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Admission Date: [2108-3-25] Discharge Date: [2108-4-4] Date of Birth: [2041-10-7] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [2108-3-30] Four Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending with saphenous vein grafts to first obtuse marginal, second obtuse marginal and ramus intermedious. [2108-3-26] Cardiac Catheterization History of Present Illness: Mr. [Known lastname 3924] is a 66 year old male with no sigificant PMH who presented with intermittent chest pain. He described the pain as substernal, and radiated to right shoulder and neck. Each episode lasted for 15 min to 2 hrs. Had six episodes in the last 24 hrs prior to admission. Chest pain was associated with shortness of breath and occured with mild exertion. At the outside hospital, the initial ekg showed normal sinus rhythm. Then during episode of chest pain, ekg notable for ST elevations in II, III, aVF. Cardiac enzymes were negative. He was started on Nitro and Heparin drip, given Aspirin and Plavix, and transferred to the [Hospital1 18] for further evaluation and treatment. Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Low-grade, Low-stage Prostate Cancer - no treatement. Hypertension Hyperlipidemia History of Recurrent Syncope Social History: Smoked less than 1 ppd for 5 years, quit 40 yrs back. ETOH occasional, no illicits. Works for financial services. Family History: Father had MI in 60s. Physical Exam: VS: 97 120/70 72 98/2l GENERAL: WDWN M 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 no JVD. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: [2108-3-25] BLOOD WBC-5.2 RBC-4.91 Hgb-15.2 Hct-44.0 MCV-90 MCH-31.0 MCHC-34.6 RDW-13.2 Plt Ct-279 [2108-3-25] BLOOD PT-14.4* PTT-150* INR(PT)-1.2* [2108-3-25] BLOOD Glucose-122* UreaN-21* Creat-1.3* Na-146* K-3.9 Cl-108 HCO3-23 AnGap-19 [2108-3-25] BLOOD cTropnT-<0.01 [2108-3-26] BLOOD CK-MB-2 cTropnT-0.01 [2108-3-25] BLOOD Albumin-4.3 Calcium-9.9 Phos-3.1 Mg-2.7* [2108-3-26] BLOOD %HbA1c-5.8 [2108-3-30] BLOOD Triglyc-86 HDL-44 CHOL/HD-3.5 LDLcalc-94 [2108-3-27] Cardiac Cath: 1. Coronary angiography of this co-dominant system revealed 2 vessel coronary disease and LMCA disease. The LMCA had a 60-70% stenosis distally that was eccentric. The LAD had a 40-50% ostial stenosis which was also eccentric and hazy. The LCX had an 80% stenosis at its origin and a 90% OM1 stenosis. The RCA had a proximal 40% stenosis. 2. Limited resting hemodynamics revealed mildly elevated systemic arterial pressure with an SBP of 147 mm Hg. The LVEDP was elevated at 23 mm Hg. 3. Left ventriculography revealed normal left ventricular systolic function with an ejection fraction of 55-60% without focal wall motion abnormality or mitral regurgitation. [2108-3-27] Echocardiogram: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Transmitral Doppler and tissue velocity imaging are consistent with normal LV diastolic function. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. [2108-3-30] Intraop TEE: PRE-BYPASS: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a trivial/physiologic pericardial effusion. POST-BYPASS: The patient is in sinus rhythm and on an infusion of phenylephrine. Biventricular function is preserved. The aorta is intact. The Swan Ganz catheter is in the proximal right PA. The examination is otherwise unchanged. [2108-4-4] Hct-29.5* [2108-4-2] WBC-9.9 RBC-3.16* Hgb-9.5* Hct-27.6* MCV-87 MCH-30.2 MCHC-34.6 RDW-14.0 Plt Ct-190 [2108-4-1] WBC-16.4* RBC-2.93* Hgb-8.7* Hct-25.4* MCV-87 MCH-29.8 MCHC-34.5 RDW-13.6 Plt Ct-221 [2108-4-4] UreaN-25* Creat-1.6* K-4.0 [2108-4-3] Creat-1.7* [2108-4-2] Glucose-106* UreaN-14 Creat-1.4* Na-140 K-4.6 Cl-107 HCO3-25 [2108-4-1] Glucose-141* UreaN-16 Creat-1.4* Na-136 K-4.2 Cl-106 HCO3-24 [2108-3-31] Glucose-130* UreaN-16 Creat-1.2 Na-135 K-4.2 Cl-107 HCO3-22 [2108-4-4] Mg-2.4 Brief Hospital Course: Mr. [Known lastname 3924] was admitted under cardiology with unstable angina. Given concern for acute coronary syndrome versus vasospasm, he was started on Integrilin and Diltiazem, in addition to Heparin and Nitro. He ruled out for myocardial infarction. He remained pain free on intravenous therapy. The following day, he underwent cardiac catheterization which revealed severe two vessel coronary artery disease including a 70% left main lesion - see result section for additional details. Cardiac surgery was consulted and further preoperative evaluation was performed. Given recent Plavix dose, surgery was delayed for several days. Preoperative echocardiogram showed normal ejection fraction with only trivial mitral regurgitation - see result section for additional detail. His preoperative course was otherwise unremarkable and he was cleared for surgery. On [3-30], Dr. [Last Name (STitle) 914] performed coronary artery bypass grafting surgery. For surgical details, please see dictated operative note. Given inpatient stay was greater than 24 hours prior to surgery, Vancomycin was given for perioperative antibiotic coverage. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics and transferred to the telemetry floor on postoperative day two. He completed a course of Ibuprofen for postoperative pericarditis. He tolerated beta blockade, and remained in a normal sinus rhythm. Beta blockade was advanced as tolerated. One unit of packed red blood cells was transfused for a hematocrit near 24%. Over several days, he continued to make clinical improvements with diuresis and was cleared for discharge to home on postoperative day five. At discharge, BP 106/66 with HR of 84 and room air saturation of 95%. All surgical wounds were clean, dry and intact. Medications on Admission: None Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 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:2 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:45 Tablet(s) Refills:0 4. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. Disp:7 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Location (un) 2203] VNA Discharge Diagnosis: Coronary Artery Disease, s/p CABG Postop Pericarditis - resolved Hypertension Dyslipidemia Prostate Cancer Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Followup Instructions: - Dr [Last Name (STitle) 914] (cardiac surgery) in 4 weeks ([Telephone/Fax (1) 170]) please call for appointment - Dr [First Name8 (NamePattern2) ] [Name (STitle) ] (PCP) in [12-16] weeks ([Telephone/Fax (1) 39136]) please call for appointment - Wound check appointment [Hospital Ward Name 121] 2 as instructed by nurse ([Telephone/Fax (1) 3071]) Completed by:[2108-4-4]	[ "41401", "2724", "4019" ]
Admission Date: [2120-11-14] Discharge Date: [2120-11-19] Date of Birth: [2072-5-1] Sex: F Service: MICU HISTORY OF PRESENT ILLNESS: Ms. [Known firstname 42408] [Known lastname 3671] is a 48-year-old woman with a history of end-stage renal disease (on hemodialysis), hypothyroidism, seizure disorder, and a history of migraine headaches who presented to the Emergency Department with complaints of a severe headache for several days. Her headache began two days prior, with a sudden onset, preceded by spots in front of her eyes. On the day prior to admission, she continued to have a headache at dialysis. After dialysis, she vomited at home and subsequently had a tonic-clonic seizure which was witnessed. She presented to the Emergency Department where she had a repeat tonic-clonic seizure lasting two to three minutes. She received intravenous Ativan and a Dilantin load. Her systolic blood pressure was noted to be greater than 200. She was ultimately placed on a nitroprusside drip in the Emergency Department for control. This resulted in a resolution of the majority of her headache. A computed tomography of the head and a lumbar puncture were negative. The patient was admitted to the Medical Intensive Care Unit for hypertensive urgency. PAST MEDICAL HISTORY: 1. End-stage renal disease (on hemodialysis for the past five years). 2. Hypothyroidism. 3. Seizure disorder. 4. Low back pain (chronic). 5. Status post right partial colectomy secondary to intussusception. 6. Status post small-bowel obstruction. 7. Status post cholecystectomy. 8. Migraine headaches. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: (To the Intensive Care Unit) 1. Fentanyl and labetalol drips. 2. Zestril 10 mg by mouth twice per day. 3. Synthroid 125 mcg by mouth once per day. 4. Dilantin 300 mg by mouth once per day. 5. Percocet by mouth as needed. 6. Renagel 800 mg by mouth three times per day. 7. Extra-Strength Tums four tablets three times per day. 8. Soma. SOCIAL HISTORY: She is an ex-smoker. No alcohol. She is a teacher. She is married. PHYSICAL EXAMINATION ON PRESENTATION: On admission her vital signs revealed a temperature of 97 degrees Fahrenheit, her blood pressure was 161/79, her heart rate was 82, her respiratory rate was 14, and her oxygen saturation was 100% on room air. In general, she was an uncomfortable African-American woman moving in bed in distress. The pupils were equal, round, and reactive to light and accommodation. The extraocular muscles were intact. There was no photophobia. The oral mucosa were moist. The oropharynx was clear. The pupils were 1 mm. Her heart rate and rhythm were regular with a 2/6 systolic ejection murmur at the left sternal border. Normal first heart sounds and second heart sounds. The lungs were clear to auscultation bilaterally. The abdomen was obese, soft, nontender, and nondistended. The extremities were warm and dry without edema. Neurologically, cranial nerves II through XII were intact. She was alert and interactive. PERTINENT LABORATORY VALUES ON PRESENTATION: White blood cell count was 7.2, her hematocrit was 36.6, and her platelets were 157. Chemistry-7 was significant for a blood urea nitrogen of 31 and a creatinine of 7.4. She had a phenytoin level of 2.9. PERTINENT RADIOLOGY/IMAGING: A computed tomography of the head showed no bleed and no mass. BRIEF SUMMARY OF HOSPITAL COURSE: After admission to the Intensive Care Unit, her blood pressure was controlled with intravenous labetalol, and she was weaned off the intravenous nitroprusside. Over the next 48 hours she was transitioned again to oral intake, and her lisinopril was bumped up to better control her blood pressure. She had no recurrent episodes of hypertension while hospitalized. She was reloaded on her phenytoin. The levels were checked and were in the therapeutic range. Throughout the remainder of her hospitalization, she had no further seizure activity. She was followed by the Neurology Service in consultation while in house. Her headaches improved shortly after admission with a dose of metoclopramide. It was believed that these actually did represent true migraine headaches; although, they may have also been related to her hypertensive urgency. She was discharged to the floor in stable condition and from the floor was discharged to home. She was to follow up with her regular nephrologist and with Neurology. DISCHARGE DIAGNOSES: 1. End-stage renal disease (on hemodialysis). 2. Hypertensive urgency. 3. Chronic hypertension. 4. Migraine headache. DISCHARGE STATUS: Discharge status was to home. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed to follow up with her regular nephrologist (Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 174]) and with her primary care physician. [Name6 (MD) 2467] [Last Name (NamePattern4) 10404], M.D. [MD Number(1) 10405] Dictated By:[Name8 (MD) 4733] MEDQUIST36 D: [2122-3-3] 11:43 T: [2122-3-3] 15:06 JOB#: [Job Number 97303]	[ "2761", "2859", "2449" ]
Admission Date: [2173-4-19] Discharge Date: [2173-4-29] Date of Birth: [2107-1-7] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old male transferred from [Hospital 1474] Hospital after ruling in for a non-Q wave myocardial infarction. He presented on [2173-4-13] when he developed significant shortness of breath at rest as well as a pressure-like chest pain. He had nausea but no vomiting or diaphoresis. EMS was called and reported an O2 saturation of 86% and ST elevation in leads 2 and 4. At the [Hospital1 1474] emergency room the patient was noted to be in congestive heart failure. He was treated with Lasix and O2. The patient was admitted to [Hospital1 1474] where further work-up revealed increased BUN and creatinine of 6.6, creatinine clearance calculated at 11. Renal ultrasound was reported as normal. Echocardiogram reported an ejection fraction of 15-20% down from 60% in [9-14], severe diffuse left ventricular hypokinesis and akinesis noted, one episode of supraventricular tachycardia to the 160s only symptomatic with palpitations. The patient was treated with Lopressor. Also hematocrit on admission was 26. The patient was transfused several units of packed red blood cells. He was transferred to [Hospital1 69] for catheterization which showed severe two-vessel disease including left main. PAST MEDICAL HISTORY: 1. Prostate cancer 12-13 years. 2. Diabetes mellitus x 10 years, insulin x 5 years. 3. Chronic renal failure. 4. Transient ischemic attack. 5. Right carotid stent. 6. Hypercholesterolemia. 7. Hypertension. HOME MEDICATIONS: 1. Accupril. 2. Diltiazem. 3. Aspirin. 4. Imdur. 5. Hydralazine. 6. Plavix. 7. Tylenol. 8. Lasix. 9. Lopressor. 10. Flutamide. 11. Lupron. 12. Insulin. SOCIAL HISTORY: The patient quit smoking cigarettes three years ago, smoked one pack per day x 30 years. PHYSICAL EXAMINATION: Temperature 98, heart rate 57, blood pressure 148/70, respiratory rate 18, 92% on room air. In general the patient was in no acute distress. He was alert and oriented x 3. HEENT: Pupils were equal, round, and reactive to light. Extraocular movements were intact. Oropharynx was clear. Neck: Supple, no jugular venous distension no bruits. Cardiac: Regular rate and rhythm, no murmurs, gallops, or rubs. Lungs: Clear to auscultation anteriorly. Abdomen: Soft, nontender, nondistended, positive bowel sounds, no masses or bruits. Extremities: No cyanosis, clubbing or edema. Vascular examination showed 2+ radial and carotid bilaterally, dopplerable dorsalis pedis and posterior tibial pulses. Neurologic: Intact. Catheterization showed PAP 30/14, left main 70%, proximal LAD 50%, mid LAD 40%, distal LAD diffuse disease, diagonals 1 and 2 diffuse disease, proximal RCA 20% at the distal end, mid RCA 20%, right posterior LAD 90%, proximal circumflex 99%, mid circumflex 100%. HOSPITAL COURSE: The patient was admitted to the hospital on [2173-4-19] and initially treated by the medical team. He was treated with aspirin and Lopressor. His ACE inhibitor was held. The patient was seen by the renal team who assisted him in obtaining dialysis. The patient was also seen by the cardiology service who recommended coronary artery bypass grafting. The patient had a PermCath placed for dialysis. On [2173-4-22] the patient was taken to the operating room where coronary artery bypass grafting was performed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 70]. After the procedure the patient required propofol, milrinone, Levophed and insulin drip. He had chest tubes and pacing wires in place. He was transferred to the cardiothoracic intensive care unit where his postoperative period was complicated by atrial fibrillation and ventricular tachycardia for which the patient received amiodarone. The patient was later also started on isosorbide and Lopressor. At the appropriate times the patient's chest tubes and pacing wires were removed. Once the patient was stable he was transferred from the intensive care unit to the regular cardiothoracic floor where he continued to do well. He was seen by physical therapy who indicated that the patient would probably benefit from a period of time in a rehabilitation center post discharge. He was also seen by electrophysiology who requested an echocardiogram be performed and signal-averaged electrocardiograms. The echocardiogram showed an ejection fraction of 25-30%. The patient had difficulty with his voiding trial. He repeatedly had to be recatheterized probably secondary to his history of prostate cancer. He was started on Flomax. It is now [2173-4-29] and the patient is being discharged to rehabilitation in good condition. He should avoid strenuous activity. He should not drive until he is off pain medications. The patient may shower but should not take baths. He should follow up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 70] in six weeks. He should also follow up with his primary care physician, [First Name4 (NamePattern1) 518] [Last Name (NamePattern1) 6700], [Name Initial (NameIs) ].D. and his cardiologist, [First Name8 (NamePattern2) 4468] [Last Name (NamePattern1) ], M.D. DISCHARGE MEDICATIONS: 1. Flomax 0.4 mg p.o. q.h.s. 2. Tums 500 mg p.o. t.i.d. 3. Amiodarone 400 mg p.o. q.d. 4. Isosorbide mononitrate 30 mg p.o. q.d. 5. Insulin flutamide 250 mg p.o. t.i.d. 6. Hydralazine 25 mg p.o. q. 6. 7. Plavix 75 mg p.o. q.d. 8. Percocet. 9. Enteric-coated aspirin 325 mg p.o. q.d. 10. Colace 100 mg p.o. b.i.d. 11. Lopressor 25 mg p.o. b.i.d. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Last Name (NamePattern4) 12487] MEDQUIST36 D: [2173-4-29] 09:33 T: [2173-4-29] 09:52 JOB#: [Job Number 44712]	[ "41071", "4280", "40391", "42731", "2720", "41401" ]
Admission Date: [2161-7-10] Discharge Date: [2161-7-13] Date of Birth: [2131-7-3] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 46917] Chief Complaint: Fever s/p sab Major Surgical or Invasive Procedure: D&C History of Present Illness: 30 yo G3P2002 LMP [2161-5-3] who began miscarrying a few days ago with heavy bleeding and cramping. She was seen by her PCP who confirmed that she was miscarrying, yet found Hct 26. She was sent to [Hospital1 18] ED and confirmed a Hct of 25.2 She was discharged home. She states tonight she began to have heavy bleeding and passage of clots, the largest the size of a tennis ball. She states she passed some white tissue and the has since decreased to spotting. She denies any abdominal pain or cramping. She has had malaise, myalgias and headache all day and had temp of 103 at 8pm at home. She reports some pain with urination earlier today but denies any flank pain, just some low back pain. Some nausea but no vomiting. No diarrhea/constipation. Last meal at noon yesterday. Past Medical History: None Past surgical history: C-section x 2 POBH: FT c/s for arrest of dilation FT Repeat c/s, no complications PGYNH: regular menses, normal flow denies abnl paps or stds not using contraception Physical Exam: 102.4 121 126/63 18 98%ra 101.5 NAD RRR CTAB soft, obese, mild RLQ and midline tenderness to deep palpation, no suprapubic tenderness, nondistended, no rebound/guarding. No CVAT bilaterally SSE: nl external genitalia, moist vaginal mucosa with pooling of dark blood, no active bleeding from os, smooth appearing cervix Bimanual: cervix closed, no CMT, Mobile enlarged tender uterus, especially towards right adnexa, no right adnexal mass palpated, no left adnexal tenderness or masses palpated. Pertinent Results: [7-10] WBC 13.8, Hct 26.6, Plt 297 hcg 321 Urine: Clear, SG 1.004, Leuk Neg, Bld Lge, Nitr Neg, Prot Neg, Glu Neg, Ket Neg, RBC 21-50, WBC 0-2, Bact Rare, Yeast None, Epi [3-23] [7-7] WBC 7.6, Hct, 25.2 Plt 294 Pelvic US [7-10]: IMPRESSION: No definite intrauterine gestation. Based on imaging, differential diagnosis include complete abortion, ectopic or early pregnancy. Given history of misscarriage, the contents in the uterine cavity likely represents blood and debris without evidence of retained products of conception. CT C/A/P [7-10]: IMPRESSION: 1. Patchy peribronchovascular opacity within the right upper lobe and superior segement of left upper lobe, concerning for an infectious process. Bilateral dependent atelectasis and small pleural effusions. 2. Subcentimeter hypodensity within the left kidney too small to characterize. 3. Asymmetric and Heterogeneous enhancement of the uterus, presumably reflecting post-operative changes. Suboptimal opacification of gonadal veins to evaluate for thrombophlebitis. 4. Fluid and gas within the endocervial canal, likley related to D and C, however cannot rule out infection. Trace free fluid is seen within the cul- de-sac, unchanged from ultrasound from same day. 5. No evidence of pulmonary embolus. Brief Hospital Course: Pt hypotensive and tachycardic in the ED with a fever to 103, admitted to the ICU for septic abortion and taken to the OR for D&C which demonstrated minimal retained products, (path pending). Continued on amp/gent/clinda post-op. Post-op, a CT of the torso demonstrated a RUL opacity consistent with pneumonia. Levaquin added, no O2 required. Received 2U pRBCs on POD#1 with stabilization of blood pressure. Complained of chest pain and was ruled out for MI with negative troponins x 3. Called out of the ICU on POD#1 after significant improvement in pain, decreased temperature and return of appetite. On discharge, pt eating regular diet, WBC normalized, Hct stable. PPD placed prior to discharge with plan to follow up result as outpatient. Discharged on Levaquin 500x7d for pneumonia, Doxycycline 100mg [Hospital1 ] for PID. Medications on Admission: None Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:7 Tablet(s) Refills:0 2. Doxycycline Monohydrate 100 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: septic abortion pneumonia Discharge Condition: stable Discharge Instructions: Please take all your antibiotics as prescribed. Call [Telephone/Fax (1) 73746] for any questions. Call if you develop a fever, abdominal pain, shortness of breath or chest pain. Followup Instructions: Gynecology: [Hospital Ward Name 23] Building [Location (un) ]. Dr. [First Name8 (NamePattern2) 14735] [Last Name (NamePattern1) 6718], [7-27] at 10:30am	[ "486" ]
Admission Date: [2167-4-3] Discharge Date: [2167-4-6] Date of Birth: [2089-10-11] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Hydantoins / Trimethadione/Paramethadione / Phenacemide / Barbiturates / Primidone / Gadolinium-Containing Agents / Mysoline Attending:[First Name3 (LF) 5510] Chief Complaint: fever,cough, g-tube out Major Surgical or Invasive Procedure: replaced G-tube in ED [2167-4-3] [2167-4-6] G-tube placement by IR History of Present Illness: Mr. [Known lastname 80433] is a 77yo nursing home resident with h/o COPD, severe restrictive lung disease from scoliosis and recurrent aspiration, recurrent pneumonias (with resistant pseudomonas) who presented to the ED with a dislodged G-tube. After patient was in the ED he noted that he had a recent fever and increased cough. Patient also states he has more difficulty with speaking than at baseline due to losing his breath. He denies any recent choking or aspiration event. He also reports that he has a chronic foley and typically has urinary symptoms with his UTIs, he denies dysuria at this point. Of note, he had 6 admissions over the past year with similar presentation, found to have recurrent pneumonia and was last d/c was [2167-2-2]. . On review of his nursing home records, it was noted that the patient had been started on keflex at his nursing home for possible cellulitis around his G-tube on [4-2]. Past Medical History: COPD with multiple admissions for exacerbations, on home O2 L since [Month (only) 1096] Recurrent aspiration PNA, particularly of LLL, s/p G tube placement Chronic elevation of left hemidiaphragm Parkinson's Disease h/o C. diff requiring MICU stay h/o UTIs with E coli and Pseudomonas resistant to quinolones; h/o chronic indwelling Foley for urinary retention AFib, not on anticoagulation h/o multiple DVTs, s/p IVC filter. Anticoagulation stopped after GI bleed in fall [2165] Severe degenerative disk disease h/o Basal cell Cancer Severe thoracic Scoliosis and spinal stenosis with chronic back pain GERD h/o Sacral decubitus ulcer h/o childhood encephalitis Anxiety h/o right shoulder surgery, no hardware in place Social History: Single, never married. Lives in [Location ] b/c of disability from Parkinsons. Nephew is HCP & visits pt regularly. Was discharged to [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 731] after [Hospital1 18] admission in [Month (only) ]. Smoked 2 packs once, but was never a regular smoker. Unable to ambulate at baseline. Family History: No significant history as pertains to patient's condition. Physical Exam: General: Alert, oriented, unable to complete sentences without SBO HEENT: Sclera anicteric, MM dry with crusting on tongue Neck: supple, JVP not elevated Lungs: Wheezing on the right, diminished breath sounds on the left, when patient asked to say S, wheezing disappeared so likely upper airway wheezing predominant CV: Regular rate and rhythm, no murmurs, Abdomen: soft, non-tender, non-distended, bowel sounds present. G-tube with area of erythema and warmth and mild purulent drainage GU: chronic foley Ext: dopplerable pulses bilateral feet, contractured feet, dusky thin legs. Pertinent Results: [2167-4-3] 02:45AM BLOOD WBC-9.6 RBC-3.76* Hgb-12.2* Hct-36.6* MCV-98 MCH-32.5* MCHC-33.4 RDW-15.0 Plt Ct-223 [2167-4-4] 04:44AM BLOOD WBC-7.8 RBC-3.58* Hgb-11.1* Hct-34.6* MCV-97 MCH-31.0 MCHC-32.1 RDW-14.7 Plt Ct-181 [2167-4-3] 02:45AM BLOOD Neuts-73.0* Lymphs-14.1* Monos-11.6* Eos-1.1 Baso-0.2 [2167-4-3] 11:06AM BLOOD PT-11.7 PTT-26.2 INR(PT)-1.0 [2167-4-3] 02:45AM BLOOD Glucose-109* UreaN-22* Creat-0.7 Na-134 K-4.3 Cl-98 HCO3-30 AnGap-10 [2167-4-4] 04:44AM BLOOD Glucose-73 UreaN-18 Creat-0.7 Na-137 K-4.2 Cl-100 HCO3-29 AnGap-12 [2167-4-4] 04:44AM BLOOD Glucose-73 UreaN-18 Creat-0.7 Na-137 K-4.2 Cl-100 HCO3-29 AnGap-12 [2167-4-3] 03:00AM BLOOD Lactate-1.1 URINE CULTURE (Preliminary): PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. OF TWO COLONIAL MORPHOLOGIES. GRAM STAIN (Final [2167-4-3]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). WOUND CULTURE (Preliminary): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. Brief Hospital Course: In the ED, initial vs were: 98.3 88 132/84 20 100. His g-tube replaced and in place by gastrograffin study. On exam, there was cellulitis around g-tube. His tmx in the ED was 100.1 and his HR ranged from 95-101. His sats were good on 2L NC but he was tachypenic to the high 30s. Mildy wheezing on exam with decreased breath sounds on the left. The resident tried to do an ABG, but he had a tremor on the right and contractures on the left so he was unable to do so. He was given nebs and his tachypnea improved to the mid 20s, he was always orientated. However, when not speaking his RR was 25 and when speaking it went up to 35. CXR was done which showed baseline atelectasis/low lung volume on the left with possible LLL pneumonia. He was given Vanco/Levo and Meropenem. This was later changed to Vancomycin and Meropenem and pt was d/c on a 10 day course (to finish out 14days of treatment) of Vanc/[Last Name (un) ] through PICC line. . # Tachypnea: Patient with low grade fever, increased cough, more shortness of breath than baseline and possible worsening of CXR on the left which is consistent with pneumonia. However, patient also with other reason to have low grade fever (cellulitis), and shortness of breath (restrictive lung disease and improvement with nebs), chronic aspiration. On physical exam his wheezing was found to be mostly upper airway so we treated him for pneumonia (VAP and pseudomonas) with Vanco/[Last Name (un) ]/Cipro. His sputum culture was difficult to obtain and grew mixed respiratory flora. He was continued on nebs and improved back to baseline within several hours. Cipro was stopped the next morning as it was felt unlikely that the patient had pneumonia given his rapid improvement. . # Cellulitis at G-tube site: Patient started on Vanco/[Last Name (un) ] for cellulitis. The area of erythema improved. Culture from the site had multiple organisms on gram stain. G tube was replaced and permanent tube placed on [4-6]. . # Positive U/A: Patient's urine was positive in the ED. He denied urinary symptoms. He has a chronic foley catheter which was changed out when he got to the ICU. His urine culture grew 2 species of pseudomonas. He was on meropenem for his possible pneumonia and cellulitis which should cover his pseudomonas. While awaiting sensitivities a second antibiotics was not added.Vanc/[Last Name (un) ] will be continued which would cover these organisms from chronic foley placement. . # COPD: -continued standing nebs with albuterol and ipratropium . # Chronic aspiration: Aspiration precautions with G-tube feeding. . # Parkinson's disease: Continued home doses of Sinemet and hyoscyamine. . # AFib: Patient in NSR on telemetry. He was continued on home dose of amiodarone. Of note, patient not on anticoagulation given h/o GI bleed. # Hyperlipidemia: Patient continued on statin and ASA . . # GERD: Patient started on Lansoprazole while in hospital (don't have omeprazole liquid on formulary). . # H/o DVTs: Patient denies any leg pain, no assymetry on exam. Was on heparin SQ for PPX while in the hospital Medications on Admission: Kelfex 500 QID Lactinex 1 package in h2o via g-tube [Hospital1 ] water flushes ASA 81mg daily Fibersource 65 ml/hr 24 hours a day robiutussin 20cc daily albuterol q4h iprat q4h amiodarone 200 daily carbidopa/levidopa 1 tab TID Omeprazole 10ml via gtube [Hospital1 ] Simvastatin 20mg qhs Ducolax prn Albuterol prn Hycoasime 1ml via gtube prn congestion/increased secretions Lorazapam 0.5 TID prn aggitation Trazodone 25 qhs prn insomnia Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [Hospital1 ]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Docusate Sodium 50 mg/5 mL Liquid [Hospital1 ]: One (1) PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO DAILY (Daily). 4. Guaifenesin 100 mg/5 mL Syrup [Hospital1 ]: Ten (10) ML PO BID (2 times a day). 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [Hospital1 ]: One (1) neb Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:10 nebs Refills:0 6. Ipratropium Bromide 0.02 % Solution [Hospital1 ]: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:10 neb Refills:0 7. Amiodarone 200 mg Tablet [Hospital1 ]: One (1) Tablet PO DAILY (Daily). 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [Last Name (STitle) ]: One (1) Tablet,Rapid Dissolve, DR [Last Name (STitle) ] DAILY (Daily). 9. Simvastatin 10 mg Tablet [Last Name (STitle) ]: Two (2) Tablet PO DAILY (Daily). 10. Trazodone 50 mg Tablet [Last Name (STitle) ]: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 11. Carbidopa-Levodopa 25-100 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO TID (3 times a day). 12. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual [Last Name (STitle) ]: One (1) Tablet, Sublingual Sublingual QID (4 times a day) as needed for congestion. 13. Lorazepam 0.5 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q8H (every 8 hours) as needed for agitation, anxiety. 14. Acetaminophen 325 mg/10.15 mL Solution [Last Name (STitle) ]: One (1) solution PO Q6H (every 6 hours) as needed for Pain, fever. 15. Vancomycin in Dextrose 1 gram/200 mL Piggyback [Last Name (STitle) ]: One (1) gram Intravenous Q 12H (Every 12 Hours) for 10 days. Disp:20 gram Refills:0 16. Senna 8.8 mg/5 mL Syrup [Last Name (STitle) ]: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 17. Meropenem 500 mg Recon Soln [Last Name (STitle) ]: One (1) Intravenous every six (6) hours for 10 days. Disp:20 grams Refills:0 18. Guaifenesin 100 mg/5 mL Syrup [Last Name (STitle) ]: Ten (10) ML PO TID (3 times a day). 19. Acetaminophen 325 mg Tablet [Last Name (STitle) ]: One (1) Tablet PO Q6H (every 6 hours). 20. Heparin (Porcine) 5,000 unit/mL Solution [Last Name (STitle) ]: One (1) Injection [Hospital1 ] (2 times a day). 21. 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: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 731] - [Location (un) 2498] Discharge Diagnosis: Hospital accquired pneumonia UTI Abdominal Celullitis G-tube replacement Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Bedbound Discharge Instructions: You were admitted because you needed your gastric tube replaced and you were also found to have a pneumonia, an urinary tract infection and an infection of the skin sorrounding your gastric tube. You were treated in the intesive care unit and your condition improved. Upon transfer to the floor we continued your antibiotics and your gastric tube was placed by interventional radiology. Mediation Changes: Please finish a 10 day course of VANCOMYCIN and MEROPENEM Followup Instructions: Please follow up with your PCP within the next 2 weeks to assess for improvement of your infections Completed by:[2167-4-7]	[ "486", "5180", "5990", "496", "42731", "53081", "2724" ]
Admission Date: [2132-10-6] Discharge Date: [2132-10-12] Date of Birth: [2058-10-28] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Known firstname 1283] Chief Complaint: CP / CAD Major Surgical or Invasive Procedure: Iliac and aortic stent placement [2132-10-6] Re-do CABG X 4, AVR(tissue) [2132-10-7] History of Present Illness: This is a 73-year-old male who had a history of coronary artery disease and had underwent a left internal mammary artery H grafted with a radial artery to the left anterior descending artery through a left anterior thoracotomy many years ago. He had progressive shortness of breath and was found to have critical aortic stenosis with aortic valve area of 0.8 cm squared and moderate mitral regurgitation. His ejection fraction was estimated to be about a 25%. He also underwent a cardiac catheterization which demonstrated that his H graft to the left anterior descending artery was patent. He had a totally occluded left anterior descending artery proximally. He also had significant stenosis of his left circumflex artery and right coronary artery. It was recommended that he undergo a coronary artery bypass grafting, aortic valve replacement, and possible mitral valve repair/replacement. After the risks and benefits were explained to the patient he agreed to proceed. Past Medical History: lisinopril 30', coreg 3.125", norvasc 5', lipitor 40', coumadin Social History: retired electrical engineer with 7 children Pertinent Results: [2132-10-7] 01:37PM BLOOD WBC-9.7# RBC-2.61# Hgb-8.1# Hct-23.2* MCV-89 MCH-31.1 MCHC-34.9 RDW-14.1 Plt Ct-95# [2132-10-10] 07:15AM BLOOD WBC-11.0 RBC-4.05 Hgb-12.9* Hct-37.0* MCV-91 MCH-31.7 MCHC-34.7 RDW-13.9 Plt Ct-137* [2132-10-11] 05:10AM BLOOD PT-11.5 INR(PT)-1.0 [2132-10-10] 07:15AM BLOOD Plt Ct-137* [2132-10-12] 05:25AM BLOOD Glucose-111* UreaN-20 Creat-1.0 Na-140 K-4.5 Cl-102 HCO3-28 AnGap-15 Conclusions: Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Resting regional wall motion abnormalities include hypokinesis of septum, anterior, posterior and lateral walls at the bases, and akinesis of all mid-segments and apex. There is moderate global right ventricular free wall hypokinesis. There are simple atheroma in the descending thoracic aorta. There are three thickened aortic valve leaflets. There is moderate aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([2-11]+) mitral regurgitation with a central jet is seen. There is no pericardial effusion. Post-CPB: A well-seated and functioning prosthetic aortic valve is seen. There are no leaks. No AI. MR is 1+. Aorta is intact. Both ventricles show slight improvement in global systolic fxn. (The patient is on low-dose epinephrine.) Other parameters as pre-bypass. Brief Hospital Course: Patient was admitted after cardiac cath overnight, then underwent an uncomplicated AVR with 23mm pericardial valve and redo cabgx3. Patient came of CPB in the OR without incident, and was treansferred to the csru intubated. pressors were weaned that nights, and patient was extubated on POD1 after ppf was switched to precedex for agitation when weaning. CTs were dc'd on POD1, bblocker and asa started. He was then transferred to the floor on POD2 after doing very well. Lopressor was gradually increased for sinus tachycardia but was then swtiched to carvedalol (his home med) to better control his HR&BP. Patient was tolerating a regular diet ambulating well when he was discharged home on POD5. Medications on Admission: lisinopril 30', coreg 3.125", norvasc 5', lipitor 40', coumadin Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:14 Tablet(s) Refills:0 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO twice a day for 7 days. Disp:28 Capsule, Sustained Release(s) Refills:0 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. 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 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:50 Tablet(s) Refills:0 9. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 10. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: AS CAD MR [First Name (Titles) 3593] [Last Name (Titles) ] hypercholesterolemia Discharge Condition: good Discharge Instructions: may shower, no bathing or swimming for 1 month no creams, lotions or powders to any incisions no driving for 1 month no lifting > 10# for 10 weeks [Last Name (NamePattern4) 2138]p Instructions: with Dr. [Last Name (STitle) ] in [3-14] weeks with Dr. [Last Name (Prefixes) ] in 4 weeks Completed by:[2132-10-12]	[ "41401", "9971", "42789", "4019", "2720", "V4581", "412", "V1582" ]
Admission Date: [2178-1-13] Discharge Date: [2178-2-10] Date of Birth: [2131-3-22] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 5893] Chief Complaint: Weakness Major Surgical or Invasive Procedure: Bronchoscopy Intubation Mechanical Ventilation History of Present Illness: Mr. [Known lastname 62558] is a 46 year-old male with a history of HIV who initially presented to [Hospital1 18] [2178-1-13] with SOB and nonbloody diarrhea and a CD4 count of 19 (pt off HAART for 1.5 year). Since admission he has been diagnosed with PCP (from BAL [1-16] treated with bactrim and steroid taper), Giardia (finished flaygl [1-23] with no residual diarrhea), KS with pulmonary involvement(treated with Paclitaxel and high dose steroids on [1-20]), thrush, HSV type II (lesion on left chin), and CMV pnuemonitis growing from [1-16] BAL, as well as CMV bacteremia (treated with gancyclovir). He also developed recurrent Hep B infection and therefore was started on HAART therapy [1-22] despite active PCP [Name Initial (PRE) 2]. Mr. [Known lastname 90417] hospital course is also notable for developing bilateral apical pneumothoraces and is s/p chest tube placement by IP. The Chest tube has since been pulled [1-28] and his bilateral pneumothoraces were stable by radiology report. However, also developed pneumomediastinum which was present on [1-27] then dissappeared on [1-30] and now present and worse on today's film. He also developed tachypnea and hypoxia and was diagnosed with hospital acquired PNA and was started on vanc/zosyn on [1-30]. Finally, his course has also been c/b SIADH. . This morning Mr. [Known lastname 62558] [Last Name (Titles) 7600] for increasing oxygen requirement. Per primary team, the pt has been stable on the floor with O2 sats in the high 80s to low 90s on 5 L nc during this hospitalization. This morning an NGT was placed for nutrition given pt very malnourished and he was noted to be more hypoxic. The NGT was removed and patient continued to have decreasing O2 sats. He was somnolent and transiently not oriented to place. He was placed on venturi mask and nasal canula and his sats remained in the mid to low 80s. He was tachypneic and complained of air hunger. He was pale on exam, with poor air movement but otherwise no rhonchi or rhales. Patient was placed on NRB and O2 sas improved to 92%. ABG at this time revealed 7.4/32/51. He was then transferred to ICU. . In the ICU, patient was placed on nc with nonrebreather on hi Flow. His O2 sats remained 89-90% despite this and he was tachypneic to mid 30s. He was somnolent but oriented x 3. Patient had no other complaints at that time. . Past Medical History: Past Medical History: HIV/AIDS - Last CD4 19. Has history of thrush and syphilis at the time of his diagnosis in [2173]. He was previously on Atripla but has been off therapy for 1 1/2 years. No history of PCP . Social History: . Social History: Lives in [Location 86] with an occasional roommate. Works in [State 1727] as Deputy Secretary of State, travels to [State 1727] during week, back home during weekends. He used to smoke cigarettes socially, quit 6 months ago, alcohol 1-2 times a week. Former drug user predominantly with crystal meth, including IV. MSM, although not currently in a relationship, history of unprotected sex. Has lived in [Location ] and [Location (un) 511] his whole life, traveled across US, Europe in [2173], Bahamas last year. . Family History: Family Medical History: Asthma, Grandparents with strokes. Father had MI at ages 45 and 50. Physical Exam: . Physical Exam on ICU admission VS: Temp: 97 BP: 101/70 HR:91 RR: 22 O2sat 80% GEN: states he is anxious yet appears somnolent, cachectic appearing, pale HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd RESP: shallow breaths, no rhonchi or rhales CV: RR, S1 and S2 wnl, no m/r/g ABD: scaphoid abdomen, nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: KS on scalp, HSV lesion on left chin NEURO: AAOx3. Cn II-XII intact. moving all limbs but decreased strength throughout . Pertinent Results: Admission Labs: [2178-1-13] 11:35AM BLOOD WBC-3.3* RBC-4.57* Hgb-13.6* Hct-40.9 MCV-90 MCH-29.7 MCHC-33.2 RDW-14.2 Plt Ct-731* [2178-1-14] 07:20AM BLOOD WBC-2.7* RBC-3.76* Hgb-11.2* Hct-33.1* MCV-88 MCH-29.8 MCHC-33.8 RDW-14.2 Plt Ct-562* [2178-1-13] 11:35AM BLOOD PT-13.1 PTT-25.7 INR(PT)-1.1 [2178-1-13] 11:35AM BLOOD Glucose-130* UreaN-14 Creat-0.6 Na-132* K-3.7 Cl-98 HCO3-23 AnGap-15 [2178-1-14] 07:20AM BLOOD Glucose-114* UreaN-13 Creat-0.5 Na-132* K-3.5 Cl-102 HCO3-23 AnGap-11 [2178-1-14] 07:20AM BLOOD ALT-29 AST-47* LD(LDH)-506* AlkPhos-105 TotBili-0.1 [2178-1-13] 11:35AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.0 [2178-1-13] 04:26PM BLOOD Type-ART pO2-63* pCO2-31* pH-7.46* calTCO2-23 Base XS-0 [2178-1-13] 04:26PM BLOOD O2 Sat-91 [2178-1-13] 04:26PM BLOOD freeCa-1.11* Legionella Urinary Antigen (Final [2178-1-14]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. MICROSPORIDIA STAIN (Final [2178-1-15]): NO MICROSPORIDIUM SEEN. CYCLOSPORA STAIN (Final [2178-1-15]): NO CYCLOSPORA SEEN. FECAL CULTURE (Final [2178-1-16]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [2178-1-16]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [2178-1-15]): This test does not reliably detect Cryptosporidium,Cyclospora or Microsporidium.. GIARDIA LAMBLIA. CYSTS AND TROPHOZOITES. Cryptosporidium/Giardia (DFA) (Final [2178-1-16]): NO CRYPTOSPORIDIUM SEEN. GIARDIA LAMBLIA SEEN. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [2178-1-15]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). Kaposi's Sarcoma - Skin, right scalp (A): Dermal vascular proliferation consistent with Kaposi's sarcoma, extending to the specimen margins (see note). CT Torso: IMPRESSION: 1. Diffuse ground-glass pulmonary infiltration, favoring the central lungs with a reticular pattern that suggests an acute-on-chronic infection consistent with pneumocystis jiroveci pneumonia. These findings are not characteristic of mycoplasma avium intracellulare infection. 2. Wedge-shaped hypodensity within the left kidney. This is most characteristic of a renal infarct; however, differential diagnosis includes focal pyelonephritis and correlation with urinalysis is suggested. 3. No appreciable lymphadenopathy. CXR [1-16]: FINDINGS: As compared to the previous radiograph, the pre-described parenchymal opacities at both lung bases and in the periphery of the left hilus are unchanged in severity and distribution. There is no evidence of pneumothorax. No newly occurred focal parenchymal opacities. Normal size of the cardiac silhouette. [1-13]: FINDINGS: There are ill-defined patchy opacities in the lung bases bilaterally, right greater than left. There is no pneumothorax or pleural effusion. The cardiomediastinal silhouette is unremarkable. IMPRESSION: Ill-defined patchy bibasilar opacities, concerning for infectious process. Given clinical context, pneumocystis pneumonia not excluded. On ICU admission: Labs: ABG 7.40/32/51 freeCa:1.06 Lactate:1.7 . 124 95 14 ------------<53 5.2 19 0.4 . Ca: 7.1 Mg: 1.6 P: 3.4 ALT: 56 AP: 241 Tbili: 0.2 AST: 108 MCV 88 11.1 1.9>----< 98 31.8 N:92 Band:0 L:4 M:4 E:0 Bas:0 . . EKG: . Imaging: CXR Wet read right PICC tip in the mid SVC. new since [1-30] tiny right apical PTX and bilateral pneuomediastinum, but these findings similar to [1-27] CXR. bilateral lung opacities, worse on the left, unchanged since [1-30]. . CXR [1-30] IMPRESSION: AP chest compared to [1-24] through [1-28]: There is no pneumothorax since [1-28] following removal of the right pigtail pleural drain. A very small right pleural effusion is little larger. Severe heterogeneous opacification of much of the left lung and right lower lung has progressed over the past three days, consistent with worsening infection, including Pneumocystis. Heart is not enlarged. Pleural effusions are small, if any. No pneumothorax. . CXR [1-27] IMPRESSION: Portable upright AP chest radiograph compared with multiple prior studies, most recent dated [2178-1-25]. A right-sided pigtail chest drain is in situ. No appreciable pneumothorax is seen: There is moderate subcutaneous emphysema, improved compared to the prior study. Multifocal bilateral mid to lower zone consolidation is increased on the left side compared to the prior study, concerning for infection. . [1-19] echo The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are elongated. Mild bileaflet leaflet mitral valve prolapse is suggested. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . [1-15] CT IMPRESSION: 1. Diffuse ground-glass pulmonary infiltration, favoring the central lungs with a reticular pattern that suggests an acute-on-chronic infection consistent with pneumocystis jiroveci pneumonia. These findings are not characteristic of mycoplasma avium intracellulare infection. 2. Wedge-shaped hypodensity within the left kidney. This is most characteristic of a renal infarct; however, differential diagnosis includes focal pyelonephritis and correlation with urinalysis is suggested. 3. No appreciable lymphadenopathy. Brief Hospital Course: Mr. [Known lastname 62558] was a 46 year-old male with a history of HIV who initially presented to [Hospital1 18] [2178-1-13] with SOB and nonbloody diarrhea and a CD4 count of 19 (pt off HAART for 1.5 year). He [Month/Day/Year ] underwent BAL with diagnosis of PJP and CMV pneumonitis which were treated with bactrim and steroid taper and Gancyclovir. KS with pulmonary involvement was treated with Paclitaxel and high dose steroids. In addition he recieved treatment for Giardia, thrush, HSV type II skin lesion and hospital aquired pneumonia. He also developed recurrent Hep B infection and was therefore started on HAART therapy. His hospital course was complicated by bilateral apical pneumothoraxes and pneumomediastinum. His pneumothoraxes were treated by chest tube which was removed after bilateral pneumothoraces were stable by radiology report. Unfortunately Mr. [Known lastname 62558] [Last Name (Titles) ] developed increasing oxygen requirement and mental status change which required his transfer to the ICU. In the ICU he was intubated for hypoxic respiratory failure, mechanically ventilated and a right chest tube was placed to prevent tension pneumothorax in the setting of known pneumothorax and positive pressure ventilation. Mr. [Known lastname 90417] ICU course was complicated by septic shock, renal failure, non resolving right bronchopleural fistula, pancytopenia and ARDS. Our attempts to wean off oxygen and pressors were to no avail. Given his multi-organ failure, his profound immune supression and his poor underlying nutritional status it was felt that he no longer had realistic chance of recovery. On hospital day 29 after discussion with his family and HCP and in keeping with their wishes Mr. [Known lastname 90417] goals of care were changed to focus on comfort measures. He was extubated in the PM and expired shortly thereafter with his mother and sister at his bedside. Death was pronounced On 15th Febuary [2177] at 06:10 PM. The cheif cause of death was Acquired Immune Deficiency Syndrome, the immediate cause of death was Respiratory Failure. Medications on Admission: Medications: Home: None - Previously on Atripla . On transfer to ICU: Sulfameth/Trimethoprim DS 2 TAB PO/NG TID (Day 1 = [1-13]) Vancomycin 1000 mg IV Q 24H (D1 [2178-1-30]) Piperacillin-Tazobactam 2.25 g IV Q6H (D1 [2178-1-30]) Raltegravir 400 mg PO BID Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY Ganciclovir 220 mg IV Q12H Nystatin Oral Suspension 5 mL PO QID:PRN thrush Azithromycin 1200 mg PO/NG QMON ([1-24]) Cepacol (Menthol) 1 LOZ PO PRN cough PredniSONE 40 mg PO/NG DAILY (started [2-1] ordered for 4 days) OxycoDONE (Immediate Release) 5 mg PO/NG Q6H:PRN pain Acetaminophen 325-650 mg PO/NG Q6H:PRN pain, fever Ipratropium Bromide Neb 1 NEB IH Q4H:PRN SOB Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheeze Potassium Chloride Replacement (Oncology) IV Sliding Scale Multivitamins 1 TAB PO/NG DAILY Magnesium Sulfate Replacement (Oncology) Potassium Phosphate Replacement (Oncology) IV Sliding Scale Order Docusate Sodium 100 mg PO BID:PRN constipation Senna 1 TAB PO/NG [Hospital1 ]:PRN constipation Guaifenesin [5-5] mL PO/NG Q6H:PRN cough Heparin 5000 UNIT SC TID Order date: [1-24] @ 1603 32. . Allergies: NKDA Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: NA Discharge Condition: NA Discharge Instructions: NA Followup Instructions: NA Completed by:[2178-2-11]	[ "51881", "99592", "78552", "486", "5849", "0389", "2767" ]
Admission Date: [2142-6-27] Discharge Date: [2142-7-13] Date of Birth: [2088-5-7] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5569] Chief Complaint: Liver failure Major Surgical or Invasive Procedure: Intubation Central venous line placement Dobhoff feeding tube placement Swan ganz catheter placement Hemodialysis line placement EGD Colonoscopy History of Present Illness: 54M w/ liver failure, child C cirrhosis from EtOH and HCV p/w worsening liver enzymes and worsening abdominal distention. Pt does have a history of HCC with nodules measuring 2.9 x 2.2 cm and 1.3 x 1.1 cm (segment 8) with attempted EtOH ablation. However, patient decompensated during the procedure and only one tumor was successfully ablated. Per OMR note in liver tumor board, patient does have residual tumor (2.6 x 1.7 cm) and was considered a non-candidate for further procedures. He was admitted to [Hospital1 112] from [2142-6-22] - [2142-6-27] for abdominal pain, jaundice, and melena. He was admitted to the MICU because of hypotension, requiring pressor support. His abdominal pain was thought to be related to gall bladder etiology; however, reports of a negative HIDA scan in setting of worsening ascites. Patient was transfused 3 units pRBC for Hct 20 on presentation. His INR was 5.7 and rose to 11 on his day of discharge. No attempts for paracentesis or endoscopies. He was treated conservatively with blood products and antibiotics for SBP prophylaxis. With initial laboratory values, MELD 33 on admission. He was discharged on [2142-6-27]. Due to worsening symptoms of lethargy and persistent melena, patient reported to [Hospital1 18] for further evaluation. On arrival, INR found to be 8.5. From labs, MELD score 46. Admitted to MICU for upper endoscopy, which only showed esophageal varices. Patient still with Hct 20's and currently transfused 3u pRBC, 8u FFP, 2u platelets, 4u cryoprecipitate. CT scan negative for any intra-abdominal bleeding. He is receiving vancomycin for one blood culture positive for coag negative stap and cipro for SBP prophylaxis. Plan for colonoscopy this evening. Per patient, reports weight gain of 30lbs over 1 month, acute worsening jaundice and feeling fatigued. Denies any fevers, SOB, or chest pains. Frequent diarrhea bc of lactulose. His last drink was [2142-3-3]. All other ROS negative. Past Medical History: Hep C (genotype unknown, treatment naive) & ETOH cirrhosis dx [2135] c/b ascites, peripheral edema and varices; s/p variceal bleed in [2134] and variceal banding [2137]; Past heavy ETOH use now sober per report since [2142-3-3]; 2 liver nodules seen [2141-6-28] concerning for HCC one measuring 2.9 x 2.2 cm and the other lesion measuring 1.3 x1.1 cm s/p CT- guided ETOH ablation at [Hospital1 112] [10-6]- pt coded in scanner ? [1-30] narcotics. Was intubated and later tracheostomy placed; anxiety; OA of right hip s/p THR [2137]; L5-S1 laminectomy in [2117]; repair of a right inguinal and an umbilical hernia in [2132-3-29]; h/o right knee cellulitis following trauma Social History: - Tobacco: started smoking at 49 yo, current smoker 2 cig/day - Alcohol: Per report, sober since [2142-3-3] - Illicits: past cocaine use in 20s. no other ilicits Works in manufacturing for his family business. Remarried with children aged 17 and 19. Family History: Mother- current 81 [Name2 (NI) ] s/p MI with [Name (NI) 2481] Father- 83- alive and well along with 2 brothers [Name (NI) 12408] died at 51 of pancreatic ca Son- ASD vs valvular disease s/p repair Physical Exam: General Appearance: Well nourished, No acute distress, Overweight / Obese, Not Anxious Eyes / Conjunctiva: Scleral icterus Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic) Peripheral Vascular: (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear, No Crackles, No Wheezes, No Rhonchi) Abdominal: Soft, Bowel sounds present, Distended, Not Tender Extremities: Right lower extremity edema: 2+, Left lower extremity edema: 2+ Skin: Warm, Jaundice Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Oriented x3, Tone: Not assessed, slight asterixis Pertinent Results: Labs on Admission: GLUCOSE-86 UREA N-17 CREAT-1.8* SODIUM-134 POTASSIUM-4.9 CHLORIDE-101 TOTAL CO2-21* ANION GAP-17 IRON-111 calTIBC-121* FERRITIN-820* TRF-93* CORTISOL-5.7 HBsAg-NEGATIVE HBs Ab-POSITIVE HBc Ab-NEGATIVE HAV Ab-POSITIVE HCV Ab-POSITIVE* WBC-8.9 RBC-1.91* HGB-6.8* HCT-19.0* MCV-100* MCH-35.6* MCHC-35.7* RDW-22.7* ETHANOL-NEG WBC-11.2# RBC-2.54 HGB-8.9* HCT-25.4* MCV-100# MCH-35.1 MCHC-35.0 RDW-22.4* NEUTS-79.2* LYMPHS-10.5* MONOS-8.4 EOS-1.5 BASOS-0.5 . . [2142-6-26] Renal U/S IMPRESSION IMPRESSION: 1. Cirrhosis of the liver without concerning liver lesions. 2. Splenomegaly and ascites, suggests portal hypertension. 3. Reversal of flow in the main portal vein. . . [2142-6-27] Echo IMPRESSION There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). A mid-cavitary gradient is identified. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Tricuspid regurgitation is present but cannot be quantified. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. . . [2142-6-28] CT Chest w/out contrast IMPRESSIONS: 1. No evidence of intraperitoneal or retroperitoneal hemorrhage to explain drop in hematocrit. 2. Cirrhotic liver with splenomegaly and intra-abdominal and esophageal varices, and a small amount of ascites, compatible with portal hypertension. 3. Small bilateral pleural effusions, with greater than expected degree of consolidation at the right lung base, and scattered foci of nodular ground glass opacity bilaterally, which is concerning for aspiration or infection. 4. Mild anasarca and mesenteric stranding compatible with third spacing. . . [2142-6-28] CT Abdomen w/out contrast IMPRESSION 1. No evidence of intraperitoneal or retroperitoneal hemorrhage to explain drop in hematocrit. 2. Cirrhotic liver with splenomegaly and intra-abdominal and esophageal varices, and a small amount of ascites, compatible with portal hypertension. 3. Small bilateral pleural effusions, with greater than expected degree of consolidation at the right lung base, and scattered foci of nodular ground glass opacity bilaterally, which is concerning for aspiration or infection. 4. Mild anasarca and mesenteric stranding compatible with third spacing. . . [7-2] Bone Scan: 1. No evidence of osseous metastatic disease. 2. Findings compatible with diffuse anasarca and possible ascites as described above. 3. Altered biodistribution of the radiopharmaceutical with relative poor uptake in the bones and increased uptake in the kidneys of unclear etiology. . . [7-2] MRI/MRA Liver: 1. Three lesions in the segment VIII of the liver at the dome, the largest one measuring 2.5 cm and arterial enhancing with washout at delayed phase. Two additional 1 cm lesions demonstrates only arterial enhancement without washout, but that are new as compared to the prior examination. In the known history of cirrhosis, these lesions most probably correspond to foci of HCC. . 2. Bilateral small-to-moderate pleural effusion. . 3. Small amount of ascites. . 4. Large recanalized paraumbilical vein. . 5. Mild splenomegaly. . 6. Irregular mild intrahepatic biliary dilatation. . . [7-5] CXR As compared to the previous radiograph, there is no relevant change. Mild pulmonary edema, as manifested by perihilar haziness and increase in diameter of the central pulmonary vessels. Moderate cardiomegaly, retrocardiac atelectasis. Minimal blunting of the left costophrenic sinus, so that the presence of a pleural effusion cannot be ruled out. Labs prior to expiration: WBC-6.9 RBC-2.64* Hgb-8.8* Hct-24.1* MCV-92 MCH-33.2* MCHC-36.3* RDW-22.2* Plt Ct-56* PT-34.9* PTT-78.3* INR(PT)-4.0* FDP-320-640* Fibrino-89* Glucose-48* UreaN-32* Creat-2.9* Na-136 K-4.0 Cl-97 HCO3-25 AnGap-18 ALT-30 AST-103* CK(CPK)-155 AlkPhos-98 TotBili-33.1* CK-MB-16* MB Indx-10.3* Albumin-3.6 Calcium-9.7 Phos-3.8 Mg-1.8 Yype-ART pO2-78* pCO2-49* pH-7.33* calTCO2-27 Base XS-0 Brief Hospital Course: Patient was admitted to the medical service on [2142-6-27]. Liver transplant evaluation initiated as patient was listed for potential organ. He was transferred to the floor shortly but required further intensive care support. The surgical service assumed care as another liver offer was made. However, patient was severely decompensated with multiple organ failure. He was made CMO and expired on [2142-7-13]. His hospital course can be summarized by the following review of systems: Neuro: Patient with worsening encephalopathy despite lactulose and rifaximin. Pulm: With worsening mental status, he was intubated on [7-10] for airway support. His oxygen saturation continue to decline despite ventilator support. Cardio: Several echocardiogram performed to assess for pulmonary hypertension. Patient did require vasopressor support to maintain blood pressures. GI: Summary per medical service and hepatology - # Worsening ESLD- The patient presented after discharge from OSH with a worsening INR and T bili consistent with worsening liver disease. The differential for the acute change acute worsening is broad and included recent sepsis with perhaps persistent SBP (got 5D ceftaz, flagyl at OSH), other infection(PNA or UTI), alcoholic hepatitis (although pt and wife state no ETOH since [3-7]) and gastro-intestinal bleed. On the evening of admission the combination of the patient's, acute worsening liver disease and renal failure, he was started on octreotide, midodrine and 50mg of albumin and lactulose. He was continued on lactulose and octreotide until the time of his transfer. A non contrast CT of the liver on [6-28] revealed a cirrhotic liver with mild ascites and intra-abdominal and esophageal varices. The patient's LFTs throughout his stay in the MICU remained elevated, likely secondary to extensive hepatic injury. Following transfer to the floor his coagulopathy worsened with a peak INR of 8.5. This required serial monitoring of coag labs and near daily transfusions of FFP, cryoprecipitate, and platelets with goals of INR<4, Fibrinogen >100, Plt>50. On [7-5] a dobhoff was placed for [Street Address(1) 65886] recs and tube feeds started. On [7-6] the patient removed the tube. The following morning he was taken to surgery for an aborted transplant operation. The tube was replaced upon his return to the floor and tube feeds were re-initiated. With worsening mental status and heavy transfusion requirement, he was transferred to the MICU for further care and then to the surgical service. # Liver Transplant - The liver transplant team was consulted. The patient states he has been sober since [2142-2-26]. His MELD listing on admission was 48. Transplant criteria lab tests and studies were initiated upon admission to the MICU. An echo was performed (results in pertinent results) and transplant studies were sent. On [7-2] MRI/MRA showed 2 new lesions thought to be HCC that were approximately 1cm in diameter. These findings coupled with his pre-existing 2.5cm HCC still feel within the [Location (un) ] criteria for transplantation. His bone scan was negative for mets and he was placed at the top of the transplant list. On [7-7] he was offered a donor liver but it was deemed to be unfit for transplant secondary to overall quality. Another offer was made but due to overall hemodynamic instability and high mortality rate, it was withdrawn. Patient resumed on supportive care but due to worsening overall condition, family discussions with medical services concluded in withdrawing all care. Patient made CMO on [2142-7-13] and shortly expired. GU/Renal/FEN: . # Acute Renal Failure - The patient's baseline creatinine was up to 2.2 on admission from a baseline of 1.0. The patient's acute renal failure was initially concerning for hepatorenal syndrome in the setting of worsening liver function versus pre-renal etiology from volume depletion in the setting of sepsis at outside hospital. The patients FeNa was 0 on admission consistent with both etiologies. The patient was given albumin on admission and received a fluid challenge on [6-29] and [6-30]. Mr. [Known lastname 3728] creatinine trended down and was 1.6 at the time of transfer making hepatorenal syndrome less likely as he responded favorably to a fluid challenge and auto-diuresed. . On the floor the patient continued to autodiurese and his Cr corrected to 0.8. Diuresis was initiated with IV lasix and spironolactone given his fluid status (see below) but the following morning his Cr had nearly doubled to 1.5. given fluid overload we restarted his diuretics. Over the next several days his Cr was monitored and when below 1.0 he was given 10mg IV lasix doses in an effort to remove the large amount of fluid he was retaining secondary to his multiple transfusions. His kidney function continued to worsen during the remainder of his hospital course as he became anuric, not responding to diuretics. With significant amount of transfusions, patient remained volume overloaded. CVVH was initiated on [2142-7-11]. However, due to labile blood pressures, diuresis was attempted but unsuccessful due to pressor need. Nephrology continued to follow patient with recommendations. . #Anasarca: Likely [1-30] large volumes of IVF and blood products given in the MICU. The patient had presented a unique fluid balance challenge and an effort was made to find a compromise between correcting his coagulopathy and avoiding fluid overload while protecting his kidney function. On [7-5] he developed an O2 requirement and a cxr demonstrated evidence of fluid overload. This is consistent with the large volumes of blood products he's been getting. He was diuresed with a return to o2 sats in the high 90's on room air. Unfortunately his Cr doubled (see above). To improve nutritional status, enteral feeding was initiated per nutritional recommendations. Heme: . # Low Hematocrit - The patient presented with guaiac positive stools and low hematocrit of 22.9. Initially there was concern was that the etiology of his acute blood loss was from a GI bleed, he had a prior history of two variceal bandings. His hematocrit dropped precipitously 3 points from his arrival in the ED to admission in the MICU. The patient was transfused 4 units of FFP before a central line was placed and 1 additional unit of FFP, 2 units of PRBC and platelets were transfused overnight. An upper endoscopy on the evening of admission, [6-27] revealed small varcies, gastropathy and no active bleeding. Vitamin K, Nadolol, IV protonix and IV cipro were started and additional units of PRBC, FFP and cryoglobulin were given. A CT of the patients torso was performed on [6-28] and ruled out evidence of lower GI bleeding. A colonoscopy on [6-29] showed no evidence of acute gastro-intestinal bleed. The patient's hematocrit was stable in the low 20s with no acute drops. No further transfusions were required and transfusion requirements were liberalized (INR>5, PLt <50 Hct < 21) as the patient was not actively bleeding. IV cipro and protonix were changed to PO medications on [6-30] as the patient was started on a soft diet and transferred to the floor. Over the next week the patient's hct continued to drop. Indirect bilirubinemia and schistocytes on smear indicated possible hemolysis. Coombs negative. The persistent anemia was thought to be secondary to splenic sequestration and active blood loss at IJ site and recent bleeding foley. The patient received intermittent transfusions. Criteria were as follows - fibrinogen > 100, platelets >50, Hct>25. His final amount of transfusions were 18 units of pRBC, 36 units of FFP, 8 units of platelets, and 23 units of cryoprecipitate. ID: Patient maintained on cipro initially for SBP prophylaxis. He was then switched to vancomycin, zosyn, and micafungin for presumed sepsis. All culture data negative. Infectious disease consulted for antibiotic approval and recommendations. Disposition: Patient made CMO and expired on [2142-7-13]. This was after discussion with social workers, hepatology and surgical services. Patient's family expressed clear understanding of his disease process and elected to remove all intervention. Medications on Admission: Cipro 750 Q wk Folic acid 1mg daily lactulose 30ml 4x daily nadolol 20mg daily omeprazole 20mg [Hospital1 ] spironolactone 50 daily MVI 1 daily thiamine 100mg daily Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Liver failure Discharge Condition: CMO - expired [2142-7-13] Discharge Instructions: N/A Followup Instructions: N/A	[ "5849", "2851", "4168", "2875", "5859" ]
