then started on Midodrine without being able to wean off pressors. He had a 17 L positive fluid balance for LOS and appeared to be developing worsening pulmonary edema and pleural effusion. Trial of hydrocortisone did not show clear improvement in his pressures. He was treated for infection as below. . # Pulmonary edema: Net 17 L positive fluid balance. Taking into account ~7L free water deficit and dehydration on admission, still likely total body volume overloaded. . # Urinary tract infection: Culture demonstrated Corynebacteria. He was treated with Vancomycin and Meropenem with improvement in his UA. . # Altered mental status: Likely hypernatremia, hyperglycemia, and UTI all contributing with the largest contribution from metabolic abnormalities. He has a history of CVA in [2130]. No known fall to suggest subdural hematoma. His MS improved, likely to near baseline by the time of discharge with electrolytes and glucose now WNL. . # Hypernatremia: Likely due to poor PO intake over many weeks with a slow increase, and thus needed to be corrected slowly. Normalized during his stay with IV fluids. . # CAD: New q waves on EKG with trop leak potentially reflective of renal failure. CK and CK-MB did not suggest infarct. Echo on [2142-2-2] did not suggest any acute ischemia. Sick sinus and tachy-brady syndrome in setting of severe AS may have contributed to his hypotension. His beta blocker and ACE-I were held. . # Hyperglycemia: His FBGs were significantly elevated on admission and normalized with Insulin and hydration. He was placed on Lantus and Humalog sliding scale. His home Glipizide was held. . # Left Heel Ulcer: Appeared unchanged since admission. Podiatry saw over weekend and suggest no need for debridement of heel ulcer and no evidence of osteo. They recommended continued off loading with Multipodus boots and dry dressing changes. . # Elevated INR: The patient was not on Coumadin at home. His INR resolved from 1.8 to 1.2 with unclear explanation. Checked LFTs which were normal. Albumin 2.[4-8] suggest anabolic liver defect possibly due to poor nutrition. . # Acute on chronic renal failure: Creatinine 1.2 on arrival to ED and up to 2.3 on floor, now back to baseline after hydration. . # Hypothyroidism: Substituted Levothyroxine 100 mcg IV daily for 200 mcg PO daily. . # Prophylaxis: Heparin SC . # Goals of Care: Discussed with family and made [Day Month 3225] on [2142-2-8] . Medications on Admission: -Seroquel 37.5 mg q am -seroquel 25mg qhs -Crestor 40mg daily -Folic Acid 1 mg daily -Hydrochlorothiazide 25 mg daily -lorazepam 0.25mg q am -KCL 10meq daily -MVI daily -glipizide 1 tab by mouth [Hospital1 ] -misoprostol 200mcg [Hospital1 ] -lantus 10 units at bedtime-colace 100mg [Male First Name (un) ] -verapamil 40mg q 8 hrs -senna 8.5mg qhs -meds crushed in apple sauce -levothyroxine 200mcg daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. Disp:30 Tablet(s) Refills:0 2. haloperidol lactate 5 mg/mL Solution Sig: One (1) 0.5-1.0 mg Injection every four (4) hours as needed for anxiety or agitation. Disp:30 Refills:0 3. morphine 5 mg/mL Solution Sig: One (1) 2-4 mg Injection Q1H (every hour) as needed for discomfort: Titrate dose to comfort. Disp:30 Refills:0 4. lorazepam 2 mg/mL Syringe Sig: One (1) 0.5-1.0 mg Injection Q3H (every three hours) as needed for anxiety or agitation. Disp:30 Refills:0 5. Patient is [Male First Name (un) 3225] 6. levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Vascular Dementia Hypernatremia Urinary Tract Infection Pneumonia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Mr. [Known lastname ], it was a pleasure caring for you during your hospitalization in the [Hospital1 18] [Hospital Ward Name 332] Intensive Care Unit. You were admitted because your family and care givers noticed a change in your mental status in the days prior to hospitalization. You were found to have infections in your urine and likely in your lungs as well as elevated levels of sodium and sugars in your blood. You were treated with antibiotics and IV fluids. Because of your infections and dehydration, your blood pressure was very low and you required medications to treat this. Your body did not completely respond to these treatments and ultimately the decision was made to focus on treating your symptoms as it did not seem we would be able to cure the underlying cause of your illness. You were discharged with ongoing treatments aimed at keeping you as comfortable as possible. Followup Instructions: Hospice Care at [Hospital3 2558] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3559] MD, [MD Number(3) 3560]	[ "0389", "486", "78552", "5849", "2760", "5990", "2449", "2720", "41401", "2859", "99592", "5859" ]