Admission Date: [2170-9-15] Discharge Date: [2170-9-28] Date of Birth: [2100-6-6] Sex: F Service: MEDICINE Allergies: Percodan Attending:[First Name3 (LF) 2145] Chief Complaint: Gi bleed Major Surgical or Invasive Procedure: EGD History of Present Illness: The patient is a 70yo female with DM2, HTN, ESRD on HD, breast ca s/p mastectomy who was transferred from [Hospital3 ] for management of acute GIB. She could not provide history due to her AMS but per OSH report presented with hematemesis accompanied by a HCT of 16. An NGT revealed coffee grounds and she was subsequently transfused 2 units PRBCs along with IV protonix bolus and gtt. . In the [Hospital1 18] ED, she remained hemodynamically stable with pressures in the 129-169 range. She received a right femoral cordis line. Her initial HCT was 25.8, and she was typed and crossed for 2 units PRBCs (she received no [Hospital1 ]). She had heme + brown stool. GI was consulted who recommended adding DDAVP due to her uremia with plans for likely inpatient EGD. She was also begun on octreotide gtt. Vitals prior to transfer were: 97.9, 78, 169/78, 100%2L. . Upon arrival to the MICU, her initial vitals were:T100.1, P76, BP 141/93, Sat100% RA. She was nonverbal and could not answer questions nor cooperate in the physical examination. She was accompanied by her Brother [Name (NI) ] and his wife, who related a recent history of PEG tube placement about a week ago at [Hospital1 2519] for caloric support. She was discharged back to her nursing home, but represented back to [Hospital1 ] with fevers prompting a several-day admission before resolving. She just returned back to her nursing home yesterday. She apparently had large volume coffee ground emesis, though no staff was available overnight at the NH to comment. Per her brother, she may have previously had a GIB, but his details are vague. She is on no NSAIDS, anticoagulants, and no significant ETOH history. . At baseline, she has mild dementia but speaks to her family, is aware, answers questions well. She was moved to [Hospital3 17461] several years ago due to inability to care for herself at home. She tends to get confused with fevers and during hospital admissions. Her MS clears upon returning home, and was normal as of a few days ago. . She undergoes HD T, Th, Sat. Her nephrologist is Dr. [Last Name (STitle) ] at Stauton. She missed an HD visit today. She has a maturing left HD fistula though only a month old. She gets HD via right tunnel IJ catheter. . ROS could not otherwise be addressed Past Medical History: - diabetes mellitus type 2 - ER negative DCIS s/p mastectomy [2162] - hypertension - ESRD on HD T, Th, Sat Social History: Lives in [Hospital3 17461] Nursing home, Unit Manager [First Name8 (NamePattern2) 13842] [Last Name (NamePattern1) 6104] [Telephone/Fax (1) 17462], [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Director of Nursing [Telephone/Fax (1) ]. Mild dementia. Smoked 30 PY, quit 20 years ago. Infrequent ETOH. Family History: DM, HTN Physical Exam: ADMISSION EXAM Vitals: T100.1, P76, BP 141/93, Sat100% RA General: eyes closed, nonverbal, contracted posture though not rigid HEENT: Sclera anicteric, MMM, oropharynx clear. NGT in place, draining coffee grounds. Neck: supple, right IJ dialysis catheter in place. Difficult to assess meningismus due to general resistance to passive movement. Lungs: Clear to auscultation on anterior exam, would not cooperate for posterior exam. no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, 3/6 SEM at the apex radiating to the axilla, and the 2nd ICS radiating to the carotid. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. G tube site nonerythematous without exudates. GU: no foley in place Ext: 4cm AV fistula in the left antecube. Warm, well perfused, 2+ DP pulses, no clubbing, cyanosis or edema . DISCHARGE EXAM Physical Exam: VS 98.1 157/68 71 18 99/RA FS 191 General: thin elderly female lying in bed with eyes closed, doesn't open eyes to voice or follow commands HEENT: NCAT pupils 3 mm, equal, reactive to light, MMM Neck: JVP non-distended R chest HD line in place Lungs: limited anterior exam, minimal air movement, shallow breathing CV: RRR chainsaw systolic murmur loudest LUSB radiates to carotids Abdomen: soft nondistended, G-tube in place GU: no foley Ext: WWP 1+ pulses no edema, in pneumoboots Neuro: as above. also note normal tone, toes downgoing. 2+ reflexes. Pertinent Results: ADMISSION LABS & LABS OF NOTE . [2170-9-15] 02:52PM [Month/Day/Year 3143] WBC-12.4* RBC-2.89* Hgb-8.8* Hct-25.8* MCV-89 MCH-30.3 MCHC-34.0 RDW-15.2 Plt Ct-140* [2170-9-15] 02:52PM [Month/Day/Year 3143] Neuts-77.6* Lymphs-17.1* Monos-4.5 Eos-0.4 Baso-0.4 [2170-9-15] 02:52PM [Month/Day/Year 3143] PT-13.4 PTT-24.0 INR(PT)-1.1 [2170-9-15] 02:52PM [Month/Day/Year 3143] Glucose-208* UreaN-113* Creat-3.6* Na-140 K-5.7* Cl-103 HCO3-23 AnGap-20 [2170-9-15] 07:06PM [Month/Day/Year 3143] ALT-15 AST-30 AlkPhos-92 TotBili-0.3 [2170-9-15] 02:52PM [Month/Day/Year 3143] Calcium-8.6 Phos-3.9 Mg-2.4 [2170-9-16] 08:37PM [Month/Day/Year 3143] TSH-0.55 [2170-9-17] 12:24AM [Month/Day/Year 3143] Lactate-1.6 . SERIAL CARDIAC ENZYMES [2170-9-15] 02:52PM [Month/Day/Year 3143] cTropnT-0.13* [2170-9-16] 08:37PM [Month/Day/Year 3143] CK-MB-3 cTropnT-0.20* [2170-9-17] 01:37AM [Month/Day/Year 3143] CK-MB-2 cTropnT-0.23* . DISCHARGE LABS [2170-9-28] 05:45AM [Month/Day/Year 3143] WBC-9.1 RBC-3.34* Hgb-10.1* Hct-30.6* MCV-92 MCH-30.2 MCHC-32.9 RDW-16.0* Plt Ct-393 [2170-9-28] 05:45AM [Month/Day/Year 3143] Glucose-185* UreaN-31* Creat-2.9# Na-138 K-3.6 Cl-95 HCO3-29 AnGap-18 [2170-9-28] 05:45AM [Month/Day/Year 3143] Calcium-8.7 Phos-3.4 Mg-2.3 . MICROBIOLOGY . BCX [9-15], [9-16], [9-17], [9-18], [9-20] - NEGATIVE MRSA NASAL SWAB FINAL REPORT [2170-9-17] POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS [2170-9-26] 8:15 am URINE CULTURE (Final [2170-9-27]): YEAST. 10,000-100,000 ORGANISMS/ML. (TWO PREVIOUS URINE CULTURES ALSO POSITIVE) . IMAGING . CT head [9-15]: IMPRESSION: 1. No acute intracranial process. No hemorrhage. 2. Stable hypoattenuation in the left cerebellum consistent with encephalomalacia, likely secondary to prior infarct. NOTE ADDED IN ATTENDING REVIEW: There is fairly marked disproportionate ventriculomegaly, which has progressed since the remote study. For example,the transverse dimention of the lateral ventricular frontal horns measures 4.9 cm (at the level of the caudate heads), whereas it measured 3.8 cm, previously; that dimension of the anterior 3rd ventricle now measures 18 mm (at the level of the foramina of [Last Name (un) 2044]), whereas it measured 13 mm before. In addition, there is now further symmetric confluent low-attenuation adjacent to, particularly, the lateral ventricular horns. While this may simply represent progressive preferential central atrophy, underlying communicating hydrocephalus is a consideration and these findings should be closely correlated clinically. tent with encephalomalacia, likely secondary to prior infarct . [9-20] EGD: Esophagus: Normal esophagus. Stomach: Normal stomach. Duodenum: Normal duodenum. Other findings: Large amount of [Month/Year (2) ] and clots were seen in the fundus, which were painstakingly removed via snare. The mucosa underneath the clots in the fundus appeared to be normal. Normal esophagus Dieulafoy lesion seen at the GE junction on retroflexion which was actively bleeding and appeared to be the source of the hematemesis. Epinephrine 1/[Numeric Identifier 961] hemostasis with success in the gastro-esophageal junction. One endoclip was successfully applied to the gastro-esophageal junction for the purpose of hemostasis. Normal duodenum Impression: Large amount of [Numeric Identifier ] and clots were seen in the fundus, which were painstakingly removed via snare. The mucosa underneath the clots in the fundus appeared to be normal. Normal esophagus Dieulafoy lesion seen at the GE junction on retroflexion which was actively bleeding and appeared to be the source of the hematemesis. (injection, endoclip) Normal duodenum Otherwise normal EGD to third part of the duodenum . [9-23] EGD PEG tube seen in body. Ulcers in the whole stomach Clip was seen at the GE junction. Otherwise normal EGD to third part of the duodenum . [9-24] EGD [Month/Day (4) ] in the stomach There was a bleeding lesion next to the clip seen on the gastric side of the GE junction. (thermal therapy) There was some oozing of [Month/Day (4) ] at the clip site at the GE junction. (thermal therapy) [Month/Day (4) ] in the duodenum The PEG insertion site was mobalized and examined. There was no ulcer under the gastric side of the PEG. Otherwise normal EGD to third part of the duodenum . CXR [2170-9-15] Nasogastric tube courses in expected position, with side port in the distal esophagus and tip just beyond the gastroesophageal junction. A large bore dialysis catheter enters the right subclavian vein and terminates in the mid right atrium. There are no pleural effusions or pneumothorax. Lungs are clear. Heart size is top normal. Calcifications are noted in the aortic arch. IMPRESSION: NG tube just beyond GE junction, recommend advancement by 2-4 cm. . CXR [2170-9-18] FINDINGS: In comparison with the study of [9-17], the area of opacification at the left base medially is less prominent and the hemidiaphragm is more sharply seen. This could reflect some clearing of either aspiration or atelectasis. There is a somewhat ill-defined area of opacification in the left suprahilar region, which could represent a focus of aspiration. Brief Hospital Course: 70yo female with ESRD, HTN, DM2 who presents with UGIB and altered mental status. . # ACUTE UPPER GI BLEED. Admission HCT 25.8 with reported history of hematemesis and coffee grounds localize her lesion to the upper GI tract. Received DDAVP which should help platelet function in the setting of uremia. Patient was placed on IV PPI ggt. GI was consulted who proceeded with an EGD which demonstrated an actively Dieulafoi lesion which was injected with epi and clipped. Per GI effective hemostasis was achieved. Post-procedure serial HCTs were monitored. Patient with no further episodes of GI bleed. In total she was transfused 2u at the OSH as well as 2units here. She was transitioned to [Hospital1 ] PPI on [9-18]. At time of transfer out of the MICU, patient with LIJ access. Hct stabilized at ~25 and gradually self-corrected thereafter. She was continued on a PPI (changed to lansoprazole which could be dosed through PEG tube). [9-23] pt with melena and decreased HCT to 21, though hemodynamically stable. Was transferred to the MICU for urgent endoscopy which showed ulcers in the stomach, sucralfate was initiated and pt transferred back to the floor. On [9-24] pt again with decreased HCT, bleeding on PEG lavage, started on PPI gtt, transferred back to the MICU, again underwent EGD showing bleeding lesion next to the clip seen on the gastric side of the GE junction and oozing of [Month/Day (4) ] at the clip site at the GE junction. Pt transitioned to PPI IV BID, continued on sucralfate. HCTs remained stable, hemodynamics remained stable. Last Hct 30.6 (baseline 29-30). She was discharged on carafate 2 g QID (high dose per GI recommendation) and lansoprazole max dose [Hospital1 ]. . # ASPIRATION PNA She was running low grade temperatures to 100.1 in the MICU. Also noted leukocytosis. Source initially unclear. [Name2 (NI) ] and urine cultures did not grow (except yeast in urine). Started vancomycin/cefepime on [9-18] due to coughing, leukocytosis, low grade temps, and equivocal left suprahilar opacification, which was concerning for aspiration. She did have a witnessed aspiration event in the ED, and spiked a fever to 102 2d thereafter. Started on vanc/cefepime. Leukocytosis resolved within 2d thereafter. Antibiotics were changed to vanc/ceftaz to cover oral flora for aspiration PNA, and for ease of administration qHD. These were stopped after an 8d course, when patient had been afebrile x several days. Recommend aspiration precautions at nursing home and during future hospitalizations. . # ALTERED MENTAL STATUS Patient thought to be in marked hypoactive delirium. At time of admission, thought to be "inexpressive" by family, a marked departure from baseline though apparently common in the hospital setting for her. Initial differential included toxic/metabolic encephalopathy from uremia, fever, possible infection. Possibly exacerbated by hospital setting. Head CT negative for acute process. Her low-baseline mental status gradually improved as her leukocytosis improved. At time of transfer out of the MICU she did not open eyes to voice and minimally responded to pain. By time of discharge she was still in hypoactive delirium and not following commands but was tracking eyes to voice and occasionally moved limbs spontaneously. Expected to improve to baseline similar to prior episodes. . # CANDIDIASIS OF THE BLADDER Pt with yeast in the urine and evidence of vulvovaginal candidiasis. Started on fluconazole x14 days day [3-5] on discharge. Pt unable to verbalize if she has pain with urination but UA was persistently positive, urine culture positive for yeast X 3 and urine appeared grossly hazy. . # RENAL FAILURE on HD Patient is on T, Th, Sat HD scheduled. Dialyzed via R tunneled HD catheter without complications. Received vancomycin at HD. Was started on phosphate binders, but developed hypophosphatemia so this was initially stopped; restarted sevelamer TID at time of discharge given mild hyperphosphatemia (Phos 4.6). . # DIABETES MELLITUS: History of type 2 DM, though home insulin regimin was unclear. Covered with a sliding scale. . # ELEVATED TROPONIN: Initially had elevated troponin without ischemic EKG changes. Thought to be a combination of demand ischemia from GIB-induced anemia and severe renal dysfunction. Hct goal >25 in this context. . # HYPERTENSION: Initially held home anti-hypertensives in light of her GIB. Had relative hypotension as her BP is normal despite holding numerous anti-hypertensives. Restarted on home losartan, amlodipine, lopressor in the MICU. These were continued, and she maintained pressures wnl on the floor. However, her BPs trended upwards to systolic 140-160 after starting carafate, suggesting that carafate decreased gastric absorption of her antihypertensives. Suggest administering antihypertensive meds 30 minutes before carafate when the administration times coincide. . # Communication was with patient's brother [Name (NI) ] [Telephone/Fax (1) 17463] and with brother [Name (NI) ] who is HCP. [Name (NI) 6419] brothers confirmed the patient's desire for code status DNR/DNI. . TRANSITIONAL ISSUES . 1. FOLLOW-UP HEMATOCRIT (check daily through [10-1] then qMonday/Wednesday/Friday for two weeks thereafter). NURSES INCLUDING DARK OR BLOODY STOOLS. WE EXPECT DARK STOOLS [Month (only) ] CONTINUE FOR A FEW DAYS BUT IF THEY PERSIST >3 DAYS, ARE LARGE VOLUME, OR BECOME DIARRHEA-LIKE AND DARK, NURSES SHOULD NOTIFY MD AND RETURN PATIENT TO THE HOSPITAL. . 2. FOLLOW-UP URINALYSIS FOR PERSISTENT YEAST FUNGEMIA IN 2 WEEKS, AFTER STOPPING ANTIFUNGAL TREATMENT. . 3. PATIENT NOTED TO HAVE ULCERS ON EGD, WILL NEED H PYLORI TESTING AS AN OUTPATIENT AT GI FOLLOW-UP APPOINTMENT. . 4. FOLLOW-UP [Month (only) 3143] PRESSURE, ENSURE PT NOT RECEIVING BP MEDS AND CARAFATE SIMULTANEOUSLY AS THIS [Month (only) ] DECREASE ABSORPTION. Medications on Admission: Home Medications (per OSH records) - losartan 100mg daily - omeprazole 40mg daily - renagel 800mg PO TID - colace 200mg daily - labetalol 200mg [Hospital1 ] - tylenol 650mg Q4hr - dulcolax suppository 10mg QOD - amlodipine 5mg daily - clonidine 0.2mg tab - prostat 30mg - metoclopramide 5mg TID - inslin lispo . MEDS FROM MICU TRANSFER: Vancomycin 1000 mg IV HD PROTOCOL (d1=[9-18]) CefePIME 1 g IV Q24H (d1=[9-18]) Labetalol 200 mg PO/NG [Hospital1 ] Amlodipine 5 mg PO/NG DAILY Losartan Potassium 100 mg PO/NG DAILY Pantoprazole 40 mg IV Q12H Sevelamer CARBONATE 800 mg PO TID W/MEALS Insulin sliding scale Acetaminophen IV 1000 mg IV Q6H:PRN pain,fever Discharge Disposition: Extended Care Facility: [Hospital3 13990] Health Care Center - [Location (un) 5110] Discharge Diagnosis: PRIMARY DIAGNOSIS UPPER GASTROENTEROLOGICAL BLEED . SECONDARY DIAGNOSES ASPIRATION PNEUMONIA CHRONIC RENAL FAILURE DEMENTIA HYPOACTIVE DELIRIUM Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic and not arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted to the hospital for bloody vomit. We found that you were bleeding into your stomach from a [Location (un) ] vessel near the boundary of your stomach and esophagus. You required multiple [Location (un) ] transfusions. You also underwent three endoscopic procedures by the hospital gastroenterologists, to directly visualize your stomach lining and treat the bleeding sites they saw. Your [Location (un) ] counts were stable after the third endoscopy -- we thought you had stopped bleeding. You also developed pneumonia while you were here, requiring treatment with antibiotics. Your pneumonia resolved by the time you went home. However, we think you are at-risk for pneumonia in the future, from swallowing saliva down the wrong pipe. We recommend that you always have your bed at a 45* angle (or upright). We made the following changes to your medications: 1. STARTED FLUCONAZOLE FOR YEAST INFECTION, TAKE 100 MG DAILY FOR 11 DAYS (for a total 14-day course, 3 doses received in-hospital). 2. STARTED CARAFATE, 2 GRAMS TWICE PER DAY, ADMINISTER 2 HOURS BEFORE OR AFTER ANY OTHER MEDICATIONS ([Month (only) ] DECREASE ABSORPTION) 3. STARTED LANSOPRAZOLE, TAKE 30 MG TWICE PER DAY 4. INCREASED tylenol TO 1000 MG EVERY SIX HOURS AS NEEDED, MAX DOSE 4 GRAMS PER DAY. 5. STOPPED OMEPRAZOLE 6. STOPPED CLONIDINE 7. STOPPED PROSTAT Please review the attached medication list and take all medications as prescribed. Followup Instructions: We scheduled a follow-up gastroenterology appointment here: Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [2170-10-9] at 1:30 PM With: [Name6 (MD) 11170] [Last Name (NamePattern4) 11171], 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 Please bring records from the Hct labs from rehab to this appointment. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 2158]	[ "5070", "40391", "2851", "2767", "25000", "V5867" ]
Admission Date: [2169-6-27] Discharge Date: [2169-7-5] Date of Birth: [2097-7-22] Sex: F Service: Trauma HISTORY OF PRESENT ILLNESS: The patient is a 71 year old female with type 2 diabetes transferred initially to the medical intensive care unit from [Hospital3 1196]. The patient had not been heard from in 48 hours and was found unresponsive at the bottom of the stairs. Intubation could not be performed by the prehospital providers but she was intubated at [Hospital1 ]. CT scan showed a subdural hematoma. The patient was transferred to [Hospital1 346] for further treatment. PHYSICAL EXAMINATION: Temp 97.7, blood pressure 112/37, pulse 97, respiratory rate 26, saturation 100% on assist control of 500 x 16, PEEP of 5. The patient was sedated, but her eyes were tracking. HEENT: Raccoon eyes, C-collar was in place. The patient had scleral injection. Chest was clear, good breath sounds bilaterally. Cardiovascular: The patient was tachypneic, irregular rhythm. Abdomen soft. Extremities nontender. LABORATORY DATA: Pertinent workup, the patient had C-spine which showed C5, C6, C7 transverse process fractures with possible epidural hematoma. CT of the head showed subdural hematoma. CT of the sinus of [Doctor First Name ] showed multiple facial fractures, left orbital fracture with herniation of the orbital fat, fracture of the sphenoid sinus. Hematocrit was 31.2, white count 13.8. Electrolytes showed sodium of 133, chloride of 90, potassium of 3.6, bicarbonate of 12, blood sugar was 1052, BUN was 73, creatinine 2.5. Lactate 7.1. PROCEDURES PERFORMED: The patient remained intubated, admitted to the intensive care unit and treated for hypothermia, acute renal failure. MI was evaluated with EKG. CPK MB labs were elevated. The patient was seen in consultation by the neurosurgery service who felt that the bolt that had been placed at the other hospital should be discontinued. Orthopedic spine service saw the patient and felt that MRA was important to rule out vertebral artery injury and ligamentous injury. The patient was also followed by Dr. __________. On [6-29], the neurosurgery service removed the right frontal bolt without difficulty. The stroke team saw the patient and also on [6-29], felt that she should be loaded with Dilantin and followed with a repeat head CT. The patient continued to be followed by the neurosurgery service and the surgical intensive care unit staff. The patient remained basically unresponsive with occasional eye opening to verbal stimuli. Electrolyte and renal function abnormalities corrected. She remained on CPAP for ventilatory support. The neurology attending felt on [7-4], that it was difficult to give an absolute prognosis. The patient continued to receive supportive care. On [7-5], a family meeting was held with the family and a long discussion was held with the daughter who is health care proxy. She understood that the prognosis for neurologic recovery was very poor. She felt that the patient would not want further aggressive care and we recommended comfort measures only and DNR status. The patient died that evening and medical examiner waived autopsy and the pathology department at [Hospital1 18] will be consulted for autopsy. CONDITION ON DISCHARGE: Expired. DISCHARGE DIAGNOSES: 1. Status post fall with subdural hematoma. 2. Severe closed head injury. 3. Type 1 diabetes. 4. Transverse process fractures of the cervical spine. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD [MD Number(2) 16263] Dictated By:[Last Name (NamePattern1) 16475] MEDQUIST36 D: [2169-12-22] 13:33:47 T: [2169-12-23] 10:28:39 Job#: [Job Number 60122]	[ "0389", "99592", "5849", "5990", "51881", "2859" ]
Admission Date: [2108-10-16] Discharge Date: [2108-10-21] Date of Birth: [2036-8-7] Sex: M Service: MEDICINE Allergies: Sulfonamides / Amlodipine / Percocet Attending:[First Name3 (LF) 348] Chief Complaint: SOB Major Surgical or Invasive Procedure: HD History of Present Illness: The pt is a 72M w/ Type 2 DM, ESRD on HD, referred by nephrologist for shortness of breath, likely from fluid overload. For the last 4 days he has been feeling more short of breath that has improved with dialysis. He also had one day of dysuria. Otherwise he has had no other symptomatic complaints including no nausea, vomiting, or diarrhea, no chest pain, no fever or chills. Reports chronic cough productive of a teaspoon of sputum, whitish-green tinged color which has been stable. . In the ED Vitals were t 98.8 Hr 126 (went to 70-80s) BP 104/54, then went to SBPs in 80s, 91 % RA. While in the ED, he was given a dose of vancomycin 1g x 1, levofloxacin 500 mg x1 and 1 g tylenol, lasix 40 IV. Past Medical History: 1)CAD s/p CABG [2102] 2)PVD: s/p fem-[Doctor Last Name ] bypass in [12-29] for cluadication, non-healing ulcer on [2-26] s/p atherectomy of L SFA popliteal tbioperoneal trunk with angioplasty x 2. Pt had recent right first toe amputation and left TMA on [2107-3-24]. 3)Paroxysmal atrial fibrillation 4)Type II DM: followed by [Last Name (un) ] 5)Hyperlipidemia 6)Chronic bronchiectasis 7)EF 35% p-MIBI [2108-2-27]: Mild-moderate anterior-lateral and apical reversible defect. 2. Mild global hypokinesis and septal akinesis. 3. Ejection fraction is 35%. 8)BPH 9)Anemia of chronic illness 10)CRI on daily peritoneal dialysis . PAST SURGICAL HISTORY: 1) s/p angioplasties of the left common femoral, superficial femoral, tibioperoneal trunk in ([2106-11-24]) 2) left CEA ([2102] at [Hospital1 2025]) 3) CABG (LIMA to the LAD and saphenous vein graft to the obtuse marginal 1 and the ramus intermedius - [2103-9-24]) 4) s/p cholecystectomy with exploratory lap with repair of liver lacerations ([2105-11-23]) 5) PD catheter placement in ([2106-9-24]) 6) right eye cataract with intraocular lens, right eye vitrectomy 7) right common femoral artery to posterior tibial bypass graft with in situ saphenous vein in [Month (only) 404] of [2106]. Social History: Significant for the absence of current tobacco use although he is a former smoker. Reports smoking 2PPD X 40 yrs, quit 30 yrs ago. There is no history of alcohol abuse. There is no family history of premature coronary artery disease or sudden death. Family History: Father with DM type 2 Two sisters and one brother--all well Physical Exam: BP 134/72 HR 88 RR 18 T98.7 O2Sat 94% on RA Gen: AAO X 3, elderly gentleman HEENT: EOMI, PERRL, sclera anicteric, MMM Neck: supple, JVP of 5 cm. Pulm: coarse rhonchi b/l with crackles at R base, increased expiratory phase Cor: RRR, normal S1S2, no rubs, murmurs, clicks or gallops. Abd: soft, NT, ND, normoactive BS Ext: no pallor, cyanosis, clubbing, trace edema with erythematous and warm LE b/l up to mid lower leg. Skin: stasis dermatitis of LE Pulses: 2+ r DP, 1+ l DP Pertinent Results: [2108-10-16] 05:28PM WBC-9.3 RBC-3.36* HGB-11.4* HCT-35.1* MCV-104* MCH-34.0* MCHC-32.5 RDW-15.8* [2108-10-16] 05:28PM PLT COUNT-474* [2108-10-16] 05:28PM PT-15.7* PTT-43.9* INR(PT)-1.4* [2108-10-16] 05:28PM CALCIUM-7.9* [2108-10-16] 05:28PM CK-MB-NotDone cTropnT-2.33* [2108-10-16] 05:28PM UREA N-16 CREAT-1.7* SODIUM-138 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-33* ANION GAP-9 [2108-10-16] 05:30PM GLUCOSE-98 LACTATE-1.8 K+-3.9 EKG: NSR with mild elevation of ST segments onf V2, V3. Otherwise unchanged from prior. . CXR: Again seen is evidence of CHF and bilateral pleural effusions. New opacity in the left upper lung, possibly represents early pneumonia versus asymmetric edema. . Chest CT [10-17] - Multifocal consolidation and peribronchial infiltration is present in all lobes. The largest region of abnormality is the apical and posterior portions of the left upper lobe, but smaller abnormalities are present in the superior segment of the left lower lobe and at the base of the right lower lobe is also mild septal thickening throughout the lungs. The lingula is largely collapsed distal to what appears to be impacted bronchi. Small-to-moderate bilateral pleural effusion is nonhemorrhagic, layering posteriorly having developed between [9-25] and 15. There is extensive central lymph node enlargement ranging up to 20 mm in the right lower paratracheal and 18 mm in diameter in the pretracheal stations of the mediastinum with many smaller lymph nodes distributed and there is no bronchial obstruction by lymph node or compromise of any other vital structures. Atherosclerotic calcification in the aorta and native coronary arteries is severe. There is no pericardial effusion. This examination is not designed for subdiaphragmatic evaluation except to note the absence of ascites. . CT scan corroborates the well-documented pattern in this patient of current episodes of pulmonary edema and pleural effusions also accompanied by mass-like consolidation. Findings of extensive central lymph node enlargement are difficult correlate with those of plain radiographs, but are not necessarily new. Differential diagnosis of the multifocal pulmonary abnormality includes current pneumonia, drug reaction, or pulmonary hemorrhage. . Past cardiology studies: . [2108-2-27] Persantine MIBI: IMPRESSION: 1. Mild-moderate anterior-lateral and apical reversible defect. 2. Mild global hypokinesis and septal akinesis. 3. Ejection fraction is 35%. . Cath [2106-12-22]: R dominant system LMCA: 60% occluded LAD: widely patent LIMA to LAD. SVG to RI 80% ostial LCX: patent SVG to OM. LCX 80% prox. RCA: proximally occluded, filled by collaterals from LIMA/SVG . Cath [2108-3-28] 1. Selective coronary angiography in this right dominant circulation demonstrated severe native vessel coronary artery disease. The LMCA was diffusely diseased with 60% distal stenosis. The LAD was totally occluded in the proximal segement. The distal LAD had mild disease and was supplied by the LIMA graft. The LCx had severe diffuse disease. The OM and Ramus were totally occluded at their origins, but filled via an SVG. 2. Saphenous vein angiography demonstrated widely patent SVG to OM and SVG to Ramus. The Ramus was totally occluded after the touchdown point and filled via collaterals from the grafted OM. 3. Arterial conduit arteriography demonstrated a widely patent LIMA to LAD. 4. Opening pressure in the central aorta was moderately elevated. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Patent LIMA to LAD. 3. Patent SVG to OM. 4. Patent SVG to Ramus, but total occlusion after touchdown point. . TTE [10-17] - 1. The left atrium is moderately dilated. The left atrium is elongated. 2. Left ventricular wall thicknesses are normal. There is asymmetric left ventricular hypertrophy. There is no asymmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue velocity imaging E/e' is elevated (>15) suggesting increased left ventricular filling pressure (PCWP>18mmHg). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. 5.The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. 6.There is a trivial/physiologic pericardial effusion. 7. There is a large pleural effusion present. Brief Hospital Course: 1) Shortness of breath: Likely due to fluid overload [1-26] paroxysmal a-fib c RVR given prior history of paroxysmal a-fib with RVR. Unfortunately, pt is not aware when he is in a-fib. Differential also included fluid overload [1-26] ESRD; however pt did not miss HD session prior to admission. CXR findings with possible element of PNA, however pt did not have leukocytosis, fever, and productive cough. Given dose of levaquin while in ED which was not continued on the floor. Sputum culture was significant only for sparse OP flora. Evaluated by renal and given daily HD during hospital course with subsequent improval in pt's shortness of breath. CT chest performed given question of diagnosis of chronic bronchietasis. CT significant for multifocal consolidation and infiltrates with lingula largely collaspsed distal to what appears to be impacted bronchi which supports diagnosis of chronic bronchiectasis. . 2) ESRD - Followed by renal consult and had HD qd during hospital course with subsequent resolution in pt's shortness of breath. On Nephrocaps. . 3) Troponin elevation: Recent troponin elevation during last admission felt to be from demand ischemia while in rapid afib in the setting of ESRD. During hospital course had troponin peak to 2.33. Likely still demand ischemia as patient did not have any signs of CP or cardiac dysfunction. EKG without new ischemic changes. Given that the patient has recent troponin leak, elevated troponins may be persistent due to poor renal function. Cardiology made aware of troponin leak and agreed that it was [1-26] rate related demand ischemia. Continued on aspirin, metoprolol, lisinopril, and statin. . 4) CHF- TTE on [10-17] significant for nl LVEF but with elevated LV filling pressures. Fluid removed via HD. Stressed importance of fluid and salt restriction to pt. Continued beta-blocker, ACE-I. . 5) Paroxysmal afib - Continued on amiodarone, metoprolol, and digoxin. Dig level checked and was therapeutic. Pt remained in NSR during hospital course with HR in 70-80s. Warfarin was also continued. . 6) Hypotension - Was transiently hypotensive with SBPs in 80s while in ED, and was admitted to MICU where low BPs resolved without intervention. Remained normotensive during remaining hospital course. . 7) DM2 - Continued outpt regimen of NPH 16 U qam and 8 U qhs, RISS with good effect. . 8) LE cellulitis- Was treated as outpatient with augmentin [1-27] weeks ago per pt. On admission, PE significant for continued b/l LE cellulitis. Was treated with Augmentin post-HD during hospital course X 5. By discharge, exam was underwhelming for active LE cellulitis and pt was not discharged on further antibiotics. . 9) Hypothyroidism - Synthroid continued. . 10) Code - DNR, DNI per patient Medications on Admission: (Per last d/c, per patient he is not taking all of these but can't remember what he isn't taking ) -- atorvastatin 10mg po qd -- ASA 81mg po qd -- levothyroxine 100mcg po qd -- vitamin E 400U po qd -- B complex-Vitamin C-Folic acid 1mg po qd -- folic acid 1mg po qd -- sevelamer 800mg po tid -- amiodarone 200mg po qd -- digoxin 125mcg po qod -- NPH 16U qam, 8U qpm -- mirtazapine 15mg po qodhs -- tamsulosin 0.4mg p qhs -- warfarin 1mg po qhs -- hydromorphone 4mg po q8h prn -- metoprolol 150mg po qd -- lisinopril 1.25mg po qd Discharge Medications: 1. Atorvastatin 10 mg 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. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 4. Sevelamer 400 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:180 Tablet(s) Refills:2 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:15 Tablet(s) Refills:2 7. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 8. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:30 Capsule, Sust. Release 24HR(s) Refills:2 9. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:30 Capsule(s) Refills:2 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:30 Cap(s) Refills:2 12. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:15 Tablet(s) Refills:2 13. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO bid as needed for pain. Disp:60 Tablet(s) Refills:0 14. Lisinopril 5 mg Tablet Sig: 0.25 Tablet PO DAILY (Daily). Disp:10 Tablet(s) Refills:2 15. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: 1.5 Tablet Sustained Release 24HRs PO once a day. Disp:45 Tablet Sustained Release 24HR(s) Refills:2 16. Atrovent 18 mcg/Actuation Aerosol Sig: 2-3 puffs Inhalation every 6-8 hours as needed for shortness of breath or wheezing. Disp:qs inhalers Refills:3 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Fluid Overload [1-26] CHF, paroxysmal a-fib c RVR Lower Extremity Cellulitis Secondary Diagnoses: Discharge Condition: stable Discharge Instructions: Please call your physician or return to the emergency room if you experience any of the following: chest pain, increased shortness of breath, fevers, chills, night sweats, increased lower extremity pain and warmth. It is very important that you continue to keep all of your outpatient dialysis sessions. It is also very important that you continue fluid restriction and adhere to a low sodium diet when you are at home. Followup Instructions: Please follow up with your primary care physician [Name Initial (PRE) 176] 1 week of discharge. You have an appointment to see Dr. [Last Name (STitle) ], a cardiologist, on 118 at 3:40 pm. Please report to [Hospital Ward Name 23] Building, [Location (un) 436]. [Telephone/Fax (1) 4022]. Please follow up with Dr. [First Name (STitle) 805] at hemodialysis. Completed by:[2108-10-21]	[ "4280", "42731", "25000", "2449" ]
Admission Date: [2156-5-16] Discharge Date: [2156-5-24] Date of Birth: [2097-3-20] Sex: F Service: MEDICINE Allergies: Codeine / Paxil Attending:[First Name3 (LF) 458] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Pacemaker placement History of Present Illness: Briefly, 59 year old female with CAD s/p PCI stent x 2 in [2149] and diastolic CHF, mechanical valve replacement and paroxysmal atrial tachycardia admitted on [2156-5-16] for EP ablation. She was admitted to the [Hospital1 1516] service for heparin bridge and coumadin held in anticipation of procedure. She got the EP procedure today and her atrial tachycardia was ablated. After the procedure, she developed junctional bradycardia to the 50's. She was reportedly given atropine without effect. She maintained her BP's in the 80's to 90's. Then her bradycardia evolved to a accelerated junctional escape to 80's. The cardiology fellow on call did a bedside echo that did not show tamponade. She is transferred to the CCU for closer monitoring. . Currently, she feels tired but does not have any specific complaints. +LH, denies CP, SOB, palpiations. Past Medical History: Rheumatic fever at age 10. Coronary artery disease status post PCI and stents x2 in [2149]. History of diastolic dysfunction with congestive heart failure. History of mechanical mitral valve replacement in [2140]. History of paroxysmal atrial fibrillation s/p cardioversion in [2155]. History of anxiety and depression. . Cardiac Risk Factors: Dyslipidemia, Hypertension . Cardiac History: . Percutaneous coronary intervention, in [2151] anatomy as follows: right dominant system with single vessel coronary artery disease. The LMCA had a 20% stenosis. The LAD had mild diffuse disease. The LCX had minimal luminal irregularities. The RCA had a total occlusion in the previously placed mid-vessel stent. Social History: Lives alone in [Location (un) 669]. Close to son. [Name (NI) ] alcohol or drugs. Smokes [1-28] ppd. Has smoked for 40 years. Family History: Mother with diabetes and coronary artery disease. Physical Exam: VS - 95.1, 82, 98/46, 22, 100%2LNC Gen: Lethargic but arousable and carries short conversation appropriately HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Neck: Supple, neck veins pulsatile to ears but likely from TR CV: RR, S1, S2. II/VI systolic murmur. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Soft faint crackles at right base, no wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: PT 1+, cannot palpate DP pulse Left: PT 1+, cannot palpate DP pulse Pertinent Results: [2156-5-16] 04:55PM BLOOD WBC-8.1 RBC-4.23 Hgb-12.7 Hct-36.8 MCV-87 MCH-30.0 MCHC-34.5 RDW-14.7 Plt Ct-193 [2156-5-20] 05:47AM BLOOD WBC-8.5 RBC-3.64* Hgb-10.9* Hct-31.8* MCV-87 MCH-30.0 MCHC-34.5 RDW-14.6 Plt Ct-113* [2156-5-16] 04:55PM BLOOD PT-28.1* PTT-150* INR(PT)-2.8* [2156-5-20] 05:47AM BLOOD PT-17.0* PTT-56.5* INR(PT)-1.5* [2156-5-16] 04:55PM BLOOD Glucose-140* UreaN-10 Creat-0.8 Na-137 K-3.5 Cl-101 HCO3-25 AnGap-15 [2156-5-20] 05:47AM BLOOD Glucose-99 UreaN-15 Creat-0.8 Na-140 K-3.2* Cl-109* HCO3-23 AnGap-11 [2156-5-16] 04:55PM BLOOD Calcium-9.7 Phos-2.8 Mg-2.0 [2156-5-20] 05:47AM BLOOD Calcium-7.6* Phos-2.0* Mg-1.9 [2156-5-22] 09:45AM BLOOD WBC-6.4 RBC-3.54* Hgb-11.0* Hct-31.3* MCV-88 MCH-30.9 MCHC-35.0 RDW-14.9 Plt Ct-97* [2156-5-23] 07:45AM BLOOD PT-19.1* PTT-59.5* INR(PT)-1.8* [2156-5-22] 09:45AM BLOOD Glucose-141* UreaN-8 Creat-0.8 Na-140 K-3.6 Cl-104 HCO3-25 AnGap-15 [2156-5-22] 09:45AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.9 . Cardiology Report ECG Study Date of [2156-5-16] 3:28:56 PM ECG [5-16]: Atrial tachycardia Modest nonspecific ST-T wave changes suggested, but atrial waveforms makes assessment difficult Since previous tracing of [2156-4-20], ventricular ectopy absent Intervals Axes Rate PR QRS QT/QTc P QRS T 74 172 78 396/420 65 71 33 . ECG Study Date of [2156-5-17] 9:04:38 AM Atrial tachycardia. Modest nonspecific ST-T wave changes suggested, but atrial waveforms makes assessment difficult. Since previous tracing of [2156-5-16], no significant change . ECG Study Date of [2156-5-18] 12:17:10 PM Sinus bradycardia. A-V conduction delay. Compared to the previous tracing of [2156-5-17] the rate has slowed. Otherwise, no diagnostic interim change. . ECG Study Date of [2156-5-18] 11:51:38 PM Junctional bradycardia with retrograde conduction as recorded previously on [2156-5-18]. No diagnostic interim change. . ECG Study Date of [2156-5-19] 7:20:44 AM Junctional bradycardia with retrograde conduction and occasional ventricular ectopy. Otherwise, no diagnostic interim change . ECG Study Date of [2156-5-20] 9:16:46 AM Junctional bradycardia with retrograde conduction and occasional ventricular ectopy. Compared to the previous tracing of [2156-5-19] no diagnostic interim change. . ECG Study Date of [2156-5-21] 8:31:10 AM Junctional bradycardia with marked Q-T interval prolongation. Compared to the previous tracing of [2156-5-20] no diagnostic interval change. . Echo [5-18]: The right atrium is dilated. The left ventricle is not well seen. Overall left ventricular systolic function cannot be reliably assessed. The aortic valve is not well seen. The mitral valve leaflets are not well seen. A mitral valve prosthesis is present. There is no pericardial effusion. IMPRESSION: Limited study due to poor echo windows and focused views. There is no pericardial effusion. The right atrium appears dilated. The right ventricle may also be dilated. Overall left ventricular systolic function is not well visualized but is probably normal. Compared with the prior study (images reviewed) of [2156-4-21], the limited findings on the current study appear similar. . CHEST (PORTABLE AP) [2156-5-18] 10:49 PM ADDENDUM: Partially imaged sclerotic focus in proximal left humerus is noted with apparent chondroid matrix. In the absence of localized symptoms, this is most likely an enchondroma and less likely a bone infarct. However, if there are symptoms in this region, dedicated humeral radiographs would be recommended for initial further assessment as communicated by phone to Dr. [Last Name (STitle) ] by phone on [2156-5-19]. There is no evidence of pneumothorax or pleural effusion. Cardiomediastinal contours are unchanged, and lungs and pleural surfaces remain clear. . CHEST (PORTABLE AP) [2156-5-19] 7:22 AM IMPRESSION: AP chest compared to [4-20] and [2156-5-18]: The lungs are clear. Patient has had median sternotomy. Heart is overall top normal in size but both atria and possibly the right ventricle are markedly dilated though unchanged since at least [2155-2-27]. . CHEST (PORTABLE AP) [2156-5-22] 7:52 AM CHEST: A dual-chamber pacemaker is present with leads in satisfactory position. There is no evidence of a pneumothorax. The lung fields are clear. The cardiac size is within normal limits. Previous CABG noted. IMPRESSION: No pneumothorax, pacemaker lines in good position. . Brief Hospital Course: ASSESSMENT AND PLAN [2156-5-23]: Patient is a 59 year old female with CAD s/p stenting x2, and mechanical mitral valve replacement [2-28] rheumatic fever and known paroxysmal atrial flutter admitted for elective atrial tachycardia ablation complicated by post-procedural junctional bradycardia and hypotension, s/p pacer placement. # Rhythm: The patient was admitted s/p atrial tachycardia ablation. Post-procedure, she had bradycardia and hypotension. She had a junctional rhythm in the 40's. Initially, she received no ionotropes and was monitored on telemetry. The following day, her sinus node had not yet recovered; she remained bradycardiac and hypotensive and she was then started on dopamine. Beta blockers, lasix, spironolactone and losartan were held. The dopamine was weaned as her blood pressure improved. Coumadin was held for pacemaker placement and she was maintained on heparin. She had a mild groin bleed the day after ablation which resolved with pressure. As she continued to have junctional bradycardia, weakness and occasional dizziness, it was decided to place a pacemaker. She underwent pacemaker placement without complication. Beta blockers, lasix, spironolactone and losartan were restarted. Coumadin was restarted and she was maintained on heparin bridge. Her INR goal is 2.5 to 3.5. She was discharged when her coumadin was above 2.0 with instructions to continue her outpatient coumadin clinic. #. CAD - History of 3 vessel disease requiring stenting of the left main and the RCA. She was continued on statin and metoprolol as above. #. Pump - Last EF>55%, history of diastolic dysfunction with chronic congestive heart failure. Lasix, valsartan, spironolactone, metoprolol as above. #. Valves - Mechanical mitral valve replacement in [2140] [2-28] rheumatic fever and 3+ tricuspid regurgitation. Target INR 2.5-3.5 for mechanical valve. 3+ TR on recent ECHO. She received heparin and coumadin as above. #. HTN - She is to continue on Lasix, valsartan, spironolactone and metoprolol as above. Metoprolol was decreased from 37.5mg to 25mg [Hospital1 ]. Medications on Admission: Warfarin 5 mg daily - held [5-14] Losartan 50 mg daily Metoprolol tartrate 37.5 mg p.o. b.i.d. Pravastatin 80 mg daily Folic acid 1 mg daily Lasix 20 mg daily Lorazepam .5-1 mg q8h p.r.n. Docusate sodium 100mg [Hospital1 ] Spironolactone 25mg daily Discharge Medications: 1. Outpatient [Hospital1 ] Work Please check INR and fax results to Dr. [First Name8 (NamePattern2) 2270] [Last Name (NamePattern1) ] office. Phone number: [Telephone/Fax (1) 3581] 2. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day. 3. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Junctional Bradycardia Chronic Diastolic Congestive heart Failure anticoagulation for mechanical valve Discharge Condition: Good, afebrile, ambulating Discharge Instructions: You were admitted to the hospital to undergo an ablative procedure by the electrophysiology department, in an attempt to eliminate your atrial fibrillation. This procedure was complicated by a resulting slow heart rate, and low blood pressure. You were admitted to the CCU for closer monitoring. You received a pacemaker in order to maintain an adequate heart rate and blood pressure. . Please continue to take your medications as prescribed. Your metoprolol was decreased from 37.5mg twice a day to 25mg twice a day. Please discuss titrating your metoprolol dose with your primary care provider. [Name10 (NameIs) 2172] other medications remained the same. . Your INR was 2.1 on discharge. Your goal is 2.5 to 3.5. Please have your INR checked with your PCP on Wednesday [2156-5-25]. . Please follow up as described below. . Please call your doctor or return to the hospital if you experience chest pain, shortness of breath, fever over 102, or any other concerning symptom. Followup Instructions: Please have your INR checked on Wednesday [2156-5-25] and fax results to your PCP office for follow up. . Provider: [Name10 (NameIs) 676] CLINIC Phone:[Telephone/Fax (1) 59] Date/Time:[2156-5-31] 2:30 . You will need to follow up with your PCP [First Name8 (NamePattern2) 2270] [Last Name (NamePattern1) ] [Telephone/Fax (1) 3581] on [2156-6-10] at 10am. . Please follow up with your cardiologist [First Name4 (NamePattern1) 122] [Last Name (NamePattern1) ] [Telephone/Fax (1) 5068], on [2156-6-15] at 10am. . Please follow up with your cardiologist (electrophysiology for your pacemaker) [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] ([Telephone/Fax (1) 15500] on [2156-6-3] at 9:20am. . Provider: [Name10 (NameIs) 706] Phone:[Telephone/Fax (1) 327] Date/Time:[2156-11-1] 3:10	[ "9971", "42731", "42789", "2767", "4280", "4019", "25000", "41401", "V4582" ]
Admission Date: [2152-7-30] Discharge Date: [2152-8-4] Date of Birth: [2067-11-11] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine / Bactrim / IV Dye, Iodine Containing Contrast Media Attending:[First Name3 (LF) 2145] Chief Complaint: Fever, lethargy, abdominal pain Major Surgical or Invasive Procedure: NONE History of Present Illness: 84 yo female with COPD, dCHF, HTN, HL, colon cancer s/p resection presents with fever, lethargy, and abdominal pain. She was in her usual state of health until she went grocery shopping with her neighbor and began falling asleep. Her neighbor decided to bring her to the emergency department. She denied any cough or any other associated symptoms. Of note, the patient had a recent EGD 1 week ago. She is also on 2LNC at rest and 4LNC with exertion at baseline. . In the ED, the patient had the following vital signs: 101 84 93/44 14 98% 10L Non-Rebreather. Her blood pressure dropped as low as 64/30 and she was started on peripheral levophed until CVL access was attained. Tmax was 102R. She was guiac negative. CXR revealed LLL pneumonia. She underwent bilateral LE U/S for her LE edema that was negative for DVT. CT abdomen/pelvis w/o contrast confirmed LLL PNA. Labs were notable for a WBC of 14.4 with a left shift (87% N, 4% band). VBG revealed 7.35/73/61/42 with normal lactate. The patient was given ceftriaxone 1gm and levoquin 1gm IV for CAP coverage. She was given vancomycin 1gm for ?cellulitis. She was given acetaminophen for fever. Given her persistent hypotension, she was started on a small dose of norepinephrine gtt with good effect. She received 1L of NS and made 500cc of urine. A subclavian line was misplaced initially, and was repositioned prior to transfer. Last set of vitals prior to transfer: 101 77 103/63 17 100%4LNC. . ROS: (+)She reports constipation and poor adherance with her bipap. (-)She denied any chest pain, shortness of breath, cough, sputum, fevers, chills, sweats, nausea, vomitting, diarrhea, black, bloody stools, weakness on one side of the body or the other, dysuria. No recent travel or sick contacts. Past Medical History: 1) Diastolic congestive heart failure (NYHA class IV) 2) Atrial fibrillation (refuses coumadin) 3) Symptomatic bradycardia status post VDD pacemaker in [11/2143] 4) Obstructive sleep apnea (on CPAP at 8-10 cm of H2O) 5) Coronary artery disease 6) Hyperlipidemia 7) Hypertension 8) Colon cancer s/p resection 9) COPD (on O2 2-4 liters at home) 10) Bronchiectasis 11) GERD 12) Pulmonary hypertension 13) Anemia 14) Pneumonia ([2145]) 15) Acute respiratory failure in [3-/2144] and again in [3-/2145] 16) History of methicillin resistant Staphylococcus aureus in her sputum following hernia repair and again in [3-/2145] with documented pneumonia . Past surgical history: 1) Status post hernia repair. 2) Status post appendectomy. 3) Status post total abdominal hysterectomy. 4) Status post back surgery. 5) Status post right total hip Social History: Lives in [Location 686]. Worked as a printer many years ago. Not married and does not have any children. No family in the area. Uses a walker or wheelchair at baseline. Patient is quite independent, and she manages her finances, cooks, and cleans herself. She is accompanied to the supermarket. Patient quit smoking >25 years ago. Drinks one whiskey a week. No illicit drug use. Family History: Sister has endometriosis and breast cancer Physical Exam: On admission: GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, CV: RR, S1 and S2 wnl, no m/r/g RESP: CTA b/l except rales at the bases with fair air movement throughout ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c, 3+ edema of LLE, 2+ edema of RLE SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. On discharge: Vitals: 98.2 76 116/62 18 96 2L GEN: A/Ox3, pleasant, comfortable, NAD CV: RR, S1 and S2 wnl, no m/r/g RESP: crackles at the bases B/L with fair air movement throughout ABD: soft, NT, ND EXT: 2+ edema of LLE, 1+ edema of RLE, erythema of LLE improved with small residual anterior region of tibia remaining. Pertinent Results: Admission Labs: [2152-7-30] 10:34PM BLOOD Hgb-10.3* calcHCT-31 O2 Sat-87 COHgb-2 MetHgb-0 [2152-7-30] 10:34PM BLOOD Type-[Last Name (un) ] pO2-61* pCO2-73* pH-7.35 calTCO2-42* Base XS-10 Comment-GREEN TOP [2152-7-30] 07:40PM BLOOD Lactate-1.7 [2152-7-31] 03:40AM BLOOD Calcium-7.7* Phos-3.4 Mg-1.8 [2152-7-31] 03:40AM BLOOD CK-MB-2 cTropnT-0.07* proBNP-7662* [2152-7-30] 07:34PM BLOOD ALT-17 AST-25 AlkPhos-94 TotBili-0.3 [2152-7-30] 07:34PM BLOOD Glucose-99 UreaN-18 Creat-0.8 Na-139 K-3.4 Cl-92* HCO3-36* AnGap-14 [2152-7-30] 07:34PM BLOOD PT-13.2 PTT-28.0 INR(PT)-1.1 [2152-7-30] 07:34PM BLOOD WBC-14.4# RBC-4.08 Hgb-12.5 Hct-37.6 MCV-92 MCH-30.7 MCHC-33.3 RDW-13.4 Plt Ct-246 IMAGING: [2152-7-30] LE US: No DVT. Calf veins not well assessed. [2152-7-30] AB CT: IMPRESSION: 1. No evidence of bowel perforation. 2. Left lower lobe pneumonia. Emphysema [2152-7-30] CXR: Left lower lobe pneumonia. Mild CHF. [2152-7-31] CXR: Compared with earlier the same day (7:22 a.m.), the right apical pneumothorax is no longer seen distinctly visible. Otherwise, no significant change is detected. MICRO: [2152-7-30] BLOOD CXS: pending [2152-7-30] URINE CXS: no growth [2152-7-31] SPUTUM CXS: [2152-7-31] 3:22 am SPUTUM Source: Expectorated. GRAM STAIN (Final [2152-7-31]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [2152-8-2]): MODERATE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. This isolate is presumed to be resistant to clindamycin based on the detection of inducible 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. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN----------- R ERYTHROMYCIN---------- R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. LABS ON DISCHARGE: [2152-8-2] 06:55AM BLOOD WBC-7.8 RBC-3.41* Hgb-10.3* Hct-32.0* MCV-94 MCH-30.2 MCHC-32.2 RDW-13.8 Plt Ct-213 [2152-7-30] 07:34PM BLOOD Neuts-87* Bands-4 Lymphs-3* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-3* [2152-8-4] 05:48AM BLOOD Glucose-79 UreaN-11 Creat-0.7 Na-140 K-3.7 Cl-101 HCO3-35* AnGap-8 [2152-8-4] 05:48AM BLOOD Calcium-8.0* Phos-3.4 Mg-2.0 Brief Hospital Course: 84 yo female with COPD, diastolic CHF, HTN, hyperlipidemia, history of colon cancer s/p resection who presented with fever, lethargy, and abdominal pain, and was transferred to the ICU for hypotension and concern for sepsis with pulmonary source. . #. Severe sepsis: Patient presented with 2/4 SIRS criteria positive, fever, white count, with presumed pulmonary source and hypotension requiring pressors resulting in diagnosis of severe sepsis. Possible concominant left lower extremity cellulitis was considered as a source on admission as well. She was at risk for health care associated organisms. Also given recent EGD 1 week PTA, also concern for aspiration. U/A clear, blood cxs without growth, and urine legionella was negative. Considered relative adrenal insufficiency given fluticasone inhaler (last documented oral steroid use in our OMR is [2150]), however cortisol was elevated. She was weaned from pressors after receiving 3 L fluid treated with vancomycin, cefepime, levofloxacin and her hypotension resolved. . #. Pneumonia: Patient was on baseline 2L at home but hypoxia on admission was likely secondary to pneumonia on top of known COPD, OSA with associated cor pulmonale. Hypercarbia likely chronic due to retention from bronchiectasis, kyphosis, OSA. BNP was elevated suggesting a component of HF, however no evidence of volume overload on CT. She was continued on BIPAP. Patient had radiographic evidence of left lower lobe pneumonia and was treated with Vancomycin and cefepime for a total of 14 day course ending [2152-8-13]. Sputum Cx grew out MRSA however this was unclear as to whether this was a 'contaminant' or a true MRSA pneumonia given her baseline colonization. Her oxygen status improved to her baseline 2L of O2. An iatrogenic small right apical pneumothorax was discovered s/p central line placement which resolved without further intervention. . #. CAD: Asymptomatic. Pt was ruled out for MI with EKG's without acute changes and CKMB's flat however she did have mildly elevated troponins of unknown clinical significance. She was continued on ASA and simvastatin. . #. dCHF/cor pulmonale: No evidence of pulmonary edema on CT, torsemide and spironoactone was held given hypotension initially. Her last echo [1-6] reveals normal EF, diastolic dysfunction. . #. A fib: Rate controlled, refuses warfarin. She was continued on aspirin. Bblocker was held given COPD. . # Abd pain: with normal CT abd/pelvis, no BM in several days. Improved with bowel regimen. . #. OSA: BIPAP was continued. . #. COPD: Stable, without wheezes at present. Surprisingly undewhelming spirometry. Patient likely with concominant interstitial disease and kyphosis contributing. Fluticasone and standing albuterol/ipatroprium were continued. . Contact: (HCP) [Name (NI) ] [Name (NI) 30908], friend phone number: [Telephone/Fax (1) 30909] Code: FULL CODE (confirmed) . Transition of care: pending completion of IV Vanc and Cefepime on [2152-8-13], her PICC line can be discontinued. Her weight on discharge is 147 lbs. Pending labs: blood cultures [2152-7-30] Medications on Admission: ALBUTEROL SULFATE - 1.25 mg/3 mL Solution for Nebulization - 1 nebulizer(s) by mouth every 4 hours as needed for shortness of breath / wheezing to use with nebulizer AZELASTINE - 137 mcg (0.1 %) Aerosol, Spray - 2 sprays intranasal twice daily BIPAP AUTO SV 11/9/6, 4 LITERS OXYGEN N.C. - (For complex SDB (RDI 45/AHI 36/71%, [2151-5-5] PSG)) - Dosage uncertain FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays intranasal once daily FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 100 mcg-50 mcg/Dose Disk with Device - 1 puff by mouth in the morning and 1 puff at night GABAPENTIN - 400 mg Capsule - 2 Capsule(s) by mouth three times a day [Last Name (un) ] - - USE AS DIRECTED MORPHINE - 60 mg Tablet Extended Release - 1 Tablet(s) by mouth twice a day OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - one Capsule(s) by mouth daily OXYGEN - (Prescribed by Other Provider) - - 2liters NC q24h POTASSIUM CHLORIDE [KLOR-CON 10] - 10 mEq Tablet Extended Release - 1 Tablet(s) by mouth twice a day PRIMIDONE - 50 mg Tablet - 2 Tablet(s) by mouth at night SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth once a day TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - Inhale contents of 1 capsule daily TORSEMIDE - 20 mg Tablet - 2 Tablet(s) by mouth once a day Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1 Tablet(s) by mouth daily CALCIUM CARBONATE [TUMS EXTRA STRENGTH SMOOTHIES] - (Prescribed by Other Provider) - 750 mg Tablet, Chewable - 2 Tablet(s) by mouth daily CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other Provider) - 1,000 unit Capsule - 1 Capsule(s) by mouth daily DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider) - 100 mg Capsule - 1 Capsule(s) by mouth twice a day FERROUS GLUCONATE - 240 mg (27 mg Iron) Tablet - 1 Tablet(s) by mouth daily MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) - Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. albuterol sulfate 1.25 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 2. azelastine 137 mcg Aerosol, Spray Sig: Two (2) sprays Nasal twice a day. 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) sprays Nasal once a day. 5. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 6. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 7. morphine 60 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day. 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. potassium chloride 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day. 10. primidone 50 mg Tablet Sig: Two (2) Tablet PO at bedtime. 11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 14. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 16. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 18. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. ferrous gluconate 240 mg (27 mg iron) Tablet Sig: One (1) Tablet PO once a day. 20. 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. 21. cefepime 1 gram Recon Soln Sig: One (1) gram Injection Q12H (every 12 hours) for 9 days: To finish on [2152-8-13]. 22. vancomycin 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous Q 12H (Every 12 Hours) for 9 days: To finish on [2152-8-13]. 23. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: Pneumonia Left leg cellulitis Secondary: Chronic Diastoloic congestive heart failure Bronchiectasis Methicillin resistent staph aureus colonization 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: You were admitted to [Hospital1 69] for fever, lethargy, and abdominal pain. You were found to have pneumonia and left lower leg cellulitis. You were treated with antibiotics and a "PICC" IV line was placed for you to continue these antibioitcs at rehab. Your breathing improved and fevers went away with treatment. MEDICATION CHANGES: START: vancomycin 500mg IV BID and cefepime 1 gram IV q12 until [2152-8-13] Please otherwise resume your home medications. Followup Instructions: Please follow-up with your primary care doctor after you leave the rehabilitation facility. Otherwise, please follow-up with the appointments listed below: Department: CARDIAC SERVICES When: MONDAY [2152-8-21] at 3:00 PM With: DR. [First Name8 (NamePattern2) ] [Doctor Last Name ] [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) ] [Name8 (MD) ] MD [MD Number(2) 2158] Completed by:[2152-8-5]	[ "0389", "99592", "78552", "32723", "4280", "41401", "42731", "2724", "4019", "53081", "2859" ]
Admission Date: [2160-3-4] Discharge Date: [2160-3-31] Date of Birth: [2082-3-7] Sex: F Service: CARDIOTHORACIC SURGERY HOSPITAL COURSE: Briefly, this is a 77-year-old female who had a history of hypertension and hypercholesterolemia, and had a history of shortness of breath for which she was given a diagnosis of CHF. The patient was admitted to [Hospital6 1760] on [3-4] with fever to 104, and diagnosed with a bacteremia and Staph aureus. She underwent dialysis on [3-6] and experienced some dyspnea after hemodialysis. A cardiology consult was obtained and a catheterization was done on the 21 which showed LAD 70% at the origin and 80% mid, LCX 80% mid and invading at OM1 origin. The patient was continued to be treated with antibiotics, and had a TE which showed 2+ MR, no vegetations, EF 35%. The patient had an episode of hypotension on the [3-12], for which she was transferred to the CCU, was bolused and then transferred back to the floor. The patient underwent Permacath placement on [2160-3-18] after she had had her original one removed at admission to the hospital. Predialysis labs on [3-20] showed a 9.3 white count, hematocrit 30.1, platelets 271, BUN 44, creatinine 7.3. The electrolytes were within normal limits, as were the LFTs. The patient had an INR of 1.3. The patient underwent a CABG x 3 with a LIMA to the LAD and a left saphenous to the circumflex, OM, and sequential to the LIMA, a mitral valve repair with 26 mm annuloplasty band. The patient tolerated the procedure without complications. She was extubated on postoperative day one and was started on oxacillin which was determined to need to be continued for four to six weeks after the date of operation. On postoperative day #3, the patient had a hypotensive event after hemodialysis and developed some atrial fibrillation which reverted back to sinus. On postoperative day #4, the patient was transferred to the floor and did well, having only a PICC line placement on postoperative day #7 for the long-term antibiotics. The patient continued to have an uncomplicated hospital course, ultimately being able to tolerate a regular diet, ambulating reasonably well, and having good po pain control. The patient was felt to be ready for discharge to a rehabilitation facility on postoperative day #10 on long-term oxacillin. DISCHARGE MEDICATIONS: The patient to be going home with 1) amiodarone 400 mg [Hospital1 ], 2) RenaGel 100 mg tid, 3) epoetin 400-600 U IV with dialysis, 4) Nephrocaps 1 qd, 5) Atorvastatin 10 qd, 6) oxacillin 2 gm IV q 4 h x 6 weeks postsurgery, 7) Vioxx 75 mg qd x 3 months, 8) Tylenol 350 mg q 4 h prn, 9) aspirin 325 mg qd, 10) Zantac 150 mg qd until follow-up with surgeon, 11) colace 100 mg [Hospital1 ], 12) Lopressor 50 mg [Hospital1 ], 13) Tums 500 mg tid. FO[Last Name (STitle) ]P: The patient to be following up with Dr. [Last Name (Prefixes) 411] in four weeks and primary care provider in one to two weeks. DISCHARGE CONDITION: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSIS: Status post coronary artery bypass graft x 3 and mitral valve repair. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Name8 (MD) 5915] MEDQUIST36 D: [2160-3-31] 11:35 T: [2160-3-31] 10:37 JOB#: [Job Number 13897] cc:[Last Name (NamePattern4) 13898]	[ "4280", "4240", "42731", "40391" ]
Admission Date: [2181-4-29] Discharge Date: [2181-5-8] Date of Birth: [2158-9-20] Sex: M Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 371] Chief Complaint: s/p Gunshot wound to the face Major Surgical or Invasive Procedure: [2181-4-30] TRACHEOSTOMY,FLEXIBLE BRONCHOSCOPY, CLOSED REDUCTION OF MANDIBLE, EXTRACTION OF TOOTH #19 AND TOOTH #31 History of Present Illness: 22 yo M s/p gunshot wound to left cheek resulting in bilateral mandibular fractures. He was transported to [Hospital1 18] for further care. Past Medical History: Denies Social History: Resides with his mother Family History: Noncontributory Pertinent Results: [2181-4-29] 12:00PM GLUCOSE-82 UREA N-12 CREAT-0.9 SODIUM-140 POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-27 ANION GAP-11 [2181-4-29] 12:00PM CALCIUM-8.4 PHOSPHATE-3.6 MAGNESIUM-1.9 [2181-4-29] 12:00PM WBC-10.8 RBC-3.48* HGB-10.6* HCT-30.5* MCV-88 MCH-30.6 MCHC-34.9 RDW-12.4 [2181-4-29] 12:00PM PLT COUNT-258 [2181-4-29] 12:00PM PT-13.9* PTT-33.4 INR(PT)-1.2* [2181-4-29] CT SINUS/MANDIBLE/MAXILLOFACIA IMPRESSION: Extensive fragmentation of the mandible, with numerous radiopaque foreign bodies located adjacent to the mandibularfragmentation, likely reflecting bullet fragments. No additional fractures areidentified. [2181-5-1] MANDIBLE SERIES INCLUD PANOREX This exam consists of a single Panorex view of the mandible plus six additional radiographs. There are markedly comminuted bilateral fractures of both mandibular bodies. These fractures are associated with a large amount of metallic shrapnel. Teeth of both the maxilla and mandible have been surgically fixated and a nasogastric tube is partially visualized. We have no previous comparison radiographs at this facility. Mandibular condyles and adjacent rami are intact and maxillary sinuses normally aerated. Brief Hospital Course: He was admitted to the Trauma service. OMFS was consulted given his mandible fractures. He was taken to the operating room on [4-30] by Trauma Surgery for an open tracheostomy and by OMFS for repair of his mandible fractures and extraction of fractured teeth. There were no intraoperative complications. Postoperatively he was taken to the Trauma ICU where he remained for several days on the ventilator. A nasogastric tube had already been placed and tube feedings were initiated. He was eventually weaned from the ventilator and was transferred to the regular nursing unit. Speech and Swallow were consulted for Passy Muir valve; initial attempts failed secondary to increased airway edema. He was kept NPO for several more days and a bedside swallow was done for which he passed. His tracheostomy was downsized and he was placed on a full liquid diet. The NG tube was removed; he continued to tolerate his full liquid diet without any difficulty. The tracheostomy was then removed. His pain was controlled with oral narcotcis elixir. He was followed closely by Social Work and the Center for Violence Prevention and Recovery for a safe discharge plan. Information regarding victim's compensation was provided to him and his family. Medications on Admission: None Discharge Medications: 1. Oxycodone 5 mg/5 mL Solution Sig: [4-29] ML's PO Q3H (every 3 hours) as needed for pain. Disp:500 ML's Refills:0 2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID (2 times a day). 3. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's PO twice a day as needed for constipation. 4. Listerine Antiseptic Mouthwash Sig: One (1) Capful Mucous membrane three times a day. Discharge Disposition: Home Discharge Diagnosis: s/p Gunshot wound to the face Bilateral mandible fractures Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Discharge Instructions: You have been given wire cutters to use in case of an Emergency such as shortness of breath, nausea with vomiting; you should cut the wires on both sides to release them. It is VERY IMPORTANT THAT YOU DO NOT move your jaw with any type of chewing motion or opening your mouth wide. Return to the emergency room immediately if your wires are cut. The opening in the front of your neck wiil close on it's own over the next several days to maybe 1 week. Keep it covered with the [Last Name (un) 26535] provided to you until it closes and then you may discontinue the dressing changes. Take all of your medications as prescribed. AVOID alcohol, illicit drugs, operating heavy machinery and/or driving whle you are on narcotics for pain. It is important that you adhere to a full liquid/soft diet, in other words do not ingest anything that requires chewing motion. Return to the Emergency room if you develop any fevers, chills, headache, increased jaw pain not relieved with the pain medication, increased cough, nausea, vomitng, diarrhea and/or any other symptoms that are concerning to you. Followup Instructions: Follow up this Friday [2181-5-11] at 3 p.m with Dr. [First Name (STitle) ], OMFS in clinic. Call [Telephone/Fax (1) 55393] if you need to reschedule the appointment. Completed by:[2181-5-15]	[ "5180", "486" ]
Admission Date: [2193-7-11] Discharge Date: [2193-7-17] Date of Birth: [2128-11-18] Sex: F Service: Cardiothoracic Service HISTORY OF PRESENT ILLNESS: Mrs. [Known lastname 26495] is a 64-year-old woman with recent onset of exertional chest discomfort with radiation to her shoulders. Catheterization done the day of admission showed 80-90% left main with 30% circumflex and 30% RCA with an ejection fraction of 70%. She was transferred from an outside hospital to [Hospital1 188] for coronary artery bypass grafting. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Asthma requiring intubation in the past, last episode in [2173]. 3. Hypertension. 4. Gastroesophageal reflux disease. 5. Oophorectomy. 6. Hypercholesterolemia. ALLERGIES: Sulfa. MEDICATIONS: 1. Theophylline 300 mg [Hospital1 ]. 2. Singulair 10 mg q day. 3. Advair 50/250 [Hospital1 ]. 4. Lipitor 10 mg q day. 5. Prilosec 40 mg q day. 6. Enteric coated aspirin 325 q day. 7. Imdur 30 mg q day. 8. Lopressor 25 mg tid. REVIEW OF SYSTEMS: Denies CVA, transient ischemic attack, no gastrointestinal bleeding, no anemia, no diabetes, no bleeding problems. PHYSICAL EXAMINATION: Temperature 98.4, heart rate 72, sinus rhythm, blood pressure 142/55, respiratory rate 12. O2 saturation 98% on room air. Neurologically, awake, alert, and oriented times three. Pupils are equal, round, and reactive to light. Extraocular movements intact. Cranial nerves II through XII are grossly intact. Cardiovascular: Regular, rate, and rhythm, S1, S2 with a 3/6 systolic ejection murmur loudest at the right sternal border, 4th intercostal space. Respiratory: Clear to auscultation bilaterally. Gastrointestinal: Positive bowel sounds, obese, nontender, and nondistended, well-healed surgical scar. No masses, no hepatosplenomegaly, normal [Doctor Last Name 515]. LABORATORY DATA: White count 8.6, hematocrit 35.4, platelets 349. Sodium 142, potassium 3.7, chloride 107, CO2 27, BUN 12, creatinine 0.7, glucose 104, PT 12.4, PTT 27, AST 22, ALT 20, LDH 220, alkaline phosphatase 82, amylase 39, total bilirubin 0.3, lipase 20. Urinalysis showed moderate blood. CHEST X-RAY: Pending. ELECTROCARDIOGRAM: Sinus rhythm, rate of 72 with no ischemic changes. Patient was admitted, placed on IV Heparin and nitroglycerin, as well as scheduled for coronary artery bypass grafting. On [7-12], the patient was brought to the operating room. Please see the OR report for full details. In summary, the patient had coronary artery bypass grafting x2 with a LIMA to the LAD and a saphenous vein graft to the OM. Her bypass time was 80 minutes and her cross-clamp time was 44 minutes. She tolerated the surgery well and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. At time of transfer, patient was in sinus rhythm at 73 beats per minute. Her mean arterial pressure was 92. She had Neo-Synephrine at 7.7 mcg/kg/min and propofol at 50 mcg/kg/min. She did well in the immediate postoperative period. Her anesthesia was reversed. She was weaned from the ventilator and successfully extubated. On postoperative day one, the patient remained hemodynamically stable. Her chest tubes were removed, and she was transferred from the Cardiothoracic Intensive Care Unit to the floor for continuing postoperative care and cardiac rehabilitation. Once on the floor, the patient had an uneventful postoperative course with the assistance of the nursing staff and Physical Therapy. Patient's activity level was gradually increased until on postoperative day five, it was decided that the patient was stable and ready to be discharged to home. At time of discharge, the patient's physical examination is as follows: Vital signs: Temperature 98.1, heart rate 88, sinus rhythm, blood pressure 117/62, respiratory rate 18, O2 saturation 97% on room air. Weight preoperatively was 81.8 kg, at discharge it was 80.6 kg. Laboratory data on day of discharge: White count 9.6, hematocrit 29.7, platelets 418. Sodium 140, potassium 3.7, chloride 104, CO2 27, BUN 15, creatinine 0.7, glucose 109. Physical examination: Neurologic: Alert and oriented times three, moves all extremities, follows commands. Respiratory: Clear to auscultation bilaterally. Cardiac: Regular, rate, and rhythm, S1, S2, sternum is stable. Incision with Steri-Strips, open to air clean and dry. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are warm and well perfused with no edema. Right endoscopic harvest site with Steri-Strips open to air clean and dry. DISCHARGE MEDICATIONS: 1. Furosemide 20 mg q day x7 days. 2. Potassium chloride 20 mEq q day x7 days. 3. Aspirin 325 mg q day. 4. Theophylline 300 mg [Hospital1 ]. 5. Singulair 10 mg q day. 6. Fluticasone two puffs [Hospital1 ]. 7. Salmeterol one puff q12h. 8. Albuterol two puffs q4h prn. 9. Atorvastatin 10 mg q day. 10. Metoprolol 25 mg [Hospital1 ]. 11. Percocet 5/325 1-2 tablets po q4-6h prn. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post coronary artery bypass grafting x2 with left internal mammary artery to the left anterior descending artery and saphenous vein graft to the obtuse marginal. 2. Asthma. 3. Hypertension. 4. Gastroesophageal reflux disease. 5. Status post oophorectomy. 6. Hypercholesterolemia. DISCHARGE STATUS: The patient is to be discharged to home. FOLLOW-UP INSTRUCTIONS: She is to have followup with the [Hospital 409] Clinic in two weeks. Follow up with Dr. [Last Name (STitle) 70] in six weeks, and follow up with Dr. ......... in four weeks. [First Name11 (Name Pattern1) ] [Initials (NamePattern4) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 75] Dictated By:[Name8 (MD) 415] MEDQUIST36 D: [2193-7-17] 13:17 T: [2193-7-17] 13:17 JOB#: [Job Number 26496]	[ "41401", "4019", "2720", "49390", "53081", "2859" ]
Admission Date: [2149-8-26] Discharge Date: [2149-8-29] Date of Birth: [2086-12-20] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 348] Chief Complaint: Syncope Major Surgical or Invasive Procedure: EGD [8-29] History of Present Illness: 62 y/o male with PMH sig for Mult CVAs, (B) ICA stenosis s/p LCEA in [6-2], HTN, hyperhol, Type 2 DM. Of note, pt AC since [5-4] for R ICA occlusion. Today wife found patient slumped over in the bathroom on the toilet after having a bm. Pt does not recall the event, no cp/sob but does note intermittent dizziness over past few days. Also notes some left hand numbess/leg weakness--seen by Neuro in ED (see plan). In short, came to [Hospital1 18] ED where had INR of 37 and HCT of 22. Melena on exam but no active GI bleeding appreciated. Pt reports having INR checked in early [Month (only) ] and it being at goal. No new meds/abx/dietary changes/change in coumdain dose. IN ED, initial VS 89/42 P 103, given 2 L NS, 2 U PRBC, 4U FFP. 10 mg SQ K. Past Medical History: peripheral [Month (only) 1106] disease anxiety htn DM inc lipids left CEA stroke [7-3] Social History: -works as a car salesman -sedentary lifestyle -2ppd x 30 smoking history, quit after stroke [7-3], on wellbutrin -h/o heavy etoh in the past -no illicit drug use -lives with wife Family History: -mother had pna -father died at 58 secondary to strokes over a 2 year period -brother with CAD and AICD Physical Exam: Gen: 98.5 100/60 87 94RA, supine 108/78 92 standing 110/76 111 CV: s1 s2 no mrg chest: exp wheezes throughout, no crackles Abd: normoactive bs, nt/nd ext: no c/c/e neuro cnII-Cnxii intact Pertinent Results: [2149-8-29] EGD Erosions in the antrum and fundus. Likely sources of bleeding in the setting of INR of 37.4 Erythema in the fundus compatible with gastritis 9//29/05 Echo The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF 70%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. [2149-8-26] 07:04PM CK(CPK)-367* [2149-8-26] 07:04PM CK-MB-14* MB INDX-3.8 cTropnT-0.11* [2149-8-26] 07:04PM HCT-21.3* [2149-8-26] 07:04PM PT-17.9* PTT-32.8 INR(PT)-2.2 [2149-8-26] 03:30PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.015 [2149-8-26] 03:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2149-8-26] 03:30PM URINE RBC-21-50* WBC-[2-1] BACTERIA-NONE YEAST-NONE EPI-[2-1] [2149-8-26] 12:15PM WBC-9.7 RBC-2.67* HGB-7.1* HCT-22.2* MCV-83 MCH-26.6* MCHC-32.1 RDW-14.2 [2149-8-26] 12:15PM NEUTS-81* BANDS-0 LYMPHS-16* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2149-8-26] 12:15PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+ [2149-8-26] 12:15PM PLT COUNT-300 [2149-8-26] 12:15PM PT-66.8* PTT-70.3* INR(PT)-37.4 [2149-8-26] 10:30AM GLUCOSE-235* UREA N-76* CREAT-1.9* SODIUM-135 POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-25 ANION GAP-14 [2149-8-26] 10:30AM ALT(SGPT)-11 AST(SGOT)-11 CK(CPK)-113 ALK PHOS-61 AMYLASE-25 TOT BILI-0.2 [2149-8-26] 10:30AM LIPASE-17 [2149-8-26] 10:30AM cTropnT-<0.01 [2149-8-26] 10:30AM CK-MB-3 [2149-8-26] 10:30AM ALBUMIN-3.9 CALCIUM-8.3* PHOSPHATE-3.7 MAGNESIUM-1.9 [2149-8-26] 10:30AM WBC-10.0 RBC-2.91# HGB-7.9# HCT-23.9# MCV-82 MCH-27.3 MCHC-33.3 RDW-14.2 [2149-8-26] 10:30AM NEUTS-77.0 LYMPHS-17.8* MONOS-4.6 EOS-0.5 BASOS-0.1 [2149-8-26] 10:30AM MICROCYT-1+ [2149-8-26] 10:30AM PLT COUNT-338 [2149-8-26] 10:30AM PT-66.7* PTT-52.4* INR(PT)-37.2 Brief Hospital Course: CC:[CC Contact Info 57993]. 62 y/o male with PMH sig for Mult CVAs, (B) ICA stenosis s/p LCEA in [6-2], HTN, hyperhol, Type 2 DM presented with INR of 37, and anemia. . 1. UGIB. The patient required admission to the MICU for management of his anemia and elevated INR> He was given 10mg IV Vitamin K, his coumadin was held and required 10 U PRBCs for management of his anemia. He had melanotic stools on admission, but did not have active bleeding and did not require emergent EGD. He was made NPO, started on a PPI and monitored. He was stabilized and transferred to the floors. Because he had leak of his cardiac enzymes, likely secondary to ischemic demand, cardiology was consulted to determine if EGD would be tolerated. Cardiology determined that he was low risk for the EGD procedure and he underwent an EGD which showed erosions in the antrum and fundus. Likely sources of bleeding in the setting of INR of 37.4. Erythema in the fundus compatible with gastritis. Gastroenterology felt it was not contraindicated to start aggrenox. . 2. Indigestion: There was a mild CK bump (150--300) with positive troponin as high as 1.51. He remained chest pain free, and the etiology was likely secondary to demand ischemia. Cardiology was consulted and although he has peripheral [Date Range 1106] disease, and history of CVAs and likely cardiac disease did not feel this was ACS and he was to follow up with outpatient stress test and possible catherization. . 3. DM: SSI . 4. Neuro sx: Essentially, felt to be to low perfusion state from anemia. Head CT without new stroke or bleed. His neuro exam was monitored without any change or worsening from baseline . 5. PPx: Holding anticoagulation given supertherapeutic INR . 6. Code: FULL . 7. Comm with pt. Medications on Admission: Wellubtrin Avandia ASA Coumadin Zocor Aggenox Altace Labetolol advair prn Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Ramipril 5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:30 Tablet(s) Refills:2 5. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR Sig: One (1) Cap PO BID (2 times a day). Disp:60 caps Refills:2 6. Tylenol Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:30 Tablet(s) Refills:0 7. Avandia Oral 8. Advair Diskus Inhalation 9. Protonix 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:0 Discharge Disposition: Home Discharge Diagnosis: GI bleed coagulopathy Myocardial damage [1-1] demand ischemia anemia hx CVA's Discharge Condition: afebrile, hemodynamically stable, with stable HCT Discharge Instructions: Please take all medications as prescribed. Please discontinue coumadin now. Please contact your primary care physician for an appointment this week. Please contact your physician or return to the emergency department if you have chest pain, shortness of breath, bleeding, lightheadedness, weakness or any other worrisome symptoms Followup Instructions: Please contact your primary physician for an appointment this week to discuss your hospital stay. You must discuss with your physician the option of having a stress test done to evaluate for coronary artery disease. Please have your blood count (hematocrit) assessed within the next week to ensure that is remains stable. Please discuss with him your ongoing use of aggrenox. If you continue to have foot pain, contact your PCP for possible prednisone or colchicine treatment for gout. Please keep the following appointments arranged for you by Dr. [Name (NI) 19759] office: Provider: [Name10 (NameIs) ] [Name11 (NameIs) 3627] [Name12 (NameIs) 3628] [Name12 (NameIs) ] [Name12 (NameIs) 3628] (NHB) Date/Time:[2149-9-4] 9:30 Provider: [Name10 (NameIs) ] [Name11 (NameIs) 3627] [Name12 (NameIs) 3628] [Name12 (NameIs) ] [Name12 (NameIs) 3628] (NHB) Date/Time:[2149-9-4] 10:30 Provider: [Name10 (NameIs) 1111],[First Name7 (NamePattern1) 1112] [Initial (NamePattern1) ] [Last Name (NamePattern4) ] SURGERY (NHB) Date/Time:[2149-9-4] 1:00	[ "41071", "2851", "4019", "2720", "25000", "49390", "V5861" ]
Admission Date: [2155-4-19] Discharge Date: [2155-4-26] Date of Birth: [2108-2-1] Sex: M Service: CCU CHIEF COMPLAINT: Chief complaint of status post ventricular fibrillation arrest. HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old male with a history of coronary artery disease, status post acute myocardial infarction 20 years ago, status post 4-vessel coronary artery bypass graft in [2136], status post myocardial infarction in [2151] (with an right coronary artery to saphenous vein graft stent), status post myocardial infarction in [2152] (with an saphenous vein graft to left anterior descending artery percutaneous transluminal coronary angioplasty; at that time had an ejection fraction of 40%), history of diabetes, and hypertension who was admitted to [Hospital1 69] after surviving a ventricular fibrillation arrest on a flight from [Location (un) 86] to Venezuelae. The plane landed in [Male First Name (un) 1056]. Per nephew, the patient had four to five weeks of progressive chest pressure with exertion with increased use of nitroglycerin. He refused to seek medical advice at that time. Per wife, the patient has had angina for several years but was told in [State 2690] there was no more they could do. On flight from [Location (un) 86] to Venezuelae, the patient had a ventricular fibrillation arrest on Thursday evening, automatic external defibrillator was used and with two to three shocks was delivered from ventricular fibrillation. No available strips at this time. The plane was diverted to [Male First Name (un) 1056] where his nephew met him. The patient was intubated on the airstrip, but answering questions appropriately at that time. He was transferred to a second hospital in [Male First Name (un) 1056] and started on amiodarone drip, heparin drip, and nitroglycerin drip. There, revealed an ejection fraction of 30%. It was reported that a maximum troponin of greater than 500 with a maximum creatine kinase of greater than 16,000. The patient was subsequently transferred to [Hospital1 188] from [Male First Name (un) 1056]. At [Hospital1 ], the patient was lightly sedated, on a propofol drip. He recognized his wife and nephew and answered all questions appropriately. He denied any chest pain. PAST MEDICAL HISTORY: 1. Coronary artery disease; status post myocardial infarction 20 years ago; status post 4-vessel coronary artery bypass graft in [2146] (saphenous vein graft to first obtuse marginal, saphenous vein graft to circumflex, saphenous vein graft to left anterior descending artery, saphenous vein graft to right coronary artery); status post myocardial infarction in [2151] and [2152]. 2. Diabetes. 3. Hypertension. MEDICATIONS ON ADMISSION: Medications on arrival included atenolol 50 mg p.o. q.d., Vascor 200 mg p.o. q.d., Imdur 20 mg p.o. q.d., sublingual nitroglycerin p.r.n., aspirin 81 mg p.o. q.d., Zantac 150 mg p.o. b.i.d., niacin 500 mg p.o. q.d., Zocor 40 mg p.o. q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives in [Location 40655]. He is an emergency medical technician physician. [Name10 (NameIs) 40656] use; quit 20 years ago. He is married with two children. PHYSICAL EXAMINATION ON PRESENTATION: The patient was intubated, on assist control of 12, tidal volume of 900, FIO2 of 40%, positive end-expiratory pressure of 5, temperature of 102.4, pulse of 69, blood pressure of 99/55, respiratory rate of 12, satting 95% to 99% on room air. In general, a middle-aged male, intubated, lightly sedated. Head, eyes, ears, nose, and throat revealed pupils were equally round and reactive to light. The oropharynx was clear. Endotracheal tube in place. Mucous membranes were moist. Jugular venous distention not visualized. Chest was clear anteriorly. No wheezes or rales. Cardiovascular examination revealed a regular rate. No murmur. First heart sound and second heart sound were normal. There was a third heart sound audible. Abdomen revealed bowel sounds were positive, soft and nontender. No rebound or guarding. Extremities revealed there was trace edema, cool extremities, good distal pulses bilaterally. No femoral bruits. There was a large left groin hematoma. On neurologic examination, the patient was lightly sedated. He opened his eyes to command, comprehended simple commands. Skin revealed there was no rash. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories revealed a white blood cell count of 13.7 (78% polys and 16% lymphocytes), hematocrit of 41.2, platelets of 170. PT of 13.6, INR of 1.3, PTT of 37.2. Sodium of 145, potassium of 3.5, chloride of 107, bicarbonate of 25, blood urea nitrogen of 18, creatinine of 1.2, glucose of 117. ALT of 179, AST of 339, alkaline phosphatase of 58, total bilirubin of 0.8. Creatine kinases on admission were 8585; MB of 14; with an index of 0.2, and a troponin of greater than of 50. RADIOLOGY/IMAGING: Chest x-ray revealed a right subclavian line in the right anterior inferior vena cava, endotracheal tube about 6 cm above the carina. There was evidence of cardiomegaly with pulmonary congestion. Electrocardiogram on arrival revealed sinus rhythm at 72, with normal axis, Q waves in V1 to V3, flat T waves throughout, biphasic D in first diagonal, tall P in lead II. HOSPITAL COURSE: 1. CARDIOVASCULAR: The patient was admitted with ventricular fibrillation arrest, likely in the setting of an acute coronary syndrome given the fact that his troponins and creatine kinases were elevated. However, the patient presented chest pain free. His aspirin, Lopressor, Lipitor, heparin drip, nitroglycerin drip were continued. The patient's creatine kinases were cycled; however, they continued to remain elevated with a negative index. The patient's statin was held secondary to elevated creatine kinases. The patient was extubated on the following morning and was stable. The patient was sent for cardiac catheterization. Cardiac catheterization revealed an occlusion of the left anterior descending artery at the site of the saphenous vein graft to left anterior descending artery graft. The patient also had two grafts that were occluded. The native left anterior descending artery was stented successfully, and the patient was returned to the Coronary Care Unit. The patient was continued on Plavix status post catheterization and Integrilin. The patient also had an echocardiogram which showed an ejection fraction of 15% to 20% with inferobasal aneurysm. The patient was started on anticoagulation for a low ejection fraction and a question of an aneurysm; initial on heparin and then converted to Coumadin. Given the patient's ventricular fibrillation arrest, the patient was taken for an Electrophysiology study which revealed fossae of ventricular tachycardia, and the patient was taken the following day for implantable cardioverter-defibrillator placement. Status post defibrillator placement, the patient's chest x-ray was okay. Interrogation revealed that the defibrillator was working, and the patient was discharged with implantable cardioverter-defibrillator in place, off amiodarone. 2. PULMONARY: The patient was admitted intubated on arrival. However, the following morning the patient was successfully extubated and had stable room air saturations. On hospital day two, after extubation, the patient developed flash pulmonary edema and was treated with intravenous Lasix, morphine, and nitrates. The patient continued to be diuresed aggressively (1 liter to 2 liters per day). The patient eventually regained stable saturations and was discharged on a low dose of Lasix 20 mg p.o. q.d. 3. INFECTIOUS DISEASE: The patient was admitted with a question of pneumonia given a temperature of 102.4 and question of a retrocardiac density on chest x-ray. The patient also with a question of dirty urine, consistent with a urinary tract infection. The patient was placed on Levaquin and will be treated with a 14-day course. The patient remained afebrile during the rest of his hospitalization. 4. ENDOCRINE: The patient with a history of diabetes and was treated initially with an insulin drip and was switched over to a regular insulin sliding-scale. 5. RHEUMATOLOGY: The patient was admitted with increased creatine kinases, although negative index, question of a myopathy versus myositis. The patient was on niacin and a statin as an outpatient which were discontinued upon arrival, and the patient creatine kinases continued to trend down with a maximum of 9000, trending down to 1700 upon discharge. DISCHARGE DIAGNOSES: 1. Acute myocardial infarction; status post ventricular fibrillation arrest; status post implantable cardioverter-defibrillator placement. 2. Congestive heart failure with inferobasal aneurysm; on anticoagulation. 3. Pneumonia. 4. Elevated creatine kinases secondary to statin/niacin. 5. Diabetes. 6. Hypertension. MEDICATIONS ON DISCHARGE: (Discharge medications included) 1. Atenolol 25 mg p.o. q.d. 2. Zestril 10 mg p.o. q.d. 3. Coumadin 5 mg p.o. q.h.s. (to be adjusted at the [Hospital 197] Clinic). 4. Lasix 20 mg p.o. q.d. 5. Aspirin 325 mg p.o. q.d. 6. Plavix 75 mg p.o. q.d. 7. Folate 1 mg p.o. q.d. 8. Colace 100 mg p.o. b.i.d. 9. Sublingual nitroglycerin p.r.n. 10. Zyrtec 10 mg p.o. q.d. DISCHARGE FOLLOWUP: The patient was to follow up with the Electrophysiology Clinic on Tuesday. The patient was also to follow up at the [Hospital 197] Clinic for an INR check. The patient was also to follow up with Dr. [Last Name (STitle) ] for follow up of his low ejection fraction and coronary artery disease. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. [MD Number(1) 2057] Dictated By:[Name8 (MD) 2439] MEDQUIST36 D: [2155-4-30] 18:40 T: [2155-5-1] 14:38 JOB#: [Job Number 40657]	[ "4280", "25000", "412", "V4581", "4019" ]
Admission Date: [2160-12-21] Discharge Date: [2160-12-27] Service: [Last Name (un) ] CHIEF COMPLAINT: Dyspnea, change in mental status. HISTORY OF PRESENT ILLNESS: The patient is an 80 year old female [Hospital 100] Rehab resident transferred for workup of dyspnea and change in mental status. The patient suffers from Alzheimer related dementia at baseline along with multi-infarct dementia and low velocity blood flow in the middle cerebral artery. The patient presents from [Hospital6 459] for the Aged with dyspnea and fever. The patient was anhistoric due to her change in mental status. PAST MEDICAL HISTORY: Dementia. Hydrocephalus. Pernicious anemia. UTI. Hard of hearing. Visually impaired. Arthritis. Hypothyroidism. Hypertension. Questionable tonic clonic seizure eight months prior. Depression. IBS. MEDICATIONS ON ADMISSION: Seroquel, calcium, Ditropan, aspirin, multivitamin, Levoxyl, Bextra, Neurontin, senna, Cosopt, Xalatan, vitamin B-12. PHYSICAL EXAMINATION: Temperature 100.6, blood pressure 112/68, pulse 116, sating 96 percent on 1.5 liters nasal cannula. Pertinent findings on exam, heart normal S1, S2. There were bilateral rhonchi and coarse breath sounds in all fields with scattered expiratory wheezes. LABORATORY DATA: CT of the head showed no acute intracranial hemorrhage. There was communicating hydrocephalus and no significant mass effect and no herniation. Chest x-ray showed multifocal pneumonia in the right middle and left lower lobes. White count 19.1 on admission. HOSPITAL COURSE: The patient was admitted for multifocal pneumonia and was started on Levaquin and Flagyl to cover for possible aspiration events, given her dementia. Initially she appeared to be improving, but then the patient was noted to have increasing oxygen requirement and tachycardia. She was also noted to have worsening mental status and increasing agitation. The patient became less alert during her hospital stay and required a one-to-one sitter. On [2160-12-25] the patient was noted to be stuporous and in severe respiratory distress. She was not awake or able to eat or drink, not able to take p.o. meds. Chest x-ray showed worsening pneumonia and mild CHF. Her antibiotic coverage was broadened to include coverage for possible MRSA pneumonia. On [2160-12-26] the patient's respiratory status was worse with a rate of 32 to 40 and increasing O2 requirement in spite of the broadening of antibiotic coverage. The geriatrics attending spoke to the patient's nephew who wanted a trial of BiPAP in the intensive care unit. The patient's sats were 94 percent on 50 percent face mask with heart rate in the 120s to 130s. The patient was transferred to the MICU for a trial of possible BiPAP. The patient did remain in the unit for one day for BiPAP. As the patient's condition continued to worsen, the MICU team [Date Range 653] the nephew. The nephew felt that he did not want the BiPAP continued any more if her condition worsened, but rather he would want comfort measures only. The patient was transferred out to the floor on [2160-12-27] where she was noted to be in severe respiratory distress with rates in the 40s. Again, the nephew was [Name (NI) 653] and agreed that the patient should be made comfort measures only. The patient was given several doses of IV morphine as well as started on IV morphine drip. A scopolamine patch was also placed behind the patient's ear. At 5:03 p.m. the patient died and was pronounced dead. Of note, after the patient passed away, her next of [Doctor First Name ] (nephew [Name (NI) ] asked if it would be possible to have her blood tested for familial dysautonomia carrier state, as her great-nephew is affected with the disease. The lab was [Name (NI) 653] and arrangements were made for one of the patient's blood samples that was still being held in the lab to be sent to [Company 2475] genetics for testing. The nephew will be notified of the results when they are available. FINAL DIAGNOSES: 1. Multifocal pneumonia. 2. Dementia. 3. Hydrocephalus. 4. Pernicious amenia. 5. Hard of hearing. 6. Visually impaired. 7. Arthritis in the shoulders. 8. Hypothyroidism. 9. Hypertension. 10. History of tonic clonic seizures. 11. Depression. 12. Irritable colon. CONDITION ON DISCHARGE: Deceased. DR. [First Name4 (NamePattern1) 1037] [Last Name (NamePattern1) ] Dictated By:[Name8 (MD) 8288] MEDQUIST36 D: [2160-12-27] 17:55 T: [2160-12-27] 17:58 JOB#: [Job Number 53130]	[ "5070", "4280", "5990", "2760", "51881" ]
Admission Date: [2109-10-24] Discharge Date: [2109-10-28] Date of Birth: [2053-9-5] Sex: F Service: SURGERY Allergies: Penicillins Attending:[First Name3 (LF) 2777] Chief Complaint: Left carotid stenosis Major Surgical or Invasive Procedure: L internal carotid stent placement History of Present Illness: Ms. [Known lastname 50416] is a 56 year old woman referred for evaluation of symptomatic left carotid stenosis. She felt right arm numbness in early [Month (only) 205], which prompted her to seek attention which included a carotid duplex which demonstrated a severe left ICA stenosis. She underwent a left CEA on [2109-8-9] at an OSH. However, she had recurrent symptoms postop which prompted repeat studies demonstrating a residual left internal carotid stenosis. She underwent a redo left CEA on [2109-8-19] but still had recurrent symptoms afterward and noninvasive studies showing a severe ICA stenosis 80-99% range. Past Medical History: HTN, hypothyroidism Social History: Smokes one pack per week Family History: CAD, HTN Physical Exam: 98.1, HR 50, BP 104/52, RR 18, SaO2 98% room air No distress Neck supple, B/L bruits Incision healing well RRR CTAB Obese abd No C/C/E Pertinent Results: [2109-10-24] 07:00PM GLUCOSE-137* UREA N-21* CREAT-0.9 SODIUM-144 POTASSIUM-3.4 CHLORIDE-111* TOTAL CO2-25 ANION GAP-11 [2109-10-24] 07:00PM CALCIUM-8.5 PHOSPHATE-3.5 MAGNESIUM-1.4* [2109-10-24] 07:00PM WBC-8.5# RBC-2.43# HGB-7.9# HCT-23.1# MCV-95 MCH-32.5 MCHC-34.0 RDW-13.9 [2109-10-24] 07:00PM PLT COUNT-231 [2109-10-24] 07:00PM PT-15.3* PTT-85.9* INR(PT)-1.6 Brief Hospital Course: The patient was admitted to the vascular surgery service and underwent a left carotid artery stent placement on [10-24]. She remained in the hospital for blood pressure control. On post-procedure day 4, she remained under good blood pressure control on a regimen to be continued at home. She was deemed ready for discharge with instructions to take her BP at home and call immediately if SBP>130, or any symptoms of headache. Medications on Admission: Lisinopril 40mg qd, HCTZ 25mg [Last Name (LF) ], [First Name3 (LF) ] 325mg qd, Levothyroxine 150mcg qd, Indomethacin 25mg qd, Lipitor, Plavix 75mg qd, Toprol XL 25mg qd, Protonix 40mg qd Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 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. Lisinopril 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Stenotic L ICA Discharge Condition: stable Discharge Instructions: Please take all medications as prescribed. Please return to the emergency room for any new nuerological sypmtoms such as uncontrolled headache, visual changes, localized numbness or weakness. Please take your blood pressure twice daily with a home blood pressure cuff and call Dr. [Last Name (STitle) ] or return to the ER if your systolic blood pressure is above 130mmHg. Followup Instructions: Please follow up in Dr.[Name (NI) 7446] clinic in 1 week, call [Telephone/Fax (1) 2625] to schedule an appointment. Please follow up with your primary care physician to monitor your blood pressure. Completed by:[2109-10-28]	[ "4019", "2449" ]
Admission Date: [2129-8-19] Discharge Date: [2129-8-26] Service: MEDICINE Allergies: Sulfonamides Attending:[First Name3 (LF) 2297] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: EGD Tagged RBC scan Intubation History of Present Illness: Mr. [Known lastname 2520] is an 85 year old gentleman discharged from the CCU service yesterday, returning with 2 episodes of painless hematochezia, approximately 500mL while defecating at his nursing home. He was found to have continued bleeding/BRBPR and sent over to [Hospital3 7571]hospital. He was transfused 1 unit of blood and 1.5 L with IVs placed and transferred to the [Hospital1 18] ED. . In the ED, initial vs were: 88 86/54. Patient was given another 2 units of blood, 1.5L of NS to achieve hemodynamic stability. Surgery and GI were consulted, 40 of Protonix was started. NG tube placed coffee ground on initial suction with 2 lavages negative thereafter. Difficult with sat monitoring, but high 90s on NRB. Given 40 Protonix x2. R Triple lumen placed. Transfer VS: 96/63 (previous BPs: 123/103 103/66 96/64) 96 95% NRB in AFIB with RBBB which appears to be a new rhythm. . On the floor, the patient is awake and confirms the story above, although he intermittently falls asleep. He denies ever having abdominal pain, chest pain or difficulty breathing. . Of note, the patient was discharged from the CCU service yesterday after an admission for CHF and diuresis. Discharge summary reviewed. Past Medical History: 1. Congestive heart failure (LVEF 58% by recent echo) 2. CAD (recent cardiac cath demonstrated severe diffuse left main disease with 75% ostial and 95% proximal LAD lesions, native RCA diffusely diseased and occluded distally) 3. HTN 4. Hyperlipidemia 5. Pulmonary HTN 6. Severe mitral regurgitation 7. Diverticulitis 8. Gastric AV malformation 9. Chronic kidney disease 10. PVD with aortoiliac aneurysm 11. Second degree AV block 12. Tachybrady syndrome 13. Anemia 14. Ulcerative colitis 15. h/o GI bleed 16. Rheumatoid arthritis 17. Central retinal artery occlusion, right eye. 18. ? Remote COPD CARDIAC RISK FACTORS: Dyslipidemia, Hypertension, ? Controlled DM2 . CARDIAC HISTORY: -CABG: s/p CABG [2097], repeat CABG [2121] with LIMA to LAD, reverse SVG to posterolateral branch RCA, reverse SVG to OM branch of circumflex Social History: Patient lives alone. His neighbor is his healthcare proxy. [Name (NI) ] has a remote smoking history, quit over 30 years ago. Reports drinking occasionally, once per week. No illicit drug use. Family History: Non-contributory. No known family history of CAD, CHF, or kidney disease. Physical Exam: Vitals: 93.7 axillary HR 88 BP 101/76 12 99% Facemask General: Alert, oriented ill appearing gentleman HEENT: Pale conjunctiva, oropharynx clear, coughing up tan secretions, NG tube in place: Lavage clear Neck: R IJ in place, JVP difficult to assess Lungs: Inspiratory crackles in left side (Lat decub position), expiratory fine rhonchi. CV: S1 & S2 fast, irregular with a II/VI holosystoic murmur. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Rectal: BRB in rectal vault GU: Foley in place Ext: Cool, mild edema, pulses only obtainable by doppler. Pertinent Results: CT Abd and Pelvis [2129-8-23] 1. Status post aortobiiliac endostent placement with left common iliac artery aneurysm repair. No definite evidence of endoleak or aortoenteric fistula on this study. 2. No evidence of focal extravasation of contrast to suggest GI bleed. If clinical suspicion persists then nuclear medicine study can be performed to determine site of bleed. 3. Large bilateral pleural effusions, ascites, and anasarca are slightly increased compared to [2129-8-20]. 4. Hepatic cyst within the left lobe of the liver is stable since [2125]. Bilateral renal cortical scarring is unchanged since most recent prior. 5. Sclerotic foci of bilateral femoral heads may represent avascular necrosis and are unchanged since the most recent priors. EGD [2129-8-23] Erythema in the stomach compatible with gastritis Erosions in the antrum Erythema and friability and erosions in the duodenal bulb compatible with duodenitis Blood noted in proximal jejunum without active source of bleeding noted. Otherwise normal EGD to proximal jejunum GI Bleeding Study [2129-8-24] Dynamic blood pool images show extravascular activity noted in the left lower quadrant throughout the initial thirty minutes suggestive of brisk bleeding likely in the sigmoid colon. Bleeding was first noticed within the first minute of dynamic imaging. [2129-8-19] 10:58PM HCT-35.3* [2129-8-19] 06:08PM HCT-30.5# [2129-8-18] 04:25AM PT-14.8 PTT-33.1 INR(PT)-1.3* Brief Hospital Course: 1) Shock/Hypotension/GI bleed: Was secondary to GI bleed and likely cardiogenic shock with diastolic failure and severe MR, other possible contributing sources were adrenal insufficiency given chronic prednisone use and sepsis from urinary source. The patient remained hypotensive despite 5 units of blood and 6L of NS at initial presentation. IV access was maintained, transfusions of PRBC were given for Hct <25, FFP>1.5. Vancomycin, cefepime and flagyl were started for presumed urosepsis, and were continued during MICU stay. Trauma line was placed for faster fluid and blood repletion and hydrocortisone was given. Pt was followed by GI, vascular and surgery services. CTA did not show active bleed or leak from endovascular graft. Levophed and vasopressin were started to maintain MAP>65. Patient was intubated on[8-21] for concern of inability to protect airway and hcts and fluid status were stable until [8-25], when there was evidence of a brisk GI bleed which was seen on tagged RBC scan and embolized by IR, thought to be [3-1] diverticulosis, and again on [8-26], for which 2 units of blood and one of FFP were given. Pressors were titrated and fluid boluses were given to maintain MAP, until the neighbors decided to initiate comfort measures only on the afternoon of [8-26], after which all interventions were discontinued except morphine drip and ativan. Mr. [Known lastname 2520] died at 21:50 on [8-26]. . 2) Acute on chronic renal failure: Initial creatinine actual represents an improvement from recent renal failure [3-1] heart failure, but worsened after studies with contrast, the CTA and IR, were done. Fluid boluses were given and Cr was trended until CMO was initiated on [8-26]. . 4) Diastolic CHF/CAD: No evidence of new ischemia on EKG and cardiac enzymes were stable. anticoagulation with Asa and heparin were held . 5) Atrial fibrillation, borderline rapid rate: Rate control with fluids/blood as above, no anticoagulation was given. Medications on Admission: Acetaminophen 1g PO Q6 PRN Aspirin 325mg PO Daily Ciprofloxacin 500mg PO BID last day [8-21] Docusate Sodium 100mg PO BID Ferrous Sulfate 300mg PO Daily Furosemide 80mg PO daily Heparin (Porcine) SC TID Mesalamine 800mg PO TID Metolazone 2.5mg PO Daily Metoprolol Tartrate 6.25mg PO TID Pediatric Multivit-Iron-min [Multi-Vitamins W/Iron] PO daily Prednisone 20mg PO Daily Sennosides [Senna] PRN constipation Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: GI bleed, cardiopulmonary arrest Discharge Condition: expired Completed by:[2129-8-27]	[ "51881", "5845", "2851", "5990", "42731", "4168", "496", "40390", "5859", "4280", "V4581" ]
Admission Date: [2191-9-9] Discharge Date: [2191-9-14] Date of Birth: [2125-2-14] Sex: M Service: CARDIOTHORACIC Allergies: Iodine; Iodine Containing Attending:[First Name3 (LF) 922] Chief Complaint: Corornary Artery Disease Aortic Stenosis Major Surgical or Invasive Procedure: [2191-9-9] Aortic Valve Replacement(25mm [Doctor Last Name ] Pericardial) & coronary Artery Bypass Grafting(LIMA to LAD, SVG-PDA, SVG-ramus,SVG-OM,SVG-diag) History of Present Illness: Mr. [Known lastname 12130] is a 66 year old male, with known CAD, who presented to the ED on [9-2] with angina. An EST on [2191-8-24] had demonstrated reversible ischemia of PDA distribution with severe systolic dysfunction of the inferior wall. He R/O for an MI and a cardiac catheterization on [9-5] revealed severe three vessel coronary artery disease. Echocardiogram on [8-8] was also notable for mild aortic stenosis and an LVEF of 50%. Based upon the above he was referred for cardiac surgical intervention. Past Medical History: Coronary artery disease Aortic stenosis Diabetes Mellitus Type II Dyslipidemia Hypertension s/p Bilateral Knee Arthroscopies s/p Right Ankle Surgery Social History: Semi retired Quit tobacco over 30 years ago Admits to social ETOH. Family History: Mother had MI in her 50s, brother had MI in his 70s. Physical Exam: A & O x 3. VSS and afebrile. Lungs- sl. decreased BS at bases Cor- SR in 80s- 90s Abd- soft and nontender . + BS Exts- [12-29]+ edema. Serosanguinous drainage from upper RT thigh at site open vein harvest. No erythema, staples intact. EVH sites clean and dry. Pertinent Results: [2191-9-13] 05:15AM BLOOD WBC-11.1* RBC-2.64* Hgb-8.2* Hct-23.2* MCV-88 MCH-31.0 MCHC-35.3* RDW-15.1 Plt Ct-173# [2191-9-13] 05:15AM BLOOD Plt Ct-173# [2191-9-13] 05:15AM BLOOD K-3.8 [2191-9-12] 05:30AM BLOOD Glucose-95 UreaN-11 Creat-0.8 Na-141 K-3.8 Cl-107 HCO3-25 AnGap-13 [2191-9-12] 05:30AM BLOOD Mg-2.0 Brief Hospital Course: Mr. [Known lastname 12130] was admitted and underwent an aortic valve replacement along with coronary artery bypass grafting surgery by Dr. [Last Name (STitle) 914]. For surgical details, please see seperate dictated operative note. He weaned from CPB with the aid of neosynephrine and epinephrine. These were weaned easily and he was extubated on POD1. On POD 2 he was stable, off pressors and CTs were removed. He went to the floor on POD3. Pacing wires were removed and he remained stable. His diabetes agents were resumed as well as beta blockers and diuretics. His right leg wound at the open harvest site was draining serosanguinous fluid but did not appear infected. The amount of drainage from the right thigh seems to be diminishing. He had a moderate amount of edema and was being diuresed. He became ambulatory and was ready for discharge to a rehabilitation facility to recover prior to return home. Discharge medications, followup appointments and restrictions had been discussed with the patient. Medications on Admission: Amlodipine/Atorvastatin 10/20 qd Lasix 20 qd Metformin 1000 [Hospital1 ] Metoprolol 50 [Hospital1 ] Actos 30 qd Diovan 160 qd Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 2. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:100 Tablet(s) Refills:0 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:100 Tablet, Delayed Release (E.C.)(s) Refills:2 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO three times a day. Disp:150 Tablet(s) Refills:2 7. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:7 Tablet(s) Refills:0 9. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day for 7 days. Disp:7 7 Refills:0 Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Coronary Artery Disease, Aortic Stenosis - s/p AVR/CABG Type II Diabetes Mellitus Hypertension Dyslipidemia Discharge Condition: Good Discharge Instructions: Shower daily. No baths or swimming. No creams, powders or lotions to incisions. No lifting more than 10 pounds for 10 weeks No driving for one month and off all narcotics report any drainage or redness of incisions report any temperature greater than 101 Followup Instructions: Dr. [Last Name (STitle) 914] in 4 weeks ([Telephone/Fax (1) 170]), call for appt. Dr. [Last Name (STitle) ] in [1-30] weeks, call for appt Dr. [Last Name (STitle) ] in [1-30] weeks, call for appt Followup at [Hospital1 18] [Hospital Ward Name 121] 6 for wound check in 1 week. Completed by:[2191-9-14]	[ "41401", "4241", "2724", "25000", "4019" ]
Unit No: [Numeric Identifier 75659] Admission Date: [2159-11-9] Discharge Date: [2159-11-20] Date of Birth: [2159-11-9] Sex: M Service: NB HISTORY: Baby [Name (NI) ] [Known lastname 2624] [Known lastname 75660], twin #1, delivered at 33- 3/7 weeks gestation and was admitted to the newborn intensive care nursery for management of prematurity. Birth weight 1710 grams (25th percentile), head circumference 30.25 cm (25-50th percentile), length 43 cm (25-50th percentile). The mother is a 39-year-old gravida 3, para 2 now 4 mother with spontaneous twin gestation. Prenatal screens included blood type O negative, antibody screen negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune and group B strep unknown. The mother's medical history is noncontributory. The mother's obstetric history includes two spontaneous vaginal deliveries with both children alive and well. This pregnancy was complicated by twin gestation and preterm labor two weeks prior to delivery. She presented two weeks prior to delivery in preterm labor, was given betamethasone at that time. On the day of delivery, there was unstoppable preterm labor progressing to a spontaneous vaginal delivery under epidural anesthesia. Membranes were ruptured 7 hours prior to delivery for clear fluid. Intrapartum, the mother had an intrapartum fever of 100.4 degrees Fahrenheit. She received intrapartum antibiotics 7 hours prior to delivery. This infant emerged with a vertex presentation, was vigorous at delivery, was dried and bulb suctioned. Apgar scores were 8 at 1 minute and 8 at 5 minutes. PHYSICAL EXAMINATION: At discharge, weight 1825 grams, pink, well perfused infant in no distress. Anterior fontanel open, soft, flat. Ears, eyes, nose, within normal limits. Red reflex present bilaterally. Breath sounds clear and equal with easy work of breathing. Heart rate: Regular rate and rhythm without murmur. Normal S1, S2. Pulses +2, both femoral and brachial. Abdomen soft, nondistended, no masses, no organomegaly, bowel sounds present. Back straight, no dimples. Hips stable without click or clunks. Active, alert, normal tone. Reflexes and activity for age. HOSPITAL COURSE: Respiratory: Has always been in room air without respiratory distress. Respiratory rates ranged in the 30's-60's. Has not had apnea of prematurity. Cardiovascular: No murmur. Heart rate ranges 140's-160's. Recent blood pressure 84/33 with a mean of 44. Fluids, electrolytes and nutrition: Was initially on IV fluids plus started feeds on day of birth. Reached full volume feeds of breast milk or premature Enfamil by day of life 4. Has been all p.o. or breast feeding two days prior to delivery, taking adequate volumes with weight gain. At discharge, the infant is breast feeding or receiving breast milk with Enfamil powder to equal 24 calories per ounce. He is voiding and stooling appropriately. GI: Peak bilirubin on day of life 4 was 11.3. Was started on phototherapy. Phototherapy was discontinued on day of life 6. A rebound bilirubin has been stable, total of 8.4, the last being on [11-17] at 8 days of age. Hematology: The infant's blood type is O positive, direct Coombs is negative. Hematocrit on admission 50%. Infectious disease: Due to preterm labor and maternal fever, a CBC and blood culture were drawn on admission. The infant was started on ampicillin and gentamicin. The CBC was benign. The blood culture was negative. The antibiotics were stopped at 48 hours. Neurology: A head ultrasound indicated exam age appropriate sensory. Audiology hearing screen was performed with automated auditory brain stem response, passed both ears. Psychosocial: The mother has been staying in [Name (NI) 86]. She lives on [Hospital1 6687] with her husband and two other children. CONDITION ON DISCHARGE: Stable 11 day old, 35 week post menstrual age infant. DISPOSITION: Discharge home with parents. PRIMARY PEDIATRICIAN: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 45938]. [Street Address(2) 75661], [Hospital1 6687], [Numeric Identifier ]. Telephone number [Telephone/Fax (1) 45939]. CARE AND RECOMMENDATIONS: 1. Feeds: Ad lib breast or bottle feeding. When bottle feeding breast milk supplemented with Enfamil powder to equal 24 calories per ounce. The mother has recipe. 2. Medications: Ferrous sulfate 0.3 ml orally once a day, Poly-Vi-[Male First Name (un) ] 1 ml orally once a day. 3. Iron and vitamin D supplementation. Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. All infants fed predominantly breast milk should receive vitamin D supplementation at 200 international units which may be provided as a multivitamin preparation daily until 12 months corrected age. 4. Car seat position screening. Infant passed. 5. State newborn screen was sent on day of life 3 and at discharge and the results are pending. 6. Immunizations received: Received hepatitis B immunization on [2159-11-20]. 7. Immunizations recommended: Synagis RSV prophylaxis should be considered from [Month (only) ] through [Month (only) 958] if the infant meets any of the following 4 criteria: 1. Born at less than 32 weeks. 2. Born between 32-35 weeks with two of the following: Daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities or school age siblings. 3. Chronic lung disease. 4. Hemodynamically significant congenital heart disease. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts, out of home caregivers. This infant has not received rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks but fewer than 12 weeks of age. FOLLOWUP: Schedule recommended. Mother has appointment with primary care provider on [Name9 (PRE) 766], 27. The mother has DNA visit on Saturday, [11-25]. DISCHARGE DIAGNOSES: 1. Prematurity at 33-3/7 weeks gestation. 2. Appropriate for gestational age. 3. Twin #1. 4. Physiologic jaundice. 5. Sepsis ruled out. [First Name8 (NamePattern2) 73452] [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], M.D. [MD Number(2) 73453] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2159-11-19] 18:51:36 T: [2159-11-19] 19:46:31 Job#: [Job Number 75662]	[ "7742", "V053", "V290" ]
Admission Date: [2139-1-4] Discharge Date: [2139-1-11] Date of Birth: [2088-4-5] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: This 50 year old female with a long-standing complicated medical history presented for preoperative admission secondary to shortness of breath. She had been scheduled for mitral valve replacement, question aortic valve replacement, on [2139-1-6]. She noted that she became significantly more short of breath right prior to admission with dyspnea on exertion and positive paroxysmal nocturnal dyspnea. She also admitted to orthopnea. She had no chest pain or pressure at the time, no fever or chills or shakiness. She denied any productive cough or any other recent congestive heart failure symptoms. Her prior cardiac catheterization [2138-12-11], showed an ejection fraction of 69 percent, three plus mitral regurgitation, diffuse disease in her mid right coronary artery. PAST MEDICAL HISTORY: Type 1 insulin dependent diabetes mellitus. Retinopathy. Neuropathy requiring bilateral lower extremity braces. Coronary artery disease. Mitral regurgitation. Congestive heart failure. Diabetic ketoacidosis. Hypertension. Gastroesophageal reflux disease. Anxiety. Gastroparesis. Hypercholesterolemia. PAST SURGICAL HISTORY: Hysterectomy. Appendectomy. Ankle surgery. Bilateral atherectomy surgery. ALLERGIES: Ace inhibitors which produced severe cough. Codeine which made her itchy. MEDICATIONS ON ADMISSION: 1. Combivent two puffs four times a day. 2. Ativan 0.5 mg p.r.n. three times a day. 3. M.S. Contin sustained release 30 mg p.o. three times a day. 4. Lantus 18 units daily. 5. Regular insulin sliding scale which she was placed on at the time of admission. 6. Tegretol 400 mg p.o. twice a day. 7. Trazodone 300 mg to 400 mg p.o. q.h.s. 8. Zoloft 300 mg p.o. daily. 9. Terazosin 2 mg p.o. daily. 10. Reglan 10 mg p.o. four times a day. 11. Enteric-Coated Aspirin 81 mg p.o. daily. 12. Losartan 100 mg p.o. daily. 13. Lipitor 20 mg p.o. daily. 14. Atenolol 50 mg p.o. daily. SOCIAL HISTORY: She had a thirty pack year history of smoking and has only stopped smoking one week prior to admission. She had no history of alcohol or recreational drug use. LABORATORY DATA: On admission, white blood cell count was 10.2, hematocrit 34.0, platelet count 272,000. Blood gas was 7.43/52/88/26/plus [8-/2125]. Prothrombin time 13.4, INR 1.1, partial thromboplastin time 23.9. AST 35, ALT 28, alkaline phosphatase 97, total bilirubin 0.3, magnesium 1.4, TSH 1.3. Sodium on admission first draw 125, and repeat on hospital day two rose to 132, potassium 3.4, chloride 88, bicarbonate 31, blood urea nitrogen 14, creatinine 0.9 with a blood sugar of 312. HO[Last Name (STitle) ] COURSE: The patient was seen immediately on consultation by the renal service for evaluation of her hyponatremia. Magnetic resonance imaging performed on [2138-12-27], preoperatively showed left ventricular ejection fraction of 24 percent, right ventricular ejection fraction of 40 percent with severe mitral regurgitation. Urine studies were recommended. The patient continued on Lasix diuresis at 40 mg p.o. daily. On examination, she had no issues neurologically in terms of her mental status. Her heart was regular rate and rhythm, with a systolic ejection murmur. Her lungs were clear bilaterally without any rales or rhonchi. Her abdomen was soft, with no bowel sounds heard and nontender, nondistended. She had two plus peripheral edema with cellulitis of her right second toe. She had two plus bilateral carotid, radial and femoral pulses. She had biphasic dorsalis pedis pulse on the left and one plus on the right and monophasic posterior tibial pulse on the left and one plus on the right. The patient was admitted for evaluation and treatment of her congestive heart failure as well as monitoring of her cellulitis of her foot. Issues to be addressed immediately were the hyponatremia. The patient was somewhat unsteady on her feet due to her neuropathy and old right ankle fracture and as previously noted uses braces to ambulate. The patient was also monitored for the issue of cellulitis in her toe anticipating mitral valve replacement at this admission. The patient complained of not eating well and did have decreased bowel sounds on her admission. She was volume overloaded with lower extremity edema. Intravenous Lasix was given. The patient had fluid restriction and the plan was to time surgery when the issues had resolved. The patient was seen by Dr. [Last Name (STitle) ] from renal who also recommended one liter a day fluid restriction and recommended keeping her on her Tegretol. Also consultation by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 16471], the [Initials (NamePattern4) 228] [Last Name (NamePattern4) ] associated psychiatrist, who managed her Tegretol therapy. The patient was also seen by case management and her primary care physician, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], and the patient continued to receive diuresis. The patient was also seen by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], the neurology attending on consultation at the request of Dr. [Last Name (Prefixes) ] for concern of her hyponatremia and the risks it presented during cardiopulmonary bypass. The patient was evaluated for her risk of central pontine myelinolysis although this was reported to be rare and was evaluated for this risk by Dr. [Last Name (STitle) ]. After discussion with Dr. [Last Name (Prefixes) ], the patient was cleared for surgery from a neurologic point of view. On [2139-1-6], the patient underwent mitral valve replacement by Dr. [Last Name (Prefixes) ] with a 25 millimeter [Last Name (un) 3843]-[Doctor Last Name ] pericardial valve. She was transferred to Cardiothoracic Intensive Care Unit in stable condition on Neo-Synephrine drip at 0.6 mcg/kg/minute and a Propofol drip at 20 mcg/kg/minute. Approximately two hours after the operation, the patient continued to have significant hemorrhage and was returned to the operating room for resternotomy by Dr. [Last Name (Prefixes) ]. An exploration of bleeding and ligation of bleeding vessels. She was transferred back to the Cardiothoracic Intensive Care Unit on a Levophed drip at 0.03 mcg/kg/minute and titrated Propofol drip. Early on the morning of [2139-1-7], the patient was awake and alert. Propofol was weaned, Precedex was started and the patient was extubated. She remained on low dose Precedex overnight for her history of anxiety but the patient was alert and oriented, following commands and moving all extremities. On postoperative day number one, after her mitral valve replacement and take back for bleeding, she had received two intravenous Lasix doses for low urine output. She remained on the Precedex drip at 0.3 and Nipride drip at 0.7. Her insulin drip was off at the time. She also continued with Lasix diuresis and her Aspirin was restarted. She had a cardiac index of 3.3 and an output of 5.3. Postoperative laboratories were as follows: White blood cell count 8.1, hematocrit 30.8, platelet count 209,000. Prothrombin time 13.0, partial thromboplastin time 29.0, INR 1.1. Sodium 136, potassium 4.5, chloride 103, bicarbonate 26, blood urea nitrogen 7, creatinine 0.4 with a blood sugar of 77. She was alert and oriented and conversant with the nurses. Her lungs were clear bilaterally. Abdomen was soft, nontender, and as stated the patient was doing very well. Her beta blocker was started and she was weaned off the Nipride on postoperative day number two. Her hematocrit remained stable. Creatinine dropped slightly to 0.3. She was on a Neo-Synephrine drip at 1.0 which brought her blood pressure back up to 125/54. This had been started at 4:00 a.m. on the morning of [2139-1-8]. She also started Losartan and Hydralazine and was receiving Lasix 40 mg twice a day. She had only trace edema in her extremities. Her chest tubes were discontinued. The focus was on her blood pressure control. She was also seen by case management after her operation to help prepare for her discharge. On [2139-1-8], she was transferred out to the floor. She was switched over to Dilaudid for pain relief. She had her baseline discomfort in her feet secondary to her diabetic neuropathy. She had some scattered crackles and decreased breath sounds at the bases but was in sinus rhythm in the 90s. The pacing wires remained in place and grounded. She was switched back to her M.S. Contin at 30 mg twice a day for her neuropathy. She was encouraged to continue pulmonary toilet as she had denied using the incentive spirometry at all and this was emphasized by the nurses. On postoperative day number three, she was tachycardic at 113 with a stable blood pressure of 124/64, saturating 95 percent in room air. Terazosin and Trazodone were also started in the evening. She was alert and oriented with a nonfocal examination. She had no peripheral edema. Central venous line was removed. Pacing wires were removed without event. The patient was evaluated by physical therapy so she could start walking again and did walk 100 feet that day with nurse and physical therapist. On postoperative day number four, the patient continued to improve and was afebrile with a heart rate in the 80s and blood pressure 110/40. She continued to have significant insulin requirement as her blood sugars were elevated. Her examination was unremarkable though she did start to have some lower extremity edema again. TEDS were placed. Her laboratory work was unremarkable other than her sodium started to decrease and was 130, again on the morning of [2139-1-10]. The patient continued to work with physical therapy, was given repletion of Magnesium Sulfate. The patient continued to have sliding scale insulin coverage. It was recommended that she continue to have close follow-up with [Hospital ] Clinic and her physician there, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10088]. The patient was saturating 95 percent in room air. Her lungs were clear bilaterally. Heart was regular rate and rhythm. She did not have any significant edema on postoperative day number five in her lower extremities. It was determined that the patient could be discharged to home on [2139-1-11]. She was instructed to follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 10088], her [Last Name (un) ] physician, [Name10 (NameIs) 3] soon as she returned home. She was also instructed to follow-up with Dr. [First Name (STitle) ] [Last Name (Prefixes) 2545] for her postoperative surgical visit in approximately four weeks postdischarge. She was also instructed to follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], her primary care physician, [Name10 (NameIs) ] approximately two weeks and to see Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], her heart failure physician, [Name10 (NameIs) ] approximately two weeks. DISCHARGE DIAGNOSES: Status post mitral valve replacement with pericardial tissue valve. Insulin dependent diabetes mellitus, type I. Retinopathy. Neuropathy. Coronary artery disease. Congestive heart failure. Diabetic ketoacidosis. Hypertension. Gastroesophageal reflux disease. Anxiety. Gastroparesis. Hypercholesterolemia. Laboratories on the day of discharge were as follows: White blood cell count 8.9, hematocrit 26.1, platelet count 354,000. Sodium 128, potassium 4.1, blood urea nitrogen 6, creatinine 0.3, chloride 93, bicarbonate 30, blood sugar 67, calcium 7.3, phosphorus 2.7, magnesium 2.0. As the patient was stable, alert and oriented, it was determined that she could schedule her appointment with the [Last Name (un) ] physician as soon as she got home. Also follow-up with her chemistries. She was also instructed to adhere to her two gram sodium diet with fluid restriction. MEDICATIONS ON DISCHARGE: 1. Lasix 40 mg p.o. daily. 2. Colace 100 mg p.o. twice a day. 3. Enteric-Coated Aspirin 81 mg p.o. daily. 4. Dilaudid 2 mg tablets, one to two tablets p.o. p.r.n. q3- 4hours as needed. 5. Lipitor 20 mg p.o. daily. 6. Sertraline 300 mg p.o. daily. 7. Tegretol 400 mg p.o. twice a day. 8. Albuterol/Ipratropium 103-18 mcg aerosol one to two puffs q6hours. 9. Metoprolol 50 mg p.o. twice a day. 10. M.S. Contin 30 mg one tablet p.o. three times a day for ten days. 11. Final dosing of insulin is not recorded in the chart. DISCHARGE STATUS: The patient was discharged to home in stable condition on [2139-1-11]. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 1288] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2139-2-11] 11:08:50 T: [2139-2-11] 19:01:46 Job#: [Job Number 104936]	[ "2761", "53081", "4019" ]