Admission Date: [2200-5-28] Discharge Date: Service: CARDIAC SURGERY Date of discharge is pending; awaiting rehabilitation bed. CHIEF COMPLAINT: New onset exertional angina and positive stress test. HISTORY OF PRESENT ILLNESS: The patient is an 81 year old male who started to experience progressive exertional angina a couple months ago. He had been having midsternal chest pain after routine activities or after walking one block. Symptoms resolved with rest. He had a stress test on [2200-5-24], which is positive. He was admitted to the Cardiac Medicine service to undergo cardiac catheterization. PAST MEDICAL HISTORY: 1. Hypertension. 2. Remote history of stomach ulcer fifty years ago. 3. Prostate cancer, status post radiation therapy five years ago. 4. Diabetes mellitus. MEDICATIONS ON ADMISSION: 1. Aspirin 81 mg q.d. 2. Amaryl 2 mg q.d. 3. Lopressor 25 mg b.i.d. HOSPITAL COURSE: The patient underwent cardiac catheterization on [2200-5-28], which showed severe three vessel disease. Cardiac surgery consultation was obtained at this point and decision for surgery was made. The patient underwent a coronary artery bypass graft times two on [2200-5-30], with left internal mammary artery to left anterior descending, and saphenous vein graft to OM. He was transferred to the CSRU postoperatively. He was extubated on postoperative day one. He was hemodynamically stable and doing well. Later on [2200-6-2], he was transferred to the regular floor. About three hours after coming out of the Intensive Care Unit, the patient developed atrial fibrillation with a rapid rate in the 130s and blood pressure in the 80s. He was given intravenous fluids and transferred back to the Intensive Care Unit for further hemodynamic management. He was started on Neo-Synephrine to maintain his blood pressure and given Lopressor to control his heart rate. Over the next few days, he slowing improved. Postoperative day six, he was deemed stable to transfer to the floor. He was complaining of some sternal misalignments. A chest x-ray was obtained which showed the wires in good position and some well aligned. He is otherwise doing very well. His pacing wires were discontinued on postoperative day seven. He is ambulatory with support. He is now ready for discharge to a rehabilitation facility. MEDICATIONS ON DISCHARGE: 1. Colace 100 mg p.o. b.i.d. 2. Aspirin 325 mg p.o. q.d. 3. Tylenol 650 mg p.o. q4hours p.r.n. 4. Amiodarone 400 mg q.d. 5. Amaryl 2 mg q.d. 6. Regular insulin sliding scale. CONDITION ON DISCHARGE: Good. FOLLOW-UP: Primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 1158] [Last Name (NamePattern1) 679], in two weeks and with Dr. [Last Name (STitle) 70] in six weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern1) 2209] MEDQUIST36 D: [2200-6-7] 09:35 T: [2200-6-7] 10:55 JOB#: [Job Number 18791]	[ "41401", "9971", "42731", "25000", "4019", "2859" ]
Admission Date: [2195-2-16] Discharge Date: [2195-2-19] Date of Birth: [2127-5-31] Sex: M Service: NEUROLOGY Allergies: No Allergies/ADRs on File Attending:[First Name3 (LF) 618] Chief Complaint: Transfer from OSH for possible pontine infarct / basilar occlusion Major Surgical or Invasive Procedure: none History of Present Illness: The pt is a 67 year-old ?-handed man with h/o HTN, CAD s/p CABG in the [2173] who is transferred here to our ICU/Neurology service after a decline in his exam at the OSH ([Hospital6 ]) and possible expansion [2-16] of a pontine hypodensity seen on the admitting NCHCT from the previous day [2-15]. Although both NCHCTs demonstrate multiple prior strokes including bilateral occipital infarcts that appear subacute, he has no known/documented prior history of stroke or Neurologic disease/deficit. By history, he has been non-adherent with medical follow-up and not taking any medications at home. He is a smoker and drinks at least four alcoholic beverages daily per his family/OSH notes. He was last known to be in his USOH at home Saturday. On Sunday, he did not answer phone calls from his daughter and was found confused and dysarthric at home. He was taken by family to the OSH, where his confusion imrpoved in the ED. He was moderately hypertensive in the 150s-160s SBP, but VS were otherwise wnl. Only mild lab abnormalities including Cr 1.3-->1.2, AST>ALT (47/22), low albumin, low HDL, borderline leukocytosis (10.5, 85% neutrophils). His exam was notable only for slurred speech and confusion, and he was noted to be "moving all extremities appropriately." His NCHCT revealed [Hospital1 ]-occipital hypodensities/strokes (subacute-appearing) on a background of multiple prior infarcts/ischemic-[Male First Name (un) 4746] disease, and a Left-paramedian pontine hypodense lesion. ECG showed LVH and e/o old inferior infarct. He was started on ASA 325, metoprolol 50mg tid, NG 1" paste, and a CIWA EtOH-w/drawal protocol, and a Neurology consult was planned. His MS improved in the ED, and he remained relatively stable, eating dinner the next day, sitting up in bed, until around noon on the day of transfer ([2-16]) when he was noted to be increasingly dysartric and lethargic, progressing to tetraplegia. A Neurology consultant ([First Name8 (NamePattern2) 333] [Last Name (NamePattern1) ]) found faint bilateral bruits L>R, dysconjugate [Last Name (un) ] (R-eye out, both down, Right facial droop, R>L ptosis, [1-17] purposeful movment of the Left arm, Right arm extensor posturing, and triple-flex responses in both LEs, brisk DTRs R>L, bilateral upgoing toes, and no grimace to noxious stimuli. He started a heparin gtt (with bolus) out of concern for a widening basilar/pontine infarct, recommended transfer here to [Hospital1 18] for MRI and possible [Doctor First Name 10788] intervention, and offered the family/daughter a "guarded" prognosis. He arrived here untresponsive, with exam similar to what was described above (see below), exhibiting intermittent brief [Last Name (LF) 89859], [First Name3 (LF) ] he was intubated by the ICU shortly after. We got a CTA of the head and neck, which revealed complete Left-ICA occlusion (preserved flow in L-MCA/ACA) and V4 segmental lack of flow in the Left vertebral a, as well as overall diminuitive/ratty-looking basilar/posterior circulation. Incidentally, there was also a spiculated pulmonary nodule in the upper lobe of the Right lung c/f adenocarcinoma. Past Medical History: 1. HTN 2. CAD s/p CABG in the [2173] 3. ?h/o PAD, fem bypass 4. ?h/o bilateral carotid endarterectomy 5. ?EtOH use/abuse (per family / OSH notes) non-adherence to medical f/u and meds Social History: Significant for smoking history Family History: No hx of early strokes Physical Exam: Neurologic examination on admission: Non-responsive to noxious stimuli. Does not follow commands. CN exam revealed: Pupils midposition, 2.5mm sluggishly reactive to light, but equal. No nystagmus. +doll's eyes/VOR. +corneals. No blink to threat in any quadrant. +weak cough on tracheal suctioning; did not elicit gag by moving ETT. Sensory/motor exam revealed: Left arm (moreso than right) responds to noxious stimulation with decorticate/extensor posturing. Intermittent spontaneous/purposeful movement of RLE, no movement of LLE other than triple-flexion withdrawal to noxious stimulation. DTRs: Diffusely brisk, with distal spread in Left>rt UE and clonus of Left knee (not ankle). No ankle jerks. Toes are up-going bilaterally. Pt passed away on [2195-2-19]. see death note for exam. Pertinent Results: CT HEAD: The bilateral occipital large regions of parenchymal hypodensity have not significantly changed compared with the study performed at the outside institution just hours prior to this exam. Also, the region of hypodensity involving the central slightly to the left midbrain and the small focus of hypodensity within the right cerebellar hemisphere has also not significantly