Admission Date: [2132-12-7] Discharge Date: [2132-12-11] Date of Birth: [2078-11-12] Sex: M Service: MEDICINE Allergies: Tetanus / Glucophage Attending:[First Name3 (LF) 358] Chief Complaint: chest pain Reason for MICU Admission: Monitoring Overnight for HCT drop Major Surgical or Invasive Procedure: endoscopy colonoscopy History of Present Illness: This is a 54yoM w/h/o laparoscopic gastric bypass([6-29]) transferred from an OSH who p/w chest pain, HCT drop, and paricardial effusion. He notes that 2 weeks ago he picked up a fire hydrant "to get it from point A to point B." 2 days later, he had CP across his chest BL, stabbing [8-31] worse w/breathing. He went to a clinic(not regular PCP) where he was prescribed prednisone and lortab(vicodin) which he took for 7 days and resolved the pain. After completion, the same CP recurred but he did not take anything more for the pain. He traveled to the [Location (un) 86] area with his mother to visit family. Because of the severity of the CP, his family brought him to the [Hospital1 3325] ED. . There, he was afebrile HR 124, BP 118/88. EKG revealed sinus tachycardia w/poor R-wave progression and TWI in V4-V6. He had guiac +stools and HCT 27.9. Cardiac enzymes were negative x 1. He recieved 1L NS, 1 unit of PRBCs, Zosyn 3.375mg IV x1, protonix IV x 1, and dilaudid IV for [10-31] stabbing left sided CP. CT chest/abdomen/pelvis was negative for PE but revealed a 2cm pericardial effusion and bilateral pleural effusions. . He was transferred here for further evaluation of GIB. . In the ED, Tm 99.7 HR 112 BP 143/86 O2sat100%2L. He received 1 unit PRBCs at [Hospital3 3583]. TTE in ED revealed 2cm pericardial effusion w/o tamponade physiology. GI was consulted and Cardiology made aware; they felt that there was no need for emergent TTE. He received Morphine and Fentanyl IV for pain. . Currently, the patient endorses [8-31] stabbing chest pain which he describes as worst w/lying on his left side, worse w/deep breaths, and sitting up, associated w/SOB. He notes that he had an + episode of diarrhea this AM, otherwise denies melena/BRBPR/abdominal pain, or N/V. He endorses an episode of lightheadedness this AM. Able to complete 4 mets at home. He otherwise denies any fevers, chills, URI sx, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. . Past Medical History: laparascopic gastric bypass [2132-6-28] normal colonoscopy [12-28] MI at age 25years Bipolar d/o Polysubstance abuse . Social History: Lives on a farm next door to his mother. On disability due to bipolar disease, + etoh abuse 3/5s hard liquor per week up to 2 weeks ago, h/o cocaine and IV heroin use quit 35 years ago, 25 pack year smoking hx, quit 1 year ago. . Family History: colon cancers, unknown etiology Physical Exam: On Presentation: Vitals: T: 96.3 BP: 138/99 HR: 114 RR: 19 O2Sat: 99% 2LNC orthostatics lying flat: BP 125/76 HR 116, sitting BP 120/80 HR 121 No pulsus noted GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, pale anicteric sclera, no epistaxis or rhinorrhea, dry MM, 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 Rectal: melenotic stool, guiac + 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. . Discharge: AF,VSS Gen-- pleasant, NAD, ambulating Heart -- regular Lungs -- clear, Abd -- benign Pertinent Results: OSH: WBC 23.7 HCT 27.9 136 100 44 ------------< 280 4.2 26 1.05 Albumin 3.0 T. bili 0.5 CK 27 . [2132-12-7] 03:30PM WBC-18.2* RBC-3.12* HGB-9.2* HCT-27.2* MCV-87 MCH-29.4 MCHC-33.7 RDW-14.9 [2132-12-7] 03:30PM NEUTS-85.9* LYMPHS-9.9* MONOS-3.7 EOS-0.2 BASOS-0.3 [2132-12-7] 03:30PM PLT COUNT-451* . [2132-12-7] 03:30PM PT-14.1* PTT-23.2 INR(PT)-1.2* . [2132-12-7] 03:30PM GLUCOSE-188* UREA N-37* CREAT-1.0 SODIUM-139 POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-29 ANION GAP-9 [2132-12-7] 03:30PM ALT(SGPT)-12 AST(SGOT)-8 CK(CPK)-20* ALK PHOS-54 TOT BILI-0.4 [2132-12-7] 03:30PM LIPASE-682* [2132-12-8] 05:59AM BLOOD Lipase-43 . [2132-12-7] 03:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-NEG [2132-12-7] 09:42PM URINE RBC-<1 WBC-5 BACTERIA-NONE YEAST-NONE EPI-<1 . [2132-12-7] 03:30PM cTropnT-<0.01 [2132-12-7] 03:30PM CK-MB-NotDone [2132-12-8] 05:59AM BLOOD CK-MB-2 cTropnT-<0.01 [2132-12-8] 05:59AM BLOOD CK(CPK)-17* . ECG: Sinus rhythm at 117 bpm, poor R-wave progress, TWI in V4-V6, earlier EKG on day of admission from OSH the same except for HR of 129 otherwise no comparison. . OSH Imaging: OSH CT chest/abdomen/pelvis: No abnormal fluid collections/free air; no acute intra bowel abnormalities, no evidence of pancreatitis. No evidence of PE, Pericardial effusion ~2cm, subcentimeter mediastinal LNs, small left and tiny right pleural effusions. CXR: negative for acute intrathoracic pathology . Dischage: [2132-12-11] 06:25AM BLOOD WBC-8.2 RBC-3.45* Hgb-10.1* Hct-30.9* MCV-90 MCH-29.2 MCHC-32.6 RDW-14.3 Plt Ct-596* [2132-12-8] 05:59AM BLOOD PT-15.1* PTT-24.9 INR(PT)-1.3* [2132-12-11] 06:25AM BLOOD Glucose-133* UreaN-11 Creat-0.9 Na-139 K-4.3 Cl-102 HCO3-29 AnGap-12 [2132-12-7] 03:30PM BLOOD ALT-12 AST-8 CK(CPK)-20* AlkPhos-54 TotBili-0.4 [2132-12-8] 05:59AM BLOOD Lipase-43 [2132-12-8] 05:59AM BLOOD CK-MB-2 cTropnT-<0.01 [2132-12-7] 03:30PM BLOOD cTropnT-<0.01 [2132-12-9] 06:15AM BLOOD Calcium-8.2* Phos-2.4* Mg-2.2 [2132-12-8] 05:59AM BLOOD Triglyc-112 [2132-12-7] 09:42PM URINE Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.032 [2132-12-7] 09:42PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [2132-12-7] 09:42PM URINE RBC-<1 WBC-5 Bacteri-NONE Yeast-NONE Epi-<1 ========= SPECIMEN SUBMITTED: GI BX'S, 2 JARS. Procedure date Tissue received Report Date Diagnosed by [2132-12-10] [2132-12-10] [2132-12-14] DR. [Last Name (STitle) ] [Last Name (NamePattern4) ]-[Doctor Last Name ]/dsj?????? DIAGNOSIS: 1. Colon, sigmoid; polypectomy (A) Surface hyperplastic change. 2. Colon, rectum; polypectomy (B) Hyperplastic polyp. ========= UPPER GI: Initial scout image demonstrates a moderate-sized left pleural effusion, with associated atelectasis and consolidation of the left lower lobe. Anastomotic sutures are seen within the left upper quadrant of the abdomen. The patient drank Conray without difficulty, with Conray passing freely into the stomach and small bowel loops, without holdup, atony, or obstruction. No leak was identified within the gastrojejunal anastomosis. Patient subsequently drank thin barium to exclude an occult leak, and no leak was identified. Delayed images demonstrate contrast passage into small bowel loops within the lower abdomen. The afferent limb of the anastomosis is not identified on this study. IMPRESSION: No leak identified in the region of gastrojejunal anastomosis. The afferent loop of the gastric bypass is not identified. ========== Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.9 cm <= 4.0 cm Left Atrium - Four Chamber Length: 6.2 cm <= 5.2 cm Right Atrium - Four Chamber Length: 5.7 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 3.7 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 60% >= 55% Left Ventricle - Stroke Volume: 75 ml/beat Left Ventricle - Cardiac Output: 7.01 L/min Left Ventricle - Cardiac Index: 3.25 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': 0.08 m/s > 0.08 m/s Left Ventricle - Septal Peak E': 0.10 m/s > 0.08 m/s Left Ventricle - Ratio E/E': 12 < 15 Aorta - Sinus Level: 3.3 cm <= 3.6 cm Aorta - Ascending: 2.8 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec Aortic Valve - LVOT VTI: 24 Aortic Valve - LVOT diam: 2.0 cm Mitral Valve - E Wave: 1.1 m/sec Mitral Valve - A Wave: 0.7 m/sec Mitral Valve - E/A ratio: 1.57 Mitral Valve - E Wave deceleration time: 106 ms 140-250 ms TR Gradient (+ RA = PASP): <= 25 mm Hg <= 25 mm Hg Pericardium - Effusion Size: 1.4 cm Findings LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. No MS. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: No PS. PERICARDIUM: Small to moderate pericardial effusion. Stranding is visualized within the pericardial space c/w organization. No echocardiographic signs of tamponade. Conclusions The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is a small to moderate sized pericardial effusion. Stranding is visualized within the pericardial space c/w organization. There are no echocardiographic signs of tamponade. ============== CXRPortable AP chest radiograph was reviewed with no prior studies available for comparison. The heart size is enlarged but according to the clinical history, the patient has known pericardial effusion. There is left retrocardiac consolidation with accompanied pleural effusion which might represent either atelectasis or infectious process. A smaller area of involvement is seen in the right lower lobe which may represent a focus of infection as well. The upper lungs are unremarkable. No evidence of edema is seen. IMPRESSION: Mild-to-moderate cardiomegaly consistent with known pericardial effusion. Left pleural effusion, small to moderate. Left retrocardiac consolidation which may represent a combination of atelectasis and pneumonia Brief Hospital Course: This is a 54yoM w/h/o laparoscopic gastric bypass who was transferred from an OSH for evaluation of GIB and management of his pericardial effusion. # GIB: Initially thought likely related to ulcerated surgical anastamosis, in light of recent steroid use. Hct initially of 27 then dropped to 25. He was transfused 2 U PRBC and placed on IV ppi. He underwent endoscopy and colonoscopy, both of which did not show any source of possible bleeding. He did have two small polyps removed in his colon, with path showing hyperplastic polyps. The pathology returned after his discharge, so results were not discussed with him. He had no recurrent episodes of blood loss. He was advised to discuss capsule endoscopy with his providers in [State 33977]. . # Pleuritis and pericardial effusion: w/o evidence of tamponade physiology; most likely pericarditis ? viral. Elevated lipase which resolved within 24 hrs and no evidence of pancreatitis on CT at OSH. No h/o recent URI/viral sx but difficult to rule out. He will follow up with his cardiologists in [State 33977]. He was advised to return to the hospital with any recurrent pain. He was also advised not to drive while taking the Percocet prescribed. - cardiac enzymes negative x 2 - pain improved throughout hospitalizaiton - no NSAIDS due to GIB . # leukocytosis: in the setting of having been on recent steroids; he has been afebrile and w/o subjective fevers. Received Zosyn at OSH. WBC normalized prior to discharge. - blood negative, urine cx negative . # Polysubstance Abuse: last drink 10 days ago, no h/o withdrawal seizures - normal LFTs, but increased INR - SW consult, advised to abstain from alcohol. . Medications on Admission: Abilify 10 mg daily MTV Calcium/vit D Discharge Medications: 1. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for 7 days. Disp:40 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: 1. pericarditis/pericardial effusion 2. acute on chronic blood loss anemia from GI bleeding Discharge Condition: Stable, Hct 30%. Discharge Instructions: You were hospitalized with chest pain and blood loss from your bowels. Your chest pain is from pericarditis, and you should follow up with a cardiologist in [State 33977] to repeat the heart ultrasound (echocardiogram) in a few weeks. You had an endoscopy and colonoscopy in the hospital to evaluate bleeding, and no source of blood was found. You may need to have a capsule endoscopy to visualize the rest of your bowels. Please discuss this with your doctors [First Name (Titles) ] [Last Name (Titles) ]. Call you primary care physician or return to the hospital if you have increasing chest pain, shortness of breath, fever greater than 101, blood in your stool, lightheadedness or any other concerns. Do not drive while taking the pain medication prescribed. Followup Instructions: See you primary care doctor and your cardiologist in TN.	[ "2851", "5180" ]
Admission Date: [2130-6-23] Discharge Date: [2130-6-26] Date of Birth: [2079-4-22] Sex: M Service: NEUROSURG HISTORY OF PRESENT ILLNESS: The patient is a 51 year old gentleman with a two month history of headache worsening over the last week with minor word finding difficulties. The patient is a right-handed gentleman with a long-standing history of Crohn's Disease on maintenance doses of Asacol who presents with a two month history of chronic low grade dull global headache and approximately one week of progressive intense headache with one week of vague mental status changes and occasional word finding difficulties. PAST MEDICAL HISTORY: 1. As above, Crohn's Disease. 2. History of depression. PAST SURGICAL HISTORY: 1. Colectomy with distal ileotomy for Crohn's Disease in [2129-11-12] with no sequelae. MEDICATIONS: 1. Celexa. 2. Asacol. ALLERGIES: The patient has no known allergies. PHYSICAL EXAMINATION: On physical examination, the patient was afebrile, 96.9 F.; 126/76; 64 is heart rate; 20 is his respiratory rate; 95% on room air. Neurologically: Pupils equally round and reactive to light. Extraocular muscles are full. Visual fields full to confrontation. Smile is symmetric. Neck supple. Chest clear to auscultation. Cardiac is normal sinus rhythm with no murmurs, rubs or gallops. Abdomen soft, positive bowel sounds in all four quadrants, nontender. Extremities with no cyanosis, clubbing or edema. Neurologically, mentation is slightly slow, perseverative with minor word finding inconsistencies. Calculations: Simple addition okay but poor with subtraction. Objects: Naming three out of three within normal limits. Pupils 2.5 down to 1.5, briskly reactive. Extraocular muscles are full with no nystagmus. Visual fields within normal limits to gross examination. Strength: He has mild right upper extremity four plus out of five paresis all major muscle groups compared to the left. Sensation is intact to light touch throughout. Deep tendon reflexes are two plus in the upper extremities and one plus at the ankles. No clonus. Positive mild right drift with no ataxia. LABORATORY: On admission, white blood cell count 7.1, hematocrit 39.2, platelets 101, INR 1.2, PT 12.9, PTT 25, 139/3/5, 102/28; 11/1.0; 96. CT scan shows a large left frontal parietal subacute subdural hematoma with shift and compression of the left lateral ventricle system. The subdural has membranes present. HOSPITAL COURSE: The patient had bedside drainage of the subdural hematoma in the Surgical Intensive Care Unit by Dr. [Last Name (STitle) 35957]. The procedure was tolerated well. The patient remained flat on bed rest. The patient had a repeat head CT scan on [2130-6-24], which showed good evacuation of subdural hematoma. The drain was discontinued and the patient was transferred to the regular floor where he remained neurologically stable. He was discharged on [2130-6-26], in stable condition with stable vital signs, awake, alert, oriented. No drift. DISCHARGE INSTRUCTIONS: 1. The patient will follow-up with Dr. [Last Name (STitle) 1327] in two weeks time with repeat head CT scan [7-12], at 12 p.m. DISCHARGE MEDICATIONS: 1. Percocet one to two tablets p.o. q. four hours p.r.n. 2. Celexa. 3. Asacol. CONDITION AT DISCHARGE: The patient was in stable condition at the time of discharge. [Name6 (MD) 1339] [Last Name (NamePattern4) 1340], M.D. [MD Number(1) 1341] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2130-6-26] 11:16 T: [2130-6-28] 13:05 JOB#: [Job Number ]	[ "311" ]
Admission Date: [2193-10-26] Discharge Date: [2193-11-8] Service: MEDICINE Allergies: Ace Inhibitors Attending:[First Name3 (LF) 1257] Chief Complaint: confusion Major Surgical or Invasive Procedure: joint aspiration joint washings by orthopaedics. MRI head CT head TTE History of Present Illness: [Age over 90 ] y.o female with chronic kidney disease, [Age over 90 499] CA s/p hemicoloectomy, HTN, DVT and recently hospitalized here from [Date range (1) 14455] with falls, mental status changes and found to have Klebsiella pneumoniae UTI and was treated with Cipro. She now returns to ER with family with complaint of a few weeks of generalized weakness and confusion. Per the family she has been complaining of right shoulder pain and right foot pain over the last few weeks. She also had difficulty getting off of the commode a few days ago. Prior to this episode she has been living independently at home. On admission to the ER she was found to be hypothermic with temps of 90.1 in ER. Her U/A on admission with + nitrite and she was given Cipro and Flagyl for possible UTI. A CXR and head CT done in the ED were without any acute abnormalities. Overnight she was found to be minimally responsive. She has remained hemodynamically stable but with blood pressure below her baseline. Temperatures have increased to 97 after warm saline and bear hugger blanket. Now urine cx with S. aureus, blood cultures with GPC in pairs and clusters. Patient also noted to have loud systolic heart murmur that is felt to be new. After blood cultures and urine cultures reported she was given 1 dose of Vancomycin 1 gram IV x 1. Past Medical History: CRI 1)[Date range (1) ] cancer - s/p R hemicolectomy; 5FU, leucovorin 2)Venous insufficiency 3)HTN 4)Glaucoma 5)Hyperlipidemia 6)Osteoarthritis 7)DVT 8)Anemia 9)Hyperparathyroidism 10)GERD 11)IBS 12)Serous Cystadenofibroma; s/p E-lap, BSO 13)Lung nodule? (no change in CT scan [2184] -> [2187]) Social History: Lives alone. Nephew is HCP/POA and helps pt with shopping/chores. Never married and no children. Denies tobacco and alcohol. Family History: Mother w/ ovarian cancer and brother w/ [Name2 (NI) 499] cancer. No CAD to her knowledge. Physical Exam: VS: Temp: 96.8 BP: 108/52 HR: 83 RR: 16 O2sat: 95 RA . Gen: In NAD, A+O x2 HEENT: EOMI. MM slightly dry Neck: Supple, no JVP elevation. Lungs: CTA bilaterally, no wheezes, rales, rhonchi. Normal respiratory effort. CV: RRR, SEM, rubs, gallops. Abdomen: soft, NT, ND, NABS, no HSM. Extremities: warm and well perfused, no cyanosis, clubbing, edema. Neurological: alert and oriented X 2, knows its [2192], is unsure who is president Skin: No rashes or ulcers. Psychiatric: Appropriate. Pertinent Results: EKG: SR at 70 RBBB, not significantly changed from ECG [2193-10-7] . Imaging: Head CT: wet read No acute IC process . CXR: IMPRESSION: No acute intrathoracic pathology. Brief Hospital Course: Patient is a [Age over 90 ] year old female with medical history pertinent for CKD, [Age over 90 499] cancer, DVT who presents with delirium secondary to MRSA sepsis. Source was not initially clear but repeat blood cultures were negative. She was continued on Vancomycin with dose increased to 1500 mg Q24. She had MRI shoulder most consistent with a neuropathic joint but effusion was noted. The Joint was aspirated with results are as follows: WBC 12.5K, 100% Polys, but gram stain and cultures showing staph aureus. She underwent surgical washout of the joint which did not reveal any pus. She had TTE which was negative for endocarditis. We did not do [Age over 90 ] because of the family's hesitancy with pursuing [Age over 90 ]. Now She will at least be treated with 6 weeks of antibiotics given joint involvement, it may not be unreasonable to not pursue [Age over 90 ]. We discussed with nephew, [Name (NI) 122] [Name (NI) 14456], also the HCP, that [Name2 (NI) ] is the more sensitive study but more invasive. Family does not want to pursue [Name2 (NI) ]. Her altered Mental Status was attributed to MRSA sepsis (delirium) but this resolved completely. Head CT X2 on admission was negative for acute event. MRI brain limited study but negative for acute changes as well. She also developed thrombocytopenia related to sepsis and resolved completely. She also developed progressive anemia requiring 2 units of RBC's. She will go to rehab to receive long term antibiotics. Her last Vancomycin dose will be by the end of [Month (only) 1096]. The ID fellow Dr. [Last Name (STitle) 976] will follow up with weekly labs and appointment on [Month (only) ]/30th. . #. Chronic Kidney Disease, Stage III. - stable, monitor . #. HTN: controlled w metoprolol. she was restarted on lower dose of Lasix because of poor PO intake ( full dose of 40 MG can be restarted if she drinks well) . #. Diet: thickened liquids, pureed solids only when awake with assistance. Speech pathology was following her. . #. DNR/DNI - discussed with HCP, [Name (NI) ] (nephew) . #. Contact: [Name (NI) ], HCP (nephew)--[Telephone/Fax (1) 14457] or [Telephone/Fax (1) 14458]; [Name (NI) ] wife, [Name (NI) 2808], [Telephone/Fax (1) 14459] . . . Total discharge time 68 minutes. Medications on Admission: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 5 days. Disp:5 Tablet(s) Refills:0 2. Alendronate-Vitamin D3 70-5,600 mg-unit Tablet Sig: One (1) Tablet PO once a week. 3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. ELESTAT 0.05 % Drops Sig: One (1) drop Ophthalmic [Hospital1 ] (2 times a day). 7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Medications: 1. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 2. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 6. Vancomycin 1250 mg IV Q 24H for 6 weeks starting from [2193-10-27]. 7. Alendronate-Vitamin D3 70-5,600 mg-unit Tablet Sig: One (1) Tablet PO once a week. 8. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 9. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 10. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 12. Outpatient Lab Work weekly CBC and Creatinine/BUN levels. Please fax the results to Dr.[Name (NI) 14460] Office at [Telephone/Fax (1) 14461]. Discharge Disposition: Extended Care Facility: [Location (un) 582] - [Location (un) ] Discharge Diagnosis: MRSA sepsis/endovascular infection possible septic arthritis Acute confusional state related to sepsis Discharge Condition: Excellent Discharge Instructions: you will receive vancomycin for about 6 weeks for possible endovascular infection/[Doctor Last Name 14462] arthritis. your first dose was on [2193-10-27]. Last dose should be 0n [2193-12-7]. you should have weekly blood tests and the results faxed to Dr [First Name8 (NamePattern2) 4035] [Last Name (NamePattern1) ] office with infectious disease. His Fax is [Telephone/Fax (1) 14461]. Followup Instructions: [Last Name (LF) ],[First Name3 (LF) ] A. [Telephone/Fax (1) 1144] Dr [First Name8 (NamePattern2) 4035] [Last Name (NamePattern1) ] office on [2193-12-10] with infectious disease.	[ "5990", "40390", "2724", "53081", "41401" ]
Admission Date: [2156-4-9] Discharge Date: [2156-4-13] Date of Birth: [2087-4-12] Sex: F Service: CARDIOTHORACIC SURGERY The patient is a 68-year-old female with a past medical history significant for type II diabetes, hyperlipidemia, hypertension, hypothyroidism who presents as a transfer from an outside hospital with a current angina and a question of cardiac ischemia. The patient has a DRUG ALLERGY TO ISORDIL, quit smoking approximately four weeks ago but has an approximate 30 pack year history of smoking, denies alcohol or drugs and a family history of a mother and a father both with coronary artery disease. The patient was transferrred to our facility, admitted to the medical service and underwent a cardiac catheterization which demonstrated a 90% ostial calcified lesion of the left main coronary artery. LAD without disease, however the patient had a right coronary artery with a moderate 50% to 60% stenosis. Based on these findings, consultation with the cardiothoracic surgical service was undertaken. The patient was deemed an appropriate candidate for coronary artery bypass grafting, so on [2156-4-10], the patient was taken to the Operating Room and underwent an off pump coronary artery bypass graft x2. Her grafts were left internal mammary artery to LAD and saphenous vein to OM. The patient tolerated the procedure well and there were no complications. She was transferred to the cardiac surgery recovery unit on no drip. She extubated without incident. The remainder of her postoperative course in the Intensive Care Unit was uneventful and she was transferred to the floor. On the floor, she continued to do well. Her chest tubes, Foley catheter and pacing wires along with her [Location (un) 1661]-[Location (un) 1662] drain were discontinued on postoperative day #2. She was working with physical therapy, ambulating, tolerating a regular diet and will be discharged home on postoperative day #3. DISCHARGE CONDITION: Stable DISCHARGE STATUS: Home DISCHARGE MEDICATIONS; 1. Plavix 75 mg po qd 2. Metoprolol 25 mg po bid 3. Lasix 20 mg po bid 4. Colace 100 mg po bid 5. ASA 325 mg q day 6. Percocet 5/325 1 to 2 po q 4 to 6 hours for pain 7. Synthroid 100 mcg po qd 8. Lipitor 20 mg po qd 9. Glyburide 5 mg po qd 10. Accupril 20 mg po qd 11. Protonix 40 mg po qd FOLLOW UP: The patient should follow up with her primary care physician and with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1537] of cardiothoracic surgery in two to four weeks. [First Name11 (Name Pattern1) 275] [Last Name (NamePattern4) 1539], M.D. [MD Number(1) 1540] Dictated By:[Last Name (NamePattern1) 22409] MEDQUIST36 D: [2156-4-12] 09:07 T: [2156-4-12] 09:15 JOB#: [Job Number 41228]	[ "41401", "2724", "4019", "2449", "V1582" ]
Admission Date: [2148-4-6] Discharge Date: [2148-4-12] Date of Birth: [2099-8-6] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1190] Chief Complaint: found at home by husband, unresponsive Major Surgical or Invasive Procedure: Artificial ventilation History of Present Illness: 48 yo woman with HIV/AIDS (last CD4 40/VL 78K), HTN, HepC, asthma, was found at home by her husband 5 days ago with epistaxis and decreased mental status. She was brought to the [Hospital1 2177] ED and was found to have labored breathing, was unresponsive. CT of the head at [Hospital1 2177] showed left basal ganglia hemorrhage, likely originating in the thalamus and extending into the ventricles causing a 4 mm midline shift. The pt was intubated and hypoventilated, given mannitol 60 mg x 1, vitamin K 10 mg sq, labatolol, and 6 Units of FFP. She was evaluated by Neurosurgery at [Hospital1 2177] and was not thought to be a surgical candidate. She was then transferred to the [Hospital1 18] for further care. Past Medical History: 1. AIDS - diagnosed 12 years ago. Her most recent CD4 = 79 ([2147-12-29] per report). Pt was started on HAART at [Hospital1 112], which was self-discontinued for the past 1 year secondary to side effects (stiffness in lower extremities). She has since transferred care to her PCP, [Name10 (NameIs) ] has not restarted therapy 2. HCV - Increased AFP w/ negative MRI liver [7-19], with some evidence of portal htn on abd u/s per report. She has since refused treatment and liver bx. 3. Asthma/COPD 4. Pancytopenia 5. Depression 6. Substance abuse (cocaine, EtOH) Social History: Pt currently lives in home with her boyfriend of 16 years and his son. She has two sons from a previous relationship. She has recent cocaine and heavy alcohol use over past 2 months. No IVDU; occassional drinking. Family History: Notable for hx of diabetes in mother and heart disease in brother, but reports no family hx of cancer. Physical Exam: VS BP 96/47, HR 66, RR 17, O2 sat 93% RA Gen: ill-appearing woman unresponsive to questions, lying in bed with eyes closed and NP airway in mouth HEENT: MMM, no JVD CV: reg s1/s2, no s3/s4/m/r Pulm: CTA anteriorly, no crackles or wheezes Abd: +BS, soft, ND Ext: warm, no edema Neuro: unresponsive to questions, remainder of exam deferred for pt and family comfort Pertinent Results: [2148-4-6] 12:41PM WBC-2.2* RBC-1.93# HGB-6.5# HCT-19.7# MCV-102 MCH-33.5* MCHC-32.9 RDW-17.9* [2148-4-6] 12:41PM PLT COUNT-72* [2148-4-6] 12:41PM NEUTS-80.2* LYMPHS-15.4* MONOS-2.7 EOS-1.1 BASOS-0.5 [2148-4-6] 12:41PM PT-14.2* PTT-38.5* INR(PT)-1.3 [2148-4-6] 12:41PM FIBRINOGE-142# [2148-4-6] 12:41PM GLUCOSE-87 UREA N-21 CREAT-0.9 SODIUM-141 POTASSIUM-3.8 CHLORIDE-115* TOTAL CO2-19* ANION GAP-11 [2148-4-6] 12:41PM ALBUMIN-2.9* CALCIUM-7.8* PHOSPHATE-3.8 MAGNESIUM-1.8 [2148-4-6] 12:41PM ALT(SGPT)-29 AST(SGOT)-61* LD(LDH)-325* ALK PHOS-94 TOT BILI-0.5 [2148-4-6] 12:41PM HAPTOGLOB-27* [2148-4-6] 12:41PM OSMOLAL-303 [2148-4-6] 01:20PM LACTATE-1.6 [2148-4-6] 01:20PM TYPE-ART TEMP-37.2 TIDAL VOL-600 PEEP-0 O2-100 PO2-390* PCO2-27* PH-7.44 TOTAL CO2-19* BASE XS--3 AADO2-307 REQ O2-56 INTUBATED-INTUBATED VENT-CONTROLLED [2148-4-6] 03:23PM URINE COLOR-Straw APPEAR-Clear SP [Last Name (un) 155]-1.034 [2148-4-6] 03:23PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [2148-4-6] 03:23PM URINE RBC-[1-5]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-[4-20] Head CT: 1. Large intracranial hemorrhage in the left hemisphere with involvement of the bilateral lateral ventricles and 3rd ventricle. There is mild shift of the rightward shift of the midline structures, and significant diffuse brain edema with effacement of all of the sulci. Unfortunately the comparison is not avaiable. 2. There is loss of the [Doctor Last Name 352]/white matter differentiation a portion of the left parietal lobe. 3. Fluid blood level is noted in the left temporal lobe, of uncertain clinical significance. Brief Hospital Course: A/P: 48-year-old woman w/ h/o HIV/AIDS, chronic HCV, asthma was admitted to MICU w/ spontaneous intracerebral hemorrhage, now transferred to Medicine for continued palliative care. 1. Intracerebral hemorrhage: she was found unresponive by her boyfriend at home, and was taken to [Hospital1 2177] where head CT demonstrated large intracerebral hemorrhage as per the HPI. At [Hospital1 18], repeat head CT confirmed left sided intracerebral hemorrhage causing midline shift. This was of unclear etiology. Possible causes include aneurysm, occult trauma, cocaine use w/ subsequent HTN, and spontaneous bleed in the setting of coagulopathy. She was admitted to the MICU, placed on SIMV, and did not show spontaneous breathing. Admission exam was notable for upgoing Babinski, no corneal reflexes, possible posturing to pain, and fixed dilated pupils. She was initially treated w/ mannitol to reduce intracerebral pressure and loaded w/ dilantin for seizure prevention. Evaluation by Neurosurgery confirmed that she was not a surgical candidate. Neurology evaluation indicated very poor prognosis, and virtually no chance of meaningful recovery. The pt spent 5 days in the MICU in which she did not demonstrate any functional improvement. On HD#5, a family meeting was held that resulted in a decision by the family to pursue palliative care. The pt was extubated at that time and was started on morphine gtt for comfort. She was then transferred to the Medicine floor for ongoing palliative care. Treatment was continued w/ morphine gtt, ativan prn for agitation, and scopolamine patch to control production of secretions. She appeared to be comfortable during the rest of her hospital stay. She died on [2148-4-12]. The next of [Doctor First Name ] declined post-mortem examination. Medications on Admission: 1. prozac 2. bactrim ss daily 3. albuterol INH prn Discharge Disposition: Expired Discharge Diagnosis: intracerebral hemorrhage Discharge Condition: deceased	[ "51881", "2762", "4019" ]
Admission Date: [2115-12-3] Discharge Date: [2116-1-1] Date of Birth: [2045-1-27] Sex: F Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 52022] Chief Complaint: Bilateral knee pain / osteoarthritis Major Surgical or Invasive Procedure: Bilateral total knee arthroplasy Placement of IVC filter History of Present Illness: 70 year old woman with a history of hypertension, osteoarthritis, herpes simplex encephalitis w/ secondary seizure disorder and memory loss with a history of increasing bilateral knee pain and difficulty with ambulation presents to [Hospital1 18] for elective bilateral total knee replacement. Past Medical History: 1. Hypertension 2. Osteoarthritis 3. Seizures and memory loss due to encephalitis 4. HSV encephalitis [2108] Social History: Mandarin speaking, lives with husband and has daughters who assist with her care. No history of tobacco or alcohol. Family History: non-contributory Physical Exam: PE: VS: T 94.2 ax 95.7 po HR 75 BP 100/63 RR O2 sat 100% Gen: Intubated and sedated. HEENT: PERRLA EOMI MM pink and moist CV: RRR no m/r/g Lungs: CTA anterior exam soft, NT, ND normoactive BS Bilateral knee incisions clean, dry, and intact. Pertinent Results: [2115-12-16] 06:05AM BLOOD WBC-9.9 RBC-3.88* Hgb-11.6* Hct-34.8* MCV-90 MCH-29.8 MCHC-33.3 RDW-15.2 Plt Ct-559* [2115-12-15] 06:00AM BLOOD WBC-9.9 RBC-3.80* Hgb-11.4* Hct-33.8* MCV-89 MCH-30.0 MCHC-33.7 RDW-15.4 Plt Ct-499* [2115-12-14] 06:10AM BLOOD WBC-11.3* RBC-3.68* Hgb-11.5* Hct-33.2* MCV-90 MCH-31.3 MCHC-34.7 RDW-16.8* Plt Ct-408 [2115-12-13] 07:30PM BLOOD Hct-34* [2115-12-13] 01:00PM BLOOD Hct-34.9* [2115-12-13] 06:00AM BLOOD Hct-29.0* [2115-12-13] 06:00AM BLOOD WBC-11.3* RBC-3.61* Hgb-11.3* Hct-32.2* MCV-89 MCH-31.3 MCHC-35.1* RDW-17.1* Plt Ct-358 [2115-12-12] 11:50PM BLOOD Hct-32.6* [2115-12-12] 04:42AM BLOOD WBC-10.0 RBC-3.72* Hgb-11.3* Hct-31.6* MCV-85 MCH-30.3 MCHC-35.7* RDW-16.1* Plt Ct-280 [2115-12-11] 09:01PM BLOOD Hct-31.9* Plt Ct-263 [2115-12-11] 01:24PM BLOOD WBC-10.3 RBC-3.67* Hgb-11.5* Hct-32.1* MCV-88 MCH-31.4 MCHC-35.9* RDW-17.0* Plt Ct-235 [2115-12-11] 05:45AM BLOOD WBC-10.3 RBC-3.67* Hgb-11.3# Hct-31.8 MCV-87 MCH-30.8 MCHC-35.5* RDW-17.0* Plt Ct-208 [2115-12-11] 12:18AM BLOOD Hct-30.6* [2115-12-10] 05:14PM BLOOD Hct-31.3# [2115-12-10] 05:01AM BLOOD WBC-9.0 RBC-2.98 Hgb-8.8* Hct-24.9* MCV-84 MCH-29.5 MCHC-35.3* RDW-16.3* Plt Ct-170 [2115-12-10] 02:09AM BLOOD Hct-25.4* [2115-12-9] 06:22PM BLOOD Hct-27.0* [2115-12-9] 05:45AM BLOOD WBC-9.7 RBC-2.94* Hgb-9.2* Hct-25.4# MCV-86 MCH-31.2 MCHC-36.1 RDW-16.0* Plt Ct-165 [2115-12-8] 11:43PM BLOOD Hct-18.7* Plt Ct-154 [2115-12-8] 04:47PM BLOOD Hct-21.2* [2115-12-8] 10:55AM BLOOD WBC-8.0 RBC-3.26* Hgb-9.9* Hct-27.8* MCV-84 MCH-30.3 MCHC-36.0* RDW-15.6* Plt Ct-105* [2115-12-8] 12:26AM BLOOD Hct-22.4* [2115-12-7] 07:35PM BLOOD WBC-8.0 RBC-2.88* Hgb-9.0* Hct-24.7* MCV-86 MCH-31.3 MCHC-36.4* RDW-16.5* Plt Ct-107* [2115-12-7] 01:39PM BLOOD Hct-26.9* [2115-12-7] 05:35AM BLOOD WBC-9.0 RBC-3.10* Hgb-9.5* Hct-26.5* MCV-86 MCH-30.6 MCHC-35.7* RDW-16.6* Plt Ct-106* [2115-12-6] 12:11PM BLOOD Hct-30.7* [2115-12-6] 05:20AM BLOOD Hct-29.3* [2115-12-6] 03:00AM BLOOD WBC-10.5 RBC-3.46* Hgb-11.0* Hct-30.0* MCV-87 MCH-31.7 MCHC-36.7* RDW-16.2* Plt Ct-96* [2115-12-5] 07:55PM BLOOD Hct-30.9* Plt Ct-96* [2115-12-5] 03:42PM BLOOD Hct-28.1* [2115-12-5] 11:47AM BLOOD Hct-30.1* [2115-12-5] 08:20AM BLOOD Hct-29.4* [2115-12-5] 06:18AM BLOOD WBC-12.7* RBC-3.40# Hgb-10.7# Hct-29.3* MCV-86 MCH-31.7 MCHC-36.7* RDW-16.0* Plt Ct-103* [2115-12-5] 01:35AM BLOOD Hct-26.9* [2115-12-4] 05:45PM BLOOD Hct-27.4* [2115-12-4] 01:02PM BLOOD Hct-28.7# [2115-12-4] 05:48AM BLOOD WBC-11.6 RBC-2.56* Hgb-8.3* Hct-22.8* MCV-89 MCH-32.2* MCHC-36.2* RDW-16.1* Plt Ct-202# [2115-12-4] 12:21AM BLOOD WBC-14.5* RBC-3.28* Hgb-10.2* Hct-29.3* MCV-89 MCH-31.2 MCHC-35.0 RDW-15.9* Plt Ct-92* [2115-12-3] 03:51PM BLOOD WBC-13.7# RBC-3.27 Hgb-10.5* Hct-29.9* MCV-91 MCH-32.1* MCHC-35.1* RDW-15.3 Plt Ct-85# [2115-12-16] 06:05AM BLOOD Plt Ct-559 [2115-12-13] 06:00AM BLOOD PT-12.5 PTT-23.4 INR(PT)-1.0 [2115-12-12] 04:42AM BLOOD Plt Ct-280 [2115-12-12] 04:42AM BLOOD PT-12.5 PTT-21.3* INR(PT)-1.0 [2115-12-11] 09:01PM BLOOD Plt Ct-263 [2115-12-11] 05:45AM BLOOD PT-12.7 PTT-22.2 INR(PT)-1.1 [2115-12-11] 12:30AM BLOOD PT-12.8 PTT-23.6 INR(PT)-1.1 [2115-12-10] 05:14PM BLOOD PT-13.4* PTT-26.2 INR(PT)-1.2 [2115-12-10] 05:01AM BLOOD PT-13.8* PTT-25.4 INR(PT)-1.3 [2115-12-9] 06:22PM BLOOD PT-15.1* PTT-43.4* INR(PT)-1.6 [2115-12-9] 05:45AM BLOOD PT-14.5* PTT-30.6 INR(PT)-1.4 [2115-12-9] 02:27AM BLOOD PT-14.6* PTT-36.4* INR(PT)-1.5 [2115-12-8] 10:55AM BLOOD PT-16.6* PTT-56.4* INR(PT)-1.9 [2115-12-7] 05:35AM BLOOD PT-14.5* PTT-39.7* INR(PT)-1.4 [2115-12-6] 03:00AM BLOOD PT-14.7* PTT-40.0* INR(PT)-1.5 [2115-12-5] 06:18AM BLOOD PT-15.6* PTT-33.2 INR(PT)-1.7 [2115-12-4] 05:48AM BLOOD PT-14.8* PTT-31.4 INR(PT)-1.5 [2115-12-3] 07:50PM BLOOD PT-13.9* PTT-27.6 INR(PT)-1.3 [2115-12-3] 03:51PM BLOOD Plt Smr-LOW Plt Ct-85# [2115-12-3] 03:51PM BLOOD PT-14.7 PTT-37.3* INR(PT)-1.5 [2115-12-12] 04:42AM BLOOD Fibrino-663* [2115-12-9] 10:39AM BLOOD Fibrino-631# D-Dimer-3171 [2115-12-7] 05:35AM BLOOD Fibrino-785* D-Dimer-2280* Thrombn-70.1* [2115-12-6] 03:00AM BLOOD Fibrino-691# [2115-12-5] 06:18AM BLOOD Fibrino-524# [2115-12-4] 05:48AM BLOOD Fibrino-292# [2115-12-3] 07:50PM BLOOD Fibrino-97* [2115-12-13] 06:00AM BLOOD Glucose-123* UreaN-19 Creat-0.6 Na-136 K-4.2 Cl-103 HCO3-24 AnGap-13 [2115-12-11] 05:45AM BLOOD Glucose-120* UreaN-20 Creat-0.6 Na-141 K-4.1 Cl-109* HCO3-24 AnGap-12 [2115-12-10] 05:01AM BLOOD Glucose-111* UreaN-17 Creat-0.6 Na-141 K-3.6 Cl-108 HCO3-26 AnGap-11 [2115-12-8] 04:27AM BLOOD Glucose-113* UreaN-11 Creat-0.6 Na-141 K-3.5 Cl-108 HCO3-25 AnGap-12 [2115-12-6] 03:00AM BLOOD Glucose-138* UreaN-9 Creat-0.6 Na-142 K-3.7 Cl-110* HCO3-24 AnGap-12 [2115-12-4] 05:45PM BLOOD Glucose-162* UreaN-18 Creat-0.9 Na-139 K-3.8 Cl-108 HCO3-21* AnGap-14 [2115-12-3] 03:51PM BLOOD Glucose-235* UreaN-17 Creat-0.8 Na-139 K-4.5 Cl-106 HCO3-19* AnGap-19 [2115-12-15] 06:00AM BLOOD ALT-82* AST-89* AlkPhos-166* TotBili-1.3 [2115-12-13] 06:00AM BLOOD ALT-49* AST-59* AlkPhos-145* TotBili-1.4 [2115-12-12] 04:42AM BLOOD LD(LDH)-437* TotBili-1.4 [2115-12-11] 05:45AM BLOOD TotBili-1.6* DirBili-0.7* IndBili-0.9 [2115-12-11] 12:18AM BLOOD ALT-50* AST-73* LD(LDH)-434* AlkPhos-135* TotBili-1.7* [2115-12-9] 06:22PM BLOOD ALT-57* AST-62* LD(LDH)-444* TotBili-2.2* [2115-12-8] 11:43PM BLOOD CK-MB-2 cTropnT-<0.01 [2115-12-8] 04:47PM BLOOD CK-MB-2 cTropnT-<0.01 [2115-12-5] 10:16AM BLOOD Type-ART Temp-36.9 Rates-/16 Tidal V-400 PEEP-5 FiO2-40 pO2-114* pCO2-39 pH-7.42 calHCO3-26 Base XS-1 Intubat-INTUBATED [2115-12-4] 06:00PM BLOOD Type-ART pO2-107* pCO2-35 pH-7.43 calHCO3-24 Base XS-0 [2115-12-4] 06:19AM BLOOD Type-ART Temp-37.6 pO2-139* pCO2-35 pH-7.37 calHCO3-21 Base XS--3 [2115-12-3] 07:54PM BLOOD Type-ART pO2-221* pCO2-33* pH-7.36 calHCO3-19* Base XS--5 [2115-12-3] 02:35PM BLOOD Type-ART FiO2-40 pO2-130* pCO2-46* pH-7.29* calHCO3-23 Base XS--4 Intubat-INTUBATED Vent-CONTROLLED [2115-12-3] 12:44PM BLOOD Type-ART FiO2-40 pO2-171* pCO2-36 pH-7.44 calHCO3-25 Base XS-1 Intubat-INTUBATED Vent-CONTROLLED Comment-ETT [2115-12-3] 11:36AM BLOOD Type-ART FiO2-40 pO2-182* pCO2-42 pH-7.39 calHCO3-26 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED Comment-ETT Brief Hospital Course: 70 F s/p bilateral total knee arthoplasty (see operative report for details) for osteoarthritis [2115-12-3]. Patient developed postoperative hypotension and transfusion requirement necessitating an ICU admission. Postop, patient was hypotensive in PACU, required pressors and was transfered to ICU for close monitoring. Postoperative hematocrit was unresponsive to repeated transfusions of PRBC. Patient was taken to the interventional radiology suite on [2115-12-5] for suspicion of arterial vs. venous bleed into the surgical bed of the right knee. Arteriographic imaging of popliteal and genicular circlution revealed "No active extravasation, pseudoaneurysm or other evidence for arterial bleeding was identified from the arteries around the knees on either side." Per interventional radiology, the decision was made to image the venous system around the knees by ultrasonography given the edema in the patient's lower extremities which would make cannulation for venography difficult. Ultrasonography on the same date showed " 1. Partially-occlusive thrombus within the right common femoral and right popliteal veins. 2. No deep venous thrombosis within the left upper extremity. 3. No evidence of a hematoma within the right knee." Patient was treated for DVT with therapeutic Lovenox (1mg/kg). -IVC filter was inserted on [2115-12-9] CT scan on [12-9] showed "within the musculature of both thighs, particularly the quadriceps, evidence of bilateral hematoma, with expansion of the musculature as well as high- and low-attenuation collections. There are hematocrit levels within both thighs. The hematoma on the left is greater than right, and extends to the height of the quadriceps musculature, and measures approximately 4.5 x 7 cm." Follow-up CTA on [12-11] showed "1. Bilateral hematomas around the recent knee joint surgery, larger on the left side. These are stable compared to recent CT. No evidence of pseudoaneurysm or active extravasation of contrast on the CTA. 2. Right lower limb deep venous thrombosis extending to the upper common femoral vein level. The patient has had [Initials (NamePattern4) ] [Last Name (NamePattern4) 260] filter placed." Patient's INR was reversed with fresh frozen plasma, Hct was stable for 48 hours, and was cleared by the ICU team for transfer to the floor. Patient subsequently continued to improve and made progress with physical therapy. She was treated with a heparin drip for DVT and continued on coumadin. Her pain was adequately controlled, she tolerated a Cardiac/Heart healthy /Pureed/Honey prethickened liquids diet. She was discharged to follow-up with Dr. [Last Name (STitle) ] in the orthopaedic surgery clinic. * This discharge summary (hospital stay [2115-12-3] - [2116-1-1]) was completed--from the inpatient chart-- by the house officer who was off service after [2115-12-13]. For further details about the hospital course after [2115-12-13] please contact [Name (NI) 1022] [Name (NI) ], the discharging PA* Medications on Admission: 1. Aspirin 81 mg daily 2. Atenolol 100 mg daily 3. Hydrochlorothiazide 25 mg daily 4. Norvasc 5 mg daily 5. Phenytoin 100 mg tid 6. glucosamine Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:60 Tablet(s) Refills:0 3. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: Goal INR 2.0-2.5 for Tx of DVT. -Please check 2x weekly -Please call result to [Telephone/Fax (1) 9118] Attn. [Doctor Last Name ] Brown. Disp:30 Tablet(s) Refills:2 4. Outpatient Lab Work Please Check INR 2x weekly. Goal INR 2.0-2.5 for Tx of DVT. Please call results to [Telephone/Fax (1) 9118]. Attn [Doctor Last Name ] Brown. Discharge Disposition: Home Discharge Diagnosis: s/p bilateral total knee replacement Bilateral OA of knees DVT R popliteal vein pharyngeal dysphagia Discharge Condition: stable Discharge Instructions: [Name8 (MD) ] M.D. for increase in severity of symptoms, breakdown of surgical wound, fever, pain, questions or other concerns. Continue with weight bearing as tolerated bilateral lower extremities. Continue to take Coumadin for treatment of DVT. Keep brace on right leg at all times when ambulating. Please call/return if any fevers, increased discharge from incision or trouble breathing. Continue with out-patient physical therapy. Please have INR checked 2x weekly while taking Coumadin. Please call results to [Telephone/Fax (1) 9118] attn. [Doctor Last Name ] Brown. Goal INR 2.0-2.5 Followup Instructions: Follow-up with Dr. [Last Name (STitle) ] in the Orthopaedic Surgery clinic in [11-8] days, please call clinic to schedule @ [Telephone/Fax (1) 1228]. Provider: [Name (NI) ] [Name (NI) 6724], PT Phone:[Telephone/Fax (1) 2484] Date/Time:[2116-1-3] 8:00 Provider: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 1228] Call to schedule appointment for 10-14 days after discharge Completed by:[2116-2-26]	[ "2851", "2875", "2762", "4019" ]
Admission Date: [2120-7-22] Discharge Date: [2120-7-25] Date of Birth: [2056-11-8] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1145] Chief Complaint: chest pain Major Surgical or Invasive Procedure: cardiac cath History of Present Illness: 63 year-old M with CAD s/p CABG ([2106] - LIMA to LAD, SVG to OM2, SVG to D1, SVG to PDA), s/p PTCA ([2114] - stents placed to SVG to D1 graft and SVG to PDA graft) who presented with chest pain to OSH, transferred here for cardiac cath, now s/p cath. He awoke from sleep at home with 8/10 chest pain, L arm discomfort, and diaphoresis. No SOB or nausea. He arose and felt lightheaded and proceeded to have a syncopal event. No trauma. He went to the OSH ED at 2 am for evaluation; he received heparin bolus and gtt, plavix, and morphine. Nitro gtt was started and patient worsened. Labs showed CK 136, MB 3.5, trop 0.16, ECG showed NSR, with 1 mm STE inf and reciprocal changes in V1/V2. He was transferred to [Hospital1 18] for cath. . Cardiac cath showed right dominant circulation with 100% ostial LAD lesion and 100% proximal RCA lesion with collaterals. distal LCX 60%. SVG-RCA occlusion, SVG-OM occluded. SVG-Diag iwth 60% proximal lesion and patent graft. 60% mid LIMA-LAD with collaterals. CO 5.64, CI 2.92, RA 9, PCWP 19, PA 29/13, RV 23/13. No interventions were performed; pt was transferred to CCU for medical therapy and hemodynamically stable. . ROS: He reports stable DOE after 1 block. Pt denies PND, orthopnea, or LE edema. No history of claudication, CVA/TIA. No fever or chills. No recent weight loss or gain. Has sinus congestion. Denied cough or palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No melena or BRBPR. No dysuria. Denied arthralgias or myalgias. No rash. Past Medical History: 1. CAD s/p CABG: [2106], LIMA to LAD graft, SVG to OM2, SVG to D1 and SVG to PDA. presented with unstable angina. EF 74%, anterolateral HK, 90pRCA, 90% LAD, 70% mLAD, 90% D2, 80% dCx, two 80% sequential OM1 lesions. s/p PTCA and stenting of the proximal, mid, and distal SVG-R-PDA and SVG to D1 in [2114]. 2. Hypercholesterolemia. 3. Hypertension. 4. History of tobacco use - quit > 40 yrs ago 5. Brachial Plexus injury Social History: The patient works in home room modeling and construction; he is a former firefighter. He is married with grown children. Occasional social alcohol use. Quit smoking >40 yrs ago. Family History: brothers, mother and father with premature CAD. brother with CVA bone Ca in father melanoma in sister [Name (NI) 5472] CA in sister Physical Exam: Admission PE: Vitals: T: 97 P: 83 BP: 136/76 RR: 15 SaO2: 93% on 3L NC General: Awake, alert, NAD. exam limited since patient required to lay flat HEENT: PERRL/EOMI, sclera anicteric. MMM, OP without lesions Neck: supple, no carotid bruits appreciated, 2+ carotid pulses. unable to assess JVP. Pulm: Lungs clear anteriorly Cardiac: RRR, nl. S1S2, no M/R/G appreciated Abdomen: soft, NT/ND, + BS, no organomegaly noted. Ext: No edema b/t, 2+ femoral, DP and PT pulses b/l. R groin with pressure dressing in place. Skin: no rashes or lesions noted. Neurologic: Alert & Oriented x 3. Able to relate history without difficulty. Pertinent Results: Admission Labs s/p cath: . [2120-7-22] 06:03AM BLOOD WBC-12.2# RBC-4.51 Hgb-13.4* Hct-38.1* MCV-85 MCH-29.8 MCHC-35.2* RDW-12.8 Plt Ct-203 [2120-7-22] 06:03AM BLOOD PT-13.1 PTT-56.1* INR(PT)-1.1 [2120-7-22] 06:03AM BLOOD Glucose-137* UreaN-13 Creat-0.9 Na-140 K-4.0 Cl-109* HCO3-21* AnGap-14 [2120-7-22] 06:03AM BLOOD CK(CPK)-352* [2120-7-22] 06:03AM BLOOD CK-MB-30* MB Indx-8.5* [2120-7-22] 06:03AM BLOOD Calcium-7.6* Phos-2.9 Mg-1.8 . Other labs: [2120-7-22] 06:03AM BLOOD CK(CPK)-352* [2120-7-22] 02:32PM BLOOD CK(CPK)-3001* [2120-7-22] 10:08PM BLOOD CK(CPK)-3179* [2120-7-23] 05:36AM BLOOD CK(CPK)-2416* [2120-7-22] 06:03AM BLOOD CK-MB-30* MB Indx-8.5* [2120-7-22] 10:08PM BLOOD CK-MB-362* MB Indx-11.4* [2120-7-23] 05:36AM BLOOD CK-MB-209* MB Indx-8.7* [2120-7-22] 02:44PM BLOOD %HbA1c-5.8 [Hgb]-DONE [A1c]-DONE [2120-7-22] 10:08PM BLOOD Triglyc-106 HDL-43 CHOL/HD-2.7 LDLcalc-51 . Cardiac Cath ([2120-7-22]): Cardiac cath showed right dominant circulation with 100% ostial LAD lesion and 100% proximal RCA lesion with collaterals. distal LCX 60%. SVG-RCA occlusion, SVG-OM occluded. SVG-Diag iwth 60% proximal lesion and patent graft. 60% mid LIMA-LAD with collaterals. CO 5.64, CI 2.92, RA 9, PCWP 19, PA 29/13, RV 23/13. No interventions were performed. . CXR ([2120-7-22]): The patient has had median sternotomy and coronary bypass grafting. Borderline cardiomegaly stable. Lungs clear. No pulmonary edema or pleural effusion. . Echo ([2120-7-22]): The left atrium is mildly dilated. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction. Overall left ventricular systolic function is moderately depressed (estimated LV ejection fraction ?40%). Resting regional wall motion abnormalities include inferior and inferolateral akinesis/hypokinesis. No definite thrombus seen (cannot definitively exclude). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. . Compared with the report of the prior study (images unavailable for review) of [2115-2-11], left ventricular systolic function is now significantly impaired. . Discharge Labs: . [2120-7-25] 05:45AM BLOOD WBC-11.1* RBC-4.07* Hgb-12.9* Hct-34.9* MCV-86 MCH-31.6 MCHC-36.9* RDW-12.9 Plt Ct-187 [2120-7-25] 05:45AM BLOOD Plt Ct-187 [2120-7-25] 05:45AM BLOOD Glucose-103 UreaN-15 Creat-1.0 Na-139 K-3.9 Cl-104 HCO3-27 AnGap-12 [2120-7-25] 05:45AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.2 Brief Hospital Course: 63 yo M with HTN, hyperlipidemia, CAD s/p CABG and PTCA, who presented with ACS s/p cath, transferred to CCU for medical managment. His hospital course for this admission is as follows: . 1 Ischemia: ACS likely from inferolateral MI from vein graft occlusion to OM or to RCA, s/p cardiac cath, no interventions, currently pain-free. We stopped intergrillin and heparin since no acute thrombosis found s/p cath. We continued ASA 325', plavix 75', and lipitor 80' initially, and plavix was discontinued on [2120-7-23] given the pt didn't have any stents placed. We started low dose bblock and ACEI initially with metoprolol 12.5mg'' and lisinopril 5mg', and titrated up to 25mg'' and 10mg', respectively, as BP and HR tolerated. He was discharged home on toprol XL 50mg PO qday. Echo on [2120-7-22] showed moderately depressed LV systolic function (estimated LV ejection fraction ~40%), with resting regional wall motion abnormalities include inferior and inferolateral akinesis/hypokinesis, We followed his Hct closely and with goal to keep Hct >30. Given patient became hypotensive on NTG, we avoided NTG and symptomatically control pain with MSO4 (pt didn't have much pain s/p cath and didn't take any pain meds in the hospital, and pain free since day 2 of his hospital stay). . 2 Pump: echo on [2120-7-22] s/p cath showed estimated LVEF approximately 40% with resting regional wall motion abnormalities include inferior and inferolateral akinesis/hypokinesis. He was continued on ACEI and bblocks. . 3 Rhythm: continued monitor on tele; remained NSR . 4 HTN: We started low dose bblock and ACEI initially with metoprolol 12.5mg'' and lisinopril 5mg', and titrated up as BP and HR tolerated to 25mg'' and 10mg', respectively. He was discharged home on lisinopril 10mg PO qday and toprol XL 50mg PO qday. . 5 Hyperlipidemia: checked lipid panels which showed total cholesterol 115, TG 106, HDL 43, LDL 51; and continued lipitor 80mg'. . 6 Prophylaxis: SC heparin (discontinued once patient started ambulating), bowel regimen, [Doctor First Name 130] . 7 FEN: cardiac diet . 8 Code Status: Full Medications on Admission: home meds: lipitor 25 QD atenolol 12.5 QD lisinopril 10 QD ASA 325 [Doctor First Name 130] . Medications on transfer: heparin gtt integrillin gtt plavix 600 PO load ASA 325 atenolol lipitor Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): hold for SBP<90. 5. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:30 Tablet Sustained Release 24HR(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis acute coronary syndrome, s/p catheterization without interventions Secondary Diagnoses: 1. CAD s/p CABG: [2106], LIMA to LAD graft, SVG to OM2, SVG to D1 and SVG to PDA. presented with unstable angina. EF 74%, anterolateral HK, 90pRCA, 90% LAD, 70% mLAD, 90% D2, 80% dCx, two 80% sequential OM1 lesions. s/p PTCA and stenting of the proximal, mid, and distal SVG-R-PDA in [2114]. 2. Hypercholesterolemia. 3. Hypertension. 4. History of tobacco use - quit > 40 yrs ago 5. Brachial Plexus injury Discharge Condition: The patient was discharged hemodynamically stable, afebrile with appropriate follow up. Discharge Instructions: 1. Please follow up with your PCP as described below. . 2. Please take all your medications exactly as prescribed and described in this discharge paperwork. We replace your atenolol with Toprol XL 50mg PO qday for your blood pressure and your heart. Increased your statins to 80mg PO qday for your lipids and heart. If you experience any dizziness, SOB, or any other symptoms, please contact your PCP directly for any adjustment of medications. . 3. Please call your doctor if you are experiencing chest pain, shortness of breath, fever, chills, or with any other concerning symptoms. Followup Instructions: Please follow up with your PCP, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 5466] [Telephone/Fax (1) 5473] on [2120-7-31] at 12:45pm for an appoitment. Completed by:[2120-7-25]	[ "41401", "2720", "4019" ]
Admission Date: [2137-12-6] Discharge Date: [2137-12-9] Date of Birth: [2078-8-10] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[First Name3 (LF) 465] Chief Complaint: Found Down EtOH intoxication Major Surgical or Invasive Procedure: None History of Present Illness: This is a 59 year old man with a history of EtOH abuse who presented to the ED with hypoglycemia. History per records, as pt is unable to give history. He was found by workers in the subway tunnels, apparently intoxicated/unresponsive and with an empty bottle of vodka. EMS was called, and FSBG was in the 40s in the field. Unclear whether he received dextrose in the field. . Of note, he has had multiple ED visits in the past for intoxication, and he takes vodka and listerine via PEG. He was most recently admitted to [Hospital1 18] in [2137-8-20] with hypotension and hypothermia, due to an old right clavicular fracture which had eroded through the skin and became infected with corynebacterium and MRSA. He was treated with vancomycin and the bone was debrided. Clean-margin resection of the infected bone plus long-term antibiotic therapy were the recommended course of treatment, but the patient did not agree with these plans and left the hospital AMA. . In the ED, he aroused to voice, but was not speaking. VS: 98.8, 90, 140/80, 13, 96% on RA initially. FSBS 40s on arrival. He received D50, as well as a banana bag with D5NS. His FSBG have been improved. His EtOH level was noted to be 454, and the remainder of his tox screen was negative. He has a poorly maintainted trach and PEG (for unclear reasons) and he began coughing mucus from the trach. He reportedly had a brief respiratory arrest in the ED, which resolved with deep suctioning and was presumably due to mucus plugging. He became violent when a foley was attempted, so foley was not placed. Past Medical History: 1) EtOH Abuse: Several ED notes describe visits for EtOH intoxication. Pt apparently administers vodka and listerine via PEG. . 2) s/p PEG and trach placement: unclear etiology . 3) Evidence on previous ED labs of macrocytic anemia. No work-up here. Social History: +EtOH abuse, homeless. Family History: unknown Physical Exam: VS: 96.4 (axillary), 94/51, 102, 12, 93% on TCM at 4L Gen: NAD, lying in bed, breathing comfortably HEENT: PERRL, MM dry, OP clear Neck: trach in place with trach collar mask, yellowish mucus Lungs: not cooperative with exam, but grossly clear Heart: RRR, no m/r/g Abd: +BS, soft, NT/ND, PEG tube in place Extrem: no edema, 2+ DP pulses Pertinent Results: CXR [2137-12-6] Mild pulmonary vascular congestion. No overt pulmonary edema. Possible vague bibasilar opacities. Further evaluation could be performed with a dedicated PA and lateral view of the chest. . CXR [2137-12-7] No acute pulmonary process. . CXR [2137-12-8] Blunting of both costophrenic angles. No evidence of aspiration pneumonia. . [2137-12-6] WBC-5.2 RBC-4.46# Hgb-12.5# Hct-36.7 Plt Ct-181 [2137-12-7] WBC-9.2# RBC-3.98* Hgb-11.0* Hct-33.2* Plt Ct-210 [2137-12-8] WBC-4.6 RBC-3.83* Hgb-10.7* Hct-32.1* Plt Ct-217 [2137-12-9] WBC-5.9 RBC-3.73* Hgb-10.8* Hct-30.9* Plt Ct-234 [2137-12-6] Neuts-63.8 Lymphs-30.7 Monos-3.2 Eos-1.9 Baso-0.4 . [2137-12-6] Glucose-160* UreaN-9 Creat-0.7 Na-134 K-4.3 Cl-94* HCO3-24 AnGap-20 [2137-12-6] Glucose-69* UreaN-7 Creat-0.7 Na-142 K-4.1 Cl-103 HCO3-29 AnGap-14 [2137-12-7] Glucose-93 UreaN-10 Creat-0.5 Na-130* K-4.1 Cl-93* HCO3-27 AnGap-14 [2137-12-8] Glucose-95 UreaN-7 Creat-0.5 Na-132* K-4.1 Cl-95* HCO3-31 AnGap-10 [2137-12-9] Glucose-110* UreaN-8 Creat-0.6 Na-128* K-4.2 Cl-91* HCO3-29 [2137-12-6] ALT-74* AST-113* LD(LDH)-359* CK(CPK)-245* AlkPhos-80 Amylase-15 TotBili-0.2 [2137-12-7] ALT-56* AST-60* LD(LDH)-167 AlkPhos-74 TotBili-0.5 [2137-12-8] ALT-40 AST-36 LD(LDH)-143 AlkPhos-69 Amylase-14 TotBili-0.4 [2137-12-6] Lipase-42 [2137-12-8] Lipase-32 [2137-12-6] CK-MB-12* MB Indx-4.9 cTropnT-0.01 [2137-12-6] CK-MB-9 cTropnT-0.01 [2137-12-6] CK-MB-8 cTropnT-<0.01 [2137-12-8] Albumin-3.2* Calcium-8.4 Phos-2.7 Mg-1.9 [2137-12-6] ASA-NEG Ethanol-454* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: This is a 59 year old man with a history of EtOH abuse who presents with hypoglycemia and with brief respiratory arrest in ED. The patient was transferred to the MICU for respiratory monitoring. The patient was then moved to the medicine floor after becoming stable from a respiratory standpoint. The following issues were addressed during this hospitalization. . 1. Hypoglycemia The pt was admitted with hypoglycemia which resolved after getting dextrose. His glucose was monitored and there were no further epidoses of hypoglycemia. He was hydrated with D5NS. By the time of discharge, he was utilizing his PEG tube for nutrition. He was maintained on thiamine and folate as well. The hypoglycemia was most likely [2-21] to poor PO intake and alcohol use. By the time of discharge, the pt was euglycemic. . 2. Respiratory arrest/distress The pt had some apparent respiratory arrest in ED, which was most likely due to mucus plugging/? aspiration event. He was maitained on aggressive pulmonary toilet with deep suctioning as needed. CXR with no clear pneumonia, no fevers, no leukocytosis. Repeat CXR was also clear of PNA. He was given ABx briefly for 2 days, and diagnosis of tracheobronchitis was considered. There was no clear evidence of PNA, fever, or elevated WBC, ABx were D/C. His sputum was positive for GPC's and GNR's on gram stain. Sputum culture also grew Pseudomonas. Initially, the pt had increased secretions which required more frequent suctioning which resolved by the time of discharge. He was not felt to need any specific additional respiratory care on follow up based on RT assessment. He was instructed that if secretions increase further, he may have bacterial tracheobronchitis which may require further treatment with antibiotics. He was instructed to [Name6 (MD) 138] [Name8 (MD) ] MD or return to the hospital if this happens. . 3. EtOH abuse EtOH level 454 on admission. Unclear how much he drinks or when last drink was, but clearly at risk for withdrawal. He was placed on a CIWA scale with valium prn. He was maintained on thiamine, folate, and MVI. He was discharged on the above vitamins. Social work was consulted and the pt declined any further intervention for his alcohol abuse. He receives some form of counseling [Street Address(1) 29735] Shelter and that is where he was discharged. He will follow up with services and his PCP [Name9 (PRE) 65673] upon discharge. The pt's PCP [Name9 (PRE) 29735] was notified that Mr. [Known lastname 5621] was here and the pt will follow up with him upon discharge. . 4. Elevated CK Mildly elevated CK with normal MB index, normal Tn. EKG with no ischemic changes. Patient did ROMI with 2 negative sets CEs. There were no further issues. . 5. Hyponatremia The pt was found to be hyponatremic with the lowest sodium of 128. Pt has a long h/o hyponatremia per discussion with his PCP which is most likely [2-21] to his alcohol abuse. His sodium will be followed by his PCP upon discharge. Medications on Admission: None Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day: Please place in PEG tube. Disp:30 Tablet(s) Refills:2 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary: Alcohol Intoxication Alcohol Abuse Chronic Hyponatremia . Secondary: s/p trach (had on admission) s/p PEG tube (had on admission) Discharge Condition: The patient was discharged hemodynamically stable afebrile with appropriate follow up. Discharge Instructions: Please call your PCP (Dr. [Last Name (STitle) 11435] at [Location (un) ] at [Telephone/Fax (1) 30392] or seek medical attention in the emergency department if you experience any chest pain, shortness of breath, nausea, vomiting, diarrhea, fever, chills, abdominal pain, or any other concerning symptom. . Please take all medications as prescribed. Please take your vitamins. . Please see Dr. [Last Name (STitle) 11435] at [Street Address(1) 5904] facility in follow up. Followup Instructions: Please follow up with Dr. [Last Name (STitle) 11435] at the [Location (un) ] facility in [1-21] weeks by calling [Telephone/Fax (1) 30392]. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 472] Completed by:[2137-12-13]	[ "51881", "2761" ]
Admission Date: [2116-8-14] Discharge Date: [2116-8-24] Date of Birth: [2066-6-11] Sex: F Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Doctor Last Name 1350] Chief Complaint: Bilateral thigh pain and left sided foot drop Major Surgical or Invasive Procedure: L3-L5 lateral lumbar interbody fusion followed by L3-S1 laminectomy and fusion with L5-S1 Transforaminal lumbar interbody fusion. History of Present Illness: 50- year-old female with a progressive and disabling syndrome of degenerative scoliosis as well as spinal stenosis. This did cause a syndrome of back and leg pain which did interfere with her ability to walk. She underwent a prolonged and progressive and multimodal course of conservative care, but despite this, her symptoms were not relieved. Due to the progressive nature of syndrome, the history of this disorder, the refractory nature of the syndrome, and the severity of symptoms, she did elect to undergo surgical treatment. Physical Exam: AVSS Well appearing, NAD, comfortable BUE: SILT C5-T1 dermatomal distributions BUE: [6-10] [Doctor First Name ]/Tri/Bic/WE/WF/FF/IO BUE: tone normal, negative [Doctor Last Name 937], 2+ symmetric DTR bic/bra/tri All fingers WWP, brisk capillary refill, 2+ distal pulses BLE: SILT L1-S1 dermatomal distributions BLE: [6-10] IP/Qu/HS/TA/GS/[Last Name (un) 938]/FHL/Per except left TA and [Last Name (un) 938] 0/5 BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle All toes WWP, brisk capillary refill, 2+ distal pulses Pertinent Results: [2116-8-14] 07:20PM GLUCOSE-215* UREA N-15 CREAT-0.5 SODIUM-140 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-23 ANION GAP-17 [2116-8-14] 07:20PM estGFR-Using this [2116-8-14] 07:20PM CALCIUM-9.0 PHOSPHATE-3.9 MAGNESIUM-1.7 [2116-8-14] 07:20PM WBC-17.9* RBC-4.59 HGB-14.9 HCT-43.3 MCV-94 MCH-32.6* MCHC-34.5 RDW-13.8 [2116-8-14] 07:20PM PLT COUNT-185 Brief Hospital Course: Patient was admitted to the [Hospital1 18] Spine Surgery Service and taken to the Operating Room for the above procedure. 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. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with a PCA. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. [Known lastname 8389] was removed on POD#2. 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. Discharge Medications: 1. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q8H (every 8 hours). 2. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Lumbar spinal stenosis with adult degenerative scoliosis Discharge Condition: Stable, alert and oriented, tolerating POs. Discharge Instructions: You have undergone the following operation: Lumbar 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: o 2-3 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. o Limit 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 may 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. - 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. - Follow up: o Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. o At the 2-week visit we will check your incision, take baseline X-rays and answer any questions. We may at that time start physical therapy. o We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound Physical Therapy: Ambulation with assistance, gait training, stair climbing. Treatments Frequency: 2-3 times a week Followup Instructions: Follow up in 2 weeks with Dr [Last Name (STitle) ] in clinic. Please call [Telephone/Fax (1) 40054] to make an appointment. Completed by:[2116-8-24]	[ "25000" ]