changed over the past few hours. The ventricles and sulci are enlarged, likely representing central and cortical atrophy. There are subtle regions of diminished attenuation within the periventricular white matter, which likely represent the sequela of chronic small vessel ischemic disease. No other areas of territorial regional hypointensity are demonstrated with the exception of the above-mentioned bilateral PCA distribution and midbrain and right cerebellar foci. There is no evidence of intracranial hemorrhage. With the exception of local mass effect associated with the bilateral occipital regions of hypodensity, there is no evidence of shift of midline structures or herniation. The visualized portions of the intracranial V4 segments of the vertebral arteries are heavily calcified proximately. The paranasal sinuses demonstrate minimal mucosal thickening within the inferior aspect of the right maxillary sinus. CTA NECK: The visualized portions of the aortic arch straight mild peripheral calcified and non-calcified atheromatous plaque. The left common carotid artery and the innominate artery share a common origin. The major cervical artery origins at the arch do not demonstrate flow-limiting stenosis, although there is calcified and non-calcified atheromatous plaque circumferentially involving the artery walls resulting in mild-to-moderate stenosis of the proximal left subclavian artery and the small left common carotid artery. The origin of the right common carotid artery and the left vertebral artery are patent with normal caliber and post-contrast enhancement. There is a moderate stenosis of the origin and proximal right vertebral artery, likely due to atheromatous disease. The common carotid arteries demonstrate circumferential calcified and noncalcified plaque with irregularity of the diameter without flow-limiting stenosis. The left carotid artery at the carotid bulb abruptly terminates in post-contrast enhancement without reconstitution consistent with occlusion, which extends to the supraclinoid left internal carotid artery. There are scattered foci of calcified atheromatous plaque along the cervical right internal carotid artery without flow-limiting stenosis. The cervical vertebral arteries demonstrate scattered foci of irregularity and moderate stenoses due to calcified and non-calcified plaque with the right cervical vertebral artery appearing to be more extensively involved. CTA HEAD: As mentioned in the above section describing the cervical vessels, the left internal carotid artery is occluded to the supraclinoid segment in which is reconstituted likely the circle of [Location (un) 431] anatomy. The right intracranial internal carotid artery demonstrates scattered foci of calcified and non-calcified atheromatous plaque with up to moderate stenosis in the cavernous segments. The anterior cerebral arteries and middle cerebral arteries demonstrate normal post-contrast enhancement and caliber. The intracranial vertebral arteries demonstrate calcified and non-calcified atheromatous plaque. The right intracranial vertebral artery demonstrates severe stenoses and irregularities with a string of contrast, short segment from the origin of the right PICA to the basilar anastomosis. The left intracranial vertebral artery also demonstrates significant calcified and non-calcified atheromatous plaque with irregular stenoses along its course. At the midpoint of the left V4 segment, there is complete loss of post-contrast enhancement of the vessel with reconstitution of the short segment distal left vertebral artery to the anastomosis forming the basilar artery. The basilar artery is small and irregular in contour, likely related to atherosclerotic disease. The bilateral PCA arteries are diminutive without definite occlusion. Small posterior communicating arteries are identified bilaterally. No evidence of aneurysm, arteriovenous malformation, or arteriovenous fistula is identified. Brief Hospital Course: Mr [Known lastname 76536] was admitted as an OSH transfer for posterior circulation strokes. He had CT imaging done of the brain and vessels which demonstrated multiple areas of infarct including the brainstem and significant stenosis by calcifications and plaques of various intracranial and extracranial vessels. The family was made aware that should he survive this hospitalization he would be left significantly impaired. They decided to make him CMO after all family members had a chance to visit with him. Medications on Admission: none Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: CMO: passed away Discharge Condition: Passed away Discharge Instructions: N/A Followup Instructions: N/A [Name6 (MD) ] [Name8 (MD) ] MD, [MD Number(3) 632] Completed by:[2195-2-19]	[ "3051", "4019", "V4581" ]
Admission Date: [2189-2-10] Discharge Date: [2189-2-20] Date of Birth: [2107-8-22] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 800] Chief Complaint: hematuria Major Surgical or Invasive Procedure: continuous bladder irrigation History of Present Illness: Mr. [Known lastname 12236] is an 81 year old gentleman with a history of prostate cancer in remission, COPD, HTN, abestosis, dementia, likely malignant pulmonary nodule who initially presented to [Hospital1 18] ED on [2-10] after 1 day of urinary incontinence and gross hematuria at home. In ED, afebrile, BP 107/70, HR 102, RR 16, 95% RA although he reportedly had labile HR in the ED, ranging from 80s to 140s as well as O2 desaturation requiring 4L of NC. He was found to have ARF with a Cr of 1.7 (from BL 1.0), and BUN in 50s. Hct was 30 at his baseline. He was found to have frank blood clots in his urine and was started on CBI. Urology consulted and thought c/w radiation cystitis. While in the ED he had ~ 400 mL of coffee ground emesis although NG lavage returned on scant amounts of coffee grounds. He was then admitted to the MICU for close monitoring. . In the MICU, he was made NPO and started on IV PPI [Hospital1 ] and repeat Hct had dropped to 24.7 so he received 2 unit of PRBCs with post-transfusion Hct of 27. He had no melena or maroon stools while in the MICU but continued to have large amounts of blood on CBI. Repeat Hct his afternoon again down to 25.7 with repeat 25. Cr peaked at 2.5 and repeat this afternoon 2.4. Initial WBC 13K increased to 27K in MICU and he was treated with Cipro for presumed UTI. He has remained hemodynamically stable with normal blood pressure and no tachycardia. Lisinopril and verapamil have been held in the setting of GI bleeding. GI planning to do EGD in am. . Currently, patient is without complaint. Denies fevers, chills, cough, abdominal pain. He does recall feeling nauseous with episode of hematemesis. Otherwise without complaints. Past Medical History: # COPD # HTN # Asbestosis # Pulmonary nodule, ? malignant - spiculated, RUL - followed by Dr. [Last Name (STitle) 2168] - No further work-up currently due to high risks of biopsy and potential treatment # Prostate cancer - [Doctor Last Name ] [8-31], T2a - s/p XRT and neoadjuvant chemotherapy, hormonal therapy - now in remission for ~ 10 years # Larynx tumor - approximately 10 years ago - reportedly benign # Cataract in R eye # dementia, multi-infarct # Macular degeneration # h/o colon polyps # h/o neck cyst removal [2179] # hearing loss # h/o lumbar compression fracture Social History: Patient lives with his son, who is bipolar. He used to work in the paint industry. He also quit smoking fifteen years ago but has a 160 pack-year history (4ppd x ~40 years). He uses a walker at home. Family History: [Name (NI) 12237] HTN [Name (NI) 12238] "oxygen problems" ([Name2 (NI) 1818]) Daughter- lung cancer Physical Exam: T: 97.4 BP: 125/52 HR: 86 RR: 19 O2 98% RA Gen: Pleasant, cachectic male, chronically ill appearing, NAD HEENT: Pale conjunctiva. MMM. OP clear. NECK: Supple, No LAD. JVP low CV: RRR. nl S1, S2. No murmurs, rubs or [Last Name (un) 549] LUNGS: Decreased BS throughout. ABD: Thin. Firm. NT, ND. +suprapubic tenderness EXT: WWP, No edema. Full distal pulses SKIN: No skin breakdown NEURO: Alert and oriented x2, knows he's in hospital. Pleasant. Follows commands. CN 2-12 grossly intact. Moving all extremities GU: Three way foley in place draining red urine without clots Pertinent Results: [2-11] renal u/s: 1. Mild left renal hydronephrosis. Simple left renal cyst. 