Admission Date: [2142-2-14] Discharge Date: [2142-3-1] Date of Birth: [2086-12-24] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 3984] Chief Complaint: CC:[CC Contact Info 62774] Major Surgical or Invasive Procedure: Bronchoalveolar Lavage History of Present Illness: 55 yo man with Hx of extensive tobacco use, metastatic esophageal cancer s/p stent placement x 2, course complicated by pain from acid reflux, unable to control at home with Tagamet, Protonix, and Carafate. He was admitted to the hospital for pain mgmnt, and poor po intake leading to acute renal failure. He complains of pain, burning and severe gas after placement of his esophageal stent on [2142-2-15].He denies any vomiting or hematemesis and complains of occassional nausea. He was evaluated by ICU team for progressive SOB x 3 days and increased work of breathing. His pulse oximetry dropped to as low as 85% on 6L NC and recovered to low 90's on 100% NRB. At that time he had a resp rate of 24, ABG was 7.43/ 36/82 on 100%NRB. in addition he was found to have tachycardia to 130's a lactate of 4.6 and WBC increase to 16.2. Received IV lasix 40 mg x 2, Nebs x 1. Past Medical History: 1)Hypertension 2)Metastatic Esophageal cancer s/p 6 cycles of cisplatin and Irinotecan. Mets to mediastinal and Abd lymph nodes, Liver, Adrenal 3)Severe GERD Social History: 2 packs of cigarette per day for the last few years, 1 ppd before that since age 20. He denies any alcohol use. He owns his loan business detail in [Location (un) ]; however, he has been unable to work since the end of [Month (only) 205]. He is divorced. He has 1 child. The child does not live locally. . Family History: Father and aunt -pancreatic cancer Uncle - liver cancer Grandfather -liver cancer Physical Exam: vitals: 99.1 130 140/83 26 87-90% on 100%NRB GENERAL: awake, in mild resp distress on NRB mask, cooperative HEENT: atraumatic, anicteric sclerae, dry mucosa, clear OP NECK: Supple, no JVD, Ant Cerv LAD LUNGS: Diffuse end exp wheeze b/l, no accessory muscle use, no ronchi or crackles BACK: no spinal or CVAT HEART: Regular, tachy, no M/R/G ABDOMEN: soft, Mild midepigastric tenderness, normal BS, no guarding, no rebound, no masses appreciated EXTREMITIES: trace b/l le edema. Warm, full DP pulses B/L NEURO: CN II-XII intact, no focal deficits Pertinent Results: [2142-2-14] 02:15PM WBC-12.0* RBC-3.81* HGB-12.2* HCT-35.7* MCV-94 MCH-32.0 MCHC-34.2 RDW-14.7 [2142-2-14] 02:15PM PLT COUNT-407 [2142-2-14] 02:15PM GRAN CT-[Numeric Identifier 60243]* [2142-2-14] 02:15PM ALBUMIN-3.5 CALCIUM-8.7 PHOSPHATE-2.5* MAGNESIUM-2.1 CHOLEST-168 [2142-2-14] 02:15PM LIPASE-14 GGT-87* [2142-2-14] 02:15PM ALT(SGPT)-21 AST(SGOT)-28 ALK PHOS-117 AMYLASE-13 TOT BILI-0.3 DIR BILI-0.1 INDIR BIL-0.2 [2142-2-14] 02:15PM GLUCOSE-119* UREA N-30* CREAT-1.6* SODIUM-133 POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-23 ANION GAP-17 [2142-2-14] 07:50PM CK-MB-2 cTropnT-0.02* [2142-2-14] 07:50PM CK(CPK)-32* ABDOMEN (SUPINE & ERECT) [2142-2-14] 4:38 PM ABDOMEN (SUPINE & ERECT) Reason: perforation, obstruction, stent placement [Hospital 93] MEDICAL CONDITION: 55 year old man with esophageal carcinoma, s/p stent placement REASON FOR THIS EXAMINATION: perforation, obstruction, stent placement INDICATION: 55-year-old man with esophageal carcinoma, status post stent placement. TECHNIQUE: Supine and upright abdominal radiographs. No comparison. FINDINGS: The patient is status post esophageal stent placement at lower esophagus and GE junction. Note is made of unremarkable bowel gas pattern with few air-fluid levels, without evidence of significant dilatation or obstruction. No evidence of ascites is seen on this radiograph. The osseous structures are unremarkable. . CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Reason: please eval pulmonary embolism with CTA, but please also inc Contrast: OPTIRAY [Hospital 93] MEDICAL CONDITION: 55 year old man with esophageal cancer, pleural effusions, worsening hypoxia REASON FOR THIS EXAMINATION: please eval pulmonary embolism with CTA, but please also include cuts to eval for worsening lung injury from chronic aspirations vs pneumonia, also eval size of pleural effusions CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Hypoxia, history of esophageal cancer. COMPARISON: Non-contrast CT from a PET study of [2142-1-25], chest x-ray from [2142-2-19]. TECHNIQUE: Multidetector CT scanning was performed of the chest before and after the administration of 100 cc of Optiray intravenous contrast. Multiplanar reformations were obtained. CT OF THE CHEST: Bilateral hilar as well as mediastinal adenopathy is seen. The heart and pericardium appear unremarkable. There is a dilated esophagus with a stent extending to the gastroesophageal junction. A central venous catheter seen with its tip terminating in the superior vena cava. The great vessels appear unremarkable. The pulmonary arteries do not demonstrate any central or segmental filling defects to suggest pulmonary embolism. Bilateral moderate pleural effusions are identified of simple fluid attenuation, which were not present on the [1-25] study. There has been new development of extensive ground glass and consolidative opacities involving the majority of the upper lobes bilaterally, as well as the lingula, right middle lobe, and lower lobes to a lesser extent. The airways are patent to the level of the segmental bronchi bilaterally. In the visualized abdomen again seen are multiple low-attenuation masses within the liver, which appear to be increased in size and extent since the prior study of [1-25]. The osseous structures demonstrate no concerning lytic or sclerotic lesions. IMPRESSION: 1. Bilateral ground-glass and consolidative opacities involving multiple lobes, but most notably the upper lobes. This has developed since the prior CT of [1-25] and is worsened since the recent chest x-ray. These findings are most consistent with aspiration pneumonia, though there may be an element of superimposed pulmonary edema. Bilateral moderate-sized pleural effusions have also developed in the interim. 2. Dilated esophagus with a stent extending to the gastroesophageal junction. Extensive hilar and mediastinal lymphadenopathy. Multiple liver hypodensities consistent with metastatic disease. 3. No evidence of central or segmental pulmonary embolism. These findings were discussed with Dr. [Last Name (STitle) ] at 4:30 p.m. on [2142-2-21]. IMPRESSION: Esophageal stent in lower esophagus and GE junction. Unremarkable bowel gas pattern. Please also refer to the official report of chest radiograph obtained on the same day. . BRONCHIAL WASHINGS Procedure Date of [2142-2-21] REPORT APPROVED DATE: [2142-2-23] SPECIMEN RECEIVED: [2142-2-22] 06-[Numeric Identifier 62775] BRONCHIAL WASHINGS SPECIMEN DESCRIPTION: Received 7.5 ml of bloody fluid and 1 hematology slide for referal. Total 2 slides. CLINICAL DATA: Known esophageal cancer, acute hypoxemic respiratory failure. PREVIOUS BIOPSIES: [2141-8-25] [-4/3463] MEDIASTINAL LYMPH NODE REPORT TO: DR. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] DIAGNOSIS: Bronchial lavage: POSITIVE FOR MALIGNANT CELLS consistent with adenocarcinoma Brief Hospital Course: A/P: 55 yo male with metastatic esophagel cancer, recent ARF [1-18] dehydration who was transferred to ICU for increased oxygen demand, Lactic Acidosis, and Elevated WBC Count: . 1. Increased oxygen demand/ARDS: Unclear etiology, initially thought to be secondary to pneumonitis/PNA 2x2 aspiration. There was no evidence of PE. BAL did not show an infectious etiology. Bacteremia was revealed by blood cultures. Patient was initially treated with IV antibiotics and ARDS low volume ventilation strategy. Despite this measures, patient continue to be febrile, with elevated lactic acidosis and high WBC. Even an steroid trial was given but patient still required high FIO2. . Fevers and elevated WBC: Initially treated as a pulmonary source. Patient initially responded to antibiotics, but later on developed high grade fevers. Last blood cultured showed Gram positive cocci. . Elevated Lactate. Persistent elevated lactate despite adequated CVP and Mix venous saturations. It was thought to be secondary to sepsis, with contribution of tumor burden and liver metaastasis. . Acute renal failure: thought to be secondary to prerenal azotemia in setting of sepsis. Creatinine remained at 1.4-1.6. . On [2142-3-1] a family meeting was held. The clinical situation was explained to the family worsening ARDS, severe dead space ventilation, worsening leukocytosis and fevers, associated with metastatic esophageal cancer gave him very low possibilities of recovery. Family felt that the medical team should direct goals of care towards confort at thats time. Patient passed away quietly in the presence of his family. Medications on Admission: Levaquin 500 mg po qd Flagyl 500 po tid Maalox QID Anzemet PRN Colace 100 mg po bid Fentanyl patch 75 mcg q72 Heparin 5000 sq tid Reglan 5 mg qid Metoprolol 50 [Hospital1 ] Morphine PCA Morphine SE 30 mg [Hospital1 ] Nexium 40 [Hospital1 ] Zantac 300 mg qhs Sucralfate 1 qid Simethicone 40 qid Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Acute Respiratory Distress Syndrome Metastatic esophageal cancer Multiorgan failure Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2437] MD [MD Number(1) 2438] Completed by:[2142-9-24]	[ "5070", "5849", "53081", "4019", "2859" ]
Admission Date: [2136-1-18] Discharge Date: [2136-1-23] Date of Birth: [2053-7-15] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 30] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 82yoM with complicated medical history including CHF (EF 25%), moderate aortic stenosis, atrial fibrillation not on Coumadin, s/p CABG [2130], AV block s/p dual chamber [Year (4 digits) 4448], COPD, presenting with hypotension and lethargy. . The patient was previously admitted to [Hospital1 18] from [12-21] - [12-28] for community acquired pneumonia, COPD exacerbation, and heart failure exacerbation. He was noted to have bilateral infiltrates and has a history of MRSA, and was treated with Vancomycin IV, Ceftriaxone po, Prednisone taper x12 days. His Lasix was decreased from 40 mg daily prior to admission to 20 mg daily on discharge for acute renal failure, and Losartan was held at time of discharge due to the elevated creatinine. His prior hospital course was complicated by dysphagia and concerns for aspiration. He was discharged to [Hospital1 599] of [Location (un) 55] on Vancomycin IV through a right double lumen PICC, Ceftriaxone po, and a 12 day Prednisone taper. Around [1-11], he was started on a 7 day course of Flagyl. Per ED documentation, the patient then developed symptoms consistent with a CHF exacerbation on [1-15] and was diuresed with Torsemide [Hospital1 ]. However, he continued to be short of breath and wheezing, and was started on Prednisone again on [1-17]. The day prior to transfer at his rehabilitation facility, the patient was noted to be lethargic and fatigued. He was found to be hypotensive in the 80's/60's with question of hypoxia and was sent to the ED by EMS. . In the ED, initial VS were: 98.2 80 99/50 18 91% 2L n/c (noted to have PO2 in the 80's on RA, later 94% on 2L NC) Labs were significant for an elevated creatinine of 2.1 from a baseline of 1.5 within the last year, elevated lactate of 2.4, and stable BNP in the 4000's consistent with prior values. A CXR was obtained and he was given a dose of Vancomycin IV and Zosyn IV empirically. He received 250cc and 500cc boluses of NS for a total of [12-18].5L with appropriate increases in blood pressure and urine output, but blood pressures subsequently decreased back to the 80's systolic. He was started on Levophed 0.3 through his right PICC, as he declined a central line placement in the ED, and SBP were 110's. Hydrocortisone 100 mg IV was given for hypotension without significant improvement in blood pressure. Although the patient denies history of shortness of breath currently, he was reported to endorse dyspnea on intial presentation to the ED and was placed on oxygen 2L NC. He was admitted to the MICU for hypotension and hypoxia in the low to mid 90's on 2L NC. . On arrival to the MICU, the patient was breathing comfortably and denied any complaints including pain, shortness of breath, cough, abdominal pain, nausea, vomiting, headache, lightheadedness, chest pain, or other symptoms. He did report feeling very tired and fatigued. Past Medical History: - COPD (not on oxygen) with moderately severe obstructive defect on PFT's - Systolic HF with LVEF 25% in [9-/2135] - Aortic stenosis with [Location (un) 109] 1.1 in [9-/2135] echo - CAD s/p CABG x4 in [2118] c/b NSTEMI in [11/2131] and unsuccessful RAMUS revascularization - s/p [Company 1543] Sigma dual-chamber permanent [Company 4448] implant secondary to high-grade AV block in [2124] - PVD w/ Bilateral aortoiliac occlusive disease s/p bilateral lower extremity revascularizations (left SFA, right TPT/PT); ABIs are 1.2 on the right and 0.6 on the left ([2134-11-17]) - Carotid stenosis: Last duplex [2134-11-17]: Right ICA less than 40% stenosis. Left ICA 70-79% stenosis by velocity criteria - Hypertension - Hyperlipidemia - History of asthma - Right renal artery stenosis (76% by angiogram [6-/2130]), baseline Cr 1.5 - Gout - Hypothyroidism - Depression (?[1-19] death of son in [Name2 (NI) 116]) - Hearing loss: Does not use hearing aids. Unclear if SNHL or conductive. Social History: - Tobacco: Former smoker x~10 pack-years - Alcohol: Occasional - Illicits: Denies Pt was previously living at the [First Name4 (NamePattern1) 533] [Last Name (NamePattern1) ]; he can walk with a walker but does get very SOB and wheezy after exertion, which was his baseline. Pt retired, former art teacher. Family History: - Father: died age 49 of a "leaky heart" valve - Mother: died 88 of unknown causes Physical Exam: Vitals: T: 97.6 BP: 106/67 P: 82 R: 17 PO2: 93%2L NC General: Alert, oriented x1-2, no acute distress HEENT: Pupils equal and round, sclera anicteric, MM dry, oropharynx clear Neck: Supple, JVP ~9cm CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Crackles at bases b/l, no wheezes, rales, ronchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: Foley in place Ext: Warm, well perfused, equal DP pulses b/l, no clubbing or cyanosis, trace pedal edema b/l Neuro: Moving all extremities, grip strength 5/5, grossly normal sensation, intention tremor present T: 97, P: 78, BP: 110/84, P: 78, RR: 20, 95% on RA General: Alert, oriented x1-2, no acute distress, confused at baseline HEENT: Pupils equal and round, sclera anicteric, MMM, oropharynx clear Neck: Supple, no lymphadenopathy CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: diminished BS at bases w/ crackles b/l, no wheezes, rales, ronchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: Warm, well perfused, equal DP pulses b/l, no clubbing or cyanosis, no LE edema Neuro: Moving all extremities, grip strength 5/5, grossly normal sensation, intention tremor present Pertinent Results: 138 99 51 ------------ 163 3.8 26 2.1 . 13.3 8.5 ------ 208 38.9 N:93.4 L:3.5 M:2.8 E:0.2 Bas:0.1 Trop-T: <0.01 proBNP: 4801 Lactate:2.4 . UA negative, CastHy: 48 . Micro: Blood cultures 2/1 negative Urine culture [1-19] negative Urine Legionella [1-19] negative Discharge Labs: [2136-1-23] 06:10AM BLOOD WBC-11.5* RBC-4.56* Hgb-13.1* Hct-40.7 MCV-89 MCH-28.8 MCHC-32.3 RDW-15.1 Plt Ct-386 [2136-1-22] 06:29AM BLOOD WBC-9.4 RBC-4.54* Hgb-13.6* Hct-40.9 MCV-90 MCH-30.0 MCHC-33.3 RDW-14.9 Plt Ct-361# [2136-1-23] 06:10AM BLOOD Glucose-79 UreaN-25* Creat-1.2 Na-142 K-4.4 Cl-105 HCO3-26 AnGap-15 [2136-1-22] 01:00PM BLOOD Glucose-235* UreaN-27* Creat-1.4* Na-144 K-4.3 Cl-108 HCO3-26 AnGap-14 CXR [1-18]: IMPRESSION: Limited, negative. PICC in appropriate position. Limited evaluation due to motion artifact, repeat CXR might be considered. CXR [1-19]: FINDINGS: Patient is status post median sternotomy and coronary artery bypass surgery. ICD remains in place as well as a right PICC. Cardiac silhouette is mildly enlarged, and accompanied by mild pulmonary vascular congestion. Persistent patchy right basilar opacity and new patchy left lower lobe opcity as well as a persistent linear area of atelectasis in the left lower lobe. The etiology of the basilar opacities is uncertain, but could represent aspiration, infectious pneumonia, or a dependent distribution of edema in the setting of known upper lobe predominant emphysema. EKG [1-19]: Ventricular paced rhythm with a ventricular premature beat and a fusion beat. Compared to previous tracing of [2136-1-18] the fusion beat is new. The ventricular rate is faster. Brief Hospital Course: # Hypotension: The patient's clinical presentation is consistent with hypotension secondary to hypovolemia, likely from overdiuresis. His Lasix dose was increased as an outpatient and he subsequently was diuresed with Torsemide just prior to admission for dyspnea that was attributed to a CHF exacerbation. The patient's mildly elevated lactate on initial presentation which down-trended with IVF, as well as hypotension responsive to small fluid boluses are consistent with hypovolemic hypotension. He was volume resuscitated gently given his chronic heart failure. He was initially given Vancomycin and Zosyn on admission intially for concern of a possible infection. This was discontinued as he did not have a leukocytosis, was afebrile and his CXR was not conerning for pneumonia. His blood and urine cultures were negative to date. We have stopped Torsemide and restarted on Lasix 40mg daily. His metoprolol and spironolactone were restarted. We also stopped [Date Range 8296], Isosorbide Mononitrate as his systolic blood pressures remained 100-120s on only these medications. . #. Chronic Obstructive Pulmonary Disease: On admission the pt was continued on a Prednisone taper that was started at and earlier admission for a COPD exacerbation. He was placed on 2L O2 NC and was sat'ing in mid 90s. We placed him on duonebs initially and then restarted his home medications. The pt's were without wheeze on exam. He was weaned off O2 without difficulty and was sat'ing in the mid 90s on RA. . #. Acute Renal Failure: The patient has had a fluctuating baseline creatinine in the past year, but in the spring of [2134] had a fairly stable creatinien ~1.5-1.7. He currently presented in acute renal failure with a creatinine of 2.1 with negative UA and hyaline casts on UA consistent with pre-renal renal hypoperfusion. This resolved with IV fluids and initially holding his diurectic regimen. He returned to his baseline range prior to discharge. . #. Hypertension: Initially held his anti-hypertensive medications. Once his blood pressure stablized metoprolol, spironolactone and losartan were restarted. We decided to hold [Year (4 digits) 8296] as his HR was well controlled and his systolic blood pressure was ranging from 100-120. . #. Chronic Systolic and Diastolic CHF: Patient has recent TTE with EF 25%, moderate AS, severe TR, and evidence of LVH indicating likely diastolic dysfunction. He currently appears hypovolemic and was volume resuscitated as mentioned above. We restarted Losartan 50mg, Metoprolol 12.5mg [Hospital1 ], spironolactone 25mg and Lasix 40mg daily. We held Torsemide as we do not feel this pt needs both Lasix and Torsemide. . # Coronary Artery Disease: Continued home ASA, Simvastatin, Clopidogrel, metoprolol . # GERD: Continued home Omeprazole. # Hyperlipidemia: Continued home Simvastatin. # Hypothyroidism: Continue home Levothyroxine. # Depression: Continue home citalopram. . #Transitional- #His blood pressure regimen should be re-evaluated as an out patient. We discontinued [Hospital1 8296] at the present time as pt has not been tachycardic while with us and his blood pressure has been low normal. If he becomes volume overloaded we recommend increasing his current dose of lasix rather than starting a new medication. Medications on Admission: - Prednisone 20 mg Tablet: once a day for 12 days: Take 3 tablets for 3 days, 2 tablets for 3 days then 1 tablet for 3 days - Lasix 40 mg daily ([1-9]) - Torsemide 20 mg daily ([1-17]) - Flagyl 500 mg tid x7 days ([1-11]) - Losartan 50 mg daily o - Aspirin 81 mg daily - Citalopram 20 mg daily - [Month/Year (2) 8296] 120 mg daily o - Docusate 100 mg daily - Flovent 110 mcg 2 puffs [Hospital1 ] - Isosorbide Mononitrate 30 mg daily o - Levothyroxine 75 mcg daily - Metoprolol 12.5 mg [Hospital1 ] o - Omeprazole 40 mg daily - Plavix 75 mg daily - Simvastatin 40 mg daily - Spiriva 18 mcg inhaler daily o - Spironolactone 25 mg daily o - Vitamin D 1000 units daily - Tylenol 650 mg q6h prn - Albuterol nebs q4h prn - Bisacodyl 5-10 mg po/pr daily prn - Milk of magnesia 30 ml daily prn - Miralax daily prn - Senna daily prn Discharge Medications: 1. prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for 2 days. 2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. losartan 50 mg Tablet Sig: One (1) Tablet PO once a day. 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 7. Flovent HFA 110 mcg/actuation Aerosol Sig: Two (2) Inhalation twice a day. 8. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 14. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath, wheeze. 16. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [12-19] Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for Constipation. 17. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 18. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL PO once a day as needed for indigestion. 19. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 20. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [Hospital1 599] Senior Healthcare of [Location (un) 55] Discharge Diagnosis: Primary Diagnosis: Hypotension, volume depletion Secondary Diagnosis: Congestive Heart Failure Chronic Obstructive Pulmonary Disease Coronary Artery Disease Atrial Fibrillation Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. [Known lastname 8291], It was a pleasure taking care of you at [Hospital1 827]. You were admitted to the hospital with low blood pressure. We believe this was due to the recent change in your diuretic medication as well as a decrease in your nutritional intake. It is very important that you continue to eat and drink on a daily basis while you are on a diurectic medication. Changes to your medications: STOP: [Hospital1 8296] Isosorbide Mononitrate Torsemide Please see below for recommended follow up appointments. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs or decreases by more than 3 lbs. Followup Instructions: The patient needs a follow up appointment with his primary care physician [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Hospital1 ] in [12-19] weeks from discharge. Department: CARDIAC SERVICES When: TUESDAY [2136-4-10] at 1 PM With: [First Name8 (NamePattern2) 1903] [Last Name (NamePattern1) 1904], NP [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: CARDIAC SERVICES When: FRIDAY [2136-4-13] at 1 PM 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 Department: CARDIAC SERVICES When: FRIDAY [2136-4-13] at 2:00 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 1008], M.D. [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "5849", "2760", "4280", "42731", "40390", "4241", "412", "2724", "2449", "V4581", "53081", "311" ]
Admission Date: [2167-10-20] Discharge Date: [2167-10-22] Date of Birth: [2087-10-1] Sex: M Service: SURGERY Allergies: Percocet Attending:[First Name3 (LF) 2777] Chief Complaint: Fall on BKA site Major Surgical or Invasive Procedure: none History of Present Illness: 80 year old male well known to our service who was recently discharged after getting a Right Below the knee amputation after he had a failed right lower extremity bypass graft with onset of ischemic rest pain and gangrene of his forefoot. Today during dialysis he had fallen out of bed. The fall that was unwitnessed. He also has been hypotension over the last 48 hours. The first episode of hypotension was during dialysis and his blood pressure medications have been held. Past Medical History: 1. CHF: diastolic & systolic HF with CRI, EF 40-45% in [1-13] and [5-14] 2. CAD s/p 2V-CABG [2161] 3. CVA: ([2154]) 3-4 days of slurred speech and right facial droop without residual symptoms. s/p CEA (documented however patient without memory of this procedure) 4. HTN 5. Hyperlipidemia 6. IDDM (retinopathy, nephropathy, neuropathy) 7. NSVT 8. Afib 9. PVD s/p R fem-[Doctor Last Name ] ([2154]), R 2nd toe amputation, gangrene L 1st toe s/p amp ([10-11]), angio with L SFA stenosis & ratty AT ([12-11]), CABG x 2, LLE AT angioplasty ([6-2]) 10. CRI (b/l around 2.9-3.1) 11. Colon ca s/p hemicolectomy 12. H/o diverticulosis 13. H/o angioectasia in stomach w/UGIB [3-/2161] and again [7-/2166] 14. Prostate ca (dx'd [2150]): s/p orchiectomy ([2150]), TURP ([2153]) & pelvic XRT ([2155]) with radiation 'proctopathy'. 15. Iron deficiency anemia on bone marrow aspirate ([2157]) 16. Interstitial lung disease w/mediastinal LAD & a negative CMA. (Differential diagnosis included burned out sarcoidosis versus interstitial pulmonary fibrosis versus malignancy.) s/p flexible bronchoscopy and cervical mediastinoscopy with biopsies ([5-9]) 17. Left cataract surgery [77]. UGIB [2-7] angioectasia ([3-8], [7-13], [5-14]) 19. CEA 20. Cervical mediastinoscopy with biopsies ([5-9]) Social History: Social history is significant for the absence of current tobacco use; he has a remote history of tobacco use but quit in his 20s. There is no history of alcohol abuse or illicit drug use. Patient is widowed and transferred from [Hospital3 1186]. He is a retired foreman for [Company 2676]. Family History: Father: DM, alcohol related death Mother: DM,passed away giving birth to 22nd child Daughter: macular degeneration Physical Exam: Physical Exam Vital Signs: T 97.0 HR 88 BP 121/95 RR 16 O2 Sat 97% on 2L NC General: No Acute distress Cardiovascular: Regular rate and rhythm Lung: clears to ausculation bilaterally Abdomen: soft nontender, nondistended Extremities: Right Below the knee amputation site: no oozing seen at this time but there are old dressings that was sucked with blood, No wound seen, no hematoma felt and sutures are still in place. Left lower extremity: palpable femoral, dopplerable DP, no PT found (which is his baseline) Pertinent Results: [2167-10-22] 05:55AM BLOOD WBC-7.1 RBC-3.07* Hgb-8.1* Hct-26.0* MCV-85 MCH-26.5* MCHC-31.4 RDW-20.4* Plt Ct-36* [2167-10-21] 06:55AM BLOOD PT-17.6* PTT-34.2 INR(PT)-1.6* [2167-10-22] 05:55AM BLOOD Glucose-76 UreaN-23* Creat-2.9* Na-139 K-4.1 Cl-103 HCO3-29 AnGap-11 [2167-10-21] 06:55AM BLOOD CK(CPK)-85 [2167-10-22] 05:55AM BLOOD Calcium-7.5* Phos-2.9 Mg-1.5* [2167-10-21] 06:55AM BLOOD Digoxin-0.8* Brief Hospital Course: pt admitted for fall on [10-20] on BKA site Admit for observations overnight. Monitor for hematoma formation of BKA site. There was no sequele from fall. Transfuse one unit of packed red blood cells for his anemia. HVT stable on DC at 26 One dose of IV antibiotics, prophylactic. No antibiotics on dc. Ne fevres or white count during this hosptial stay. Pt did recieve HD as scheduled. renal consulted PO lopressor and digoxin was initially held for low BP after HD. This will be restarted at Rehab. On Dc pt sable F/U arranged Medications on Admission: [Last Name (un) 1724]: Albuterol nebs prn, Amiodarone 200', Digoxin 0.0625 QOD, Colace 100", Gabapentin 300 QHS, Gabapentin 100", Glargine 9 QHS, HISS, Atrovent nebs prn, Metoprolol 25", Omeprazole 20', Simvastatin 10', Nephro 1', Tylenol prn, Dulcolax prn, Nitroglycin prn, tramadol 25mg PO Q6 hours prn pain Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Digoxin 125 mcg Tablet Sig: 0.5 tabs Tablet PO once a day: Total dose 0.0625 daily. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at [Last Name (un) 21013]). 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Insulin Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose Fingerstick QACHS Insulin SC Fixed Dose Orders Dinner Glargine 9 Units Insulin SC Sliding Scale Breakfast Lunch Dinner [Last Name (un) ] Humalog Glucose Insulin Dose 0-60 mg/dL [1-7] amp D50 61-159 mg/dL 0 Units 0 Units 0 Units 0 Units 160-179 mg/dL 2 Units 2 Units 2 Units 0 Units 180-199 mg/dL 4 Units 4 Units 4 Units 2 Units 200-219 mg/dL 6 Units 6 Units 6 Units 4 Units 220-239 mg/dL 8 Units 8 Units 8 Units 6 Units 240-259 mg/dL 10 Units 10 Units 10 Units 8 Units 260-280 mg/dL 12 Units 12 Units 12 Units 10 Units > 280 mg/dL Notify M.D. 11. Lantus 100 unit/mL Cartridge Sig: One (1) 9 units Subcutaneous at [Month/Day (2) 21013]: with SSI humulog. 12. Tramadol 50 mg Tablet Sig: 0.5 tabs Tablet PO three times a day: prn. 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day: hold for SBP less then 100 / HR less then 60. Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: s/p fall on Amputation site CRI - On HD CHF chronic systolic IDDM neuropathy, CAD, CHF EF 50%, HTN, hyperlipidemia, Fe def anemia, Discharge Condition: good Discharge Instructions: DISCHARGE INSTRUCTIONS FOLLOWING TRANSMETATARSAL / ABOVE KNEE OR BELOW KNEE AMPUTATION This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. ACTIVITY: There are restrictions on activity. On the side of your amputation you are non weight bearing for 4-6 weeks. You should keep this amputation site elevated when ever possible. You may use the heel of your amputation site for transfer and pivots. But try not to exert to much pressure on the site when transferring and or pivoting. If possible avoid using the heel of your amputation site when transferring and pivoting. No driving until cleared by your Surgeon. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s). New pain, numbness or discoloration of your foot or toes. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Exercise: Limit strenuous activity for 6 weeks. Do not drive a car unless cleared by your Surgeon. No heavy lifting greater than 20 pounds for the next 14 days. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home. No bathing. A dressing may cover you??????re amputation site and this should be left in place for three (3) days. Remove it after this time and wash your incision(s) gently with soap and water. You will have sutures, which are usually removed in 4 weeks. This will be done by the Surgeon on your follow-up appointment. WOUND CARE: Sutures / Staples may be removed before discharge. If they are not, an appointment will be made for you to return for staple removal. When the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. Avoid taking a tub bath, swimming, or soaking in a hot tub for four weeks after surgery. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new prescription for pain medication, which can be taken every three (3) to four (4) hours only if necessary. Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. CAUTIONS: NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. Avoid pressure to your amputation site. No strenuous activity for 6 weeks after surgery. DIET: There are no special restrictions on your diet postoperatively. Poor appetite is expected for several weeks and small, frequent meals may be preferred. For people with [Hospital6 1106] problems we would recommend a cholesterol lowering diet: Follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. Additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. Since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and LDL (Low Density Lipoprotein-the bad cholesterol). Exercise will increase your HDL (High Density Lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. You may be self-referred or get a referral from your doctor. If you are overweight, you need to think about starting a weight management program. Your health and its improvement depend on it. We know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude. If interested you can may be self-referred or can get a referral from your doctor. If you have diabetes and would like additional guidance, you may request a referral from your doctor. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. The key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. Things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. Don't let them go untreated! Please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are 8:30-5:30 Monday through Friday. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE HD as scheduled Followup Instructions: Provider: [Name10 (NameIs) 251] [Last Name (NamePattern4) 1490], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2167-11-4] 10:15 Completed by:[2167-10-22]	[ "40391", "4280", "V5867", "V4581", "2724" ]
Admission Date: [2164-5-8] Discharge Date: [2164-6-5] Date of Birth: [2117-12-21] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 5880] Chief Complaint: s/p Motor vehicle crash Major Surgical or Invasive Procedure: [5-8] Splenectomy [5-19] Open tracheostomy; open g-tube placment [5-25] ORIF right tib/fib fracture [5-30] Tracheosotmy decannulation @ bedside [5-12] Treatment of fracture/dislocation of T3-4 and T4-5. Posterior decompression with laminectomy, medial facetectomy at T2-3, T3-4, T4-5. Posterior arthrodesis, T2 to T6. Instrumented segmental posterior T2 to T6 with rod screw hook construct. Left iliac crest bone graft. Application of morcellized allograft. History of Present Illness: 44 yo male s/p high speed [Male First Name (un) ] motor vehicle crash, unrestrained driver who complained of severe abdominal pain/chest pain at scene. Approx 1 hour extrication with + LOC, +EtOH. He was med flighted to [Hospital1 18] and attempt at intubation by med flight crew failed due to blood in air way. LMA was placed during flight. He was intubated via fiber optics upon arrival in the operating room. We are consulted for Past Medical History: HTN Depression EtOH abuse Social History: Married +EtOH Family History: Noncontributory Physical Exam: PE: 97.3 93 133/87 17 100% [Name (NI) 5442] Pt intubated/sedated Unable to assess extra-ocular muscle movement at this time. Significant edema of bilateral conjuctiva. No crepitus of orbital walls. No septal hematoma Pertinent Results: [2164-5-8] 04:34PM GLUCOSE-97 UREA N-11 CREAT-0.8 SODIUM-142 POTASSIUM-4.6 CHLORIDE-112* TOTAL CO2-21* ANION GAP-14 [2164-5-8] 04:34PM CALCIUM-7.8* MAGNESIUM-1.5* [2164-5-8] 04:34PM WBC-12.8* RBC-3.15* HGB-10.0* HCT-29.3* MCV-93 MCH-31.8 MCHC-34.2 RDW-14.6 [2164-5-8] 04:34PM PLT COUNT-255 [2164-5-8] 03:37PM TYPE-ART RATES-/16 TIDAL VOL-700 O2-50 PO2-114* PCO2-48* PH-7.27* TOTAL CO2-23 BASE XS--4 INTUBATED-INTUBATED [Month/Day/Year ]-CONTROLLED [2164-5-8] 12:47PM ASA-NEG ETHANOL-152* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST IMPRESSION: 1. Grade 3 splenic injury, with large perisplenic hematoma, with possible areas of vascular disruption in the splenic hilum, and foci of active contrast extravasation. Small amount of blood also extends around the liver. 2. Perisplenic hematoma approaches and slightly displaces the left hemidiaphragm, and sagittal images suggest possible discontinuity in the left hemidiaphragm. Diaphragmatic injury and/or rupture cannot be excluded. 3. Multiple bilateral rib fractures, multifocal areas of pulmonary contusion, and blood in the pleural spaces bilaterally. 4. Markedly comminuted right acetabular fracture, and posteriorly displaced right femoral head. 5. Possible fracture of the posterior aspect of the T4 vertebral body. When the patient is clinically stabilized, MRI or thin-slice CT is recommended for further evaluation. Above findings were discussed with the surgical team at the time of study interpretation on [2164-5-8], and wet [Location (un) 1131] was placed in the ED dashboard conveying the above findings at 1400 hours on [2164-5-8]. CT T-SPINE W/O CONTRAST IMPRESSION: 1. Acute small avulsion fracture of anterior-inferior endplate of T4 as well as bilateral fractures of the T5 pedicles at their junction with the vertebral body. 2. In conjunction with a recent MRI examination, there is involvement of all three spinal columns making this an unstable injury and neurosurgical/ orthopedic spine consult is recommended as discussed with caring trauma team physician, [Last Name (NamePattern4) ]. [Last Name (STitle) 33863] on date of exam at approximately 3 p.m. Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1352], orthopedic attending physician, [Name10 (NameIs) ] the case with us by telephone at 4PM. 3. Unchanged appearance to bilateral multiple rib fractures and bilateral pleural effusions and adjacent compression atelectasis. ADDENDUM : There is apparent overdistention of endotracheal tube balloon cuff on scout image. Discussed this observation with Dr. [Last Name (STitle) ] at approximately 6:49 p.m. on date of exam. CHEST (PORTABLE AP) FINDINGS: Comparison is made to previous study from [2164-5-19]. There is unchanged cardiomegaly. Spinal fixation hardware is identified and unchanged. There is a left retrocardiac opacity with obscuration of the left hemidiaphragm. This may be secondary to pleural fluid, atelectasis, or developing infiltrate. There are no signs for overt pulmonary edema. The right lung is clear. Brief Hospital Course: He was admitted to the Trauma Service. Orthopedics, and Orthopedic Spine Surgery were immediately consulted because of his injuries. He was taken to the operating room for an exploratory laparotomy and splenectomy. Orthopedics also performed a closed reduction, right hip dislocation with traction pin placement and splinting and closed reduction of right distal tibia fracture at that time. He would later be taken back to the operating room by Orthopedics for Open reduction internal fixation right posterior column and transverse acetabular fracture. On [5-12] he was taken back to the operating room by Orthopedic Spine Surgery for treatment of fracture/dislocation of T3-4 and T4-5 posterior decompression with laminectomy, medial facetectomy at T2-3, T3-4, T4-5, posterior arthrodesis, T2 to T6, instrumented segmental posterior T2 to T6 with rod screw hook construct, left iliac crest bone graft and application of morcellized allograft. Plastic Surgery was also consulted because of facial fractures noted on CT imaging; these injuries were deemed nonoperative. No further interventions regarding this was recommended. He remained in the Trauma ICU, vented and sedated. A decision was made on [5-19] to perform an open tracheostomy and open gastrostomy tube placement. He was eventually weaned from ventilator and sedation and was transferred to the floor in the next few days. A right femoral percutaneous Bard G2 type inferior vena cava filter was also placed because of risk for DVT and PE given his multiple orthopedic injuries. Once awake Psychiatry was consulted given history of depression and concerns for if this auto crash was an attempt to harm himself. He was placed on 1:1 sitters and it was recommended that he go to an inpatient psychiatric facility once medically cleared. Both patient and his wife were in agreement to this. His tracheostomy was removed on [5-30] and he is managing his secretions and maintaining adequate oxygen saturations. Physical, Occupational and Speech therapy were all consulted. He made significant gains with the therapies. He is to remain non weight bearing on his right leg; he passed the swallowing evaluation. He is no longer receiving tube feedings and is tolerating a regular diet. Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 3. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Enoxaparin 30 mg/0.3 mL Syringe Sig: 0.3 ML's Subcutaneous Q12H (every 12 hours). 7. Metoprolol Tartrate 50 mg Tablet Sig: 1 [11-29] Tablet PO TID (3 times a day). 8. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 9. Oxycodone 5 mg Tablet Sig: 3-4 Tablets PO Q3H (every 3 hours) as needed for breakthrough pain: hold for RR <12. 10. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Discharge Disposition: Extended Care Facility: [Hospital1 ] 4 Discharge Diagnosis: s/p Motor vehicle crash Liver laceration Splenic laceration Right acetabular fracture Right tibia/fibula fracture T4 fracture Discharge Condition: Stable Discharge Instructions: DO NOT bear any weight on your right leg. Followup Instructions: Follow up in Trauma Clinic with Dr. [Last Name (STitle) ], in 2 weeks, call [Telephone/Fax (1) 6439] for an appointment. Follow up with Dr. [Last Name (STitle) ] in [Hospital 5498] Clinic in 2 weeks, call [Telephone/Fax (1) 1228] for an appointment. Follow up with Dr. [Last Name (STitle) 1352], Orthopedic Spine Surgery, in 2 weeks, call [Telephone/Fax (1) 1228] for an appointment. Completed by:[2164-6-5]	[ "51881", "311", "4019" ]
Admission Date: [2168-5-25] Discharge Date: [2168-6-22] Date of Birth: [2097-6-30] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Keflex / Sulfa (Sulfonamides) / Nickel / Erythromycin Ethylsuccinate Attending:[Last Name (NamePattern1) 1561] Chief Complaint: increased shortness of breath, trachealmalacia. Allergic to metal stents, admitted for silicone stent placement Major Surgical or Invasive Procedure: s/p tracheobronchoplasty + R thoracotomy due to tracheomalacia and tracheostomy on [5-30]. History of Present Illness: 70-year-old woman who has had a lifelong history of ineffective cough with inability to properly clear secretions and history of recurring bronchitis. She has required yearly treatments for her bronchitis but has never been hospitalized with pneumonia. She does have orthopnea and as a result sleeps in the incline position using a medical bed. She does not have a significant cough. She has always reported that she has something essentially stuck in her chest and if she could only clear she could breathe better. In the past several years, she has developed progressive dyspnea and on [2167-8-6] she was diagnosed by you with tracheobronchomalacia. Of note, she has required prednisone since [2165] and was also started on inhalers in [2167]. Past Medical History: GERD, osteoporosis, tracheabronchialmalacia, polymyalgia rheumatica, s/p TAH, chronic obstructive pulmonary disease, pneumonias Social History: Lives in [State 622] w/ husband. Daughter and son and their families live nearby. Very supportive family network. Brief Hospital Course: Patient admitted [2168-5-25] for rigid bronch for tracheal stent placement for trachealmalacia. Pt developed respiratory distress POD#1, despite inhalers, suctioning and aggressive CPT. Pt transferred to MICU for Heliox inhalation therapy, steroids, and recemic edpinephrine. [2168-5-27] bronch pt found to have subglottis swelling and [5-27] stent was removed. Pt extubated during procedure and remained so post-op and transferred to MICU stable and intubated. Episodes of extreme cough and valsalva manuvers> R blot retinal [Last Name (un) 22392], seen by Ophthamology,advised no treatment. F/U clinic upon discharge as needed. [5-28]- Pt did not tolerate spon breathing trial w/ ^ HR, BP, RR and anxiety and decision to re-sedate and keep comfortable and intubated until trachealplasty [5-30]. [2168-5-30] trachealplasty via right thoracotomy and tracheostomy done. Post op in CSRU, ventilated, sedated and pain control w/ epidural w/ Dilaudid and bupivicaine. VAnco (for total 14 days s/p trachealplasty) and aztreonam (for total 7 days for UTI) started. POD#[2-1]- Weaned off vent then placed back on CPAP for decompensation, epidural for pain control cont, bronch for airway clearance and confirmation of trach in good position, tube feeding restarted POD#[5-3]-- Weaning from vent on CPAP,awake, OOB- CPT, receiving Lasix for diuresis w/ goal of 1L neg/day to assist w/ vent wean, tube feeding advanced w/ 1 episode of vommitting, regaln started, dulcolox w/ min result, pain control w/ Dil+ bup epidural transitioned to PCA- dilaudid. POD#6- Episode of Afib-tx w/ amiodarone, lasix changed to diamox w/ excellent result, tube feeding to be advanced if doboff post pyloric. thoracotomy incision and CT dsg C/D/I. Antibx vanco(for total 14 days) and aztreonam cont. POD#7- Weaned from vent x24hrs, bronch done, preference to avoid NGT sx and bronch for secretions in setting of endobronchial bleeding. Transfer to ICU - Surgery/thoracic border.Diamox d/c, lasix resumed qd for diuresis. ID consulted. POD#8- [Hospital 59313] transfer to floor, TF to goarl, cont diuresis. Speech and swallow eval- unable to tolerate passey-muir valve die to excessive secretions. POD#9-Episode of Afib overnight, tx w/ lopressorIV x2and Amiod IV 15omg bolus. Po amiod resumes, Sx and pul toilet cont via tracheostomy. POD#10 ([2168-6-9])- Bradycardic, unresponsive, no pulse- ACLS started, ? from resp arrest w/ mucous plugging; transferred to SICU for care. Bronch in am -no plugging, clear airways. POD#10--14- SICU course Neuro-sedation weaned, anxiety medicated w/ versed and ativan, now ativan po RTC; REsp- Vent CPAP slow wean, bronch qd -qod for secretions- no plugs, bovona trach placed [6-11] due to sig air leak; Cardiac- NSR rate controlled w/ amiod iv>po, esmolol IV> lopressor po [6-13]. With rate > 70 pt has PVC's and runs VT, diuresis qd w/ lasix 10 mg qd until [6-13] when auto diuresing began. GI- Tube feeds at goal via post pyloric doboff. NGtube d/c [6-12]. BM- [6-13]. Activity- OOB> chair [6-13], PT resumed. Aztreonam cont for UTI w/ sig antibx resistance, vanco d/c today. WBC 16K POD#14-23- Vent weant was persistently delayed by two problems. [Name (NI) ], there was a tendency for patient to go into an idiopathic arryhtmia after 4-6 hours on trach mask. Although she remained hemodynamically stable throughout these events, they were uncomfortable for the patient and neccesitated abortion of vent wean. Cardioloy was consulted and they recommended Amiodorone 400mg [Hospital1 ] for 1 week (starting [6-20]), then Amio 400mg QD x1 wk, and finally amio 200mg QD. Vent wean was also delayed by a large amount of agitation/anxiety during wean. Patient was on benzodiazepines pre-op for anxiety, supplementing these during wean appeared to help wean attempts. Medications on Admission: advair", theophylline 200", albuterol/atrovent nebs, aciphex 20", asa 81', fosamax qwk, prednisone 10mg qd Discharge Disposition: Extended Care Facility: [Hospital3 7] & Rehab Center - [Hospital1 8] Discharge Diagnosis: tracheabronchialmalacia, gastroesophogeal reflux disease, osteoporosis Discharge Condition: good Discharge Instructions: Call Dr.[Name (NI) 1816] office for; fever, shortness of breath, chest pain, drainage or reddness at incision site. Continue all medications as previous to hospitalization. Take all new medications as directed. Specifically, prednisone will be tapered over 1 month Followup Instructions: Follow-up appointment w/ Dr. [Last Name (STitle) 952] once leaving rehab facility- Call [Telephone/Fax (1) 170] prior to returning to [State 622] Completed by:[2168-6-22]	[ "42731", "5119", "5990", "51881", "53081", "2859" ]
Admission Date: [2159-7-27] Discharge Date: [2159-8-7] Date of Birth: [2092-2-16] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 6743] Chief Complaint: Advanced ovarian cancer ICU admission #1: hypotension, intubation, require intense monitoring immediately post-operation. ICU readmission #2: desaturation secondary to flash pulmonary edema. Major Surgical or Invasive Procedure: -exploratory laparotomy, radical resection of tumor, infragastric omentectomy, left hemicolectomy, end colostomy, BSO for advanced ovarian cancer -intubation History of Present Illness: Ms [Known lastname 66172] is a 67 year old with a history of ER/PR positive breast cancer who presented with a recent CT scan revealing a large right adnexal mass, ascites as well as peritoneal irregularities suggestive of metastatic disease. This scan was obtained after a fall caused significant low back and abdominal pain. She also notes having had abdominal distention, lack of appetite, fatigue and diarrhea. She denies nausea, vomiting, and vaginal bleeding. CT scan at an OSH revealed a 9.4 x 7.1 x 12.0 cm right adnexal mass, cystic with areas of nodularity. There was abdominal ascites noted. There were several areas of nodularity within the omentum, measuring up to 6.0x3.0 cm, as well as small bilateral pleural effusions. CA-125 was elevated at 989. Past Medical History: PMH: Asthma, HTN, depression, panic attacks, ER/PR positive DCIS of the right breast. Denies h/o DM, thromboembolic disorder. PSH: Vaginal hysterectomy secondary to prolapse [2132], left breast biopsy [2141], right breast biopsy [2156], right breast lumpectomy [2156]. OB: G1P1, NVD x1 GYN: Menarche age 12, regular. LMP [2132] s/p vag hyst. Denies h/o fibroids, ovarian cysts, STI/PID, and abnormal pap smear. Social History: Never smoker, denies ETOH, denies illicit drugs Family History: Mother had breast cancer in her 70s. MGF had DMII. PGF had HTN and CAD. Physical Exam: Admission exam to the ICU after the surgery: General: Intubated, sedated, no acute distress HEENT: Sclera anicteric, oropharynx clear, 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-distended, bowel sounds hypoactive, no tenderness to palpation, no rebound or guarding, JP drain in place, ostomy in periumbilical region GU: Foley catheter in place Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, left arm cooler than right, but intact pulses Neuro: withdraws to pain Pertinent Results: Admission Labs: [2159-7-27] 03:23PM BLOOD WBC-3.3# RBC-4.46 Hgb-12.8 Hct-37.7 MCV-84 MCH-28.6 MCHC-33.9 RDW-15.3 Plt Ct-437 [2159-7-27] 03:23PM BLOOD Neuts-79 Bands-1 Lymphs-14* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [2159-7-27] 03:23PM BLOOD PT-15.0* PTT-27.5 INR(PT)-1.4* [2159-7-27] 03:23PM BLOOD Fibrino-158* [2159-7-28] 09:00PM BLOOD Ret Aut-1.6 [2159-7-27] 03:23PM BLOOD Glucose-217* UreaN-12 Creat-0.6 Na-141 K-3.8 Cl-111* HCO3-22 AnGap-12 [2159-7-27] 11:06PM BLOOD CK(CPK)-236* [2159-7-27] 11:06PM BLOOD CK-MB-2 cTropnT-<0.01 [2159-7-27] 03:23PM BLOOD Calcium-7.7* Phos-4.4 Mg-1.3* [2159-7-27] 12:40PM BLOOD Type-ART Temp-36.4 pO2-234* pCO2-41 pH-7.33* calTCO2-23 Base XS--4 [2159-7-27] 11:02AM BLOOD Glucose-162* Lactate-2.4* Na-133 K-3.9 Cl-108 calHCO3-22 [2159-7-27] 12:40PM BLOOD freeCa-1.02* Discharge labs: [2159-8-6] 06:15AM BLOOD WBC-15.8* RBC-4.85 Hgb-13.2 Hct-41.4 MCV-86 MCH-27.3 MCHC-32.0 RDW-15.5 Plt Ct-615* [2159-8-7] 06:20AM BLOOD Glucose-124* UreaN-14 Creat-0.7 Na-139 K-4.1 Cl-101 HCO3-26 AnGap-16 [2159-8-7] 06:20AM BLOOD LDLmeas-87 [2159-8-7] 06:20AM BLOOD TSH-4.3* [2159-8-7] 06:20AM BLOOD HIV Ab-PND [8-2] urine culture: PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.GRAM NEGATIVE ROD(S). ~1000/ML. Sensitivites: CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- S TOBRAMYCIN------------ <=1 S [7-27] CXR: NG tube tip has been inserted and its tip is in the stomach. ET tube tip is 4.5 cm above the carina. Mediastinal drain is in place. Heart size is top normal. The assessment of the mediastinum demonstrates bulging of the aortopulmonic window that might be due to pericardial effusion or hematoma, attention to this area is recommended. Patient has mild pulmonary edema. Left retrocardiac opacity is new and might reflect atelectasis, although aspiration cannot be excluded. [7-28] CXR: As compared to the prior study, there is interval improvement of the mediastinal appearance, most likely consistent with resolution of atelectasis. Bilateral pleural effusions have slightly increased as well as bibasal atelectasis. No pneumothorax is present. [8-2] CTA: No evidence of pulmonary embolus. Bilateral pleural effusions, increased in size since [7-19], with overlying atelectasis; however, infectious process cannot be excluded, particularly in the right lower lobe. Mild pulmonary edema. Slightly enlarged mediastinal lymph nodes since [7-19]. Calcified thyroid nodule in the right lobe. [8-3] CXR: Heart size and mediastinal contours remain within normal limits allowing for technique. There is marked interval improvement in bilateral upper zone pulmonary vascular re-distribution and patchy consolidation consistent with improvement in pulmonary edema. Bilateral infrahilar and bibasilar opacities persist. Probable small left pleural effusion. No evidence of pneumothorax. [8-6] ECHO: Very poor image quality. Overall left ventricular systolic function is probably moderately depressed (LVEF= 30-35 %). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. with normal free wall contractility. There is no pericardial effusion. Compared to the prior study dated [2159-8-2], no clear change (LVEF was probably overestimated on prior). Brief Hospital Course: 67 yo female with history of ER/PR positive breast DCIS s/p ex lap, resection of tumor, infragastric omentectomy, left hemicolectomy, end colostomy, BSO for advanced ovarian cancer, who was admitted to the ICU for post-procedure extubation and hypotension and another ICU admission for flash pulmonary edema. #ICU admission #1 for hypotension, intubation, require intense monitoring immediately post-operation: 2 liters of ascitic fluid was drained upon opening of her abdomen, estimated blood loss for the surgery was 1 liter. During the surgery, patient transiently dropped her blood pressure during the procedure to 50s/30s, she was initiated on phenylephrine gtt through peripheral IV. She received 10 liters NS IVF during her procedure, ~2 liters NS while in PACU, 2 units PRBCs, 2 units FFP. Serial labs were obtained for monitoring. Pt was gradually weaned off the phenylephrine gtt. HCT were monitored and there was a slow decrease in her HCT but no evidence of active bleeding, she was given 2 additional units of PRBC. Once pt's condition improved, she was extubated and transferred out of the ICU. # ICU admission #2/desaturation secondary to flash pulmonary edema: [2159-8-2] she had respiratory distress after CTA of the chest was performed for tachypnea and persistent tachycardia in the 100's. CTA was negative for pulmonary embolism but showed worsening bilateral pleural effusion with pulmonary edema. She did not improve with non-rebreather mask and was transferred to the ICU for the 2nd time during her hospital stay. Her Lung exam was significant for extensive inspiratory crackles, CXR consistent with worsening pulmonary edema. EKG showed left bundle branch block that is unchanged compared to EKG on [2159-7-23]. She was placed on BiPAP. Nebulizers were given with minimal improvement. IV Lasix was administered with good urine output during her 2nd ICU stay. A small troponin leak was noted during her 2nd admission to the ICU. Echo was of suboptimal image quality and showed ? EF of 45%. She was placed on IV Nitro drip for a period of time for SBP in the 150-160's. Cardiology team was consulted and following along. Nitro drip was weaned off and carvedilol 6.25 mg twice daily was initiated. Cardiology recommended aspirin of 81 mg daily, Lasix 20 mg daily, continue with home medication Lisinopril 40 mg daily and Simvastatin. BiPAP was gradually weaned off and pt was transferred out of ICU with saturation in her 90's on NC of 2-3L. Repeat Echo on [8-6] confirmed prior Echo and showed moderately depressed LVEF at 30-35%. Pt will follow up as outpatient with Dr.[Last Name (STitle) 32255] (cardiologist) [2159-8-16] for medication adjustment and possible outpatient perfusion imaging versus catheterization. # Hypotension: she had large volume fluid shifts during surgery and hypovolemia due to blood loss. There was low suspicion for sepsis or cardiogenic causes. She received 12 liters IVF resuscitation, and was placed transiently on phenylephrine gtt for pressure support and on propofol for sedation. Her sedation and vasopressors were weaned without any difficulty, and her blood pressure remained normal at the time of transfer out of the ICU and continue to be stable prior to discharge to rehab. # Hematocrit: Patient's hematocrit dropped from 39.9 on admission to 30.0 post-surgery. She received aggressive fluid resuscitation due to hypotension (see above) and some component of her HCT drop is likely dilutional. She was transfused with 4 units blood cells and 2 units of FFP throughout her hospital stay, and her HCT was stable at 41 at the time of transfer to rehab. # s/p Intubation: Patient was intubated for surgical procedure and was admitted to the ICU sedated with propofol. This was slowly weaned and she was extubated without complication. # Advanced ovarian carcinoma: s/p ex lap with resection of tumor, infragastric omentectomy, left hemicolectomy, end colostomy, BSO, and optimally debulked. She will continue treatment as outpatient with Dr. [Last Name (STitle) 15759]. #Ostomy care: s/p consult and teaching from ostomy nurses. #Incisional cellulitis/wound care: small 1.5 cm incisional opening, continue with twice daily wet to dry wound packing; mild erythema around the incision and wound opening, pt was started on a 10 day course of Keflex. # UTI: urine culture was positive for Pseudomonas aeruginosa and it was pan-sensitive. She was started on a 10 day course of Cipro. # post-op de-conditioning: pt was evaluated by the inpatient physical therapists and they recommended rehab care. Once pt was medically stable, she was transferred to rehab for physical therapy. Chronic issues: # Hypertension: continued home med lisinopril, additional anti-HTN meds were added due to the heart failure ( Lasix 20 mg daily, Carvedilol 6.25 mg twice daily) # Asthma: continued home meds fluticasone and nebs PRN # Depression/anxiety: Continued home meds bupropion and sertraline # Hypercholesterolemia: Continued home meds simvastatin Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. azelastine NF 0.15 % (205.5 mcg) NU 4 sprays [Hospital1 ] 2. BuPROPion 150 mg PO DAILY 3. fenofibrate NF 145 mg Oral daily 4. Fluticasone Propionate 110mcg 4 PUFF IH [Hospital1 ] 5. Lisinopril 40 mg PO DAILY 6. Sertraline 100 mg PO DAILY 7. Simvastatin 10 mg PO DAILY 8. Xopenex Neb NF 0.63 mg/3 mL Inhalation PRN SOB Discharge Medications: 1. BuPROPion 150 mg PO DAILY 2. Fluticasone Propionate 110mcg 4 PUFF IH [Hospital1 ] 3. Lisinopril 40 mg PO DAILY 4. Sertraline 100 mg PO DAILY 5. Xopenex Neb NF 0.63 mg/3 mL Inhalation PRN SOB 6. Aspirin 81 mg PO DAILY 7. Carvedilol 6.25 mg PO BID Hold for SBP < 100, HR < 60 8. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days 9. Famotidine 20 mg PO Q12H 10. Furosemide 20 mg PO DAILY please hold for SBP < 100 11. Ibuprofen 600 mg PO Q8H:PRN pain 12. Simvastatin 10 mg PO DAILY 13. fenofibrate NF 145 mg Oral daily 14. azelastine NF 0.15 % (205.5 mcg) NU 4 sprays [Hospital1 ] 15. Oxycodone-Acetaminophen (5mg-325mg) [1-8] TAB PO Q4-6PRN pain RX oxycodone-acetaminophen 5 mg-325 mg [1-8] tablet(s) by mouth every 4-6 hours Disp #50 Tablet Refills:0 16. Cephalexin 500 mg PO Q6H Duration: 10 Days Discharge Disposition: Extended Care Facility: [Hospital 3548] [Hospital 3549] Nursing and Rehab Center Discharge Diagnosis: Ovarian cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair, and some ambulation with assistance and walker. Discharge Instructions: Dear Ms [Known lastname 66172] You were admitted to the gynecologic oncology service after undergoing the procedures listed below. You have recovered well after your operation, and the team feels that you are safe to be discharged home. Please follow these instructions: General instructions: Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex), no heavy lifting of objects greater than 10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * Your staples will be removed at your follow-up visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call [Telephone/Fax (1) 2806]. Followup Instructions: -Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone: ([Telephone/Fax (1) 20259] (Office), ([Telephone/Fax (1) 112097] (Fax); address: [Last Name (NamePattern1) 26916], [Location (un) 47], [Numeric Identifier 83195] Date/Time: [2159-8-16] 10:00. -Please call [Telephone/Fax (1) 160] to schedule a follow-up appointment with Dr. [Last Name (STitle) ] in the [Hospital 7819] Clinic in 2 weeks -Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 5777] Date/Time:[2159-8-22] 2:15 -Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 5777] Date/Time:[2159-9-5] 2:15 [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] MD [MD Number(2) 6753] Completed by:[2159-8-7]	[ "5119", "5990", "2851", "49390", "4019", "311", "4280", "32723" ]