2. Echogenic material within the urinary bladder presumed to be blood clot. History of hematuria is provided. No definite etiology for hematuria is identified and MRI could be helpful for further evaluation. . [2-10] CXR: In comparison with study of [2188-8-11], there is again hyperexpansion of the lungs with coarseness of interstitial markings consistent with chronic pulmonary disease. Pleural calcification is again consistent with asbestos-related disorder. Tip of nasogastric tube extends only to the lower esophagus. This information was telephoned to the referring clinician by the resident on call. Brief Hospital Course: 81 year old male with a history of prostate cancer in remission, COPD, HTN, abestosis, dementia, and presumed malignant pulmonary nodule here with hematuria, ARF, leukocytosis, and coffee ground emesis. . # Coffee ground emesis: Patient had initial Hct drop although he had no recurrent hematemesis. He underwent upper endoscopy which revealed an ulcer at the GE junction with clot but no evidence of active bleeding. This was not treated given its location. Felt to be pill esophagitis vs PUD. His Hct remained stable after 4 units of PRBCs. He was continued on PPI [Hospital1 ] with IV transition to po after 72 hours. His diet was advanced following EGD without issue. He will need to have endoscopy repeated in [3-25] weeks to assess for resolution per GI recommendations. . # Hematuria: required CBI for >1 week while in house. Per Urology concerned about radiation cystitis although XRT in distant past. No obvious etiology seen on ultrasound. Patient had persitent hematuria with clots despite multiple days of CBI. Urology changed to larger foley catheter and after aggressive manual irrigation, cleared multiple blood clots. A CTU was obtained which showed nonspecific bladder wall thickening but was otherwise unremarkable. He was continued on CBI. It was recommended that he have outpatient cystoscopy performed. He was continued on oxybutynin with foley in place to prevent spasm but that was stopped once CBI discontinued to prevent urinary retention. He was also started on flomax. He was treated with a 7 day course of cipro for possible UTI although it was never clear that he had active infection in his urine. PSA was normal. Foley removed upon discharge and was able to urinate . # ARF: Cr 1.7 on admission, from baseline 1.0. Peak in ICU 2.5 and then downtrended to settle around 1.2. Initially concern for obstructive pathology given clots and hematuria but renal u/s showed only unlateral hydronephrosis. Thought to be most likely pre-renal ARF due to acute GI bleed which resolved to IVF and blood transfusions. He had a CTU performed which showed renal cysts without other abnormality. His lisinopril was held in the setting of ARF. . # leukocytosis: unclear source at this time. Left shifted. Given known GU pathology, would make this most likely source although U/A was unrevealing and urine cultures were negative. No other obvious source of infection outside GU tract. CXR without obvious infiltrate although known lung nodule could predispose to pneumonia or superinfection. No diarrhea. Mental status at baseline. Could also be stress response in the setting of GU and GI processes. WBC count trended down and he received a 7 day course of cipro. . # COPD: no spirometry in our system but severe emphysema on CT chest 10/[2188]. Former tobacco use. He received alb/atrovent nebs . # htn: normotensive in setting of GIB and verapamil and lisinopril held. Once stabilized, BPs increased and verapamil was restarted at low dose. Lisinopril was restarted without change in creatinine and improvement in hypertensive episodes . # Code: FULL for now confirmed with HCP. However patient's PCP feels that son who has untreated bipolar does not have capacity to make decisions for patient. Social work and social services involved. . # Comm: A family meeting was held on [2189-2-18] with discussion about his HCP. Discussion included the patient's extensive care requirements. The patient does have care requirements that exceed those that his family is able to provide. Prior to discharge from [Hospital1 1501], the PCP (Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] should be contact[Name (NI) ]) -[Name (NI) 449] "[Doctor First Name 12239]" [Known lastname 12236] [Telephone/Fax (1) 12240] -[First Name8 (NamePattern2) ] [Known lastname 12236] [Telephone/Fax (1) 12241](HCP) -[Name (NI) ] [Name (NI) 12236] [Telephone/Fax (1) 12242] Medications on Admission: Docusate Sodium 100 mg [Hospital1 ] Senna 8.6 mg 1-2 Tablets PO BID prn Acetaminophen 325 mg 1-2 Tablets PO Q4H as needed. Oxybutynin Chloride 7.5 mg [Hospital1 ] Verapamil 360 mg Tablet Sustained Release Q24H Ferrous Sulfate 325 mg DAILY Multivitamin,Tx-Minerals DAILY Lisinopril 10 mg DAILY Discharge Medications: 1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Discharge Diagnosis: Primary: - hematuria - acute renal failure, post-obstructive - upper GI bleed - acute blood loss anemia Secondary: - COPD - HTN - Asbestosis - Pulmonary nodule, ? malignant - Prostate cancer - Larynx tumor - Cataract in R eye - dementia, multi-infarct - Macular degeneration - h/o colon polyps - h/o neck cyst removal [2179] - hearing loss - h/o lumbar compression fracture Discharge Condition: Afebrile. Hemodynamically stable. Discharge Instructions: You were admitted to the hospital for blood in your urine. Please continue to take all medications as prescribed. . Please follow up with your primary providers as listed below. . Please call your doctor or return to the hospital for fevers, chills, chest pain, shortness of breath, recurrent blood in your urine, decreased urine output, abdominal pain, nausea, vomiting, blood in your stools, black stools, or any other concerns. Followup Instructions: Please follow up with your PCP [Last Name (NamePattern4) ]. [Last Name (STitle) ] 1-2 weeks after discharge Phone: [Telephone/Fax (1) 1579]. . Please have repeat endoscopy [3-25] wks after initial EGD. . Please follow up with Urology. . Please follow up with Dr. [Last Name (STitle) 2168] of Pulmonary in [2-24] weeksPhone: ([Telephone/Fax (1) 513] [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 810] MD, [MD Number(3) 811]	[ "5849", "2851", "5990", "496", "4019" ]
Admission Date: [2103-1-1] Discharge Date: [2103-1-6] Date of Birth: [2055-7-29] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2641] Chief Complaint: chest pain, etoh withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: This is an unfortunate 47yo M with ETOH abuse c/b dilated cardiomyopathy (EF49% 9/07), HCV, h/o lung aspergillosis c/b cavitary lesion who p/w etoh withdrawal and his chronic reproducible chest pain. Pt has had mutliple ED visits at our institution and others for similar complaints. He currently drinks [1-3] gallon of vodka daily, his last drink was 2pm yesterday. He also notes that he fell 3 days ago while cleaning his apt. He landed on his back and has some residual back pain from the fall. He denies cough/F/C. no brbpr/melena. no n/v/d/c or abdominal pain. He has an exercise tolerance of 2 to 3 flights of stairs limited by shortness of breath. No orthopnea/PND/palpitations. Last stress [9-9] negative for ischemia. He notes that he takes his meds ~every other day. . In the [Name (NI) ], pt received Thiamine IV, FoLIC Acid IV, Multivitamin IV and Acetaminophen 650mg for his chronic chest pain. His serum etoh level 274, +benzos, o/w tox screen (-) head CT- negative; EKG was unchanged from baseline and first set of cardiac enzymes negative. He received IV valium 10mg. . On the floor, he was hypertensive to 190s. He has been given a total of 30 mg of valium, his last dose at 6:30 am of valium 10 mg PO. Past Medical History: Past Medical History: - EtOH abuse - h/o withdrawl seizures - Alcoholic Dilated Cardiomyopathy (EF 25%) - cocaine abuse (last use ~ 3 weeks ago) - hypothyroidism - h/o head and neck cancer s/p resection and radiation in [2093] - bilateral cavitary lung lesions; bx demonstrated Aspergillous fumigatus and [Female First Name (un) 564] albicans [2-/2102] - h/o C. diff colitis - h/o IVDA per OSH records (pt denies) . Social History: Smokes < [1-3] ppd recently; prior to that he smoked 1 ppd x30 years. Heavy EtOH use (usually >1 gallon vodka per day). Sober x10 years up until ~2 years ago; more