Admission Date: [2146-4-1] Discharge Date: [2146-4-8] Date of Birth: [2090-8-14] Sex: F Service: MEDICINE Allergies: Albay Honey Bee Venom Attending:[First Name3 (LF) 2290] Chief Complaint: Left leg cellulitis Major Surgical or Invasive Procedure: Biopsy of the left lateral thigh on [4-4] History of Present Illness: A 55 Year old female with PMH RA, fibromylagia, hypothyroidism is transferred from [Hospital3 ] for evaluation of cellulitis of the left lower extremity due to concern for necroizing faciitis. She reports that she had a flu like illness 1 week ago with associated malaise, nausea and vomiting, she was unable to tolerate oral intake and did not take spironolactone. She noted tightness in her left leg beginning 5 days ago and redness begining 4 days ago distally and spreading proximally to the hip. She had subjective fevers and chills and presented to the [Hospital3 ] ED for evaluation where labs showed WBC 27.6 and Cr 1.36, she was treated with ceftriaxone, vancomycin and evaluated by surgery who expressed concern for necrotizing faciitis and recommended transfer to [Hospital1 18] for further evaluation. In the ED, initial vitals were: 100.0 100 120/90 20 99% 2L Nasal Cannula, Labs showed Cr 1.5 (baseline unknown) Na132 WBC 25.6 89%PMN She was seen by general surgery who recommended CT to rule out necrotizing faciitis. CT showed diffuse swelling but no air to suggest necrotizing fasiitis, no abcess. She was given morphine 5mg IV x3 and admitted to medicine. Vitals: 98 NSR, RR 24, 112/67, 98% 2L NC, temp 98.2 On the floor, she repoted anxiety but denied pain. She denies recent car trips or plane flights, denies history of DVT. Past Medical History: TN Asthma Rheumatoid arthritis Fibromyalgia Hypothyroidism Anxiety/depression Alcoholism sober x 20 years Morbid obesity Restless Leg Syndrome Past Surgical History: Hysterectomy ([2128]) Removal of ganglion on wrist Social History: Lives alone but is in close contact with two sisters who reside nearby. Works as a tutor and office manager at family business. History of alcoholism x 20 years. Smoker, >20Pack year history Denies illicits/IVDU. Family History: Rheumatoid arthritis, endometrial and other GYN cancers Physical Exam: Physical Exam on Admission: VS: t98.0 bp131/73 p96 rr14 SaO2 94% 2LNC GENERAL: Middle aged overweight female appearing anxious but in NAD, comfortable, appropriate. HEENT: PERRLA, EOMI, sclerae anicteric, MMM NECK: Supple, no elevated JVP HEART: RRR, no MRG, nl S1-S2. LUNGS: CTA bilat, no ronchi/rales/wheezes ABDOMEN: Overweight Soft/NT/ND, no rebound/guarding. EXTREMITIES: Left lower extremity: Blanching Erythemia extending from the ankle to the upper thigh extending medially near the vaginal area. Dry, crusted skin with underlyuing edema. DP/PT pulse 1+ Right lower extremity: no erythemia, tace edema DP/PT pulse 1+ NEURO: Awake, A&Ox3, CNs II-XII grossly intact Physical Exam on Discharge: Vitals: T 98.3 BP 140/77 HR 91 RR 20 O2sat 97% RA GENERAL: Obese female who looks comfortable and in no acute distress. HEENT: PERRLA, EOMI, sclerae anicteric, conjunctiva pink, dry mucous membranes, oropharynx clear. NECK: Supple, no JVD, thyroid barely palpable bilaterally. Carotids 2+ bilaterally w/o bruits. HEART: RRR, nl S1-S2, no MRG. LUNGS: Wheezes bilaterally. No rhonchi or rales. ABDOMEN: Obese. Soft/ND. Diffuse tenderness to palpation. No rebound/guarding. Multiple pinpoint purple nonblanching macules over the lower two quadrants. EXTREMITIES: LLE has a much improved blanching erythematous rash from hip to dorsum of foot. Induration is now absent and much of the erythema has dissipated. Erythema over lateral hip has advanced a bit beyond the borders but unchanged from 2 days ago. Bullae on posterior and lateral aspect of thigh have opened up and finished weeping. Bullae have begun to scab over. Bullae on posterior ankle is open and weeping w/ skin sloughing off. No crepitus. PT and DP pulse 2+. RLE: no erythemia, trace edema. PT and DP 2+. NEURO: Awake, A&Ox3, CNs II-XII grossly intact. Pertinent Results: Admission labs: [2146-3-31] 10:45PM BLOOD WBC-25.6* RBC-4.71 Hgb-13.5 Hct-42.7 MCV-91 MCH-28.7 MCHC-31.6 RDW-13.8 Plt Ct-166 [2146-3-31] 10:45PM BLOOD Neuts-89.3* Lymphs-7.1* Monos-2.8 Eos-0.5 Baso-0.3 [2146-3-31] 10:45PM BLOOD Glucose-110* UreaN-21* Creat-1.5* Na-132* K-3.4 Cl-93* HCO3-23 AnGap-19 [2146-4-1] 07:15AM BLOOD ALT-20 AST-27 AlkPhos-141* TotBili-0.2 [2146-4-2] 06:30AM BLOOD Albumin-2.9* Calcium-7.8* Phos-4.4 Mg-2.2 [2146-4-2] 06:30AM BLOOD CRP-GREATER TH [2146-4-1] 07:15AM BLOOD Vanco-4.8* [2146-3-31] 11:12PM BLOOD Lactate-1.8 Pertinent Labs: Sodium and Renal Function Trend: [2146-4-1] 07:15AM BLOOD Glucose-105* UreaN-20 Creat-1.3* Na-132* K-3.4 Cl-94* HCO3-24 AnGap-17 [2146-4-2] 06:30AM BLOOD Glucose-103* UreaN-13 Creat-1.3* Na-133 K-3.5 Cl-95* HCO3-25 AnGap-17 [2146-4-3] 06:40AM BLOOD Glucose-102* UreaN-14 Creat-1.6* Na-127* K-3.6 Cl-90* HCO3-23 AnGap-18 [2146-4-3] 03:30PM BLOOD Glucose-110* UreaN-17 Creat-2.0* Na-125* K-3.9 Cl-89* HCO3-22 AnGap-18 [2146-4-4] 02:00PM BLOOD Glucose-94 UreaN-21* Creat-2.4* Na-120* K-4.0 Cl-83* HCO3-19* AnGap-22* [2146-4-4] 05:00PM BLOOD Glucose-89 UreaN-22* Creat-2.4* Na-120* K-3.6 Cl-84* HCO3-22 AnGap-18 [2146-4-4] 07:39PM BLOOD Glucose-93 UreaN-23* Creat-2.4* Na-122* K-3.4 Cl-85* HCO3-21* AnGap-19 [2146-4-5] 12:14AM BLOOD Na-119* K-3.8 Cl-84* [2146-4-5] 05:50AM BLOOD Glucose-100 UreaN-25* Creat-2.6* Na-125* K-4.3 Cl-90* HCO3-22 AnGap-17 [2146-4-5] 04:21PM BLOOD Glucose-134* UreaN-26* Creat-2.5* Na-130* K-4.1 Cl-95* HCO3-23 AnGap-16 [2146-4-6] 05:48AM BLOOD Glucose-99 UreaN-28* Creat-2.6* Na-133 K-3.9 Cl-98 HCO3-28 AnGap-11 ABGs [2146-4-4] 12:31PM BLOOD Type-ART pO2-73* pCO2-53* pH-7.23* calTCO2-23 Base XS--5 [2146-4-4] 05:50PM BLOOD Type-ART pO2-72* pCO2-62* pH-7.20* calTCO2-25 Base XS--4 Intubat-NOT INTUBA [2146-4-4] 08:13PM BLOOD Type-ART pO2-76* pCO2-72* pH-7.15* calTCO2-26 Base XS--5 [2146-4-5] 09:47PM BLOOD Type-[Last Name (un) ] Temp-36.5 pO2-39* pCO2-56* pH-7.25* calTCO2-26 Base XS--3 Imaging: CT Lower leg [2146-3-31]: Diffuse subcutaneous soft tissue edema and fluid along the superficial fascial planes in the left lower extremity, predominantly in the left leg, consistent with known history of cellulitis. No evidence of subcutaneous air to suggest necrotizing fasciitis. LENI Left [2146-4-1]: IMPRESSION: No evidence of deep vein thrombosis in the left leg. CXR [2146-4-6]: Cardiac size is top normal. Right PICC tip is in the lower SVC. There is no pneumothorax or pleural effusion. Aside from improving atelectasis in the right lower lobe, the lungs are clear. There are no new lung abnormalities. Brief Hospital Course: 55 yo F w/ PMH of morbid obesity, COPD, Rheumatoid Arthritis and hypothyroidism was treated for Left leg bullous cellulitis and hospital course complicated by hyponatremia, acute kidney injury and transient respiratory acidosis. #Left leg Bullous cellulitis- the patient had extensive bright red, indurated, hot, entire left leg with edema and concern for possible necrotizing fascitis so was sent here from Lawrenece General. CT scan showed no evidence of subcu air, and there was no evidence on exam of necrotizing fasciitis. She was followed by surgery who felt no surgical interventions were necessary. She was originally on vancomycin and when she developed bullae she was broadened to Vanc/Cefepime and Clinda for a few days. Dermatology was consulted because of the extensive bullae and areas of sloughing for concern of something like scaleded skin syndrome or SJS due to new antibiotics. They felt that her rash was consistent with a bullous cellulitis, and took a biopsy on [4-4] to r/o linear IGA reaction to vancomycin. She was afebrile and her WBC was downtrending throughout her hospital course and she was never hypotensive or with signs of sepsis. She was transitioned to oral antibiotics on [4-7] to complete a total of 14 days of antibiotics. At the time of discharge she still has extensive skin changes on her left leg, with darkening of the skin compared to the right, with multiple coalescing bullae especially over the left lateral hip, and crusting over and scabing on the inner thigh with some sloughing on the posterior leg. -Started Doxycycline 100mg po BID -Started Keflex 500mg TID (will need to be uptitrated to QID when patient's renal function normalizes) #Hyponatremia- the patient came in with a low sodium. She was given a few liters of fluid and it was stable. Her sodium then decreased. Her volume status was difficult to assess. She was briefly fluid restricted with worsening in her hyponatremia. Ultimately, it was felt that she was hypovolemic and she was aggressively given IV fluids wiht improvement in her sodium. Her sodium was noraml at the time of discharge. #Acute renal failure- patients renal function was elevated on admission at 1.4 (up from her baseline of 0.7). She developed worsening renal function 48 hours into her hospitalization. Her creatinine peaked at 2.6 and was downtrending at the time of discharge. The etiology of her renal failure was likely a combination of contrast nephropathy and hypovolemia. Her medications were renally dosed at this creatinine clearance, and this will need to be followed up on by her PCP. [Name10 (NameIs) ] was discharged off of her atenolol and spirinolactone. #Asthma Exacerbation- patient takes spiriva at home for her asthma. She had extensive wheezes on admission and required multiple nebulizer treatments and her lungs were clear at the time of discharge. #Respiratory Acidosis- Around the time of the patient's acute renal failure, she was noted to be very drozy with an oxygen requirement. An ABG was performed which revealed a severe respiratory acidosis. She was briefly transferred to the ICU where it was believed that her acidosis was in part due to hypoventilation from narcotics (exacerbated by her decreased renal clearance of morphine). She received narcan and was treated with BiPAP with improvement. At the time of discharge, she no longer needed oxygen and had a normal respiratory and mental status. She may, however, benefit from an outpatient sleep study as she likely has a component of OSA #Tobacco Abuse- patient was counseled on quiting smoking given her COPD. -She reported that she has quit smoking and is currently on wellbutrin which will likely help with this #Depression/Fibromyalgia- she was stable -NSAIDS were held during this admission and at the time of discharge as her renal function is not back to baseline Transitional Issues: Pending labs/studies: None Medications started: 1. Doxycycline 100mg by mouth twice a day (antibiotic) through [4-13] 2. Keflex 500mg by mouth three times a day (antibiotic) through [4-13] Medications changed: None Medications stopped: 1. Ibuprofen (important not to take until your kidney's are back to normal) 2. Spironolacone (hold until you are told to by your PCP) 3. Ropinerole (hold until you are told by your PCP) 4. Atenolol (hold until your PCP tells you to restart) Follow-up needed for: 1. You will need to get your labs drawn on [4-11] and your doctor will discuss these with you at your follow-up appointment 2. You will follow-up with Dermatology (per below) 3. You will need to have your blood pressure monitored since you are off of your blood pressure medication due to the kidney function 4. Improvement of the cellulitis 5. You will need to have your stitches removed from your skin biopsy on [4-18] (your primary care physician can do this) Medications on Admission: Atenolol 100 mg daily Fluoxetine 40 mg daily Buproprion 150 mg TID Ropinirole 1 mg [11-22] PRN Spironolactone (50 mg daily Pravastatin 10 mg daily Hydroxychloroquine 200 mg [Hospital1 ] Lyrica 75 mg [Hospital1 ] Omeprazole 20 mg [Hospital1 ] Levothyroid 100mcg Spiriva Daily Multivitamin Discharge Medications: 1. Device Patient requires a bariatic small base quad cane. 2. fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. 3. Wellbutrin 75 mg Tablet Sig: Two (2) Tablet PO three times a day. 4. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 8. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 10. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day): on area under left breast. Disp:1 tube Refills:2 11. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours): take through [2146-4-13]. Disp:11 Capsule(s) Refills:0 12. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours): take through [2146-4-13]. Disp:17 Capsule(s) Refills:0 13. Outpatient Lab Work CBC and Chem-7 to be drawn on [2146-4-11] ICD9 584.9 Please fax to Dr.[Name (NI) 37061] office at Fax #: [Telephone/Fax (1) 88047] Discharge Disposition: Home Discharge Diagnosis: Primary: Cellulitis, Acute kidney injury, respiratory acidosis Secondary: COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [Known lastname ], It was a pleasure taking care of you while you were here at [Hospital1 18]. You were transferred to [Hospital1 18] because of concern over your left leg infection. The doctors at the [Name5 (PTitle) ] hospital were concerned that this is something that would require surgery so they sent you here to [Hospital1 18]. You were evaluated by the surgeons who felt that you did not require surgery based on the imaging and your exam. You were treated with IV antibiotics and then as it improved we switched you over to oral antibiotics and you were tolerating those well at the time of discharge. Because your skin was blistering on top, we had the dermatologists see you and they performed a biopsy and felt that this blistering was due to the excess fluid that was in your leg. Your leg had dramatically improved while you were here and will continue to heal after you go home. It will be important to keep your leg elevated whenever you are not on your feet. While you were here you had a lot of wheezing and were not exhaling out as much as you needed too, so we briefly had you in the ICU to give you a special kind of breathing treatment called BIPAP, and then you were back on the regular medical floor. It will be important to keep up with your inhalers as an outpatient. You were breathing well without wheezing at the time you were discharged. -We recommend that you get a sleep study as an outpatient to determine if you would benefit from sleeping with CPAP Your kidneys were not working 100% on admission and this was worsened by having the IV contrast that you needed for the CT scan of your leg. This was improving but not back to normal at the time of your discharge, so it will be important to have your labs drawn on MOnday [4-11] and your PCP will [Name9 (PRE) 702] on this and decide if you need to see a kidney specialist or not. Transitional Issues: Pending labs/studies: None MEdications started: 1. Doxycycline 100mg by mouth twice a day (antibiotic) through [4-13] 2. Keflex 500mg by mouth three times a day (antibiotic) through [4-13] Medications changed: None Medications stopped: 1. Ibuprofen (important not to take until your kidney's are back to normal) 2. Spironolacone (hold until you are told to by your PCP) 3. Ropinerole (hold until you are told by your PCP) 4. Atenolol (hold until your PCP tells you to restart) Follow-up needed for: 1. You will need to get your labs drawn on [4-11] and your doctor will discuss these with you at your follow-up appointment 2. You will follow-up with Dermatology (per below) 3. You will need to have your blood pressure monitored since you are off of your blood pressure medication due to the kidney function 4. Improvement of the cellulitis 5. You will need to have your stitches removed from your skin biopsy on [4-18] (your primary care physician can do this) Followup Instructions: Department: Primary Care Name: Dr. [First Name4 (NamePattern1) 4768] [Last Name (NamePattern1) ] When: Dr. [Last Name (STitle) 79357] office is working on a follow up appointment for 4-8 days after your hospital discharge. Please call the office number listed below on Monday [4-11] to discuss this appointment. Thank you, Location: [Location (un) ] FAMILY PRACTICE Address: [Location (un) 4769], [Location (un) ],[Numeric Identifier 4770] Phone: [Telephone/Fax (1) 4771] If your leg is not improving or you have more questions about the rash. You call to schedule a follow-up with [Hospital 2652] clinic at [Telephone/Fax (1) 1971] to make an appointment.	[ "2762", "5849", "2761", "2449", "311", "3051" ]
Admission Date: [2163-7-18] Discharge Date: [2163-8-25] Date of Birth: [2114-8-15] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1283] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [2163-7-19] Mitral Valve Replacement(25/33 Onx Mechanical Valve) via Right Thoracotomy History of Present Illness: Mr. [Known lastname 1968] is a 49 year old male with extensive cardiac history and complicated past medical history. He has had progessive dyspnea on exertion. Echocardiogram was notable for severe mitral regurgitation and mild pulmonary hypertension. In preperation for upcoming surgery, he underwent cardiac catheterization which confirmed severe mitral regurgitation with a mean PA pressure of 20mmHg. The vein graft to the LAD was patent while there was only mild disease in the vein graft to the right coronary artery. He was subsequently admitted to the [Hospital1 18] for cardiac surgical intervention. Past Medical History: Diastolic Congestive Heart Failure secondary to Mitral Regurgitation, History of Endocarditis - s/p Bentall/Homograft/MV debridement [2156] and [2157], Coronary Artery Disease - s/p CABG [2157], History of TIA, Hypertension, Hypercholesterolemia, History of Paroxysmal Atrial Fibrillation, Type II Diabetes Mellitus, History of Seizure, History of Acute Renal Failure, History of Hypoxic Encephalopathy, History of ARDS with ventilator dependence, Prior Septic Emboli(brain, lung, kidney), Depression, History of PEG/J-tube for Necrotizing Esophagitis, Peptic Ulcer Disease/GERD, Chronic Malnutrition, History of Aspiration, Bowel Dysmotility, History of Fungemia, Tracheal-cutanous fistula closure in [2159], s/p Right Hemicolectomy, Chronic Intermittent Chemical Pancreatitis, History of multiple pneumonias, Hypercalcemia, s/p Right Cochlear Implant Social History: No history of tobacco and denies ETOH. He is currently disabled but previously employed as a truck driver. He is divorced. Family History: Denies premature coronary disease Physical Exam: BP 108-117/69-74, HR 63, RR 14 Weight 150lbs, Height 5ft 8inches Thin male in no acute distress, very HOH Oropharynx benign, PERRL, EOMI, sclera anicteric Neck supple with no JVD, full ROM. Transmitted murmurs noted. Lungs clear bilaterally. Chest with well healed sternotomy and thoracotomy. Heart regular rate, [3-4] holosystolic murmur throughout chest Abdomen soft, nontender, nondistended with normoactive BS. Mulitple scard that are well healed. Extremities warm, no edema. Well healed leg incisions. Alert and oriented, cn 2-12 grossly intact, no focal deficits noted. Distal pulses 2+ bilaterally Pertinent Results: [2163-7-18] 04:05PM BLOOD WBC-5.2 RBC-4.87 Hgb-14.1 Hct-41.0 MCV-84 MCH-28.9 MCHC-34.3 RDW-13.9 Plt Ct-234 [2163-7-18] 04:05PM BLOOD PT-12.0 PTT-29.2 INR(PT)-1.0 [2163-7-18] 04:05PM BLOOD Glucose-85 UreaN-25* Creat-1.5* Na-138 K-5.1 Cl-102 HCO3-28 AnGap-13 [2163-7-18] 04:05PM BLOOD ALT-41* AST-31 LD(LDH)-180 AlkPhos-182* TotBili-0.5 [2163-7-19] 09:32PM BLOOD Lipase-51 [2163-7-18] 04:05PM BLOOD Albumin-4.4 [2163-7-18] 04:05PM BLOOD %HbA1c-5.6 [2163-8-24] 05:59AM BLOOD WBC-11.7* RBC-3.07* Hgb-9.1* Hct-28.3* MCV-92 MCH-29.7 MCHC-32.2 RDW-16.0* Plt Ct-534* [2163-8-25] 09:03AM BLOOD PT-29.1* PTT-38.4* INR(PT)-3.0* [2163-8-24] 05:59AM BLOOD PT-29.2* INR(PT)-3.1* [2163-8-23] 06:22AM BLOOD PT-22.6* PTT-40.8* INR(PT)-2.2* [2163-8-22] 06:22AM BLOOD PT-20.7* PTT-62.1* INR(PT)-2.0* [2163-8-22] 12:37AM BLOOD PT-20.5* PTT-68.8* INR(PT)-2.0* [2163-7-29] 04:36AM BLOOD Fact II-19* Fact V-180* FactVII-6* FacVIII-341* Fact IX-30* Fact X-12* [2163-8-24] 05:59AM BLOOD Glucose-101 UreaN-23* Creat-1.1 Na-133 K-4.4 Cl-100 HCO3-25 AnGap-12 [2163-8-23] 06:22AM BLOOD Glucose-100 UreaN-24* Creat-0.9 Na-135 K-4.5 Cl-102 HCO3-27 AnGap-11 [2163-8-22] 06:22AM BLOOD Glucose-98 UreaN-23* Creat-1.0 Na-136 K-4.3 Cl-102 HCO3-27 AnGap-11 [2163-8-21] 05:37AM BLOOD Glucose-101 UreaN-19 Creat-0.9 Na-136 K-3.8 Cl-100 HCO3-28 AnGap-12 [2163-8-20] 04:30AM BLOOD Glucose-92 UreaN-18 Creat-1.0 Na-136 K-3.9 Cl-102 HCO3-28 AnGap-10 [2163-8-25] 09:03AM BLOOD ALT-211* AST-130* LD(LDH)-338* AlkPhos-438* Amylase-399* TotBili-1.0 [2163-8-24] 05:59AM BLOOD ALT-189* AST-121* LD(LDH)-296* AlkPhos-428* Amylase-408* TotBili-0.9 [2163-8-23] 06:22AM BLOOD ALT-185* AST-139* LD(LDH)-261* AlkPhos-391* Amylase-371* TotBili-1.0 [2163-8-22] 06:22AM BLOOD ALT-161* AST-187* LD(LDH)-315* AlkPhos-369* Amylase-331* TotBili-0.9 [2163-8-25] 09:03AM BLOOD Lipase-757* [2163-8-24] 05:59AM BLOOD Lipase-858* [2163-8-23] 06:22AM BLOOD Lipase-845* [2163-8-22] 06:22AM BLOOD Lipase-827* [2163-8-21] 05:37AM BLOOD Lipase-642* [2163-8-25] 09:03AM BLOOD Albumin-3.2* [2163-8-25] Chest x-ray: The heart size is mildly enlarged but stable. The prosthetic mitral valve is in unchanged position. Mediastinal contours are unremarkable. There is no significant change in right lower lobe atelectasis. Small right pleural effusion is again noted, unchanged with no pneumothorax present. The rest of the lungs are unremarkable. The right PICC line tip terminates in mid SVC. Brief Hospital Course: Mr. [Known lastname 1968] was admitted one day prior to surgery for further work-up do to his extensive past medical and surgical history. On [7-19] he was brought to the operating room where he underwent a Mitral valve replacement via a right thoracotomy. Please see operative report for surgical details. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. He required multiple blood transfusions during initial post-operative period. He required Nitro for hypertension but was weaned off by post-op day two and started on beta-blockers. He had episodes of atrial fibrillation on post-op day two which was treated with beta blockers. Despite this he continued to have intermittent atrial fibrillation and Amiodarone was started. Coumadin with a Heparin bridge was initiated on this day and he was transferred to the SDU for further care. Chest tubes and epicardial pacing wires were removed per protocol. On post-op day six Mr. [Known lastname 1968] was c/o nausea. KUB revealed a right paracardiac density, compatible with large hematoma. Liver/GB US showed Cholelithiasis with a stone identified in the neck. General surgery was consulted for the cholelithiasis and following day a chest CT was performed to further evaluate hemothorax and drop in hematocrit. CT showed a large right hemothorax and Heparin was immediately stopped. Mr. [Known lastname 1968] was then transferred back to the CSRU where a chest tube was inserted but without evacuation of hematoma. Therefore he was brought to the operating room where he underwent an exploration and evacuation of hemothorax through his Right thoracotomy incision. Please see operative report for details. Following surgery he has rapid atrial fibrillation which was cardioverted and treated with beta blockers and diuretics. Mr. [Known lastname 1968] remained intubated over two days and was weaned from sedation and extubated on [7-28]. He continued to have slow decrease in his hematocrit and he again was transfused. He did have rise in his creatinine over next several days (over 3.2), evident of acute renal failure, but he kidney function improved and creatinine trended down. Chest tubes were ultimately pulled on [7-30]. General surgery was reconsulted for prior GB US and patient now having increased LFT's and Amylase/Lipase. They believed patient had pancreatitis and hyperbilirubinemia (secondary to hemolysis) and recommended to keep pt NPO. Coumadin was eventually restarted with a Heparin bridge for his mechanical valve. On [8-2] he appeared stable and was transferred to the SDU for further care. Later on this day patient had tarry black guaiac positive stools with emesis with small streaks of blood. Therefore GI were consulted and recommended IV PPI's (d/t his PMH) with checking H. Pylori serologies and following lab-work. Over next several days he remained stable and NPO without N/V. H. Pylori serologies were positive and he was appropriately treated. Repeat GB US and ABD CT on [8-6] and [8-7] showed mildly enlarged pancreas, which can be seen with early pancreatitis and cholelithiasis without evidence of cholecystitis. On [8-8] a PICC line was placed for TPN while patient continued to remain NPO. A ERCP was recommended to further assess the cholelithiasis with possible stone but patient refused. Over the following week he remained stable while receiving TPN and medical management and his LFT's and Amylase and Lipase were closely watched. On [8-15] clear liquid diet was initiated and slowly advanced and he was treated fir a UTI. On [8-18] vascular surgery was consulted d/t swelling in his upper extremity and patient was found to have a hematoma possibly related to IV on US. Patient continued to receive medical management while being treated for above complications with help from multiple services. During this time he continued to receive Coumadin with a Heparin bridge for his mechanical valve. Eventually Mr. [Known lastname 1968] [Last Name (Titles) 8337] food well, TPN was discontinued with resolution of his pancreatitis. On [8-25] (post-op day 37) he was discharged to home with VNA services and the appropriate meds and follow-up appointments. Medications on Admission: Lisinopril 20 qd, Fexofenadine 180 qd, Reglan 10 qd, Keppra 500 [Hospital1 ], Lexapro 10 qd, Amoxicillin prn dental procedures Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 3. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:30 Tablet, Delayed Release (E.C.)(s) Refills:0 5. 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 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 8. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:50 Tablet(s) Refills:0 9. Coumadin 5 mg Tablet Sig: 1.5 Tablets PO once a day for 2 days: Take as directed by Dr. [First Name (STitle) ] for INR goal of [1-29].5. Disp:45 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Mitral Regurgitation s/p Mitral Valve Replacement via Right Thoracotomy PMH: History of Endocarditis - s/p Bentall/Homograft/MV debridement x 2, Coronary Artery Disease - s/p CABG, History of TIA, Hypertension, Hypercholesterolemia, History of Paroxysmal Atrial Fibrillation, Type II Diabetes Mellitus, History of Seizure, History of Acute Renal Failure, History of Hypoxic Encephalopathy, History of ARDS, Prior Septic Emboli(brain, lung, kidney), Depression, History of PEG/J-tube for Necrotizing Esophagitis, Peptic Ulcer Disease/GERD Discharge Condition: Good Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. 6)Please take Warfarin as directed. INR should be followed closely by Dr. [First Name (STitle) ] after discharge from hospital. Warfarin should be adjusted for goal INR between 3-3.5. Followup Instructions: Dr. [Last Name (STitle) 1290] in [3-3] weeks, call for appt Dr. [Last Name (STitle) ] in [1-1] weeks, call for appt Dr. [First Name (STitle) ] in [1-1] weeks, call for appt Dr. [First Name (STitle) ] (Surgery) 7-10 days Completed by:[2163-9-22]	[ "4240", "9971", "42731", "5849", "486", "25000", "V4581" ]
Admission Date: [2164-10-15] Discharge Date: [2164-11-4] Date of Birth: [2103-10-13] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[First Name3 (LF) 2745] Chief Complaint: transfer for management of pancreatitis Major Surgical or Invasive Procedure: Central line Arterial line History of Present Illness: HPI: This is a 61 year-old female with a history of EtOH abuse, cholelithiasis s/p cholecystectomy, who presents from an OSH with likely acute pancreatitis. . Pt was initially admitted to the OSH [Date range (1) 29693] for two episodes of epigastric pain and abnormal LFTs (AST 466 ALT 268). US and MRCP were reportedly normal. She was discharged with diagnosis of alcoholic hepatitis. That evening, pt called her GI doctor complaining of severe abdominal pain, n/v, tremulousness. She presented to the ED and was re-admitted. She was noted to be jaundiced, groggy, with a protuberant abdomen. WBC was 13.8, K 2.8, Bili 7.7, AST 324, ALT 370, alk phos 251, lipast 4877. Tox screen and EtOH levels were negative. Her abdomen became distended, tense, very tender, with no bowel sounds. She was transferred to the ICU for closer monitoring. She was treated with IVF and aggressive pain control with dilaudid 1mg IV q3. Additionally she was sedated on precedex and an ativan drip at 4mg/h. Pt was intubated for airway protection on the morning of [10-14]. CT of the abdomen revealed enlarged indistinct pancreas, extensive peripancreatic fluid consistent with severe pancreatitis and pancreatic necrosis, no loculated or drainable fluid collections or evidence of perforation. Also noted were small bilateral pleural effusions and moderate amount of free fluid in the deep pelvis. . Past Medical History: EtOH abuse HTN h/o cholelithiasis s/p cholecystectomy OA of hips s/p bilateral THR Depression h/o heart murmur Social History: Divorced, no children, lives alone. Works as a ballet teacher. Former smoker, quit 20 years ago. Drinks 1 bottle of wine per day. Family History: Family Medical History: Mother died of lung CA at age 76. Father died of MI at 43. Brother with hypertension. Multiple family members with alcoholism. Physical Exam: Vitals: T: 97.9, BP: 103/52 HR: 77 RR: 19 O2Sat: 100% Vent settings: PS 10/5, RR 19, FiO2 40%, Vt 400s GEN: intubated, sedated HEENT: icteric sclera, pupils pinpoint and sluggishly responsive, NGT (with bilious drainage) and dobhoff NECK: No JVD, no bruits, no cervical lymphadenopathy, trachea midline, L infraclavicular line COR: RRR, 2-3/6 SEM at LLSB PULM: Lungs CTAB anteriorly ABD: tense, distended, very decreased bowel sounds EXT: cool hands and feet, no C/C/E NEURO: sedated, non-responsive to painful stimuli SKIN: jaundiced Pertinent Results: ========== Radiology/Neurology ========== MRCP [10-16] 1. Necrotozing, hemorrhagic pancreatitis involving majority of the body and tail and portions of the head and neck. Small portion of enhancing pancreatic tissue remains in the distal tail and portions of the head. There is no pancreatic ductal dilatation, however, a portion in the region of the genu is attenuated but not disrupted at this time. 2. Large bilateral pleural effusions and small-to-moderate ascites. 3. The portal vein, SMV, and SMA are patent. Note is made CT Head [10-16] There is no evidence of acute intracranial hemorrhages, edema, masses, mass effect, or large area of infarction. The lateral ventricles are slightly prominent for age and represent mild volume loss. The sulci are normal in caliber and configuration. There is no evidence of bony fracture. EEG [10-17] Markedly abnormal portable EEG due to the moderately severe suppression of the background throughout. The background was slow, and it was intermittent, alternating with much lower voltage patterns. There was a brief episode of some "lightening," but the background remained encephalopathic throughout. Medication effect is probably the most common cause of such recordings. There were no areas of prominent focal slowing, but encephalopathies may obscure focal findings. There were no epileptiform features. MR [Name13 (STitle) 430] [10-18] No intracranial abnormalities detected. Specifically, no evidence of hemorrhage or infarction. Incidentally noted adipose accumulation over the right malar eminence and right maxillary sinus air-fluid level. CT A/p [10-19] IMPRESSION: 1. Severe pancreatitis with extensive pancreatic necrosis sparing portions of the head and tail. 2. Bilateral pleural effusions, slightly increased. 3. Marked narrowing of the splenic vein and possible non- occlusive thrombus within its mid portion. 4. Peripancreatic phlegmon and free fluid in pelvis. TTE [10-19] The left atrium is normal in size. The right atrial pressure is indeterminate. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). The estimated cardiac index is high (>4.0L/min/m2). There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to increased stroke volume due to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Suboptimal image quality. No valvular vegetations identified, but cannot definitively exclude given poor acoustic windows. Hyperdynamic left ventricular function with resting tachycardia. Normal left ventricular systolic function. Technically suboptimal to exclude focal wall motion abnormality. Moderate pulmonary hypertension CT Chest [10-23] 1. Multifocal patchy areas of consolidation may reflect an infectious process. 2. Moderate pulmonary edema including moderate pleural effusions, slightly smaller compared to the recent abdominal CT. 3. 2.3-cm spiculated right right lobe nodule is worrisome for malignancy. for which short interval followup, after patient's acute symptoms resolved, is recommended. 4. Anasarca. 5. Hemorrhagic pancreatitis, incompletely assessed. CT Chest [10-26] IMPRESSION: 1. No pulmonary embolism. 2. Interval worsening of multifocal areas of consolidation, probably reflecting an ongoing infectious process. 3. Moderate pulmonary edema with slightly increased moderate pleural effusions bilaterally. 4. 8-mm right lower lobe opacity, smaller compared to the previously seen 2.3 cm spiculated right lower lobe nodule and probably represents atelectasis versus consolidation. A chest CT following resolution of patient's acute symptoms is again advised. 5. Anasarca. ========== Labs ========== [2164-10-15] 05:29PM LACTATE-1.3 [2164-10-15] 05:24PM ALT(SGPT)-174* AST(SGOT)-80* LD(LDH)-764* ALK PHOS-107 AMYLASE-614* TOT BILI-2.8* [2164-10-15] 05:24PM LIPASE-676* [2164-10-15] 05:24PM ALBUMIN-2.3* CALCIUM-7.8* PHOSPHATE-2.4* MAGNESIUM-2.2 [2164-10-15] 05:24PM NEUTS-59 BANDS-20* LYMPHS-11* MONOS-7 EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-1* NUC RBCS-1* [2164-10-15] 05:24PM PT-13.3 PTT-29.7 INR(PT)-1.1 Brief Hospital Course: # Acute severe hemorrhagic pancreatitis: Lipase was elevated to 4788 at the OSH. OSH CT showed pancreatitis and concern for pancreatic necrosis. EtOH pancreatitis is the most likely etiology. She underwent MRCP at our hospital which demonstrated hemorrhagic, necrotic pancreatitis. Patient was managed conservatively with aggressive fluid replacement. A surgery consult was obtained and did not advise any operative or IR procedures for the peripancreatic inflammation. She subsequently developed acute lung injury, bilat pleural effusions, anasarca,and ascites as a result of the severe pancreatitis. Her course was complicated by vent associated pneumonia as well. She also showed altered mental status during her ICU stay related to toxic and metabolic encephalopathy. Patient required insulin replacement therapy while she was in the unit and on the floor. She was then transferred from the ICU to the floor. There, she had PT/OT, blood transfusion for anemia from hemorrhagic pancreatitis, and diuresis. Before transfer to rehab she was noted to have significant and had CXR. This showed possible loculated left upper lobe effusion. She underwent repeat CT of the chest on [2164-11-2] which showed moderate bilateral pleural effusions and anterior loculated left pleural effusion. Case was discussed with interventional pulmonary service and given the patient's improving clinical status and lack of active evidence of infection, they recommended not performing a paracentesis to evaluate the loculated effusion. The patient was educated to return if she develops fevers, rigors, sweats, worsening difficulty breathing. . # Altered mental status: Her mental status was altered and related to toxic and metabolic encephalopathy. Head imaging was negative (CT and MRI)including EEG. She is back to normal mental functioning after her prolonged and complicated course. . # VAP: Sputum grew MSSA (imipenem sensitive). She was initially on Vancomycin and imipenem. Vancomycin d/ced ([Date range (1) 82010]). She was transition ed from Imipenem ([10-16] ?????? [10-22]) to Nafcillin on [10-22], but Imipenem was restarted again given decompensating respiratory status. CT chest on [10-26] was concerning for worsening multifocal pneumonia, so her antibiotics were changed from Imipenem to Vanco/Zosyn. Microbiology data has been negative since [10-17]. 14 day course of antibiotics were completed on [10-30]. Cough improved with expectorant and mucous clearing device. Before transfer to rehab she was noted to have significant and had CXR. This showed possible loculated left upper lobe effusion. She underwent repeat CT of the chest on [2164-11-2] which showed left anterior loculated effusion. . # Pulmonary edema/Acute lung injury: Extubated [10-21] but emergently re-intubated [10-23] during event with SVT and hypotension. Patient was extubated again [10-25]. CT chest showed interstitial changes and pleural effusions. Bronchoscopy on [10-17] was WNL, and samples significant only for 2+ polys and staph aureus. She continued to receive to Lasix with effective diuresis. . # SVT: Patient has prior h/o of Afib. Reportedly never anticoagulated. Episodes of SVT appear to be precipitated by diuresis. She was emergently re intubated on [10-23] during episode of SVT with hypotension that did not respond to electrical cardioversion. Patient was loaded on amiodarone and remained in NSR thereafter. CTA was negative for PE. She was then placed on maintenance dose of 200 mg /day. Patient was also continued on home dose of metoprolol. . # Horase voice: patient had traumatic intubation and continues to have a hoarse voice. ENT reports vocal cords functional and will continue to take time to recover. Plan for pt to f/u with ENT in 2 wks after discharge. . # RLL nodule ?????? RLL nodule appreciated on Chest CT. This will require outpatient follow up in 10 - 30 days after discharge. PCP was notified on [2164-11-2]. . # Nasal skin necrosis possibly related to her ICU stay. She was seen by plastic surgery on [2164-11-2]. The necrosis is not infected. They recommended local care and out patient follow up at their resident clinic. . . . Medications on Admission: Toprol xl 50 qd Celexa 80 qd Lisinopril 40mg pO qd HCTZ 25 Oxycodone 5 q6 Discharge Medications: 1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [11-16] Drops Ophthalmic PRN (as needed). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever. 4. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed. 5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 7. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 10. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Discharge Disposition: Extended Care Facility: [Location (un) 582] Of [Location (un) 620] Discharge Diagnosis: severe necrotizing haemorrhagic pancreatitis acute respiratoy failure acute lung injury VAP Discharge Condition: stable. Discharge Instructions: You had severe necrotizing haemorrhagic pancreatitis resulted in respiratoy failure, intubation, acute lung injury, lung infection and anemia. we found a small lung lesion that needs to be followed up with repeat CT of the chest once you recover. Followup Instructions: PCP: [Name10 (NameIs) ],[Name11 (NameIs) ] [Name Initial (NameIs) ]. [Telephone/Fax (1) 2115]. Please call the office at [Telephone/Fax (1) 82011] to schedule appointment in a 1 or 2.	[ "51881", "2851", "4019", "311" ]
Admission Date: [2101-12-27] Discharge Date: [2102-1-4] Date of Birth: [2024-11-3] Sex: F Service: MEDICINE Allergies: Bactrim / Sulfa (Sulfonamide Antibiotics) Attending:[Last Name (NamePattern4) 290] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: Intubation History of Present Illness: 76 yo female with Diastolic CHF (EF of 60%), SLE, ESRD on HD, diverticulosis, CAD on plavix/ASA, known colovaginal fistula, presents with bright red blood per vagina mixed with feces starting 9AM this morning while going to the bathroom. Patient is currently intubated and sedated, but per report, she was in her usual state of health until this morning w/ no N/V/abd pain/F/C. Pt has had h/o vaginal bleeding previously, but never to this extent. She also has a long history of urosepsis [2-22] stool output from vagina, most recently in [2-/2101] per [Hospital1 18] records. Past Medical History: Diastolic CHF (ECHO [2098]: LVEF 60%) SLE w/ chronic renal insufficiency [2-22] focal sclerosis (baseline Cr 2.5-3.0) CKD on HD (on Aranesp?) Atrial fibrillation off coumadin HTN CAD s/p CABG ([2093]) on plavix Hyperlipidemia Gout Mod-Sev MR h/o diverticulitis Rectovaginal Fistula Osteoporosis h/o esophagitis h/o aspiration pneumonia s/p cholecystectomy Social History: Cantonese speaking only. - Tobacco: none - Alcohol: none - Illicits: none Family History: Non-contributory Physical Exam: Physical Exam on Admission: GEN: intubated, sedated PULM: cta b/l but decr BS at left base CARD: RRR, no m/r/g ABD: +BS, soft, NTND EXT: diminished pulses radial and PT/DP GU/RECTAL: Brown stool, guaiac positive in rectum. Oozing bright red blood from vagina, no masses or packing on digital vaginal exam. Pertinent Results: Labs on Admission: [2101-12-27] 11:10AM PT-13.0 PTT-28.1 INR(PT)-1.1 [2101-12-27] 11:14AM GLUCOSE-115* LACTATE-1.7 NA+-137 K+-4.9 CL--95* TCO2-23 [2101-12-27] 12:30PM WBC-6.8# RBC-2.88* HGB-11.0* HCT-34.4* MCV-119* MCH-38.3* MCHC-32.1 RDW-14.8 [2101-12-27] 08:20PM FIBRINOGEN-276 Micro: [12-29] Blood Cx: budding yeast [12-28] Urine Cx: E.Coli [12-29] C.diff negative Imaging - CT abd/pelvis [12-27]: 1. No definite evidence for active extravasation in the region of the known colovaginal fistula. 2. Saccular infrarenal aortic aneurysm measuring up to 3 cm in diameter is stable in size. 3. Extensive diverticulosis without evidence for diverticulitis. 4. Atrophic kidneys with multiple cysts bilaterally consistent with history of end-stage renal disease. -Echo [12-29]: The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. An eccentric, posteriorly directed jet of moderate (2+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity [Known firstname ] be significantly underestimated (Coanda effect). An echodensity associated with the anterior mitral leaflet, on its atrial aspect is seen, most likely representing an acoustic artifact, but a vegetation cannot be excluded with certainty. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. Significant pulmonic regurgitation is seen. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [2101-2-24], the findings are similar. If clinically indicated, a transesophageal echocardiographic examination is recommended. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. . Echo [1-2]: Thickened mitral leaflets with moderate to severe mitral regurgitation, but no discrete vegetation. Mild aortic regurgitation without discrete vegetation. Moderate pulmonary hypertension. . US AV graft [1-2]: IMPRESSION: No fluid collection or evidence of abscess is seen at the site of the patient's left arm AV fistula. Brief Hospital Course: 76 yo F with lupus nephritis, CKD on HD, CAD s/p CABG, HTN, rectro-vag fistula who presented to the ER with likely GI bleeding of diverticular source admitted to the MICU for GI bleed, hypotension and respiratory failure. . # GI bleed: The patient presented to the ER with bright red blood per vagina mixed with feces while going to the bathroom. The patient has had h/o vaginal bleeding previously, but never to this extent. She also has a long history of urosepsis [2-22] stool output from vagina from a known rectal vaginal fistula. CTA did not demonstrate active bleeding. No further BRBPR during her admission. Gyn, GI and Surgery were consulted in the ER and followed while in the MICU. The likely source of the bleeding was deemed to be from a diverticular bleed that was near the fistular opening. GI did not pursue colonoscopy at this time given patient's tenuous status. GYN stated the potential for fistula repair via a sub-total colectomy followed by exision of the fistula, should the patient stabilize clinically. Patient had no further bleeding after first night of admission and hematocrit was stable, but was critically ill throughout her stay so no surgical intervention or workup of the fistula was pursued. . # Hypoxic respiratory failure: In the ER she received 1.7L of fluid for hypotension and shortly thereafter the patient developed acute pulmonary edema and tachypnea. She received Bipap, nitro SL, and nitro gtt with no improvement. Her BP dropped to 80's/40's and she was intubated. She was sent to the MICU for management of her respiratory failure. Thoughts for her hypoxic respiratory failure included infection, hypervolemia, CHF exacerbation. Less likely TRALI or ARDS following blood transfusion since per ED report pt had received fluids prior to intubation. She remained intubated and sedated until she was terminally extubated at the decision of her family given her critical illness and lack of improvement. . # Septic Shock: On [12-29], pt had positive blood cultures that was + for [Female First Name (un) ] with Urine cx showing E.Coli. Source of blood infection unclear, thought to be ascending urinary tract, vaginal infection given fistula or AV fistula source. No evidence of infection in AV fistula or any lines per transplant surgery. The patient was started on Micafungin. A TTE was performed which showed an echodensity and they could not rule out a vegetation. A TEE did not demonstrate any evidence of vegetation and AV graft showed no evidence of infection. Transplant surgery did not think the graft looked infected either. The patient was given Vanc/Cefepime/flagyl for broad-spectrum antibiotic coverage, then started on micafungin when [Female First Name (un) ] grew in the bloodstream. OB/GYN and ID felt candidemia [Known firstname ] be secondary to source from fistula, and blood cultures cleared after she was started on micafungin. However, patient remained on double pressors and CVVH during MICU stay. Stress dose steroids were also tried one day prior to death. . # Rectovaginal fistula: The patient has a known diagnosis of rectovaginal fistula diagnosed in [2096]. Surgery, GI, and gyn consulted. No indication to repair while patient septic and intubated. . # CRF: Given hypotension, Pt did not undergo her usual Tues/Thurs/Sat HD and instead underwent CVVH for K,H+ clearance. When initially started on this on [12-28], she became hypothermic to 92 degrees and it was stopped. It was restarted the next day using a bear hugger and the patient maintained her temperature. Her medications were renally dosed. Medications on Admission: Prednisone 5mg every other day Plaquenil 200mg daily Lipitor 5mg daily Levothyroxine 50mg daily Renagel 800mg TID Protonix 40mg daily Allopurinol 100mg QOD Metoprolol XL 25mg daily Torsemide 40mg daily Plavix 75 mg daily Colace 100mg daily B12 2000mg daily ASA 325mg daily B Complex/Vitamin C/Folic Acid daily Vitamin D 1,000 units daily Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: 1. Candidemia 2. Septic Shock 3. Gastrointestinal Bleed 4. Rectovaginal Fistula Discharge Condition: Expired Discharge Instructions: Patient expired Followup Instructions: N/A [Initials (NamePattern4) ] [Last Name (NamePattern4) ] [Name8 (MD) ] MD [MD Number(1) 292]	[ "0389", "51881", "78552", "40391", "99592", "4280", "2724", "V4581" ]
Admission Date: [2173-5-28] Discharge Date: [2173-6-3] Date of Birth: [2121-5-18] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1384] Chief Complaint: Diarrhea/dehydration Major Surgical or Invasive Procedure: [2173-6-1]: Cardioversion History of Present Illness: 52M s/p pancreas transplant 3wks ago now w/ diarrhea/dehydration & syncope in new onset Afib. Had been well then 2 days ago began diarrhea, fatigue. Difficulty with continence as diarrhea progressively worsening. Nonbloody, liquid brown stools. Mild intermittent nausea, no vomiting. No fevers or chills. No abdominal pain. No chest pain. This AM was getting up to go to the bathroom and felt his vision go dim and possibly syncopized transiently slumping to the floor. Did not hit head. No c/o palpitations or dizziness otherwise. FSBS all <120. +anorexia. ROS: (+) per HPI (-) no headache, CP, SOB, dyspnea, orthopnea, fever, chills, dysuria, hematuria, hematemesis, hematochezia, myalgias, arthralgias. Past Medical History: DM-1 CVA [2147] Hypertension Hyperlipidemia Renal osteodystrophy Multiple UTIs Anemia PSH: Kidney panc transplant- [2162-5-4] - [Doctor Last Name ] [Hospital1 ] Multiple podiatric procedures for hyperkeratotic feet leisions Social History: Lives at home with parents Works as police dispatcher Family History: Non-contributory Physical Exam: 98.6 88-120 122/65 18 96 A&O, NAD. appears comfortable Irregular rate/rhythm, no M/G/R Lungs CTA b/l Abd soft, staples at midline incision, healing well without erythema or induration or drainage, JP bulb in RLQ with serous output, low volume No LE edema no carotid bruits Pertinent Results: On Admission: [2173-5-28] WBC-3.1# RBC-3.01 Hgb-9.1* Hct-26.8* MCV-89 MCH-30.3 MCHC-33.9 RDW-16.2* Plt Ct-195 PT-12.9 PTT-29.2 INR(PT)-1.1 Glucose-106* UreaN-39* Creat-2.0* Na-133 K-4.2 Cl-106 HCO3-17* AnGap-14 ALT-12 AST-17 LD(LDH)-210 AlkPhos-67 Amylase-34 TotBili-0.4 Lipase-21 Calcium-8.1* Phos-3.3 Mg-1.5* TSH-2.3 Free T4-1.1 tacroFK-13.0 On Discharge: [2173-6-3] WBC-3.3* RBC-3.09* Hgb-9.4* Hct-27.8* MCV-90 MCH-30.4 MCHC-33.7 RDW-16.1* Plt Ct-194 PT-25.0* PTT-40.3* INR(PT)-2.4* Glucose-102* UreaN-36* Creat-1.5* Na-133 K-4.9 Cl-111* HCO3-14* AnGap-13 Amylase-28 Lipase-18 Calcium-8.7 Phos-2.8 Mg-1.5* tacroFK-9.6 Brief Hospital Course: 52 y/o male s/p pancreas after kidney on [2173-5-6] who presented to the ED with reports of diarrhea and appearing dehydrated with a witnessed syncopal episode. While in the emergency room he was noted to have Atrial fibrillation and was borderline hypotensive. In the ED he received 2 units RBCs, 3 liters of fluid, cardiac enzymes were cycled, and for the diarrhea his cellcept was cut to 500 mg [Hospital1 ]. He was transferred to the SICU for further close monitoring. He was started on a heparin drip, esmolol and IV lopressor. He continued to be in Afib despite these medication maneuvers. On [5-31] he had a cardiac echo that verified the rhythm as atrial fibrillation and that there were no thrombi in the atria. On [6-1] a TEE was performed showing No LA/LAA/RA/RAA thrombus seen. Mild mitral regurgitation. Normal biventricular systolic function. Complex (>4 mm, nonmobile) plaque in the descending aorta. He was cardioveted with a single shock resulting in a normal sinus rhythm. He was maintained on the beta blocker, coumadin was initiated and he was stable for transfer to the regular surgical floor. The patient was continued on telemetry with no evidence of recurrent AF. His INR was monitored daily and the heparin was discontinued when therapeutic. Prograf dosing was done based on daily levels, and he had adjustemts as needed and was discharged on 2 mg [Hospital1 ]. His cellcept was kept at 500 [Hospital1 ] and he remained on the 5 mg prednisone he was receiving at time of admission. He was tolerating diet, ambulating and had bowel function at discharge. PT/INR to be followed initially by transplant center. He has follow up appointment with Cardiology who will determine at that time the duration of anticoagulation. Medications on Admission: ATENOLOL 25 mg Tablet - half Tablet(s) by mouth once daily, FAMOTIDINE 20 mg [Hospital1 ], MYCOPHENOLATE MOFETIL 1000 mg [Hospital1 ], NYSTATIN - 100,000 unit/mL Suspension - 5 ml Suspension QID, PREDNISONE 5 mg daily, Bactrim SS daily, TACROLIMUS 3 mg [Hospital1 ], VALGANCICLOVIR [VALCYTE] 450 mg daily, ASPIRIN 81 mg daily, CALCIUM CARBONATE-VIT D3- 600 mg (1,500 mg)-400 unit Tablet daily Discharge Medications: 1. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 4. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1) Tablet PO once a day. 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day: Have PT/INR checked. Dose changes based on lab results. Disp:150 Tablet(s) Refills:1 9. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:120 Tablet(s) Refills:2 12. Outpatient Lab Work For Friday [2173-6-4]: Please draw A PT/INR, fax results to transplant clinic at [Telephone/Fax (1) 697] Discharge Disposition: Home Discharge Diagnosis: New onset atrial fibrillation now on anticoagulation Dehydration s/p pancreas transplant [2173-5-6] Discharge Condition: Stable A+Ox3 Ambulatory Discharge Instructions: Please have PT/INR drawn Friday [6-4] with results to the transplant clinic at [Telephone/Fax (1) 697]. Continue twice weekly labwork per transplant clinic guidelines Monitor for fevers, chills, nausea, vomiting, diarrhea, constipation, inability to take or keep down food, fluids or medications, pain over the pancreas. Monitor for chest pain, difficulty breathing or palpitations, you should proceed to the emergency room if you are having any heart issues. You are being changed off atenolol and to start metoprolol. It is important that you do a blood pressure and heart rate [Location (un) 1131] daily, document your readings and bring a copy with you to your clinic visits. Monitor for bleeding, to include nosebleed, rectal bleeding or easy bruising. Call the transplant clinic immediately if any of these occur. No heavy lifting No driving if taking narcotic pain medication Followup Instructions: [Name6 (MD) 2105] [Name8 (MD) 2106], MD Phone:[Telephone/Fax (1) 673] Date/Time:[2173-6-8] 2:00 [Name6 (MD) 251] [Last Name (NamePattern4) 677], M.D. Phone:[Telephone/Fax (1) 62] Date/Time:[2173-7-9] 1:20 Completed by:[2173-6-4]	[ "42731", "4019", "2859" ]
Admission Date: [2131-10-30] Discharge Date: [2131-11-1] Date of Birth: [2078-7-16] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 613] Chief Complaint: DKA Major Surgical or Invasive Procedure: none History of Present Illness: 53 yo male with h/o DMI, HTN, HL, and PAD who presents to the ED with DKA. . On arrival to the ED, vitals were 98.3 170 161/86 16 100% 6L. He triggered for tachycardia on arrival. He appeared tachypnic with shallow breathing. He was noted to have a BS >500 when EMS arrived and received 300cc on route to the hospital. Glc was 602 in the ED. His bicarb was 5 and his gap was 30. He received 10 units of insulin IV and was started on an insulin gtt at 6/hr and given 6L of IVF. His repeat chem 7 was notable for a bicarb of 6 and a gap of 23. His glc improved to 381. His white count was elevated to 20.5 with 83.7% neutrophils. His creatinine was elevated to 1.9 up from 0.9 in [Month (only) 1096] of last yr. His serum tox screen was negative. His EKG was notable for inferior and laterally t wave changes that were thought to be rate related. There was concern for etoh withdrawal and he was given 4mg of IV ativan for anxiety and a banana bag was hung. His last drink was last night. He had reported cough and fever at home. His CXR showed + spine sign. His vbg was pH 7.00 pCO2 21 pO2 96 HCO3 6. he had 2 18 gauge IVs in place. Vitals prior to transfer were 139/74 HR 174 RR25 99% RA. . On arrival to the floor pt reports pain in his bottom. He reports that his emesis started on Saturday evening. Of note he had traveled to [Location (un) 3844] and had 7-9 beers. He denies any history of etoh withdrawal and says that he generally drinks 2-3 beers a night. When he arrived home he began to have non bloody emesis. He reports that he took his insulin as [Location (un) 2875]. BS on Saturday were between 140s-170s and on Sunday were 120s-160s. He reported having a cough only after starting to vomit and it was generally unproductive. He has been unable to keep any food down since Sunday night. He reports his last episode of DKA was overa yr ago. His BS was 381 on arrival to the floor. It was rechecked in 1 hr and was 398. Insulin gtt was turned up from 6 to 9units/hr. Past Medical History: Diabetes Mellitus, Type 1: diagnosed in [2126-2-5]. Hypertension Hypercholesterolemia PAD s/p fem-[Doctor Last Name ] on [2129-12-13] Social History: Social History: Firefighter. Lives with wife. Denies IVDU. Smokes [2-8] cig/day. 30 yr smoking hx per records. Drinks 2-3 beers most nights. Admits to drinking up tp 5-6 beers at night at times. . Family History: Family History: Mom - cancer history on mom's side + HX of SCD: Dad - deceased from MI at age 42 Physical Exam: VS: T97.3 BP122/68 HR161 RR22 98% RA GEN: fatigued, A & O x3 (thought it was [2131-11-1]) HEENT: PERRL, [Month/Day/Year 3899], anicteric, very dry mm, no supraclavicular or cervical lymphadenopathy RESP: CTA b/l with good air movement throughout CV: tachycardic, S1 and S2 wnl, no m/r/g ABD: mild tenderness in the lower abdomen +b/s, soft, no rebound or guarding EXT: no c/c/e, radial and dp pulses +2 SKIN: no rashes NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated Pertinent Results: Admission labs: [2131-10-30] 01:35AM NEUTS-83.7* LYMPHS-10.4* MONOS-5.1 EOS-0.4 BASOS-0.4 [2131-10-30] 01:35AM WBC-20.5# RBC-4.71# HGB-15.3# HCT-48.7# MCV-104# MCH-32.5* MCHC-31.4 RDW-13.6 [2131-10-30] 01:35AM CALCIUM-9.3 PHOSPHATE-7.7# MAGNESIUM-2.4 Brief Hospital Course: 53 yo male with h/o DMI, etoh abuse, PAD, HTN, HL, and smoking who presents in DKA in the setting of recent alcohol use and ? of an aspiration pneumonia. . #. DKA: s/p 6L of IVF in the ED with gap and bs both improved. Likely infectious etiology given WBC of 20.5. CXR with + spine sign. UA negative for infection. He was given Unasyn for possible aspiration pneumonia. He was initially given NS and insulin gtt. NS was transition ed to D5 1/2 NS when FSBG <250. Potassium and phosphate were repleted. Electrolytes were monitored q4h until anion gap closed. The patient was transferred to the floor where he was stable with good glucose control and his electrolytes remained normal. A repeat CXR was negative for pneumonia and his ABX were discontinued. An attempt was made to schedule follow up with his PCP and his [Name9 (PRE) ] endocrinologist however due to the holiday the appointments could not be made. He was told to call them the Monday after the holiday to schedule follow up. #. Tachycardia: HR 160s on arrival. Pt tolerating it well with SBP 130/79. EKG showed likely AVRT vs AVNRT. This may have been secondary to a combination of DKA, severe dehydration, withdrawal from etoh, and infection. After metoprolol IV, this resolved. Home beta blocker was restarted. On the floor his HR remained normal. His home BB was continued. . #. EKG changes: Pt with CAD equivalent given h/o DMI. Pt with t wave inversions in the inferior and lateral leads and ST depressions in lateral leads. Repeat EKG in ICU still with t wave inversions but resolution in ST depression. He received 325 mg [Name9 (PRE) ]. Enzymes were cycled and negative. He was without chest pain and this was not felt to be ischemic in nature. . #. Acute on chronic renal failure: Ace inhibitor was initially held but with resolution of his [Last Name (un) ] was restarted.. #. PAD: Home [Last Name (un) ] was continued . #. Etoh abuse: CIWA scale 5mg-10mg po q2hr prn CIWA >10 was ordered. He did not require this. He was given a banana bag followed by MVI, folate, thiamine. He was counciled to reduce his alcohol intake. Medications on Admission: -INSULIN GLARGINE [LANTUS] 100 unit/mL Solution - 25 units daily -INSULIN [NOVOLOG] 100 unit/mL Solution - sliding scale with meals -LISINOPRIL 10 mg by mouth daily -ROSUVASTATIN [CRESTOR] 30 mg by mouth DAILY -ASPIRIN 81 mg by mouth DAILY -FERROUS GLUCONATE 325 mg by mouth daily -MULTIVITAMIN by mouth daily **Supposed to be on per OMR, but not taking per pharmacy records- -METOPROLOL TARTRATE - 25 mg Tablet - one Tablet(s) by mouth twice a day Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s)* Refills:2 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. rosuvastatin 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lantus 100 unit/mL Solution Sig: Twenty Five (25) units Subcutaneous once a day: or as directed by Dr.[Name (NI) 4849]. 6. Novolog 100 unit/mL Solution Sig: Sliding scale Subcutaneous three times a day: with meals according to sliding scale. 7. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 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). Disp:30 Tablet(s) Refills:2 10. multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. ferrous gluconate 325 mg (36 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: - Diabetic ketoacidosis - Type I diabetes mellitus - Acute renal failure (resolved) Secondary: - Hypertension - alcohol abuse Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [Hospital1 69] with complaints of nausea and vomiting. Blood tests showed that you had very elevated blood sugar and an electrolyte imbalance consistent with an episode of diabetic ketoacidosis (DKA). You were admitted to the medical ICU where you received IV fluids and insulin, and your electrolytes and blood sugar improved. You were transferred to the medical wards where your electrolytes returned to [Location 213]. You were treated with IV antibiotics for a possible infection in your lungs, but a chest x-ray taken prior to your discharge did not show a clear infection, so antibiotics were stopped. We have made the following changes to your medication regimen: - BEGIN TAKING metoprolol tartrate 25 mg by mouth twice daily - BEGIN TAKING folic acid 1 mg by mouth daily - BEGIN TAKING thiamine 100 mg by mouth daily Please take your medications as [Location 2875] and follow up with your doctors as recommended below. Given your type I diabetes, we recommend that you do not drink alcohol. If you choose to drink alcohol, you should limit your intake to no more than one drink per day. Followup Instructions: PRIMARY CARE - Dr. [Last Name (STitle) ] Phone: [Telephone/Fax (1) 24796] - Please call on the next business day to schedule a follow up appointment for 1-2 weeks ENDOCRINOLOGY ([Last Name (un) ]): Dr.[Doctor Last Name 4849] [Telephone/Fax (1) 2378] - Please call on the next business day to schedule a follow up appointment for 1-2 weeks [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "5849", "5859", "40390", "V5867", "2724", "2720", "3051" ]
Admission Date: [2133-3-31] Discharge Date: [2133-5-21] Date of Birth: [2092-7-8] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 398] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: Right subclavian central line. Intubation. History of Present Illness: 40 y/o male with a h/o IPF, s/p B/L lung tx [2128], h/o recurrent pneumonia, chronic rejection and obliterative bronchiolitis, polymiositis, recent hospitalization for acute on chronic respiratory failure and multilobar pneumonia requiring chest tubes and PEJ placement by IR (discharged on [2133-2-26]) and recent admission for PEJ tube blockage and resp distress (discharged on [2133-3-4]) who presented with acidemia, hypercarbia, and hypoxia at rehab (7.28/96/63 initially). . In the [Name (NI) ], pt had initial ABG 7.12/151/217 on FiO2%:40; Rate:/32; TV:300; PEEP:9; Mode:AC. Pt received vanc/ceftaz, solumedrol 125mg, and sodium bicarbonate 50mEq x2, Ativan, as well as versed, fentanyl, and propofol. He was reportedly afebrile. A right femoral line and A-line was placed. Transplant surgery was called, but did not consult as pt is not followed here for his lung transplant. Past Medical History: Chronic resp failure/ vent dependent since [2132-2-3] Chronic bronchitis Status post bilateral lung tranplant in [2128] [3-6] idiopathic pulmonary fibrosis complicated by chronic rejection and frequent aspiration pneumonia idiopathic pulmonary fibrosis since [2122] status post tracheostomy placement in [2132-2-3] esophageal dysmotility GERD HTN Paroxysmal atrial fibrillation hyperlipidemia DM II sacral decubitus ulcer now healed severe anxiety depression anemia of chronic disease pancreatitis chronic renal insufficiency Social History: Lives at [Hospital 671] Rehab, wife is supportive. Has two sons. [Name (NI) ] drinking, smoking, drug use. Family History: NC Physical Exam: Vitals: T 97.3 BP 140/70 HR 93 RR 30 O2 100% Vent: AC TV 280 R 28 FIO2 0.5 PEEP 5 Gen: pt ventilated, sedated and paralyzed, diaphoretic HEENT: MMM, PERRL, sclera anicteric Neck: no JVD, cervical [Doctor First Name ], thyroidmegaly Cardio: RRR, ? systolic M, no rubs/gallops Resp: course breath sounds b/l R>L. no wheezes Abd: soft, NT, ND, no HSM, + PEJ tube with dressing c/d/i Ext: no c/c/e, 1+ DP pulses Neuro: pt sedated and paralyzed. Pertinent Results: Numerous lab and imaging studies were obtained during this greater than 6 week hospital stay. Please check the record for individual test results. Brief Hospital Course: Unfortunately Mr. [Known lastname ] did not survive this hospitalization. During his hospitalization he suffered from: Worsening lung graft regection. Severe hypercarbic respiratory failure. Circulatory collapse. Renal Failure due to chronic exposure to FK506 and/or circulatory collapse- the patient was briefly on CVVHD. Herepes Zoster re-credescence. Positive beta glucan indicative of disseminated fungal infection. Proteus and Acinetobacter PNA. Ultimately the patient succumbed to circulatory collapse in the setting of overwhelming organ failure and infection as detailed above. After the patient's death his family requested a post mortem examination. Medications on Admission: Novolin SS Albuterol Six Puff Inhalation Q4H prn. Ipratropium Bromide Six (6) Puff Q4H prn. Nexium 20mg qd Bactrim DS (0.5 tabs?) qd Mycophenolate Mofetil 1000 mg PO BID Atorvastatin 10 mg PO DAILY Clonazepam 0.5 mg PO QHS Quetiapine 50 mg PO BID Prednisone 10 mg DAILY Docusate Sodium 50 mg PO BID Zolpidem 5 mg PO HS Metoprolol Tartrate 100 mg PO TID HCTZ 25 mg one PO Daily Tacrolimus 9 mg PO BID Lovenox 40mg qd Acetaminophen 1000mg qid prn Aranesp 40mcg SC qfri Celexa 40mg qd Senna qhs kayexalate 30gm x 2 (today only) . Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Death Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: NOne Completed by:[2133-5-31]	[ "2762", "5845", "40391", "42731", "2851", "5990", "4280", "2760", "53081" ]
Admission Date: [2115-1-9] Discharge Date: [2115-1-11] Date of Birth: [2030-5-8] Sex: M Service: NEUROSURGERY Allergies: No Allergies/ADRs on File Attending:[First Name3 (LF) 1271] Chief Complaint: Headache after fall Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 50434] is an 84 yo Right handed man with a PMH significant for HTN, possible baseline dementia and A-fib, for which he is maintained on coumadin. Eliciting a history from the patient is difficult as he is currently aphasic. It seems as though he had a mechanical fall. This apparently occured 4 days ago. His wife apparently found him to be more consfused so he was taken to [Hospital ] hospital where a CT (done at 15:17 today) showed a Left temporo-parietal IPH. I reviewed this and the hematoma is fairly large, about 4X3cm in maximal dimensions with surrounding edema. There does not appear to be any midline shift. The patient's INR at [Hospital1 ] was 2.5. There, he received 10mg of Vitamin K and 1 unit of FFP. He was then transferred here and is currently receiving a 2nd unit of FFP. Here, his only other salient issue is A-flutter with a rate of 100-120. Past Medical History: 1. HTN 2. A-fib 3. dementia 4. Anxiety/depression Social History: Lives with spouse at home Family History: NC Physical Exam: O: T: Afeb BP: 169/102 HR: 113 R 15 Gen: WD/WN, comfortable, NAD. 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. Speech is hesitant with frequent word finding difficulties and circumlocutions. Some difficulty with naming, cannot name ring, for example. Cannot repeat complex phrases. He does follow 3 step commands for me, and is able to put a black pen over a blue pen on command. Cannot/refuses 20 to 1 and MOYB. 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 voice. IX, X: Palatal elevation symmetrical. [Doctor First Name 81]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [5-30] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 2 0 Left 2 2 2 2 0 Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin On Discharge: A&Ox3, expressive aphasia PERRL 3-2mm bilaterally EOMs: intact Face symmetrical, bilateral periorbital ecchymosis, R forhead edema. tongue midline Motor: [5-30] Pertinent Results: [2115-1-9] 07:25PM URINE RBC-[3-30]* WBC-[3-30] BACTERIA-FEW YEAST-NONE EPI-0 [2115-1-9] 07:25PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2115-1-9] 07:25PM PT-20.0* PTT-27.3 INR(PT)-1.8* [2115-1-9] 07:25PM PLT COUNT-219 [2115-1-9] 07:25PM WBC-5.8 RBC-4.32* HGB-14.5 HCT-42.0 MCV-97 MCH-33.5* MCHC-34.5 RDW-12.9 [2115-1-9] 10:53PM PT-18.2* PTT-30.2 INR(PT)-1.6* CT Head [1-9] 3.5 x 2.5cm left temporal ICH with no midline shift or hydrocephalus. CT Head [1-9] Stable appearance of left temporal ICH. Brief Hospital Course: Pt was admitted to neurosurgery service and the ICU on [1-9] after he was found to have a left temporal ICH at OSH. On arrival his INR was 1.8 after receiving FFP and vitamin k at the OSH and he recieved another 2 units of FFP and a dose of vitamin k. His SBP was controlled to less than 160 and he was given 1g of dilantin IV x 1 and started on 100mg q8 for seizure prophylaxis. On admission, a repeat CT head was obtained and it showed stable appearance of left temporal ICH. On [1-10] he was transferred to the floor in stable condition and was seen by the physical therapy team who recommended that the patient be discharged home with 24hr supervision and PT. He was discharged home on [1-11] with a some aphasia, but otherwise nonfocal exam. Medications on Admission: 1. Namenda 20mg [Hospital1 ] 2. Coumadin 5mg daily (7.5mg on Monday andf Friday) 3. ASA 325mg daily 4. Atenolol 25mg [Hospital1 ] 5. Crestor 20mg daily 6. Cymbalata 60mg daily 7. Flomax 0.4mg daily Discharge Medications: 1. atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, 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. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: Left temporal intracranial hemorrhage. Discharge Condition: Awake and alert, following commands. Activity as tolerated. No heavy lifting greater than 10 pounds. Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? You may begin taking your aspirin on [1-17] after 1 week ?????? You may not begin taking your coumadin until you see Dr. [Last Name (STitle) 739] in follow up. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([Telephone/Fax (1) 88] to schedule an appointment with Dr. [Last Name (STitle) 739], to be seen in 4 weeks. ??????You will need an MRI of the brain with and without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. [Name6 (MD) 742] [Name8 (MD) ] MD [MD Number(2) 1273] Completed by:[2115-1-11]	[ "4019", "42731", "V5861" ]
Admission Date: [2134-7-20] Discharge Date: [2134-8-2] Date of Birth: [2071-8-24] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2534] Chief Complaint: C6 fracture Major Surgical or Invasive Procedure: -Posterior cervical decompression with laminectomy at C6 and instrumented fusion C4-C5, C6-C7 and T1 using lateral mass screws at C4-5 and pedicle screws at the C7-T1. ICBG and allograft. History of Present Illness: Patient was driving dump truck and had rollover accident. He was unrestrained and had +LOC. He complained of back and shoulder pain. His BAC was 127 at 0900 (one hour after accident). He was found to have a C6 fx, L1 fx, multiple right rib fractures and avulsion of his scalp and R ear. The spine service was consulted for his injuries. Past Medical History: Prostate CA surgery PNA 4 years prior Social History: Married Alcoholism Family History: NA Physical Exam: Afebrile, VSS Stitches and scar over scalp and ear Alert, oriented x 3, NAD NR RR CTAB Abdomen soft, NTND LE warm, no edema Brief Hospital Course: Patient was admitted to surgical service after resucitation in the emergency department. His scalp and ear were repaired by plastics in the Emergency department. He was treated for infection with Unasyn prophylactically. He also had a posterior cervical decompression with laminectomy at C6 and instrumented fusion C4-C5, C6-C7 and T1 with Dr. [Last Name (STitle) ]. Please see Dr. [Name (NI) 14232] operative note for more details. After surgery he was admitted to the ICU d/t trouble extubating the patients. In the ICU, he had active withdrawal from ETOH was managed with Diazepam via CIWA protocol. His high HR and BP which were managed telemetry, lopressor, and hydralazine. Patient was lethargic in the unit for several days. His benzos and narcotics were discontinued. He was able to move out of the ICU to the surgical service. There he received physical therapy. He was discharged to home eating a normal diet, urinating without a foley, and with his pain managed with PO medications. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:60 Capsule(s) Refills:2 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:40 Tablet(s) Refills:0 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [1-1] Inhalation Q4H (every 4 hours) as needed for wheezing. 7. Ipratropium Bromide 0.02 % Solution Sig: [1-1] Inhalation Q6H (every 6 hours) as needed for wheezing. 8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). 10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q4H (every 4 hours) as needed for Constipation. 11. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for SPB>160. 13. Chlordiazepoxide HCl 25 mg Capsule Sig: Four (4) Capsule PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Cervical fracture dislocation C6 with bilateral lamina fracture, bilateral facet fractures, and left-sided superior and inferior articular process fractures. Discharge Condition: -Hemodynaically stable, tolerating a regular diet, pain adequately controlled. Discharge Instructions: * You must continue to wear the cervical collar at all times until follow up. Please refrain from nicotine products(both cigarettes and patch) while your fusion is healing; this can inhibit bony fusion. * AVOID alcohol and other narcotics/illicit drugs while you are on Dilaudid for pain. * Return to the Emergency room if you develop any fevers, chills, productive cough, chest pain, shortness of breath, nausea, vomiting, diarrhea and/or any other symptoms that are concerning to you. Followup Instructions: 1) NEUROSURGERY FOLLOW-UP: Please call [Telephone/Fax (1) 1669] to schedule a follow up appointment with Dr. [Last Name (STitle) ] for approximatley 6 weeks post-opperation, approximately [9-2]. You will need a CT scan of your head and neck at this time. 2) EAR NOSE THROAT FOLLOW-UP: Please call [Telephone/Fax (1) 41] to schedule an appointment with Dr. [Last Name (STitle) 3878] in approximantely 2 weeks. 3) PLASTIC SURGERY FOLLOW-uUP: Please call [Telephone/Fax (1) 5343] to schedule an appointment for next friday [8-13] at the [Hospital 23] clinic. 4) You should follow-up with your primary care provider regarding your hypertension. Completed by:[2134-8-2]	[ "5070", "4019", "3051" ]
Admission Date: [2123-2-5] Discharge Date: [2123-2-11] Date of Birth: [2051-4-13] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 4071] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: 72 yo male with hx of MVR/AVR on coumadin presented to OSH on [2123-2-4] s/p fall down his stairs and head impact. Patient noted that he was sleeping on couch, got up and went upstairs to collect his clothes to get ready for the next day. He collected his clothes and was walking back down his carpeted stairs with them in hand when he slipped and fell forward down the stairs, impacting his head on the R side. He remembers slipping and he remembers hitting his head and the time afterwards but does not remember the actual fall. His wife heard him fall and saw him seconds afterwards. She notes he was conscious and was asking "What happened to me?". Denies any antecedent lightheadedness, SOB, CP, palpitations. Both he and his wife note no loss of bowel or bladder continence, no tongue biting, and no post-ictal state or confusion. At the OSH he was noted to have a parasagittal and L Sylvian fissure SAH. He was transferred to [Hospital1 18] for neurosurgery eval. His INR at that time was 1.6. In the ED, his BP was briefly elevated to SBP>180, controlled via a labetolol drip which was only required for a few hours. He was admitted to the Trauma SICU for closer monitoring. Of note, at this time his exam showed no neurologic deficits. His blood pressure was controlled with his home medications and a repeat CT and CT showed no extension of his bleed and no aneurysm. During this time his INR was not actively reversed but his coumadin was held. In consultation with cardiology, the risk of a thrombotic event was quickly overtaking the risk of an extension of his SAH. Given the lack of aneurysm and lack of extension on his CT, it was felt necessary to restart his anti-coagulation after 3 days off. He is now called out to the cardiology floor to initiation of heparin with a bridge to coumadin. Currently, his only complaint is mild-moderate pain in his head when he rotates it quickly. Otherwise, denies HA, vision changes, CP, SOB, palpitations, DOE, N/V/D, diaphoresis, abdominal pain, focal weakness or numbness, bowel/bladder incontinence or retention, or dysphagia Past Medical History: Hypertension Hyperlipidemia MVR/AVR with [Hospital3 9642] 18 years ago, unclear cause, ? RF ?TIA vs. small stroke in [2120], 8 minutes of diffuse body tingling, possible small finding by report on CT scan. No recurrence Social History: No current tobacco or ethanol use. Family History: NC Physical Exam: VS: T: 99.2 P: 67 BP: 123-145/49-84 RR: 18 O2: 96% RA I/O: [Telephone/Fax (1) 76267] Gen: Well appearing male, NAD, AOx3 HEENT: PERRL, EOMI, MMM, no LAD or thyromegaly noted, JVD not appreciated. Sutured laceration on R forehead CV: RRR, loud metallic S2, MRGs appreciated Resp: CTAB, no wheezes, rubs, rhonchi Abd: Soft, NT/ND, +BS, no masses or HSM noted Ext: no edema, no cyanosis Neuro: AOx3, Strenght [5-31] in all, sensation intact to gross, CN [3-9] intact, fluent speech, DTRs 2+ in patella/biceps bilaterally. Pertinent Results: [2123-2-8] 06:30AM BLOOD WBC-10.1 RBC-4.65 Hgb-13.6* Hct-39.7* MCV-85 MCH-29.1 MCHC-34.1 RDW-14.7 Plt Ct-330 [2123-2-11] 12:45PM BLOOD PT-24.9* PTT-35.0 INR(PT)-2.4* [2123-2-8] 06:30AM BLOOD PT-14.1* PTT-77.0* INR(PT)-1.2* [2123-2-5] 02:10AM BLOOD PT-20.9* PTT-33.3 INR(PT)-2.0* [2123-2-5] 02:10AM BLOOD Glucose-124* UreaN-26* Creat-1.1 Na-136 K-4.2 Cl-102 HCO3-27 AnGap-11 [2123-2-6] 04:39AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.0 CT Head [2123-2-5]: A small amount of subarachnoid hemorrhage is present within the anterior aspect of the suprasellar cistern, midline falx, and superior aspect of the right sylvian fissure. There is a small amount of interventricular blood within the occipital [Doctor Last Name 534] of the right lateral ventricle. No significant mass effect or shift of normally midline structures is present. The major intracranial cisterns are preserved. Note is made of a cavum septum pellucidum and vergae. The [Doctor Last Name 352]-white matter differentiation is preserved. There is a small scalp hematoma over the right frontal region without underlying fracture. The paranasal sinuses and mastoid air cells are clear. IMPRESSION: 1. Acute subarachnoid hemorrhage within the suprasellar cistern and pericallosal artery distribution. No significant mass effect. MRI/MRA is recommended to evaluate for underlying aneurysm. 2. Small right frontal scalp hematoma without underlying fracture. NOTE ADDED AT ATTENDING REVIEW: The blodd distribution is more typical of minor hemorrhage after trauma than an aneurysmal hemorrhage. However, I agree that further evaluation is warranted. A CTA is usually more reliable than MRA for this purpose CTA Head follow up [2123-2-5]: HEAD CT: Unchanged in appearance is a small amount of subarachnoid bleeding located within the right sylvian fissure, the suprasellar cistern and the pericallosal artery distribution. No new hemorrhage is seen. No mass effect or shift of normally midline structures is seen. The ventricles (with cavum septum pellucidum and cavum vergae) and sulci are unchanged in appearance. No fracture is identified. HEAD CTA: The internal carotid and distal vertebral arteries and their major branches are patent with no evidence of stenosis. There is no evidence of aneurysm formation or other vascular abnormality. The distal internal carotid arteries measure 5 mm in diameter on the right and 4 mm in diameter on the left. IMPRESSION: 1. Unchanged appearance of small amount of subarachnoid hemorrhage within the pericallosal artery distribution and the suprasellar cistern. 2. No aneurysm, stenosis, or other vascular abnormality. CXR: Median sternotomy wires are intact. There is mild cardiomegaly. The lungs are clear. No effusion or pneumothorax is present. The hilar structures appear normal. No displaced rib fractures are detected. There is degenerative change with joint space narrowing and marginal osteophyte formation at the right acromioclavicular joint. IMPRESSION: No displaced rib fracture or pneumothorax detected. Brief Hospital Course: Sub-arachnoid Hemorrhage: The patient had a mechanical fall down the stairs with impact on his right forehead. On presentation to the OSH he was diagnosed with a small parasagittal and L Sylvian fissure SAH. He had no neurologic deficits but was transferred to the [Hospital1 18] trauma SICU for closer monitoring and neurosurgery evaluation. Repeat CT scan showed no extension of the bleed and a follow up CTA confirmed no aneurysm present and again no extension of his bleed. Of note, his INR was 2 upon presentation to [Hospital1 18]. His INR was not actively reversed but allowed to drift down for 3 days in the setting of an acute bleed. He was also begun on prophylactic phenytoin for a total course of 10 days. He was monitored in the ICU for 2 days and maintained a normal neurologic exam throughout. Cardiology consultation was called about restarting his anticoagulation who recommended restarting it after 3 days without. He was started on IV Heparin and restarted on his normal coumadin dosing. He was observed over the course of 4 days as his INR slowly became therapeutic with no change in his neurologic status. He felt well and had no complaints. His INR was 2.4 upon discharge and he will get his INR rechecked in 4 days at his normal spot at [Hospital1 ]. He will follow up with his PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) 73675] and the neurosurgeon, Dr. [Last Name (STitle) ], in approximately 4 weeks with a CT scan obtained prior to his appointment with Dr. [Last Name (STitle) ]. He will finish up the last 4 days of his phenytoin course at home. Hypertension: His blood pressure was slightly elevated during his admission to the systolic 160s at times. His enalapril was increased from 20mg daily to 40mg daily with good effect. His verapamil was also consolidated to once-a-day dosing for patient convenience. He was continued on his HCTZ. Hyperlipidemia: Continued on Zetia and Lipitor Medications on Admission: Coumadin 10 mg MWF 7.5 mg STTS Enalapril 20mg PO daily Zetia 10mg PO daily HCTZ 25mg PO daily Lipitor (unsure of dose) Discharge Medications: 1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Phenytoin 50 mg Tablet, Chewable Sig: Six (6) Tablet, Chewable PO once a day for 4 days. Disp:24 Tablet, Chewable(s) Refills:0 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO TUES/THURS/SAT/SUN (). 7. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO MON/WED/FRI (). 8. Enalapril Maleate 20 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:60 Tablet(s) Refills:2 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Verapamil 360 mg Cap,24 hr Sust Release Pellets Sig: One (1) Cap,24 hr Sust Release Pellets PO once a day. Disp:30 Cap,24 hr Sust Release Pellets(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Small sub-arachnoid hemorrhage after mechanical fall Mechanical aortic and mitral valves Hypertension Discharge Condition: All vital signs stable. No neurologic deficits. Ambulatory. Discharge Instructions: You were admitted after a fall that caused a small amount of bleeding in your brain. However, this bleeding did not affect you at all and you required no surgery. Your coumadin was initially held until we were sure that your bleeding had stabilized. It was restarted and you were given IV blood thinners until your coumadin level was high enough. We have also increased one of your Enalapril to better control your blood pressure. You will also continue on an anti-seizure medication called phenytoin for 4 more days at home. We have also changed your verapamil to have once a day dosing. Please take all your medications as prescribed. Please make all of your follow up appointments. Please call your doctor or return to the hospital if you experience any localized weakness, numbness, tingling, slurred speach, loss of vision, worsening headache, chest pain, shortness of breath, fevers, chills or any other symptom that concerns you. Followup Instructions: Please call Dr.[Name (NI) 76268] office at [Telephone/Fax (1) 40969] to schedule a follow up appointment for early next week. Please have your INR (coumadin level) checked Friday and Monday at your normal place at [Hospital1 ]. Please call Dr.[Name (NI) 9034] office (neurosurgery) to schedule a CAT scan and a follow up appointment in approximately 4 weeks. [Telephone/Fax (1) 1669] Please call Dr.[Name (NI) 76268] office to schedule a follow up appointment in [1-28] weeks. [Name6 (MD) ] [Name8 (MD) ] MD [MD Number(2) 4074]	[ "4019", "2724" ]
Admission Date: [2151-7-22] Discharge Date: [2151-8-16] Date of Birth: [2099-5-5] Sex: F Service: SURGERY Allergies: Penicillins / Percocet / Iodine; Iodine Containing Attending:[First Name3 (LF) 4748] Chief Complaint: Right lower extremity claudication. Major Surgical or Invasive Procedure: [2151-7-22] 1. Right superficial femoral artery to anterior tibial bypass graft with nonreversed left arm vein. 2. Angioscopy with valve lysis. 3. Thrombectomy of right superficial femoral artery. [2151-7-26] 1. Right leg graft disruption and thigh hematoma. 2. Thrombosed right superficial femoral artery to anterior tibial graft. [2151-8-10] R - BKA History of Present Illness: The patient is a 52-year-old female, with peripheral [Month/Day/Year 1106] disease, who has undergone several previous percutaneous procedures on her right lower extremity, including atherectomies and stents to her distal SFA and popliteal artery, which have occluded. Past Medical History: 1. Severe peripheral [Month/Day/Year 1106] disease status post right femoral-popliteal bypass in [2149-11-1], now found to be occluded. 2. Status post thoracic aortic replacement. 3. COPD. 4. CAD with 90% RCA and 60% LAD lesions by recent catheterization. 5. Severe hyperlipidemia, cholesterol level of about 600 and triglycerides of approximately 3,000. 6. Insulin dependent diabetes. 7. Hypothyroidism. 8. Hypertension. 9. Pancreatitis. 10. Degenerative joint disease status post laminectomy. 11. Status post cholecystectomy. 12. Status post right femoral embolectomy. 13. Obesity. Social History: She admits to a 45 pack year history of tobacco. She is still smoking. Pt lives alone. She has 3 children. Family History: noncontributory Physical Exam: Obese female, NAD NCAT / PERRL / EOMI neg lesions nares, oral pjharnyx, auditory Supple / FAROM neg lymphandopathy, supra - clavicular nodes RRR CTA b/l soft NTND, pos BS, neg CVA GU defered Right AKA - C/D/I Left triphasic AT, biphasic DP; 2+ radial Pertinent Results: [2151-8-15] WBC-7.0 RBC-3.21* Hgb-8.9* Hct-27.1* MCV-85 MCH-27.8 MCHC-32.9 RDW-15.5 Plt Ct-590* [2151-8-10] PT-17.3* PTT-27.3 INR(PT)-2.0 [2151-8-14] Glucose-59* UreaN-13 Creat-0.7 Na-140 K-4.3 Cl-103 HCO3-22 AnGap-19 [2151-7-28] ALT-17 AST-26 AlkPhos-87 Amylase-27 TotBili-0.2 [2151-8-14] Calcium-9.1 Phos-4.1 Mg-2.0 [2151-7-26] Type-ART pO2-179* pCO2-39 pH-7.36 calHCO3-23 Base XS--2 [2151-7-26] 10 Glucose-186* Lactate-1.1 Na-135 K-4.4 Cl-107 [2151-7-26] Hgb-10.2* calcHCT-31 [2151-7-26] freeCa-1.17 [2151-8-12] Urine: Color-Yellow Appear-Clear Sp [Last Name (un) ]-1.014 Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG RBC-0-2 WBC-[3-6] Bacteri-FEW Yeast-NONE Epi-0 [2151-8-1] Blood cx: FINAL REPORT [2151-8-7] AEROBIC BOTTLE (Final [2151-8-7]): NO GROWTH. ANAEROBIC BOTTLE (Final [2151-8-7]): NO GROWTH. [2151-8-10] EKG Sinus rhythm. Normal ECG. Compared to the previous tracing of [2151-7-8] no diagnostic interim change. Intervals Axes Rate PR QRS QT/QTc P QRS T 66 140 86 [Telephone/Fax (2) 12298] 31 [2151-8-10] CHEST (PRE-OP PA & LAT) INDICATION: Preoperative assessment prior to BKA procedure. The patient is status post prior median sternotomy. The heart is upper limits of normal in size and stable. Pulmonary vascularity is normal. The lungs are clear, and there are no pleural effusions. Mild degenerative changes are seen within the spine. Finally, note is made of a right PICC line, terminating in the superior vena cava. IMPRESSION: No evidence of acute cardiopulmonary process. [2151-8-4] CATH Study BRIEF HISTORY: 52 yo woman with a long well-documented history of peripheral arterial disease, s/p many percuateneous interventional procedures on her right lower extremity including, most recently, directed thrombolytic therapy and throbectomy for an occluded recent bypass graft to her RLE. She now returns to the lab with probable re-occlusion of her graft. INDICATIONS FOR CATHETERIZATION: Limb threatening peripharal arterial disease PTCA COMMENTS: Initial angiography demonstrated a total occlusion of the SFA at just proximal to the proximal graft anastamosis. Heparin was started prophylactically. A stiff angled Glidewire was advanced though the native SFA into the distal popliteal artery were angiography demonstrated the AT and PT to be totally occluded and the peroneal artery to be patent as the main blood suppy to the foot but with moderate diffuse disease. The Glide wire was exchanged for a Mircale Bros 6 wire and atherectomy of the distal SFA into the distal politeal artey was performed. A wire was passed into the AT and distal injection confirmed that there was no distal runoff via the AT and flow did not improve with atherectomy of the origin of the AT. We were unable to cross in to the PT with a wire. We then turned our attention to the peroneal artery where atherectomy was performed on the proximal and mid vessel with restoration of flow into a large distal collateral, however the PT never filled. A distuption was noted in the mid peroneal artery at this point with diminished flow into the distal artery. In spite of thrombectomy with an Excisor catheter and several balloon inflations with 2.0 mm balloons. The case was terminated due to excess flouro time and contrast load. Final angiography revealed no significant impprovement in blood flow to the foot. COMMENTS: 1. Arterial access was obtained in retrograde fashion via the LFA with a 6 French short sheath. 2. Selective angiography of the right lower extremity revealed the SFA to be totally occluded just proximal to the anatamosis of the graft. 3. Failed percutaneous intervention on the right lower extremity. Final angiography revealed no restoration of flow into the infrapapliteal vessels (see PTA comments). FINAL DIAGNOSIS: 1. Total occlusion of the right SFA. 2. Failed intervention on the right SFA and infrapopliteal vessels. [2151-8-2] PICC W/O PORT [Hospital 93] MEDICAL CONDITION: 52 year old woman with R SFA-AT bypass with L arm v. Graft reexploration and thrombectomy. REASON FOR THIS EXAMINATION: Please place a midline in RUE. Unable to get PIV on floor. Unable to get midline on floor. We want to d/c her R IJ. HISTORY: Status post right SFA-AT bypass with graft reexploration and thrombectomy. Needs IV access. PROCEDURE AND FINDINGS: The right upper arm was prepped and draped in the usual sterile fashion. Since no suitable superficial veins were visible, ultrasound was used for localization of a suitable vein. The basilic vein was patent and compressible. After local anesthesia with 2 cc of 1% lidocaine, the basilic vein was entered under ultrasonographic guidance with a 21 gauge needle. A 0.018 nitinol guidewire was advanced under fluoroscopy into the superior vena cava. It was determined that a length of 37 cm would be suitable. The PICC line was trimmed to length and advanced over a 4 French introducer sheath under fluoroscopic guidance in the superior vena cava. The sheath was removed. The catheter was flushed. Final chest x-ray was obtained demonstrating the tip to be in the superior vena cava. The line is ready for use. A Stat-Lock was applied and the line was heplocked. IMPRESSION: Successful placement of 37 cm long right basilic single lumen PICC line with tip in the superior vena cava. The line is ready for use Brief Hospital Course: PT had difficult hospital course. Chart thinned. Pt admitted on [2151-7-22] Pt underwent the below procedure. She tolerated the procedure well. There were no complications. Pt extubated in the OR, Tansfered to the PACU in stable condition. After recovery from the anesthesia. Pt transfered to the VICU in stable condition. PROCEDURES: 1. Right superficial femoral artery to anterior tibial bypass graft with nonreversed left arm vein. 2. Angioscopy with valve lysis. 3. Thrombectomy of right superficial femoral artery. [7-23]/-[7-25] Pt was doing well. She started to c/o pain in her right leg. It was decided that the pt had a clot in her graft. she was taken back to the OR immediatly. [2151-7-26] Pt underwent the below procedure. She tolerated the procedure well. There were no complications. Pt extubated in the OR, Tansfered to the PACU in stable condition. After recovery from the anesthesia. Pt transfered to the VICU in stable condition. PROCEDURE: 1. Re-exploration of right superficial femoral artery to anterior tibial graft and graft thrombectomy. 2. Evacuation of thigh hematoma. Pt started on heparin IV / coumadin started. [7-27] - [2151-8-9] Pt was doing well. Pt was ready for discharge. Pt recieved PCA / PICC line placement. INR / PTT monitered. Pt goal achieved. Pt again started to experience pain. Another angiogram was done. Showed occluded graft, despite being on anticogulation. Post PVR were done showed flat metatarsal b/l. At this time it was decided to amputate the leg, for failed graft x 2. [2151-8-10] Pt underwent the below procedure. She tolerated the procedure well. There were no complications. Pt extubated in the OR, Tansfered to the PACU in stable condition. After recovery from the anesthesia. Pt transfered to the VICU in stable condition. PROCEDURES: R-BKA. [8-11] - [8-16] Pt recooperated from the aforementioned surgery. Anticoagulation was DC'd post operatively. On discharge pt taking PO, OOB to [Last Name (un) ], urinating without difficulty, pos BM. Medications on Admission: ASA 325', plavix 75', atenolol 50', lisinopril 10', atorvastatin 80', gemfibrozil 600'', niacin 250', roglitazone 4'', protonix 40', NTG prn, propoxyphene 65', lantus 90', RISS Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Niacin 100 mg Tablet Sig: One (1) Tablet PO Q 24H (Every 24 Hours). 5. Rosiglitazone Maleate 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed. 8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily) as needed. 10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Hydromorphone 4 mg Tablet Sig: 2-3 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed for pain. 12. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for pruritis. 14. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety/racing thoughts. 15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 16. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO Q8H (every 8 hours). 18. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 19. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours): DC [2151-8-30]. 20. PICC LINE Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 21. INSULIN CHANGE Insulin SC Sliding Scale & Fixed Dose Fingerstick QACHS Insulin SC Fixed Dose Orders Bedtime Glargine 90 Units Insulin SC Sliding Scale Q6H Regular Glucose Insulin Dose 0-60 mg/dL 1 amp D50 61-159 mg/dL 0 Units 160-199 mg/dL 4 Units 200-239 mg/dL 7 Units 240-279 mg/dL 10 Units 280-319 mg/dL 13 Units > 320 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [Hospital3 1107] [Hospital ] Hospital - [Location (un) 38] Discharge Diagnosis: Right lower extremity claudication. Discharge Condition: Stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOLLOWING BELOW OR ABOVE KNEE AMPUTATION This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. ACTIVITY: There are restrictions on activity. On the side of your amputation you are non weight bearing until cleared by your Surgeon.You should keep this amputation site elevated when ever possible. You may use the other leg to assist in transferring and pivots. But try not to exert to much pressure on the amputation site when transferring and or pivoting. Please keep knee immobilizer on at all times to help keep the amputation site straight. No driving until cleared by your Surgeon. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s) Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. EXERCISE: Limit strenuous activity for 6 weeks. Do not drive a car unless cleared by your Surgeon. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home. No bathing. A dressing may cover you??????re amputation site and this should be left in place for three (3) days. Remove it after this time and wash your incision(s) gently with soap and water. You will have sutures, which are usually removed in 4 weeks. This will be done by the Surgeon on your follow-up appointment. WOUND CARE: Sutures / Staples may be removed before discharge. If they are not, an appointment will be made for you to return for staple removal. When the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. Avoid taking a tub bath, swimming, or soaking in a hot tub for four weeks after surgery. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new prescription for pain medication, which can be taken every three (3) to four (4) hours only if necessary. Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. CAUTIONS: NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. Avoid pressure to your amputation site. No strenuous activity for 6 weeks after surgery. DIET: There are no special restrictions on your diet postoperatively. Poor appetite is expected for several weeks and small, frequent meals may be preferred. For people with [Location (un) 1106] problems we would recommend a cholesterol lowering diet: Follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. Additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. Since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and LDL (Low Density Lipoprotein-the bad cholesterol). Exercise will increase your HDL (High Density Lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. You may be self-referred or get a referral from your doctor. If you are overweight, you need to think about starting a weight management program. Your health and its improvement depend on it. We know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude. If interested you can may be self-referred or can get a referral from your doctor. If you have diabetes and would like additional guidance, you may request a referral from your doctor. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. The key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. Things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. Don't let them go untreated! Please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are 8:30-5:30 Monday through Friday. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE Followup Instructions: Call Dr [Last Name (STitle) 1391] [Name (STitle) 12299] at [Telephone/Fax (1) 1393] and schedulae an appoiintment for 2 weeks. Call Dr [First Name (STitle) ] at [Telephone/Fax (1) 4023] and schedule an appointment in four weeks. ( on an off clinic day ) Keep the following appointments: Provider: [Name10 (NameIs) ] STUDY Where: CC CLINICAL CENTER RADIOLOGY Phone:[Telephone/Fax (1) 327] Date/Time:[2151-10-26] 11:00 Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 3184], M.D. Where: [Hospital6 29] CARDIAC SERVICES Phone:[Telephone/Fax (1) 920] Date/Time:[2151-10-26] 1:00 Completed by:[2151-8-16]	[ "5990", "V5867", "2449", "4019", "2724" ]
Admission Date: [2126-3-26] Discharge Date: [2126-3-30] Date of Birth: [2049-4-13] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 76 year old female who was referred to Dr. [Name (STitle) ] for evaluation of critical aortic stenosis. By report, the patient has experienced symptoms consistent with congestive heart failure since [2119]. An echocardiogram obtained at that time demonstrated a normal left ventricular chamber size with concentric left ventricular hypertrophy and impaired relaxation with preserved systolic function and moderate aortic stenosis, with a mean gradient of 22 millimeters of Mercury and mild aortic insufficiency with trace to mild mitral regurgitation and a dilated left atrium and ascending aorta. The patient underwent an exercise test in [2119-12-30] which demonstrated no evidence of ischemic changes and heart rate at 60% of predicted maximum at six minutes on [Doctor First Name ] protocol. A repeat echocardiogram obtained in [2123-12-30] demonstrated an aortic valve with a mean gradient of 26 millimeters of Mercury and two plus aortic insufficiency which did not appear significantly changed from her [2121] study. Symptomatically, the patient described progressive weakness and diminishing endurance associated with shortness of breath. The patient underwent cardiac consultation on [2126-3-7], which concluded a cardiac catheterization notable for moderate disease of the mid- left anterior descending with mild disease of the circumflex and right coronary arteries. In addition, the study demonstrated a mildly dilated proximal ascending aorta with what appeared to be a trileaflet aortic valve with significant restriction of systolic opening along with two plus aortic insufficiency. The patient was subsequently referred to Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] and thereafter recommended for aortic valve replacement, to be scheduled on [2126-3-26]. PAST MEDICAL HISTORY: 1. Hypertension. 2. Diabetes mellitus. 3. Hypercholesterolemia. 4. History of transient ischemic attack. 5. Atrial fibrillation. 6. Degenerative joint disease. 7. Chronic swollen legs. 8. Status post cataract surgery. MEDICATIONS ON ADMISSION: 1. Accupril. 2. Atenolol. 3. Lasix. 4. Metformin. 5. Plavix. 6. Digoxin. 7. Plendil. 8. Lipitor. 9. Celebrex. 10. Levoxyl. ALLERGIES: Morphine SOCIAL HISTORY: Originally from [Country ]; lives with daughter. HOSPITAL COURSE: On [2126-3-26], the patient underwent an aortic valve replacement in conjunction with an aortic root enlargement. The patient tolerated the procedure well and had a cross clamp time of 108 minutes and a bypass time of 131 minutes. The patient's pericardium was left open, lines placed including arterial lines and a Swan-Ganz catheter; wires placed included both ventricular and atrial wires. Tubes placed included a mediastinal and right pleural tubes. The patient was subsequently transferred to the Cardiac Surgical Recovery Units, intubated, where she remained on SIMD ventilation until the morning of [3-27]. The patient was successfully extubated on postoperative day number one and was subsequently cleared for transfer to the floor under the direction of the cardiothoracic surgery service. Prior to transfer, the patient's chest tubes were removed without complication. Postoperatively, the patient's clinical course was uneventful and she progressed well. On postoperative day number two, the patient's Foley catheter was removed without complication and she was subsequently noted to be uneventfully productive of adequate amounts of urine for the duration of her stay. Evaluation by Physical Therapy suggested the patient was an adequate candidate for short term rehabilitation following discharge and the patient was subsequently screened by extended care facilities for post-discharge care. On the evening of postoperative day number two, the patient demonstrated a run without complication. Prolonged episode of atrial fibrillation with good rate control and no evidence of clinical compromise. The patient was thereafter begun on an amiodarone dosage schedule which was maintained for the duration of her stay. On postoperative day number three, the patient's pacer wires were removed without complication. The patient was subsequently noted to be afebrile and stable with healing incisional wounds and no evidence of discomfort. The patient was noted to be fully tolerant of p.o. intake and independently productive of adequate amounts of urine. The patient was thereafter cleared for discharge to an extended care facility with instructions for follow-up. DISPOSITION: The patient is to be discharged to an extended care facility with instructions for follow-up. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS: 1. Potassium chloride 20 mEq p.o. q. 12 hours. 2. Docusate sodium 100 mg p.o. twice a day. 3. Aspirin 325 mg p.o. q. day. 4. Percocet 5/325 one to two tablets p.o. q. four to six hours p.r.n. for pain. 5. Plavix 75 mg p.o. q. day times three months. 6. Metformin 500 mg p.o. twice a day. 7. Atorvastatin 10 mg p.o. q. day. 8. Captopril 12.5 mg p.o. three times a day. 9. Lasix 40 mg p.o. q. 12 hours. 10. Amiodarone 400 mg p.o. three times a day times one week followed by amiodarone 200 mg p.o. three times a day times three weeks. DISCHARGE INSTRUCTIONS: 1. The patient is to maintain her incisions clean and dry at all times. 2. The patient may shower, but she is to pat-dry the incisions afterwards; no bathing or swimming. 3. Regular diet. 4. The patient is to limit physical exercise; no heavy exertion. 5. No driving while taking prescription pain medications. 6. The patient is to start her amiodarone at 400 three times a day initial doses scheduled by one week, followed by three weeks of amiodarone at 200 mg p.o. three times a day. 7. The rehabilitation facility has been advised to be aware for prolonged QT intervals while the patient is dosed on amiodarone. 8. Should the patient continue to experience atrial fibrillation, it is recommended that she be begun on a Coumadin dosage schedule while at rehabilitation. 9. The patient is to follow-up with her primary care physician in one to two weeks following discharge. 10. The patient is to follow-up with Dr. [Name (STitle) ] four weeks following discharge. 11. The patient has been advised to call to schedule both appointments. [Doctor Last Name 412] [Last Name (Prefixes) 413], M.D. [MD Number(1) 414] Dictated By:[Last Name (NamePattern1) 1053] MEDQUIST36 D: [2126-3-30] 12:33 T: [2126-3-30] 15:50 JOB#: [Job Number 49056]	[ "4241", "4280", "42731", "4019", "25000", "2720" ]
Admission Date: [2109-7-12] Discharge Date: [2109-7-16] Date of Birth: [2071-10-20] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1505] Chief Complaint: Angina, palpitations and dyspnea on exertion Major Surgical or Invasive Procedure: [2109-7-12] Aortic Valve Replacement(19mm St. [Male First Name (un) 923] mechanical valve) and Mitral Valve Replacement(25mm St. [Male First Name (un) 923] mechanical valve) History of Present Illness: Ms. [Known lastname 3234] is a 37 year old female with history of rheumatic heart disease who presented with worsening shortness of breath, chest pain and palpitations. She has been followed with serial echocardiograms for aortic and mitral valve stenoses/regurgitation. Given congestive heart failure symptoms, she was admitted for elective aortic and mitral valve replacements. Past Medical History: 1. Rheumatic valvular heart disease with: - moderate-to-severe aortic stenosis - mild-to-moderate aortic regurgitation - moderate mitral stenosis - mild mitral regurgitation. 2. Mild secondary pulmonary hypertension 3. Breast Fibroma 4. Childhood Asthma 5. s/p Cesarean Section Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. The patient is originally from [Location (un) 13366], [Country 13622] Republic. She immigrated to the United States in [2106]. She currently works nights as a cleaning lady at a bar. She lives with her sister and her two children and also the patient's 5-year-old daughter. The patient's 5-year-old daughter has difficulty speaking and is currently in special education classes. The patient denies smoking, drinking, or using illegal drugs. Family History: Noncontributory. Physical Exam: Pulse:61 reg. Resp: O2 sat: B/P Right: 120/77 Left: 132/73 Height: 62" Weight: 142# General:NAD, well-nourished Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x]anicteric sclera, OP remarkable Neck: Supple [x] Full ROM [x]no JVD noted Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur: 4/6 SEM radiates loudly to carotids, [2-22] diastolic murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no HSM/CVA tenderness Extremities: Warm [x], well-perfused [x] Edema-none Varicosities: None []mild superficial spider veins bilat. Neuro: Grossly intact, MAE [5-21] strengths, nonfocal exam Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [Name (NI) 167]: 2+ Left: 2+ Radial Right: 1+ Left: 1+ Carotid Bruit : murmur radiates to bil. carotids Pertinent Results: [2109-7-12] WBC-26.4# RBC-3.08# Hgb-9.7# Hct-28.6# MCV-93 MCH-31.4 MCHC-33.8 RDW-12.7 Plt Ct-179 [2109-7-14] WBC-19.1* RBC-2.90* Hgb-9.2* Hct-27.0* MCV-93 MCH-31.8 MCHC-34.2 RDW-13.2 Plt Ct-198 [2109-7-15] WBC-14.1* RBC-2.86* Hgb-9.2* Hct-26.6* MCV-93 MCH-32.1* MCHC-34.5 RDW-13.2 Plt Ct-213 [2109-7-16] WBC-9.8 RBC-2.68* Hgb-8.3* Hct-25.2* MCV-94 MCH-31.0 MCHC-32.9 RDW-13.4 Plt Ct-266 [2109-7-13] Glucose-131* UreaN-11 Creat-0.6 Na-137 K-4.7 Cl-109* HCO3-21* [2109-7-14] Glucose-96 UreaN-9 Creat-0.7 Na-135 K-4.2 Cl-103 HCO3-24 [2109-7-15] Glucose-137* UreaN-10 Creat-0.7 Na-138 K-4.0 Cl-102 HCO3-27 [2109-7-14] PT-15.5* PTT-28.9 INR(PT)-1.4* [2109-7-15] PT-27.8* PTT-52.5* INR(PT)-2.7* [2109-7-15] PT-28.0* PTT-31.0 INR(PT)-2.7* [2109-7-16] PT-30.9* PTT-33.2 INR(PT)-3.1* Brief Hospital Course: Ms. [Known lastname 3234] was admitted to [Hospital1 18] on [2109-7-12] and taken to the operating room for aortic and mitral valve replacements with St. [Male First Name (un) 923] mechanical valves. See operative note for details. Immediately post-operatively she remained intubated and was admitted to the ICU for intensive care. She was extubated on POD#1 and started on betablockade and diuretics. Her chest tubes and temporary pacing wires were removed per protocol on POD#2 without complication. Anticoagulation was started with IV heparin and PO coumadin. Once her INR was therapeutic, the heparin drip was discontinued. Over several days, she maintained stable hemodynamics and continued to make clinical improvements with diuresis. She was evaluated by physical therapy and claered for discharge to home on POD#4. Her INR will be followed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] in [Company 191] coumadin clinic. Her first INR check will be on [2109-7-18]. Medications on Admission: Toprol XL 50 qd, Lasix 20 qd, penicillin VK 250 mg [Hospital1 ] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [Hospital1 ]:60 Capsule(s) Refills:0 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [Hospital1 ]:60 Tablet(s) Refills:2 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). [Hospital1 ]:100 Tablet, Delayed Release (E.C.)(s) Refills:2 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. [Hospital1 ]:50 Tablet(s) Refills:0 5. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. [Hospital1 ]:30 Tablet Sustained Release 24 hr(s) Refills:2 6. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: take twice daily for seven days, then drop to once daily until follow up with cardiologist or PCP. [Name Initial (NameIs) ]:30 Tablet(s) Refills:0 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day: please do not take without lasix. [Name Initial (NameIs) ]:30 Tab Sust.Rel. Particle/Crystal(s) Refills:0 8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Warfarin should be titrated for goal INR between 2.5 - 3.5. [Name Initial (NameIs) ]:60 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Rheumatic Heart Disease - Aortic and Mitral Valve Stenosis Secondary Pulmulmonary Hypertension Chronic Diastolic Congestive Heart Failure Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [Name2 (NI) 5059] at ([Telephone/Fax (1) 1504]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) Take Warfarin as directed by MD/[Hospital 197] Clinic. Daily dose may vary according to INR. Warfarin should be titrated for goal INR between 2.5 - 3.5. 8) Please call cardiac [Hospital 5059] with any questions or concerns. Followup Instructions: - Dr. [First Name (STitle) ] [Name (STitle) ] in 4 weeks [Telephone/Fax (1) 170] - Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] (PCP) in [2-19] weeks - Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 171] (cardiologist) in 2 weeks - Wound check on [Hospital Ward Name ] 6 as scheduled by [Hospital Ward Name 121] 6 nurses - First INR check should be on [2109-7-18]. VNA should fax results to [Company 191] coumadin clinic @ [Telephone/Fax (1) 3534]. [Hospital 191] [Hospital 197] Clinic office number is [Telephone/Fax (1) 2173]. Completed by:[2109-7-16]	[ "4241", "4240", "4280", "4168" ]
Admission Date: [2126-5-4] Discharge Date: [2126-5-12] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2195] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Lumbar Puncture Arterial Blood Gas Thoracentesis History of Present Illness: Ms. [Known lastname 85375] is an 87 year old woman with hearing impairment, atrial fibrillation, and recent hip fracture. She was in her usual state of health yesterday. This morning she appeared confused and was unable to communicate. Early this morning her son noted that she left the water on in the bathroom and walked back to bed. She normally asked for assistance in walking to the bathroom. Her son noted a rapid heart rate and then called EMS. . In the ED, initial vs were: T 103 P 150 BP 150/102 R 40s. She was 92% on RA. She was in atrial fibrillation with RVR, but her blood pressure medications were hold because of concern for sepsis. She was given vancomycin, cefepime, aspirin, and tylenol. In the ED she was arousable, but unable to communicate. She had 2 PIVs. . VS prior to transfer were 120 117/91 30 100% on NRB. When she arrived on the floor the history was partially obtained from the patient who communicates by writing and [Location (un) 1131] lips. The majority of the history was obtained through the son. The patient's husband who is also hearing impaired. He notes that she has had a cough recently that has been non-productive. She has had 1-2 episodes of urinary incontinence over the couple of months since her hip surgery. She has had episodes of diarrhea/constipation that are typical for her. She has not been complaining of pain. Her overall appetite has been slowly decreasing, but not acutely. Past Medical History: # CHF, chronic systolic & diastolic heart failure # Atrial Fibrillation on coumadin # S/p Right hip replacement [1-9] # Hypothyroidism # Hyperlipidemia # Chronic headaches # Depression # GERD, history of H. Pylori # History of bilateral pleural effusion thought [1-1] heart failure, s/p thoracentesis in [2121]. # History of fall and pelvic fracture # H/o pneumonia # H/o cataracts # Chronic Headaches Social History: Married. Lives with her husband who is also hearing impaired. Has 2 children. Denies tobacco, alcohol or drug use. Lives in duplex with son in one half. Uses a walker since hip fracture. Family History: Sister with [Last Name ] problem. Brother with high cholesterol and heart disease. Physical Exam: Vitals: T: 98.3 BP: 115/96 P: 114 R: 24 O2: 99 RA on 35% O2 General: appears comfortable, pulling off face mask, able to nod appropriately, unable to provide written history or sign with son [Name (NI) 4459]: dry MM Neck: supple, JVP not elevated Lungs: dullness throughout the left lung field almost to the apex. Decreased breath sound at the right base. CV: irregularly irregular, tachycardic Abd: +BS, NT, ND GU: foley Ext: able to lift legs from bed, difficulty following commands so could not assess strength Exam on discharge: Sitting up in a chair eating lunch, smiling, interacting with family. No agitation. Decreased breath sounds at left base. Pertinent Results: Microbiology Data [2126-5-6] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID CULTURE- pending [2126-5-6] BLOOD CULTURE Blood Culture, Routine-PENDING [2126-5-5] FLUID RECEIVED IN BLOOD CULTURE BOTTLES Fluid Culture in Bottles- pending [2126-5-5] MRSA SCREEN MRSA SCREEN- negative [2126-5-5] URINE URINE CULTURE- no growth [2126-5-4] URINE URINE CULTURE- no growth [2126-5-4] MRSA SCREEN MRSA SCREEN- negative [2126-5-4] BLOOD CULTURE Blood Culture, Routine-PENDING [2126-5-4] BLOOD CULTURE Blood Culture, Routine-PENDING . Imaging [2126-5-7] Transthoracic Echo The left atrium is elongated. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Diastolic function could not be assessed. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Mild aortic and mitral regurgitation. Mild pulmonary hypertension. Normal estimated systemic venous pressures. Study unable to adequately assess diastolic LV function in the setting of what appears to be atrial fibrillation. [2126-5-4] CT Head IMPRESSION: 1. No acute intracranial hemorrhage. Extensive small vessel ischemic disease. In case of clinical concern for acute infarction, an MRI can be obtained if not contra-indicated. 2. Right nasal polypoid lesion (2:4), arising from the nasal septum. This can be further evaluated with direct visualization. . [2126-5-4] Chest Xray IMPRESSION: 1. Large left pleural effusion and left basilar opacity, possibly represent atelectasis, but infection is not excluded. Please note that a left hilar mass cannot be excluded and a CT chest with IV contrast can be otained for further evaluation. 2. Small right pleural effusion. 3. Apparent air-fluid level overlying the cardiac silhouette in the right lung base. Dedicated PA and lateral is recommended for further evaluation. . [2126-5-4] Chest CT IMPRESSION: 1. Bilateral pleural effusions, left greater than right with mediastinal shift towards the right. Atelectasis of the left lung with only minimal aeration of the left upper lung zone. No evidence of underlying mass lesion. 2. Left atrial enlargement. 3. Subcentimeter AVM in the left lobe of the liver. 4. Vascular calcifications. . [2126-5-5] Thoracentesis Fluid NEGATIVE FOR MALIGNANT CELLS. Abundant neutrophils, mesothelial cells and histiocytes . [2126-5-5] Chest Xray Moderate volume of left pleural effusion persist after large volume left thoracentesis. No pneumothorax. Moderate right pleural effusion is larger. The cardiac silhouette is now more reliably imaged, moderately enlarged. Mild pulmonary edema may be present. Left lower lobe is largely airless and the left lower lobe bronchus opacified which could be due to obstruction or at least retained secretions. Followup advised. . [2126-5-6] Chest Xray Moderate bilateral pleural effusion, left greater than right, is roughly unchanged since [5-5], but difficult to compare because of variations in patient position. Left lower lobe remains collapsed and the lower lobe bronchus is airless, although it should be noted that intervening chest CT showed no mass or endobronchial obstruction. The lower lobe bronchus could be malacic or otherwise collapsed due to the persistent left pleural effusion and/or chronic atelectasis. Moderate cardiomegaly improved. Left perihilar opacification is probably mild residual edema related to recent reexpansion. . Labs on discharge: Brief Hospital Course: Ms. [Known lastname 85375] is an 87 year old woman with hearing impairment, atrial fibrillation, and large left sided pleural effusion. She presented with altered mental status, tachycardia, and fevers. . Fevers: Patient was febrile to 103 in ED but remained afebrile througout the rest of her hospitalization. She initially received vancomycin and cefepime in the ED. Her U/A looked positive initially, but urine cultures had no growth. Blood cultures have remained no growth to date. LP was negative. Pulmonary infection thought the most likely process given possible consolidation/collapsed lung on CT scan. She was placed on community acquired pneumonia coverage with vancomycin, ceftriaxone, and azithromycin (d# 1 = [2126-5-4]) for CAP. She completed a seven day course. . Altered mental status: CT of the head showed no clear evidence of hemorrhage. Altered mental status likely multifactorial to fever, hypoxia, CHF, and ICU delirium. Patient improved significantly when transferred out of the ICU, with residual minor confusion. She was continued on her standing Haldol, but has not required a PRN Haldol dose since [2126-5-9]. She has not required restraints while on the general medicine floor. . Pleural Effusion: Patient presented with a large pleural effusion. She had a history of a prior pleural effusion in [2121]. Thoracentesis performed on [2126-5-5] and revealed transudative effusion consistent with CHF. BNP was elevated at 3405 (unknown baseline). An echocardiogram showed preserved ejection fraction. She was initially diuresed with IV furosemide and has been given a standing dose of Lasix 40mg PO daily while on the general medicine service. . Atrial fibrillation: Upon presentation patient was in atrial fibrillation with RVR. Given concern for her mental status her Digoxin was discontinued and her beta-blocker was up titrated. After discussion with her PCP regarding the risks and benefits of Coumadin she was placed on a Lovenox to Coumadin bridge. Her heart rates ranged from 55-80 while on the medicine floor. If bradycardia becomes a problem would recommend decreasing Metoprolol to q8 hours. . Hypothyroidism: Continue home dose. TSH within range. . GERD: Continue home ranitidine and calcium carbonate. . Code Status: Per son, code status will remain Full Code pending further discussions with his sister. Medications on Admission: -Metoprolol tartrate 50 mg PO four times/day -Venlafaxine XR 75 mg [Hospital1 ] -Senna 2 tabs [Hospital1 ] -Digoxin 0.125 mg daily -Levothyroxine 100 mcg daily -Raloxifene 60 mg PO daily -Ca Carbonate 500 mg PO TID -Docusate 100 mg PO BID -Ranitidine 150 mg PO BID -Polyethylene Glycol PO MWF -Prostat nutritional supplement -Furosemide 20 mg PO MWF, 40 mg PO Tue, Thurs, Sun -Acetaminophen 1000 mg PO BID -Coumadin 3 mg TRSun, 2.5 mg MVFSat Discharge Medications: 1. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for pain. 9. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily (). 10. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg Subcutaneous Q12H (every 12 hours): Until INR>2 for 48 hours. 11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). 12. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 16. Haloperidol 0.5 mg IV Q6H:PRN agitation Discharge Disposition: Extended Care Facility: [Location (un) 582] of needham10 Discharge Diagnosis: Pneumonia Atrial fibrillation 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 after being found to be less responsive at home. You were diagnosed with a pneumonia and received IV antibiotics. Your heart rate was also elevated, and your heart medications were adjusted. Your mental status improved significantly, and your heart rate remained stable. Followup Instructions: Please follow-up with your primary care physician within one week of discharge from Rehab.	[ "486", "5119", "5180", "42731", "4280", "2449", "2724", "311", "53081", "V5861" ]
Admission Date: [2178-5-17] Discharge Date: [2178-6-4] Date of Birth: [2148-9-1] Sex: M Service: MEDICINE Allergies: Levofloxacin / Nsaids Attending:[First Name3 (LF) 2181] Chief Complaint: Shock Major Surgical or Invasive Procedure: Patient had a tunnelled HD line placed on [2178-6-3]. . Patient was intubated at OSH, extubated [5-28] - total of 11 days. History of Present Illness: 29 year-old male patient with a history of DM2, obesity, OSA and pericarditis (6 months ago) who presented to [Hospital1 14360] on [2178-5-16] with chest pain, back pain, fevers, chills and shortness of breath for one day. His pain was described as sharp, worse with inspiration and on laying supine and relieved by sitting and leaning forward. He also reported diaphoresis and cough productive of green sputum. He had a similar episode 6 months prior to admission and was diagnosed with pna and "fluid accumulation around the heart". He was treated with NSAIDS at a hospital in [State 3914]. . His vital signs on presentation to the OSH were: Temp 103, BP 89/30, HR 116-138, RR 28, 97% on 2 L. His WBC was 15 (73 N, 11 L), CPK 253, (MB 21.5, Index 8.5), trop I 2.88. Glucose was 310. Bili 4.2, alk phos 91, ast 416, alt 325, LDH 1130. CXR was negative for infiltrates, ECG with STE 1mm in I and AVL, PR depression in I and AVL. He received 2L IVF boluses, 1gm of CTX and 500mg of Azithromycin. He was given a diagnosis of percarditis, treated with Motrin 800mg tid, and admitted to teh ICU. . An Echo showed an EF 25%, global HK, dilated LV. There was no pericardial effusion and RV appeared normal size. Dopamine was used for BP support and the patient was subsequently intubated for respiratory distress. He was found to be in DKA with blood glucose in the 600's and ketones in the urine. 100mg of lovenox was given empirically and was transferred to [Hospital1 18] for further management. . In the [Hospital1 18] CCU, the patient was thought to be in either cardiogenic shock or septic shock from a pneumonia. He was continued on Vancomycin, ceftriaxone, and azithromycin. Renal, GI and ID were consulted for renal failure, transaminitis (to AST 11,916) and septic shock of somewhat unclear etiology. Renal did not feel that there is an acute need for HD at this point and agreed with IVF and pressors. Infectious disease got a history of the patient recently removing dead rodents from an automobile fan and felt that atypical organisms were highly likely. They recommended changing azithromycin to doxycycline. Hepatology felt the clinical picture was most consistent with shock liver. The patient is being transferred to MICU per the request of ID and given evolving septic shock. Past Medical History: 1. Obesity 2. DM2 3. OSA on BiPAP 4. h/o Pericarditis 6 months ago Social History: Patient is married and has a 12 year-old daughter. [Name (NI) ] works as a restaurant manager at [Company ] Fridays (contact with food). Denies tobacco and reports rare ETOH use. No hx of IVDU. Recently moved to this area from [State 3914] (wooded area). No recent tick, bug or animal bites. No sick contacts. [Name (NI) ] travel. His car recently had two large rodents removed from car fan. His wife previously worked in a Nursing Home, but hasn't in several months. Family History: Unknown Physical Exam: VS: Tm 103.7 Tc 101.4, BP 112/68 (88-122/62-88), HR 123 (125-150), RR 24 97% on Vent: AC: Tv: 700 x 24, FIO2 0.4, PEEP 10 -> PIP 35, Plateau 29, ABG 7.34/30/99, 7.32/28/130 CVP 23, CO 8.5, CI 2.63, SVR 687, MVO2 76 GEN: morbidly obese young man intubated and sedated HEENT: ETT in place, mmm Neck: large neck but no JVD appreciated CV: tachycardic, regular rhythm, no m/r/g PULM: mechanical breath sounds appreciated, crackles at the bases bilaterally ABD: obese, NABS, NT/ND Ext: cool extremities, no c/c/e, 1+ DP and PT b/l Neuro: intubated, sedated Derm: no rashes noted. Pertinent Results: CXR ([5-17]): Ill-defined opacities are present in the left mid and lower zones consistent with pulmonary consolidation. CXR ([5-18]): Air bronchogram present in the left lower lobe suggesting LLL pneumonia. Increased opacification in the right lower zone c/w atelectasis rather than pneumonia Abd US ([5-18]): Limited examination. Echogenic liver consistent with fatty infiltration. Other forms of liver disease, including more significant hepatic fibrosis or cirrhosis, cannot be excluded on the basis of this examination. Patent left and middle hepatic veins and left portal vein. Otherwise, extremely limited Doppler examination of the liver. Chest/Abd CT ([5-18]): Moderate-sized bilateral pleural effusions. No acute abdominal pathology Sinus CT ([5-18]): No sinusitis. Echo ([5-18]): Mild symmetric LVH. LV cavity moderately dilated. Severe global left ventricular hypokinesis with EF 15-20%. No masses or thrombi are seen in LV. RV systolic function appears depressed. LV inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure ECHO [2178-5-25]: Conclusions: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild global left ventricular hypokinesis. EF 45%. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [2178-5-18], the LVEF has improved and the LV cavity size has normalized. B/L LE US: CONCLUSION: Study is limited by body habitus, but there is no evidence of DVT in the left or right lower extremity. CT CHEST/ABDOMEN [5-27]: IMPRESSION: 1. Overall stable appearance of the chest, abdomen and pelvis. No CT evidence of pancreatitis. 2. Stable bilateral lower lobe consolidations which could represent aspiration or atelectasis. 3. Stable splenomegaly. Brief Hospital Course: Shock: There was an initial concern for cardiogenic shock in the setting of possible pericarditis/myocarditis, EKG changes, elevated cardiac enzymes and Echo showing EF 25%. However, fevers, elevated WBC count and low SVR suggested more of a septic picture. Additionally, his cardiac output was elevated (though difficult to use those numbers which were from CVP and not swan). Shock was complicated by acute renal and hepatic failure, respiratory failure, relative adrenal insufficiency, cardiac depression and DKA. Source of septic shock was initially unclear and included multifocal pneumonia, pericarditis/myocarditis, atypical organism in setting of exposure to rodents. ?Hanta virus vs. [Location (un) ] vs. Mycoplasma? Chest/Abd CT without pathology. No sinusitis on Sinus CT. In terms of BP, pt was appropriately switched from Dopamine to Levophed which was quickly titrated down, and discontinued more than a week before discharge. He remained hemodynamically stable throughout the remainder of his hospital course. He was treated with Zosyn and Vancomycin for a total of 13 days, and Azithromycin for a total of 5 days. All blood and urine cultures showed no growth, he had negative serologies for Chlamydia pneumoniae, [Location (un) ] B, Leptospira, Mycoplasma pneumoniae, HCV, HBV, Influenza and Parainfluenza,ANCA and [Doctor First Name ]. He was IgG positive, but IgM negative for EBV and CMV. He also tested positive for Legionella Antibodies and hepatitis. He was further tested positive for IgM Hantavirus, however the confirmatory [Doctor First Name ] for Sin Nombre virus was negative. A repeat serology was sent to the state lab and the results were still pending on discharge. He was afebrile, with stable blood pressures at discharge. . Fever: As above, the etiology of his septic shock was unclear. There was a suggestion of multifocal infiltrates on CXR suggesting possible pneumonia with bacterial pathogen. ID was consulted and considered atypical organisms such as mycoplasma, chlamydia, legionella, Leptospirosis and viral pathogens such as hepatitis, influenza, adeno, CMV, EBV, HIV, [Location (un) ] and Hanta virus. Legionella IgG antibody returned with high titers of 256. This should be repeated at the end of [Month (only) 116] (around 30th); a fourfold rise in titer confirms acute infection. He completed a 5 day course of doxycycline, followed by a 5 day course of azithromycin as it was thought the doxycycline may have contributed to his pancreatitis. He continued to run low grade fevers until [5-28]. US of LE were done bilaterally without evidence of DVT. His fevers were likely related to atelectasis, with possible contribution of pancreatitis (see below). They resolved on their own by [5-29]. By the time of discharge he had completed a 13 day course of vancomycin and zosyn, as well as a 5 day course of azithromycin and was afebrile. He has scheduled follow-up with ID and his hantavirus serologies will be followed at that visit. . Cardiomyopathy: Echocardiogram on [5-18] showed EF 15-20% in the setting of tachycardia (25% at the OSH on [5-17]), although windows suboptimal. Likely viral myocarditis (possible induced by [Location (un) ] B vs. adenovirus vs. Hep C vs. CMV vs. Echovirus vs. EBV) vs. sepsis-induced cardiomyopathy vs. restrictive pericarditis given recent episode of pericarditis and filling defect on Echo. MVO2 73 and CO normal, with good oxygenation, making primary cardiogenic shock somewhat less likely. His BP was stable and heart failure and fluid retention was treated with CVVH. Original primary still unknown at this point, as all blood cultures remained negative and he tested negative for all above mentioned possible viruses. Unclear if possible Hantavirus infection could have been contributory and final results were still pending at discharge. Repeat echo about a week into his hospital course demonstrated recovery of EF to 45% (on [5-25]), normal LV cavity size, and no pericardial effusion. He should follow-up with cardiology to deal with this issue as an outpatient and was given their number. . Acute renal failure: The patient's creatinine rose to 11.3 from a normal baseline. FENa was less than 1% and his renal failure was felt to be a complication of his shock. His potassium gradually increased and his volume status worsened and he was started on CVVH on [5-21]. He had improvement in his K, Cr and acidosis. Large volumes of fluid were removed with ultrafiltration. On [5-26] he was changed over to HD. He remains HD dependent, and had a HD tunneled line placed on [6-3]. Initial anuria resolved and pt puts out small amounts of urine now. He will receive HD as an outpatient and will follow-up with nephrology for further treatment adjusments. . Acute hepatitis: The patient was admitted with markedly elevated LFTs to an AST of 11,916. The height of his LDL ([Numeric Identifier ]) and the speed of the rise in LFTs is suggestive of shock liver and not congestion. Hepatology was consulted during his stay and agreed with this as the likely cause. His INR and LFTs improved dramatically, confirming this diagnosis, steadily trending down over the course of his hospital stay. . Respiratory distress: The patient was intubated at the outside hospital in setting of respiratory distress and DKA. There was no evidence of ARDS on imaging exams and he did well on the ventilator. He underwent a bronchoscopy on [5-19] which showed scant secretions that were negative for organisms. He had bilateral lower lobe infiltrates on CT scan, and was started on vancomycin/zosyn, as well as doxycycline for atypical coverage, as above. He was eventually weaned to PSV and then extubated on [5-28] without complication after almost 2 weeks of intubation.His O2 Saturation remained stable after extubation, 96-98% on RA, no drop in O2Sat on ambulation. Patient's respiratory status was stable on discharge. . DKA: The patient was admitted with elevated blood sugars, anion gap and trace ketones in urine. He was treated effectively with an insulin drip. He had a persistent anion gap which was felt to be secondary to his renal failure, as repeat ketone/beta hydroxybutyrate assays were negative. His sugars were well controlled on an insulin sliding scale. . Pancreatitis: He had low grade fevers even after about 9 days of antibiotics, and in search of a cause, his pancreatic enzymes were found to be elevated. An abdominal CT scan did not reveal radiographic evidence of pancreatitis. It was noted that the enzymes trended up shortly after restarting propofol for sedation, and that this had happened once previously. His amylase and lipase both began to trend down after propofol was discontinued again. There was a thought that doxycycline could also have contributed, and this was changed to azithromycin. Once extubated, he denied abdominal pain, and his fevers resolved. After transfer to the floor his lipase and amylase steadily came down, pt was non-tender in epigastric area on exam and denied abdominal pain. . Splenomegaly: He was noted to have splenomegaly on both of his abdominal CT scans here. It is unclear if this has been present previously. EBV IgG was positive but not IgM. He had no hilar or mediastinal adenopathy making sarcoidosis less likely. He does not drink alcohol excessively. It's possible that he developed portal hypertension acutely in the setting of shock liver. He should likely have a repeat CT scan at some point in the future to re-evaluate the spleen. His CBC should be monitored periodically as well. On the floor he complained of transient LUQ pain on two occassions for which he did not require any treatment or further work-up. He should follow-up with his PCP for repeat CT and CBC monitoring. He has been set-up with a PCP, [Name10 (NameIs) 14169] he did not have one previously, and is scheduled to see him on [2178-6-11] in [Hospital 191] clinic. . Hypertension/tachycardia/bigeminy: The patient had persistent tachycardia during the hospitalization, probably related to his fevers, as well as his body habitus/deconditioning. He was treated with beta blockers (labetalol drip peri-extubation, with transition to PO metoprolol). He was noted to have ventricular bigeminy just after starting HD on [5-27]. His bigeminy resolved with calcium supplementation (his free calcium was noted to be low). Pt's blood pressures were well controlled on metoprolol. . Leg pain: Pt developed leg swelling, discolorisation (red to purple), blisters (bloody and non-bloody), necrotic changes on toes and pain in both feet. These changes were most likely due to malperfusion, secondary to cardiogenic shock. His legs improved during his stay, though he still reported dull pain, 'pins and needles' in his feet. He did not require pain medication for that during the days prior to discharge. He will follow up with plastic surgery, and an appointment was scheduled for [6-12], for further evaluation and treatment. . Nausea: Pt had waxing and waining episodes of nausea during the course of his hospital stay which were well controlled with Prochlorperazine. On the day of discharge pt has some nausea and was treated with prochloperazine. Medications on Admission: 1. Metformin CR 2gm daily 2. Afrin 3. Blood pressure medication, which he isn't taking . On transfer to MICU 1. Zosyn 2.25g IV q8h 2. Doxycycline 50mg IV q12 (after 100mg loading dose) 3. Vancomycin 1G IV daily 4. Aspirin 325mg daily 5. Lansoprazole 30mg NG daily 6. CaCO3 1g TID 7. Acetaminophen 325mg-650mg q4-6h prn, do not exceed 2g/day 8. Colace 100mg [Hospital1 ] 9. Fludrocort 0.05mg daily 10. Hydrocort 50mg IV q6h 11. Hep SQ 12. Senna 1 tab [Hospital1 ], prn Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) SC injection Injection TID (3 times a day). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Insulin sliding scale Please place the patient on an insulin sliding scale per the protocol of your institution 5. Metoprolol Tartrate 25 mg Tablet Sig: [1-12] Tablet PO three times a day. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [Hospital1 ] (2 times a day) as needed. 10. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [Hospital1 ] (2 times a day). 11. Prochlorperazine 10 mg IV Q6H:PRN 12. Dolasetron Mesylate 12.5 mg IV Q8H:PRN nausea 13. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every [4-16] hours as needed for pain. 14. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: no more than 2 gm per day. Discharge Disposition: Extended Care Facility: [Hospital6 1293] - [Location (un) 1294] Discharge Diagnosis: Primary Diagnosis: Septic Shock Acute Respiratory Distress Shock Liver Pancreatitis Acute Renal Failure Cardiomyopathy Diabetic Ketoacidosis . Secondary Diagnosis: Diabetes Hypertension Discharge Condition: Stable condition with low UOP and dialysis dependent Discharge Instructions: You are being discharged to a rehabilitation facility. . Please take all your medications as prescribed. . Please call your doctor or return to the ER if you have nausea, vomiting, chest pain, shortness of breath, abdominal pain, fevers, increased difficulty with urination, blood in your urine or other concerning symptoms. Followup Instructions: Please follow up in plastic surgery clinic as below. Please call 2-3 days prior to your appointment to give them your information. Provider: [Name10 (NameIs) ] SURGERY CLINIC Phone:[Telephone/Fax (1) 4652] Date/Time:[2178-6-12] 2:30 . Please follow-up with Infectious Disease. We have scheduled an apppointment for you with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] on [2178-7-1] at 10 am, Phone:[Telephone/Fax (1) 457]. Please call in prior to your appointment at the above mentioned number to check directions. . For your information: Dr. [Last Name (LF) 9138], [First Name3 (LF) ], primary care physician, [Name10 (NameIs) 66825] in obesity, working at the [Hospital 18] clinic. If you are interested in seeing her please scheduled an appointment with her. Her phone number is [Telephone/Fax (1) 250].	[ "0389", "78552", "5845", "486", "51881", "5180", "32723", "42789", "99592" ]