recently, reports several months of sobriety. +Cocaine abuse; last use several wks ago. He denies IVDA. Sexually active with his girlfriend. . Family History: Mother with CAD. Sister with h/o CVA. . Physical Exam: T 99.5 BP 140/91 - 181/110 HR 91 RR Sat 95% on ra General: pleasant, cooperative, tremulous [Month/Day (2) 4459]: symmetric periorbital edema; no icterus, conjunctival erythema, pupils 5mm and symmetric Neck: supple; s/p resection of left SCM muscle Chest: clear to auscultation throughout CV: rrr, II/VI systolic murmur at RUSB Abdomen: soft, NTND, normal BS, no HSM Extr: no edema, 2+ PT pulses Skin: no rashes or jaundice, face is flushed; + back wound Neuro: alert& oriented x 3, cooperative; CN 2-12 intact; [5-7] strength in both arms and legs Pertinent Results: EKG: NSR at 74 unchanged compared to [2102-12-15] CXR: Stable radiograph with known cavitary lesions in both lung apices and associated changes Imaging: CT head on admission: No hemorrhage. Sinus mucosal disease. [2103-1-1] 07:00PM CK-MB-5 cTropnT-<0.01 [2103-1-1] 07:00PM ALT(SGPT)-49* AST(SGOT)-82* CK(CPK)-235* ALK PHOS-59 TOT BILI-0.4 [2103-1-1] 07:00PM GLUCOSE-70 UREA N-13 CREAT-0.9 SODIUM-140 POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-23 ANION GAP-20 [2103-1-1] 07:00PM WBC-3.1* RBC-3.32* HGB-10.7* HCT-31.3* MCV-94 MCH-32.3* MCHC-34.4 RDW-15.7* Brief Hospital Course: # Alcohol withdrawal - He was initially tremulous on admission and required increasing CIWA scale. He was transferred to the MICU on hospital day #2. While in the MICU he required valium q1 hours. When transferred back to the floor, he was tapered off of valium. By hospital day #4, valium was tapered to 5 mg [Hospital1 ] and on discharge valium was discontinued. He was also continued on MVI, thiamine, folate. He was also seen by SW prior to discharge. He was discharged home as he stated that he wished to go home to pay rent prior to seeking treatment in inpatient rehab. . # Chest pain - His chest pain is chronic, reproducible and sharp. His EKG on admission was unchanged from baseline, and he had 3 sets of negative cardiac markers. CXR remained stable from previous showing known cavitary lesions unchanged from baseline. His exercise MIBI from [9-9] without evidence of ischemia. . # Hypertension- On admission he had labile blood pressures ranging between 100s to 200s requiring IV hydralazine in the MICU. By hospital day #4, his blood pressures normalized and he was continued on home regimen of lisnopril 30, toprol 150 daily . # Dilated Cardiomyopathy (EF 25%)- He appeared euvolemic on exam. He was continued on ASA, BB and ACE-I. . # Hypothyroidism- He was continued on his outpatient regimen levothyroxine . # Dysphagia- This is chronic as per his history. This is likely secondary to XRT, but recurrence of neck ca is a possibility. He will schedule an outpatient appointment with his PCP and will likely need an EGD. Medications on Admission: Aspirin 81 mg PO DAILY Levothyroxine 75 mcg PO DAILY Buspirone 10 mg PO BID Toprol XL 150 mg Tablet PO once a day Lisinopril 30 mg PO DAILY Trazodone 50 mg PO HS Olanzapine 5 mg PO HS vit B1 vit B12 Hexavitamin Discharge Medications: 1. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:30 Tablet(s) Refills:0 10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 11. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital3 ] VNA Discharge Diagnosis: Primary: Alcohol withdrawal Secondary: Anxiety Hypertension Alcoholic cardiomyopathy Discharge Condition: stable Discharge Instructions: You were admitted to the hospital for alcohol withdrawal. You should continue to abstain from drinking. Please take all medications as prescribed. If you develop chest pain, shortness of breath, persistent fever > 101, please return to the nearest emergency room. Followup Instructions: We have scheduled a follow up appointment for you in the [Hospital 191] clinic. Your appointment information is as below: [2103-2-5] 02:30p [Last Name (LF) ],[First Name3 (LF) 156] [Doctor First Name ] [Hospital6 29], [Location (un) ] [Hospital 191] MEDICAL UNIT Completed by:[2103-1-31]	[ "2449", "4280", "4019" ]

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