Admission Date: [2156-8-11] Discharge Date: [2156-8-13] Date of Birth: [2135-8-8] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1257] Chief Complaint: Unresponsiveness Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [Known lastname 83157] is a 21M with mood disorder, substance abuse admitted after being found unresponsive at his psychiatric facility ([Hospital ] Hospital, [0-0-]). Per discussion with charge nurse [First Name8 (NamePattern2) ] [Last Name (Titles) ], patient presented yesterday at insistance of parents for detox. Given alcohol use on plane, he was sent to [Hospital6 1597] for evaluation of agitation. Hospital course at [Hospital3 ] not available, although he was reported to have tried to escape from ED. He was sent back to [Last Name (un) ] yesterday evenining. On initial evaluation, he has HR 148, was unresponsive, and had abrasions on his face. In the interim, patient was noted to go to bathroom with pill bottles (Seroquel, gabapentin - pill count not known). On evaluation by paramedics, head injury was suspected (for unknown reason) and patient was sent to [Hospital1 18] ED for further evaluation. Of note, patient was to enter OOP detox program ($55,000/month). He previously lived with parents in [Location (un) 14336]. . In the ED, initial vs 99.4, 99, 123/62, 12, 100%RA. He was somnolent, and alertness waxed and waned throughout ED stay. His EKG was normal (HR 84), without prolonged QTc, without evidence of acute ischemia (by report). His urine and serum tox screens were positive for benzodiazepines. Patient was given naloxone without improvement, NS 1L IVF. Head CT was negative for bleed. He was seen by the toxicology service who felt no further intervention aside from close monitoring was required. Psychiatry was consulted but did not see the patient in the ED. He is transferred to [Hospital Unit Name 153] for close monitoring. On transfer, 81, 11, 97%RA, 133/59, 99.0. . On evaluation in the ICU, patient recalls taking a "handful" of gabapentin, and reports this was not a suicidal attempt. Denies recent alcohol use - on discussion family, used alcohol on airplane on [2156-8-10]. Denies acetaminophen use. He also recalls having a seizure one week ago after not taking benzodiazepenes for 1-2 days; at that time, he suffered abrasions and was taken to an ED. Prior to that, he spent 3 months at a transition rehab center in [State 4565]; this program ended on [2156-7-25]. On review of systems, he reports feeling weak, nauseous, with generalized bodyaches, and with 20lb weightloss over 3 month period. He denies headaches, tinnitus, visual changes or blurry vision, sinus congestion, cough, chest pain, back pain, diarrhea, constipation, blood in stools. He has pain in right arm since fall last week. Past Medical History: - Mood disoder - Alcohol abuse - 1 bottle vodka per day; last drink yesterday; denies history of withdrawal seizures, DTs - Cocaine use - Smokes crack, denies IV use; last used [2156-8-7] - Chronic pain - Eatting disoder (bulimia) - Seizure disorder when coming off of BZD, per patient report Social History: From [Location (un) 14336]. Lives with parents, 21 year-old sister [Doctor Last Name ], and 18 year-old brother [Doctor First Name ]. Alcohol, illicit drug use as detailed above. 1PPP x6 years. Per discussion with family, also uses marijuana, Oxycontin. Homosexual. Family History: Parents, siblings healthy. Physical Exam: On transfer from [Hospital Unit Name 153] to medical floor: 97.8, 71, 124/69, 20, 97% RA General: Easily arousable, able to have full conversation, AOx3, alternatingly agitated and apologetic. Skin: Abrasion (stitched) at right posterior upper arm; few abrasions on face; not diaphoretic HEENT: Right orbit scleral lateral hemorrhage; EOMI; vertical nystagmus; dilated pupils, equal and reactive to light; oropharynx nonerythematous and without exudates; good dentition Neck: Supple; no lymphadenopathy Pulm: Few crackles left base; otherwise clear to auscultation bilaterally; no wheezes, rales, rhonchi CV: RRR, normal S1/S2, no murmurs Abd: Normoactive bowel sounds, soft, nontender, not distended Extrem: Radial and DP pulses 2+; no lower extremity edema; swelling at right elbow, posteriorly; no TTP right shoulder, wrist; no resting tremor Neuro: CNII-CXII intact; right elbow extension [3-28], flexion 5-, and slightly decreased handgrip; LUE [4-27] grossly; LLE, RLE strength 5/5 grossly Lines/tubes/drains: Foley in place Pertinent Results: On admission [2156-8-11]: WBC-5.6 RBC-3.34* Hgb-10.6* Hct-30.2* MCV-91 MCH-31.6 MCHC-34.9 RDW-13.6 Plt Ct-204 PT-11.8 PTT-22.7 INR(PT)-1.0 Glucose-88 UreaN-6 Creat-0.6 Na-139 K-4.6 Cl-103 HCO3-26 AnGap-15 ALT-26 AST-44* LD(LDH)-257* CK(CPK)-660* AlkPhos-58 TotBili-0.6 Calcium-8.8 Phos-3.4 Mg-1.9 VitB12-398 Folate > 20 ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG Lactate-1.0 Fibrino-222 . CT Head (final): No acute intracranial abnormality. . X-ray R Elbow (PRELIM): No fracture. . On transfer [2156-8-12]: WBC-5.6 RBC-3.26* Hgb-10.6* Hct-30.0* MCV-92 MCH-32.6* MCHC-35.3* RDW-13.7 Plt Ct-169 PT-11.3 PTT-25.7 INR(PT)-0.9 Glucose-121* UreaN-6 Creat-0.8 Na-141 K-3.3 Cl-104 HCO3-26 AnGap-14 CK(CPK)-324* Calcium-8.7 Phos-4.4 Mg-2.1 VitB12-398 Folate-GREATER TH . Hepatitis serologies- pending Brief Hospital Course: 21 M with mood disorder and substance abuse admitted from psychiatric inpatient facility with unresponsiveness: . #. Altered Mental Status: Patient had some agitation overnight and was given seroquel. He is no longer somnolent and as obtunded as on admission. He has episodes of being very angry and upset which is then followed by feeling apologetic and depressed. Patient threatened to leave AMA several times overnight for small reasons, such as him not being able to shave, not being able to smoke, not having his ipod, not having his luggage, parents taking his bank and health cards. . Initial concern was for ingestion, particularly gabapentin, which patient admitted to taking a lot of. Toxocology was consulted and recommended supportive care. Patient no longer somnolent, and was awake and oriented. Given patient??????s history we must also consider benzo, cocaine overdose, alcohol. Urine BZD positive, but patient does take BZD at home and most likely received them at OSH. Also considered head trauma given abrasions on face but repeat CT head showed no acute intracranial process. Unclear at this time if this was a suicidal attempt, although patient denies that he was feeling suicidal. He was started on a nicotine patch. . #. Seizure: Patient had an episode of questionable seizure last night that was witnessed by the 1:1 sitter with 15 seconds of shaking. Patient reports not remembering what happened. There was no postictal confusion, no loss of continence. Repeat head CT was performed right afterwards which showed no acute intracranial process. Patient did not need any benzos after the episode, he reported feeling fine. . #. Alcohol abuse: He has a significant history of alcohol abuse. Patient denies alcohol withdrawal seizures; reports seizures secondary to coming off of BZDs. He was monitored on the valium CIWA protocol for withdrawal. He is currently medically cleared but needs to be monitored for withdrawal. He received 85mg valium in the [Hospital Unit Name 153]. . #. Mood disorder: His seroquel 300mg qhs and clonidine 0.1mg [Hospital1 ] was restarted but the rest of his psychiatric medications were held awaiting recommendations from psychiatry. Seroquel was increased to 400mg PO qHS per psych recommendations. He was monitored with a 1:1 sitter. . #. Anemia: Normocytic (MCV = 91). [Month (only) 116] be secondary to nutritional deficiency, although given significant alcohol use, must also consider varices/PUD. [Month (only) 116] also have hematoma at right elbow secondary to recent fall, swelling - although hct 30 too low to fully attribute to this. His folate and B12 were normal. . #. Right arm swelling, weakness: This occurred after a fall last weak in context of seizure, per patient's report. He cannot recall the event. An x-ray found no fracture. Medications on Admission: Seroquel 300mg PO QHS Clonidine 0.1 [Hospital1 ] Wellbutrin 300mg PO QAM Neurontin 600mg PO TID Celexa 40mg PO daily Klonipin 1mg PO Q6hrs PRN Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 6. Diazepam 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Quetiapine 200 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 8. Nicotine (Polacrilex) 2 mg Gum Sig: One (1) Gum Buccal Q1H (every hour) as needed for nicotine craving: Patients should chew gum until they notice a peppery taste or slight tingle, then park the gum between their cheek and gum. Repeat process until the peppery taste or tingle is gone (usually about 30 minutes). . 9. Diazepam 5 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2 hours) as needed for CIWA>10, anxiety: Diazepam 5-10 mg PO Q2H: PRN CIWA>10, anxiety . 10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Discharge Diagnosis: 1. Alcohol withdrawl 2. Acute mental status changes 3. Mood disorder Discharge Condition: Stable, alert. Discharge Instructions: You were admitted to [Hospital1 18] because you were found to be unresponsive at [Hospital 23686] Hospital after taking a number of pills. Your heart electrial function was normal. A CT was done and did not show a head bleed. You were treated for alcohol withdrawl. Some of your psychiatry medications were held in the setting of your withdrawl. Followup Instructions: [Hospital 23686] Hospital	[ "3051", "2859" ]
Admission Date: [2139-8-22] Discharge Date: [2139-8-27] Date of Birth: [2139-8-22] Sex: M Service: NB INTERIM REPORT: [2139-8-27]. This interim report covers from [8-22] through [2139-8-27]. HISTORY OF PRESENT ILLNESS: Baby [Name (NI) ] [Known lastname ], twin A, is a now 5-day-old, ex-32-6/7 weeks who is corrected to 33-4/7 weeks gestation. This infant was twin A of a set of IVF di-di twins who were born by cesarean section for breech-breech presentation. Mom is a 40-year-old G2, P0-2, woman with the following prenatal screens: A negative (status post RhoGAM), DAP negative, RPR nonreactive, Rubella immune, hepatitis B surface antigen negative and GBS unknown. Mom's past obstetric history was notable for spontaneous abortion times one. This pregnancy was complicated by mild preeclampsia that was noted less than a week before delivery leading to an admission and administration of betamethasone. Mom was on bed rest until spontaneous onset of preterm labor of unclear etiology. This progressed to cesarean section for twin breech presentation. Rupture of membranes was at delivery yielding clear amniotic fluid. There were no concerns for maternal fever or other evidence of chorioamnionitis. Resuscitation was unremarkable with only blow-by oxygen necessary. Apgars were 7 and 8 for this infant. He was subsequently admitted to the Neonatal Intensive Care Unit for further management of prematurity. PHYSICAL EXAMINATION: Birth weight: [2105] grams. Head circumference: 31.5 cm. Length: 44 cm. General: Premature infant consistent with stated gestational age. HEENT: Anterior fontanelle open and soft. Nondysmorphic. Palate intact. Mild nasal flaring on nasal cannula. Red reflex present and symmetrical. Chest: Minimal retractions with good breath sounds bilaterally. No rales. Cardiovascular: Well perfused. Regular rate and rhythm. Normal S1, S2. No murmur present. Abdomen soft, non- distended, no organomegaly, no masses. Anus patent. Three vessel cord. Genitourinary: Normal male with preterm genitalia. Testes descended bilaterally. Neurological: Active. Tone and reflexes appropriate for gestational age. Extremities, spine, limbs, hips and clavicles within normal limits. HOSPITAL COURSE BY SYSTEM: Respiratory: This infant had a small oxygen requirement from the time of delivery and still remains on oxygen at this time. While originally we thought his respiratory symptoms were related to TTN, his clinical course seems more consistent with mild HMB. At present he is only 13-25 cc of oxygen with a possibility of a trial off again today. Cardiovascular: This infant has been stable from a cardiovascular standpoint without concerns for murmur. Fluids, Electrolytes and Nutrition: This infant was able to start feeds on day of life one with gradual advance. He has currently made it to 130 cc/kilogram/day of [Last Name (un) 14748] Special Care or breast milk 22 Kcal. He has been at 130 rather than increased fluids as he evidences some intolerance and spittings. Intention was for trialing greater volumes again in the future. Gastroenterology: This infant had a mild course of hyperbilirubinemia with a peak bilirubin of 7.3 on day of life three. His phototherapy was discontinued with a reassuring rebound at 4.9. Hematology: This infant had an admitting CBC with an hematocrit of 39.8, platelet count of 340,000. Infectious Disease: [Known lastname ] received 48 hours of ampicillin and gentamicin for rule out sepsis. His cultures were negative and CBC was reassuring with a white count of 12.7 and 26 polys. Psychosocial: A family meeting has been held with discussion of hospital course and future care. Family is interested in the possibility of transfer to [Hospital1 ] once bed space available. INTERIM DIAGNOSES: Prematurity at 32-6/7 weeks, twin A. Respiratory distress syndrome, resolving. Rule out sepsis, negative. Hyperbilirubinemia, resolved. Feeding intolerance. DR.[Last Name (STitle) ],SYLIA 50-393 Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2139-8-27] 16:32:48 T: [2139-8-27] 17:18:47 Job#: [Job Number ]	[ "7742" ]
Admission Date: [2126-11-22] Discharge Date: [2126-12-9] Date of Birth: [2053-12-23] Sex: M Service: VSU HISTORY OF PRESENT ILLNESS: The patient is a 72 year old gentleman who underwent an endovascular repair of an abdominal aortic aneurysm with a [Hospital1 ] stent graft approximately seven years ago at another institution. This graft has developed endo leaks twice in the past which have required endovascular repair. The graft is extremely kinked and tortuous and has developed yet a third significant endo leak with aneurysmal expansion and he was advised to have this graft removed and converted to a conventional repair. The patient, therefore, presents to [Hospital1 190] for open repair of his abdominal aortic aneurysm with removal of the aortic endo graft. PAST MEDICAL HISTORY: Significant for hypertension, hyperlipidemia, abdominal aortic aneurysm, status post endovascular repair and subsequent endo leak. MEDICATIONS: 1. Zestril 20 mg p.o. q. Day. 2. Aspirin 325 mg p.o. q. Day. 3. Zocor 20 mg p.o. q. Day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives with his family. He has a long smoking history. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Vital signs: Heart rate 62; heart 122/68; saturating 100 percent on room air. General: No apparent distress. Alert and oriented. Head, eyes, ears, nose and throat: Normal cephalic, atraumatic. Extraocular movements intact. Mucous membranes are moist. Heart: Regular rate and rhythm, no murmurs. Lungs: Distant lung sounds but clear to auscultation bilaterally. Abdomen soft, nontender, mild groin bulge in the right inguinal area. No bruits. 2 plus femoral pulses bilaterally. Extremities: Clubbing of nail beds but no cyanosis. 2 plus dorsalis pedis and posterior tibial bilaterally. 5/5 strength. Sensation is intact. Neurovascular examination: Cranial nerves 2 through 12 are grossly intact. LABORATORY DATA: Hematocrit of 38.1; platelets 295; sodium of 137; potassium of 4.6; chloride of 102; bicarbonate of 26; BUN 18; creatinine 0.8; glucose 91. HOSPITAL COURSE: The patient was admitted to [Hospital1 346] on [2126-11-22] for removal of an aortic endo graft and repair of abdominal aortic aneurysm with an aorta [Hospital1 ]-iliac graft. For further details of surgery, please see associated operative note. Initially, the patient's postoperative course was uncomplicated and he was doing well. His pain was controlled with the help of an acute pain service consult. On [11-24], the patient began to report respiratory distress with dyspnea. No acute cause for his respiratory distress was found. On [11-25], while changing a line, the patient again had respiratory distress. Chest x-ray showed right lobe patchy infiltrates, consistent with aspiration. The patient was transferred to the Medical Intensive Care Unit for aggressive pulmonary toilette and antibiotics. He was followed by the Surgical Intensive Care Unit team as well as the vascular team. An electrocardiogram obtained that day showed ST elevations. The patient was initially stable hemodynamically but quickly deteriorated over the course of that day. His agitation increased and his heart rate and blood pressure went up. The patient had to be intubated. An nasogastric tube was in place. The patient was somewhat disoriented and had trouble remembering where he was on the date. The patient was started on Levofloxacin and Flagyl for aspiration pneumonia. It was determined on [2126-11-25], the patient had suffered a postoperative myocardial infarction as he had electrocardiogram changes and his troponin levels had bumped to 0.51 and his CK MB rose to 13. A cardiology consult was called. The patient had an echo done that demonstrated an ejection fraction greater than 55 percent. He underwent a head CT to further evaluate his mental status changes as well as a carotid ultrasound that showed no significant blockage. His head CT demonstrated an area of hypo attenuation in the left occipital lobe, in the territory of the left posterior cerebral artery. This was consistent with acute stroke. A neurology consult was obtained. A magnetic resonance scan of the head was obtained on [2126-11-30] and showed normal flow within the arteries. On this day, the patient self-extubated, but had to be reintubated for the magnetic resonance scan. The patient was then extubated on [2126-12-1] and tolerated it well. He was maintained on Levaquin for gram negative rods that grew out of his sputum. On [2126-12-2], the patient underwent and esophagogastroduodenoscopy for slight red blood per rectum. A small hiatal hernia was seen. There was a localized, linear erosion of the mucosa with a central eschar and surrounding heaped up erythema at the gastroesophageal junction. There was no active bleeding. This was presumed to represent [Initials (NamePattern4) ] [Last Name (NamePattern4) ]-[Doctor Last Name ] tear or esophagitis. The stomach and duodenum were normal. The patient was continued on Protonix. The patient was transfused multiple times throughout his stay in the hospital for a blood loss anemia, with a goal hematocrit greater than 30. On [2126-12-3], the patient underwent a colonoscopy. Small streaks of clotted blood were seen in the terminal ileum and cecum and a few also seen in the left colon. Careful lavage showed none of them were adherent to any underlying region. Grade two internal hemorrhoids were noted. A 2 cm patch of erythematous and edematous mucosa was noted in the sigmoid colon at 30 cm from the anal verge. There was the suggestion of a central depression but no distinct ulceration. The surrounding mucosa was entirely normal. There was no stigmata of bleeding. A biopsy was taken. To maintain the patient's nutrition, tube feeds were necessary to keep his calorie counts high. He also started p.o. intake after he passed a swallow study on [12-4]. On [2126-12-9], the patient was stable enough to be discharged to home with services. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Home with services. DISCHARGE DIAGNOSES: 1. Failed endovascular stent. 2. Postoperative volume fluid overload, corrected. 3. Aspiration pneumonia with respiratory failure, resolved. 4. Postoperative myocardial infarction. 5. Postoperative left occipital stroke. 6. [Doctor First Name ]-[Doctor Last Name ] tear/esophagitis. 7. Internal hemorrhoids. 8. Blood loss anemia, transfused, corrected. 9. Abdominal aortic aneurysm. DISCHARGE MEDICATIONS: 1. Simvastatin 20 mg p.o. q. Day. 2. Aspirin 325 mg p.o. q. Day. 3. Acetaminophen 325 mg to 650 mg p.o. every four to six hours prn for pain. 4. Lansoprazole 30 mg capsule, p.o. q. Day. FOLLOW UP: The patient was instructed to follow-up with Dr. [Last Name (STitle) ] in two weeks and to call for an appointment. The patient was also instructed to follow-up with Dr. [First Name (STitle) ] of the Neurology Stroke team in two months. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) ], [MD Number(1) 5697] Dictated By:[Last Name (NamePattern1) 11988] MEDQUIST36 D: [2126-12-30] 23:33:38 T: [2126-12-31] 07:54:14 Job#: [Job Number 104935]	[ "51881", "5070", "9971", "2851", "4280", "4019", "2724" ]
Admission Date: [2124-12-11] Discharge Date: [2124-12-20] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 2387] Chief Complaint: Cough, shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 84 year old male with past medical history of Parkinson's disease, CHF, CAD, and DM, who presents with 1 week history of productive cough, 4 days of nausea and vomiting, and 1 day of diarrhea. He states that he has been feeling 'sick' for the past week, with the above constellation of symtpoms. He has not had a fever or chills. He started with some loose stools, then developed a cough productive of white sputum. The cough has persisted. He then developed some nasusea and vomiting. . He has also felt a bit more SOB this past week. He relates that he does not do much walking at baseline, but gets SOB with going up 5 stairs. He has felt some SOB at rest this past week. He has not had any chest pain. His LE swelling has been much better recently. . He has continued to take all of his medications this week, including his oral hypoglycemics, warfarin, and lasix. . ED Course: Patient's vitals were noted to be: 97.3 75 86/56 16 96%ra. He was given 750 mg of levofloxacin, potassium, Vancomycin 1 gram, and 10 mg of Vitamin K. He had a CXR which was not read as a pneumonia. . ROS: Denies sick contacts or recent hospitalizations. He denies dysuria, abdominal pain, HA, ST, chest pain, hematochezia, melena, myaligias. He endorses knee pain bilaterally, rhinorrhea. . Past Medical History: 1. CAD, cath 5 years ago at NEBH (cardiologist [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]) 2. CHF, TTE [3-5] w/depressed EF 3. Hypertension, per daughter pt's bp usually 90s-100s on meds 4. Severe Lumbar Spinal stenosis, mild cervical stenosis 5. Sleep apnea, on 2L home O2 at night 6. Afib, s/p DCCV which failed, now rate controlled 7. Arthritis 8. Gout 9. COPD? No PFTs 10. NIDDM 11. E-coli-Sepsis (admission [2122-12-23] - [2123-1-1]) 12. BPH? (Flomax) 13. Parkinson's disease ? ?sinemet Social History: Patient uses a cane for assistance at baseline. He lives with his daughter [Name (NI) 13118]. Formerly worked at Sears. Widowed. No tobacco or EtOH use. Family History: Notable for CAD, HTN, and stroke. Physical Exam: PE on admission: Physical Exam: 98.0 90/50 75 18 95% 2L General: Elderly male with masked facies, speaking full sentences, NAD HEENT: MMdry, anicteric, EOMI, no sinus tenderness Neck: Supple, JVP 6cm, no LAD Cardiac: Irreg irreg, no m/r/g Chest: Bilateral diffuse wheeze, no rales, no consolidation Abdomen: obese, soft, nt, nd, pos bs on left, quiet on right Extr: no c/c/e Skin: multiple excoriations, scar from prior BCC removal on back Neuro: AAO x 3, masked facies, cn intact, pill rolling tremor, minor cogwheel rigidity on right Psych: Flat affect, appropriate Msk: FROM at both knees, right slightly warmer than left . On transfer from MICU to medicine floor: Baseline Physical Exam (on transfer to medicine floor from MICU): t 98.8 bp 96/56 hr 80 rr 20 by vitals sheet; 28 by my exam slightly later o2 sat: 98% RA . General: Elderly man with visibly faster-than-usual respiratory rate but without evident discomfort HEENT: PERRL, EOMI; anicteric Neck: JVD not appreciated on my exam (8 cm by prior MICU attg note) Cardiac: Mostly regular rate with occasional "extra beats"/irregular beats; no murmurs or rubs appreciated Chest: Expiratory wheezing heard throughout, good air movement throughout, no rales appreciated Abdomen: BS+, NT, ND Extr: 1+ edema Skin: ecchymoses on arms, IV sites, hands; several scabs on face Neuro: strength 4+ and symmetrical at: grip, pedal dorsi/plantarflexion, biceps/triceps, shoulder shrug. CN: as above EOMI and PERRL, tongue to midline, palate elevates, no facial asymmetry, no slurring of speech, shoulder shrug intact. Alert and oriented to place, town, date, day, year, self. Psych: appropriate range of affect Msk: slightly swollen R knee with bandaid and betadyne stains c/w recent tap; tender inferior and medial to patella. . Pertinent Results: [2124-12-11] 08:57PM WBC-13.8* RBC-4.30* HGB-13.8# HCT-40.4 MCV-94 MCH-32.2 MCHC-34.2 RDW-14.4 [2124-12-11] 08:57PM NEUTS-83.9* LYMPHS-8.3* MONOS-7.0 EOS-0.6 BASOS-0.1 [2124-12-11] 08:57PM PLT COUNT-232 [2124-12-11] 08:57PM PT-64.5* PTT-55.3* INR(PT)-8.1* . [2124-12-11] 08:53PM LACTATE-2.0 . [2124-12-11] 08:57PM GLUCOSE-87 UREA N-94* CREAT-3.9# SODIUM-133 POTASSIUM-3.1 CHLORIDE-87* TOTAL CO2-25 ANION GAP-24* . [2124-12-11] 08:57PM CK(CPK)-173 [2124-12-11] 08:57PM CK-MB-4 cTropnT-0.05* . [2124-12-11] 11:42PM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.011 [2124-12-11] 11:42PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [2124-12-11] 11:42PM URINE RBC-[7-9]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 Brief Hospital Course: Patient is an 84 year old male with past medical history significant for CAD, CHF, DM, and atrial fibrillation who presents from home with one week of productive cough, decreased PO intake, diarrhea, and N/V. . # Cough/N/V: As the hospital course continued, we felt it most likely that he had a viral syndrome that led to nausea, vomiting, decreased PO intake, and cough. His productive cough with a leukocytosis was initially concerning for pneumonia; however, his chest x-rays were unrevealing. His vomiting by his history was actually ambiguous and may have represented violently coughing up large quantities of white sputum, according to his daughter's history. . Given the possibility of pneumonia, he was started on levofloxacin for community acquired pneumonia, which was discontinued on the equivalent of day [7-6] of the course (uncertainty based on changing renal function at the time of discontinuation). Vancomycin was started as well for this, but was discontinued given that patient lives at home and has not had a lot of exposure to the healthcare system. Vancomycin was re-introduced for concern for septic joint (see below). Cultures were unrevealing, influenza DFA was negative, legionella ag was negative, and follow-up chest x-rays were unrevealing. . When on the medicine floor he continued to be afebrile. His white count rose while on the medicine floor; given that his respiratory status remained stable, this was judged unlikely to be secondary to the respiratory infection, and ultimately, more likely to be the result of a florid gout flare. . # Atrial fibrillation: In the MICU he was continued on sotalol, dosed 40 mg [Hospital1 ] in light of ARF; he is on 80 mg [Hospital1 ] at baseline. As his renal function improved he had an episode of afib with RVR to the 150s, with hypotension (70s over palp), for which he was triggered, given IV metoprolol and IV fluids; this eventually resolved, and he was then continued on 80 mg sotalol [Hospital1 ] thereafter, and had no further episodes of RVR. . His anticoagulation was held, first because of supratherapeutic INR, and then because of concern for hemorrhagic joint. He was started on enoxaparin (Lovenox) on [2124-12-17]. He was then started on warfarin on [2124-12-18]. . # Hypotension: Appears to be at baseline at this time, mainly in 90s-100s, and his baseline SBP is 80's to 90's per OMR records. He responded well to the fluids given during first day of admission. His lactate was 2.0 at admission, and he remains not tachycardic. Ultimately we felt that it was more likely that his hypotension was due to low baseline BP and severe dehydration in setting of poor PO intake and diarrhea/vomiting. He had one other episode of hypotension, which was clearly secondary to afib with RVR, described above. . # Knee swelling, likely gout: Patient has right knee that appeared bruised on admission, with possible joint effusion appreciated. Rheumatology was consulted, given history of gout as well as history of septic joint in setting of gout infection. Joint aspiration of the R knee revealed hemarthrosis with joint fluid Hct of 42, which was confirmed by MRI. Joint aspiration of the L knee revealed a high white count ([Numeric Identifier 24869]). Both taps showed gout crystals. Because of our initial concern for septic joint we treated first with Ancef, and then when his white cell count continued to rise and his joints appeared to be more inflamed, we switched to vancomycin with concern for MRSA. However, he remained afebrile and joint cultures were negative, as were joint fluid gram stains; we thus discontinued antibiotics for the joint. We consulted the [Numeric Identifier 1083] diseases service which recommended this discontinuation of antibiotics followed by close observation. . We treated pain with colchicine, celebrex, lidocaine patches, tylenol, ultram, and ultimately steroids to reduce inflammation. We avoided opioids because his family had given us the history of delirium with mild opiates (likely codeine), and we judged him to be at significant risk for delirium as well as for falls should he become delirious. . At this point we believe that the hemarthrosis in the R joint would be best dealt with by physical therapy that kept the joint flexible, and would expect that this hemarthrosis will gradually dissolve and be reabsorbed, particularly in the context of anticoagulation therapy; we see no indication of rebleeding. We had been holding colchicine in the setting of ARF but restarted it. He also got celebrex as an anti-inflammatory. . # Diarrhea: He has had several days of diarrhea, with no recent exposure ot antibiotics or health care institutions. This could be part of a viral syndrome. With a climbing white count we were concerned for C. diff and had him on flagyl for several days; however, C. diff toxin assays were negative twice and he was taken off precautions and we did not continue flagyl. He had formed stool starting several days before discharge. His cultures were all negative. . # Acute renal failure: His creatinine was 3.9 at admission. With hydration and holding his lasix, his creatinine declined to 1.5 before rising slightly again before discharge once a small dose of lasix (40 mg daily compared to his 160 mg daily home dose) was restarted. This was held once more. His urine lytes and clinical picture was consistent with a mainly pre-renal picture, worse on admission secondary to poor PO and diarrhea. Urine output improved substantially. He will need to have his lasix dose titrated back up as his gout flare and renal function improve again, as he has consistently had lower extremity edema that has responded well to lasix in the past. . # Coronary artery disease: Per records, he had a cath at NEBH with Dr. [Last Name (STitle) ] that showed non-obstructive coronary disease. We restarted ASA 81 daily, as he does take this as an outpatient. We continued his statin. . # Chronic diastolic congestive heart failure: He appears to be well compensated at this point, with no clinical evidence of failure. We monitored i/o, had him on a low Na diet, and checked several chest x-rays during the course of his admission to look for signs of worsening failure. We held lasix as above but he did not have clinical indications of heart failure with us. . # Diabetes: Patient is on glipizide at home. Given poor PO intake and his renal failure, his PO [Doctor Last Name 360] was held in the MICU, replaced by insulin sliding scale; and given changing circumstances of high white blood count, changing intake, and changing renal function, we continued his insulin scale while on the medicine floor. . # Parkinson's disease: We continued home medications of carbidopa. He did not have significant manifestations of parkinsonism while on the medicine floor, though as above he apparently did have manifestations on arrival to the hospital. . # Coagulopathy: He received some vitamin K in the ED. Coumadin was held. His INR drifted down over the admission; as above, enoxaparin (Lovenox) was started on [12-17] and warfarin was restarted on [12-18]. . # AG acidosis: Resolved. Was felt to be likely due to acute renal failure. Also, he was hypochloremic from vomiting. He had no ketones in his urine. His lactate remained within normal limits. . # COPD: He had wheezes on exam fairly frequently which improved with nebulizers and beta-agonist inhalers (levalbuterol to minimize cardiac effect). Per Dr. [Last Name (STitle) ], he has had no clear diagnosis of COPD or history of wheezing. He had PFT's at NEBH in [2120] which showed a restrictive pattern with a mildly decreased TLC and diffusion capacity. He is not on an inhaler at home, but his daughters report this is partly because when he has been prescribed them he has been unable or unwilling to learn how to use them properly. His overall wheezing improved over the admission. Given that he did not have signs of progression of heart failure the wheezing was more likely secondary to bronchitic infection, likely viral. The wheezing seemed to benefit from steroids, which were started for gout. . # BPH: He had been on Flomax at home. We held this for concern for labile blood pressure as described above. This could be restarted. . # FEN: Cardiac [Doctor First Name ] diet. . # PPx: Anticoagulated (high INR), PPI . # Code status: Full, discussed with patient . # Communication: Daughter [Name (NI) 13118] [Telephone/Fax (1) 40195] . # Dispo: To rehabilitation to build ability to walk independently. . Medications on Admission: Wellbutrin 100mg ER by mouth every morning Celebrex 200 mg qd Coumadin 2.5 mg alternating with 5 mg Protonix 40 mg, Lasix 160 mg, potassium 20 mEq, Crestor 5 mg, carbidopa 25 mg/100 mg one three times a day, Flomax 0.4 mg, glipizide 5 mg two a day, colchicine 0.6 mg every other day, Niaspan 500 mg, trazodone 100 mg at bedtime, [Doctor First Name ] 180 mg, sotalol 80 mg two times a day, doxepin 100 mg at bedtime for skin itch, lidocaine patches on the knees. metolazone MWF . MEDICATIONS ON TRANSFER Acetaminophen 650 mg PO q6h Aspirin 81 mg PO Bupropion 100 mg PO qAM Carbidopa-levodopa 25-100 1 tab po TID Docusate 100 mg PO BID:PRN Fexofenadine 60 mg PO BID Insulin scale Ipratropium bromide Neb, 1 neb IH q6h Levofloxacin 750 mg PO q48h Lidocaine 5% patch 1 ptch TD daily Niaspan 500 mg oral daily Ondansetron 4-8 mg IV q8H: nausea Pantoprazole 40 mg PO q24h Potassium prn per lytes Rosuvastatin calcium 5 mg PO daily Senna 1 tab PO BID:PRN Sotalol 40 mg PO BID Tamsulosin 0.4 mg PO HS Xopenex 0.63 mg/3 mL inhalation q6-8h prn wheezing/SOB Trazodone 100 mg PO HS:PRN Discharge Medications: 1. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for 2 doses: start [12-22], after 25 mg dose on [12-21]. 2. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO daily () for 2 doses: after 20 mg doses. 3. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for 2 doses: after 15 mg doses. 4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO daily () for 2 doses: after 10 mg doses. 5. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for knee pain. 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours) as needed for knee pain. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 11. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 15. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Niacin 500 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO daily (). 17. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 18. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1) inhalation Inhalation q6-8h prn () as needed for wheezing/SOB. 19. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Celecoxib 200 mg Capsule Sig: One (1) Capsule PO daily (). 21. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): do not give more than 4 grams per day. 22. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 23. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 24. Guaifenesin 100 mg/5 mL Syrup Sig: [2-1] 5 mL doses PO four times a day as needed for cough. 25. Warfarin 2.5 mg Tablet Sig: 1-2 Tablets PO once a day: 1 tablet (2.5 mg) MWF; 2 tablets (5 mg) SaSuTuTh. 26. Insulin Regular Human 100 unit/mL Solution Sig: One (1) injection Injection ASDIR (AS DIRECTED): SCALE: Breakfast, lunch and dinner scale: Glucose 0-75 mg/dL: 4 oz. juice. 76-149: none. 150-199: 3 units. 200-249: 5 units. 250-299: 7 units. 300-349: 9 units. 350-400: 11 units. >400: notify MD. . BEDTIME SCALE: Glucose 0-75 mg/dL: 4 oz. juice. 76-149: none. 150-199: 2 units. 200-249: 4 units. 250-299: 6 units. 300-349: 8 units. 350-399: 10 units. >400: notify MD. PLEASE NOTE: THIS SCALE WILL LIKELY REQUIRE ADJUSTMENT OVER THE NEXT FEW DAYS BECAUSE PATIENT IS ON RAPID PREDNISONE TAPER. . 27. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 28. Prednisone 10 mg Tablet Sig: 2.5 Tablets PO 1x on [2124-12-21] for 1 days: starting on [12-22], use doses listed elsewhere on this list, continue taper accordingly. (each dose for 2 days, decreasing 5 mg, 2 more days at lower, decreasing 5 mg again, and so on.). Discharge Disposition: Extended Care Facility: [Hospital3 2732] & Retirement Home - [Location (un) 55] Discharge Diagnosis: Primary Diagnosis: Diarrhea Gout Atrial Fibrillation with Rapid Ventricular Rate Leukocytosis . Secondary Diagnosis: Coronary Artery Disease Chronic Diastolic Heart Failure Diabetes Mellitus Discharge Condition: Good Patient stable, with no fevers Discharge Instructions: You were admitted to the hospital with diarrhea and a cough. This was most likely due to a viral infection, although we gave you antibiotics to treat a possible bacterial infection in your lungs, which you have finished. You also developed swelling of your knees, which is likely due to gout. We started steroid therapy for gout, which will be "tapered"--that is, its dose will be reduced every two days. Your rehabilitation facility will have instructions about how to continue this therapy. . Please take all of your medications as prescribed. We held your lasix and reduced its dose on discharge because of concern about your kidneys. As your health improves, it's likely that you'll need to go back to your home dose of 160 mg daily. . Your allopurinol was stopped because of concern about your kidneys. This will also likely need to be restarted later as your health improves. Finally, your 81 mg of aspirin was held because of the prednisone you are taking; it should be restarted once you are finished with the prednisone. . Work with the rehabilitation facility staff, particularly the physical therapists, to try to improve your mobility and your overall health. Once you are discharged, please call your doctor or return to the ER if you have chest pain, feelings that your heart is racing fast, diarrhea, abdominal pain, fevers, chills, shortness of breath, increasing pain in your knees, or other concerning symptoms. . Go to a follow-up appointment with Dr [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) ] at the [Hospital1 ] Wednesday [1-10], 3 pm. . Go to the rheumatology follow-up appointment with Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], Tuesday [1-9], 2 pm. [Last Name (NamePattern1) 439], [Hospital1 18]. Followup Instructions: Go to a follow-up appointment with Dr [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ]. [Last Name (NamePattern1) ] at the [Hospital1 ] Wednesday [1-10], 3 pm. [Telephone/Fax (1) 7960]. . Go to the rheumatology follow-up appointment with Dr [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], Tuesday [1-9], 2 pm. [Last Name (NamePattern1) 439], [Hospital1 18]. [Telephone/Fax (1) 2226]. . Lasix dose is 160 mg at home; we have held it until today because of concern re renal function; his renal function has improved and we are dosing it at 40 mg daily to start. This will likely need to be increased but renal function should be followed. . His blood sugar levels have been in flux due to prednisone. His scale was recently increased slightly, and the scale for discharge represents a slight further increase. Because the prednisone is on a fairly rapid taper downward, the appropriate approach to blood sugar control is likely to change over the next 2 weeks, and this will need to be followed. . We have thus far avoided opiates for pain control because of concern about hospital delirium, which his family reports he has had in the past. . Please feel free to contact [Name (NI) ] [Last Name (NamePattern1) 4427], MD, via the [Hospital1 18] operator at [Telephone/Fax (1) 2756] if you have further questions about the inpatient course for this complicated and treasured patient; Dr. [Last Name (STitle) 4427] is the medical intern who followed Mr [Known lastname ] for this admission.	[ "5849", "2762", "5990", "41401", "42731", "25000", "496", "4280", "40390", "5859" ]
Admission Date: [2183-4-7] Discharge Date: [2183-4-17] Date of Birth: [2119-11-18] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[First Name3 (LF) 1505] Chief Complaint: SOB Major Surgical or Invasive Procedure: [2183-4-11] MV repair ( 26mm [Company 1543] 3D ring)/ CABG x 2 (LIMA to LAD, SVG to PDA) History of Present Illness: 63 yo female was in good health until 3 weeks ago when she thought she had the flu. Treated with abx and eventually developed severe SOB. Admitted to [Hospital1 ] on [3-27]. She had NSTEMI with ST depression and a + troponin. Treated with heparin and admitted to the CCU. Cardiac cath there [3-28] revealed severe 3VD and [1-29]+ MR. On [3-31] she had 3 DES placed in the CX. Loaded with plavix and has had a continued daily dose. Treated with ACE-I and beta blocker, but did not tolerate them well. Transferred here for MVR/CABG. Past Medical History: coronary artery disease s/p CX stents [3-31] mitral regurgitation hypertension GI ulceration renal calculi gastroesophageal reflux disease Social History: one ppd for 50 years, quit 3 weeks ago lives alone ETOH rare school cafeteria worker last dental exam 2 weeks ago Family History: non-contrib Physical Exam: HR 88 RR 18 99% RA sat 103/69 5'3" 53.5 kg skin dry and intact PERRLA, EOMI, neck supple, full ROM CTAB RRR soft, NT, ND, + BS warm, well-perfused, no edema or varicosities neuro grossly intact 2+ bil. fem/DP/PT/radials no carotid bruits Pertinent Results: Conclusions PRE-BYPASS: The left atrium is elongated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild to moderate regional left ventricular systolic dysfunction with focalities in the basal, m id and apical lateral walls. Overall left ventricular systolic function is moderately depressed (LVEF= 40 %). Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral regurgitation vena contracta is >=0.7cm. Severe (4+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [Last Name (STitle) ] was notified in person of the results on [Known firstname ] [Known lastname 76883] at 8AM before surgical incision. Post_Bypass: Normal RV systolic function. Intact thoracic aorta. Post repair, there is a mitral annular prosthesis which is stable and functioning well. There is a mild residual mitral regurgitation and at worst a mild to moderate degree with the vitals at 110/70. This was conveyed to DR.[Last Name (STitle) ]. Trivial TR. No AI. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [Name6 (MD) 3892] [Name8 (MD) 3893], MD, Interpreting physician [Last Name (NamePattern4) ] [2183-4-11] 11:31 [2183-4-15] 06:10AM BLOOD WBC-11.5* RBC-3.48* Hgb-10.8* Hct-32.7* MCV-94 MCH-31.1 MCHC-33.1 RDW-15.3 Plt Ct-155 [2183-4-13] 04:21AM BLOOD PT-13.7* PTT-27.2 INR(PT)-1.2* [2183-4-15] 06:10AM BLOOD Glucose-75 UreaN-16 Creat-0.7 Na-140 K-4.3 Cl-106 HCO3-25 AnGap-13 [2183-4-8] 12:30AM BLOOD ALT-15 AST-15 LD(LDH)-250 AlkPhos-101 TotBili-0.6 Brief Hospital Course: Ms. [Known lastname 76883] was admitted on [4-7] and completed a pre-operative workup. A pre-operative echo and CT of chest to evaluate aorta were completed. Dental clearance was obtained. A carotid ultrasoun showed 40-59% [Doctor First Name 3098] and 60-69% [Country ] stenoses. She underwent surgery with Dr. [Last Name (STitle) ] on [4-11]. She tolerated the surgery well and was transferred to the CVICU in stable condition on titrated phenylephrine, epinephrine, and propofol drips. Ms. [Known lastname 76883] was extubated later that day. Her chest tubes were removed. Her beta-blockade was titrated as tolerated. She was transferred to the floor on POD #3 to begin increasing her activity level. Her pacing wires were removed and her diuresis was continued. By post operative day six she was ready for discharge to home. Medications on Admission: plavix 75 mg daily ( received ?600 mg on [3-31]) lisinopril 10 mg daily zantac 150 mg [Hospital1 ] proventil IH ( recently) 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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days. Disp:14 Tablet(s) Refills:0 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:30 Tablet(s) Refills:0 8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Disp:240 Tablet(s) Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) 1110] VNA Discharge Diagnosis: coronary artery disease mitral regurgitation s/p MVrepair/CABG x2 NSTEMI hypertension GI ulceration renal calculi gastroesophageal reflux disease Discharge Condition: good Discharge Instructions: no lotions, creams or powders on any incision shower daily and pat incisions dry no driving for one month and off all narcotics no lifting greater than 10 pounds for 10 weeks call for fever greater than 100, redness, drainage, or weight gain of 2 pounds in 2 days or 5 pounds in one week Followup Instructions: see Dr. [First Name (STitle) ] in [11-29] weeks ([Telephone/Fax (1) 82655] see Dr. [Last Name (STitle) 32255] in [12-31] weeks [Telephone/Fax (1) 6256] see Dr. [Last Name (STitle) ] in 4 weeks at [Hospital1 ] [Telephone/Fax (1) 6256] please call for appts. Completed by:[2183-4-17]	[ "4240", "41071", "5990", "41401", "V4582", "4019", "53081" ]
Admission Date: [2124-2-12] Discharge Date: [2124-2-16] Date of Birth: [2047-10-15] Sex: M Service: MEDICINE Allergies: Tetracycline Analogues / Niacin / Almond Oil / Tree Nut / Fruit Extracts / Nafcillin / cefazolin Attending:[First Name3 (LF) 759] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: A-line placement History of Present Illness: 76 y/o male with sCHF (EF 35-40%), AS s/p biologic AVR, CAD, pAF, DMII c/b neuropathy, hypothyroidism and stage III/IV CKD, with a recent admission for [Female First Name (un) 564] fungemia, who presented from [Hospital1 ] [Location (un) 620] with SOB and altered mental status. He was recently hospitalized at [Hospital1 18] from [Date range (1) 4108] with [Female First Name (un) 564] fungemia (no evidence of endophthalmitis and TEE without evidence of Endocarditis) with a hospital course complicated by a left IJ DVT (for which he was bridged to Coumadin with Heparin), acute on CKD (CKD [1-20] AIN, most likely [1-20] Nafcillin, with baseline creatinine of ~ 2.3, 2.9 at discharge on [2124-2-3]), and a systolic CHF exacerbation. . He was discharged to [Hospital ] Rehab on [2124-2-3]. He states that since his discharge he has been profoundly short of breath with minimal exertion, especially over the last few days. He states that initially he was making good urine to his Lasix 100 mg [Hospital1 ] but that one to two days ago he stopped making urine. He was also noted to be increasingly confused at [Hospital1 ]. . On [2124-2-11], he was taken to [Hospital1 ] [Location (un) 620] Emergency Department for severe SOB and altered mental status. On arrival to [Hospital1 ] [Location (un) 620] he was noted to be hypotensive. A right IJ central line was placed and he was given Zosyn and started on Levophed prior to transfer. A BNP was reportedly 34,000. He was transferred to [Hospital1 18] [Location (un) 86] for concern for hypotension from CHF vs. sepsis. . On arrival to [Hospital1 18] ED, his initial vitals were 97.5, 60, 96/54, 25, 91%on RA. The Levophed was discontinued but his blood pressure subsequently dropped to 56/46 and the Levophed was restarted. His CBC was notable for a WBC of 17.9 with 82.1% PMNs but no bands. His extended chemistry was notable for a potassium of 5.6, HCO3 of 20, a BUN of 85, a Cr of 4.7, a calcium of 7.6, and a phosphorus of 9.5. His lactate was 5.2 and his INR was 4.1. A CXR was consistent with pulmonary edema. He received Vancomycin, zosyn and 100 cc of NS. His vital signs at transfer were 99/50, 62, 17, 94 on 4L. . On arrival to the MICU, his vitals were 96, 64, 113/56 (on 0.12 mcg/kg/min), 24, 97% on 4L. He looked uncomfortable but was in no apparent distress. He reported the history as detailed above. He additionally reported a nagging non-productive cough in addition to his worsening DOE. He denied any recent fevers, chills, chest pain, palpitations, nausea, vomiting, abdominal pain, diarrhea, dysuria or hematuria. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -Chronic Systolic Heart Failure (EF 35% to 40% in [2119]) -s/p biologic AVR [2119] -CABG: -s/p CABG in [2113] and [2119] -PERCUTANEOUS CORONARY INTERVENTIONS: -multiple stents [10/2123] -PACING/ICD: -pacer insertion [2119] ([Company 1543] Sensia dual-chamber pacemaker) [1-20] transient heart block post-op AVR 3. OTHER PAST MEDICAL HISTORY: - DM type II c/b neuropathy - HTN - HLD - CAD - Paroxysmal Atrial Fibrillation - h/o epistaxis requiring blood transfusion while on coumadin - BPH - Hypothyroidism - CKD stage III/IV - H/o AIN - ? history of stroke - anemia of chronic disease (baseline between 27-30) Social History: Prior to his admission at [Hospital1 ], He lived at home with his wife. [Name (NI) ] ambulates with a walker. He has had multiple hospitalizations since the fall requiring a stay at NewBridge on the [Doctor Last Name ]. He was discharged 3 days ago. He denies tobacco, alcohol, illicit drug use. Family History: Mother died at 81 and had a brain tumor. Sibling with Alzheimer disease. There is also thyroid and lung cancer in other family members. Brother with pancreatic and liver cancer. No family history of CAD or sudden cardiac death. Physical Exam: ADMISSION EXAM: T 96 BP 121/61 HR 67 O2 sat 95% 4L NC RR24 General: uncomfortable, NAD HEENT: MMM, OP clear, RIJ in place, unable to assess JVP CV: RRR, distant heart sounds, unable to appreciate any m/r/g, normal S1 and S2 Lungs: labored, crackles to the mid-posterior lung fields bilaterally Abdomen: distended but soft, BS+, NT/ND GU: foley in place Ext: warm, arterial ulcers on pedal surface of feet bilaterally, [1-21]+ pitting edema in bilateral lower extremities tapering to trace pitting edema at the sacrum Neuro: AAOx3 (person, place and time), right facial droop, strength not assessed Pertinent Results: ADMISSION LABS [2124-2-12] 01:25AM BLOOD WBC-17.9* RBC-3.95* Hgb-8.8* Hct-31.3* MCV-79* MCH-22.2* MCHC-28.1* RDW-17.3* Plt Ct-296 [2124-2-12] 01:25AM BLOOD Neuts-82.1* Lymphs-14.5* Monos-3.1 Eos-0 Baso-0.2 [2124-2-12] 02:21AM BLOOD PT-41.4* PTT-42.0* INR(PT)-4.1* [2124-2-12] 01:25AM BLOOD Glucose-130* UreaN-85* Creat-4.7# Na-140 K-5.6 Cl-103 HCO3-20* AnGap-23* [2124-2-12] 01:25AM BLOOD ALT-793* AST-[2092]* LD(LDH)-1394* CK(CPK)-127 AlkPhos-430* TotBili-0.5 [2124-2-12] 01:25AM BLOOD CK-MB-12* MB Indx-9.4* [2124-2-12] 01:25AM BLOOD cTropnT-0.17* [2124-2-12] 06:00PM BLOOD CK-MB-12* MB Indx-8.7* cTropnT-0.16* [2124-2-12] 01:25AM BLOOD Albumin-2.7* Calcium-7.6* Phos-9.5# Mg-2.3 [2124-2-12] 08:36AM BLOOD Type-ART pO2-31 pCO2-47* pH-7.20* calTCO2-19* Base XS--10 PERTINENT LABS AND STUDIES [2124-2-12] 01:43AM BLOOD Lactate-5.2* [2124-2-12] 10:44AM BLOOD Lactate-5.8* [2124-2-13] 12:54AM BLOOD Lactate-3.4* [2124-2-12] 04:57AM BLOOD O2 Sat-39 [2124-2-12] 06:06PM BLOOD freeCa-0.93* [2124-2-13] 12:54AM BLOOD freeCa-0.70* MICROBIOLOGY: Urine cx [2-12]: negative Blood cultures 2/25: pending, negative to date [2124-2-12] 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 mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild to moderate regional left ventricular systolic dysfunction with infero-lateral akinesis and inferior hypokinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The ascending aorta is mildly dilated. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Trace aortic regurgitation is seen. 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. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. CXR [2124-2-12]: 1. Right internal jugular central venous catheter with tip in the right atrium. Consider retraction by approximately 2-3 cm. 2. Mild interval improvement of pulmonary edema. 3. Bilateral collapse/cponsolidation and possible small effusions. Brief Hospital Course: 76M with sCHF (EF 35-40%), AS s/p biologic AVR, CAD, pAF, DMII c/b neuropathy, hypothyroidism and stage III/IV CKD, with a recent admission for [Female First Name (un) 564] fungemia, who presented from [Hospital1 ] [Location (un) 620] with hypotension and initial concern for sepsis vs. CHF. Given concern for possible sepsis, he was continued on fluconazole, and also started on broad spectrum antibiotics (vanco/meropenem). However, further work-up revealed his clinical picture was more suggestive of cardiogenic shock in the setting of decompensated sCHF. The patient's physical exam and CXR were consistent with left and right heart failure. A repeat TTE showed worsened right heart failure. His central venous O2 was 36 and his CVP 23. As he was hypotensive with evidence of significant end-organ damage, diuresis was not an option. The patient was continued on norepinephrine for blood pressure support. Renal was consulted, and the patient was initiated on CVVH. With CVVH, approximately 6.5L of fluid were removed, with improvement in patient's respiratory status. He was weaned off pressors. However, the patient continued to have profoundly altered mental status and tenuous respiratory status. After further discussion between the MICU team and the patient's family, a decision was made to transition to comfort focused care. Dialysis was stopped, and his HD line was removed. A-line removed. Antibiotics were stopped, and all other medications were discontinued. The patient was called out to floor. Palliative care and social work were consulted. The patient was started on morphine as needed for dyspnea, lorazepam as needed for anxiety, and a scopolamine patch to help with secretions. The patient expired on [2124-2-16]. Medications on Admission: 1. Aspirin 81 mg Tablet qd 2. Vitamin D 1,000 unit Tablet qd 3. clopidogrel 75 mg Tablet qd 4. Lasix 100 mg [Hospital1 ] 5. Lantus 100 unit/mL Solution Sig: Twenty (20) units HS 6. insulin aspart 100 unit/mL QID 7. levothyroxine 50 mcg qd 8. metoprolol tartrate 50 mg [Hospital1 ] 9. multivitamin 10. pantoprazole 40 mg Tablet, 11. tamsulosin 0.4 mg Capsule HS (at bedtime). 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID 13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID 14. warfarin 2 mg q4 PM. 15. fluconazole 200 mg Tablet q24 16. ferrous sulfate 325 mg qd 17. albuterol sulfate neb q4 prn 18. ipratropium bromide q6prn Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Cardiogenic shock Systolic congestive heart failure exacerbation End stage renal disease Discharge Condition: Patient expired. Discharge Instructions: N/A Followup Instructions: N/A	[ "5845", "2762", "V4581", "2724", "42731", "2449", "40390", "4280", "2767" ]
Admission Date: [2181-3-9] Discharge Date: Service: C-MED CHIEF COMPLAINT: Second opinion for coronary artery bypass graft versus PCI. HISTORY OF THE PRESENT ILLNESS: The patient is an 81-year-old female transferred from [Hospital 1514] Hospital in New [Location (un) ] for possible CABG versus cardiac catheterization. She originally presented to [Hospital ] [Hospital 107] Hospital in [Location (un) 3320], [Location (un) 3844] on [2181-2-22] with symptoms of fever,chills, and decreased appetite. She had no nausea, vomiting, diarrhea, abdominal pain, or chest pain. The LFTs were somewhat abnormal on admission there with an elevated alkaline phosphatase and GGT while the AST, ALT and the bilirubin were within normal limits. Ultrasound done showed gallstones, but no clear evidence of cholecystitis. She had bladder and urine cultures, which were negative. She did grow S. aureus from a right toe ulcer. She had x-rays done of the right foot, which showed no gross lytic process, but possible some early changes consistent with early osteomyelitis. She had a surgical consultation for this and it was felt that there was no active infection at this time and nothing further was done. She was originally treated with Zosyn for possible cholecystitis and then switched to Augmentin p.o. The white blood cell count went from 17.2 down to 11.0 and the patient became afebrile. On [2-28], the patient began to have left chest, shoulder, and arm pain. The EKGs done showed anterolateral ST depressions without any evidence of ST elevations. She was started on IV nitroglycerin and Lovenox and transferred to the to the ICU. The CKs remained flat, but she had a borderline elevated troponin at 2.1, with greater than 0.5 considered to be positive at the Speare [Hospital1 107] Laboratory. She was transferred to [Hospital 1514] Hospital on [2-20] for urgent cardiac catheterization. In [Hospital 1514] Hospital the patient was kept on IV nitroglycerin and subcutaneous Lovenox. The Infectious Disease Service felt that her fever was secondary to cholecystitis and recommended remaining on Augmentin for a total of 14 [Known lastname ]. The patient also developed diarrhea with C. difficile positive stool documented on [3-4], and the patient was started on Flagyl for this. Regarding the patient's chest pain, she continued to have intermittent episodes of chest pain and left arm discomfort with associated EKG changes while at [Hospital 1514] Hospital. A cardiac catheterization was performed on [3-6] by the left brachial approach, which showed significant left main stenosis of 60%, LAD with 90% ostial and 80% mid LAD lesions with a very narrow distal vessel. She also had a 99% ostial lesion of the RCA and a 60% to 70% left circumflex lesion. The left ventricular echocardiogram was not performed. Echocardiogram was obtained which showed diffuse left ventricular hypokinesis most severe in the anteroseptal and apical regions. The EF was estimated at approximately 40%. She had severe tricuspid regurgitation with pulmonary artery pressure estimated at approximately 54-mm mercury. Cardiac surgery evaluated the patient at [Hospital 1514] Hospital and felt that she was not a surgical candidate. She is now transferred to [Hospital1 346] for repeat evaluation for possible CT surgery versus PCI. She has been pain free for three [Known lastname ] upon her admission to [Hospital1 69]. PAST MEDICAL HISTORY: 1. Type 2 diabetes mellitus since the early [2169]. 2. Arthritis. 3. Peripheral vascular disease status post bilateral TMAs and status post bilateral femoral popliteal bypass done two and three years ago. 4. Coronary artery disease with cardiac catheterization as described in the HPI. 5. Status post left hip replacement. 6. Cerebrovascular accident with a history of left arm weakness over the last one to two years. 7. C. difficile diarrhea. 8. Trochanteric bursitis status post injection on [2181-2-28] at [Hospital ] [Hospital 107] Hospital. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON TRANSFER: 1. Lopressor 50 mg q.6h. 2. Amlodipine 5 mg p.o.q.d. 3. Lisinopril 5 mg p.o.q.d. 4. Aspirin 81 mg p.o.q.d. 5. Lovenox 1 mg per kg subcutaneously q.12h. 6. Nitroglycerin patch 0.4 mg topically q.d. 7. Augmentin 500 mg p.o. b.i.d. 8. Flagyl 250 mg p.o.t.i.d. 9. Pepcid 20 mg p.o.b.i.d. 10. Glyburide 5 mg p.o.b.i.d. 11. Regular insulin sliding scale. 12. Subcutaneous nitroglycerin p.r.n. SOCIAL HISTORY: The patient is a widower. She has a former tobacco history of up to two packs per [Known lastname ]. She quit over 20 years ago. She denied any alcohol use. PAST MEDICAL HISTORY: 1. Chronic O2 use at home during the night only. The patient states that she does not known what her actual diagnosis is, but states she was put on the nighttime oxygen to "increase her ability to think clearly." PHYSICAL EXAMINATION: Examination revealed the following: Temperature 98.3, blood pressure 108/50, pulse 56, respiratory rate 16, oxygen saturation 97% on two liters. The patient's weight is 110 pounds. GENERAL: The patient is a thin, frail, elderly woman in no acute distress. HEENT: Left pupil is reactive and the right pupil to be irregular and nonreactive. Sclerae are anicteric. Mucous membranes moist and pink. NECK: Neck was supple. There are bilateral carotid bruits. LUNGS: Lungs have bibasilar crackles. HEART: The heart has a regular rate and rhythm. There was a 2/6 systolic murmur at the left upper sternal border. The abdomen is soft, nontender, and nondistended. There are normal bowel sounds. EXTREMITIES: Extremities are without clubbing, cyanosis or edema. There is an ulcer on the right first TMT with granulation tissue present. The right lateral heel has an necrotic ulcer. There is no erythema and no exudate. NEUROLOGICAL: Cranial nerves II to XII intact except for the right pupil being fixed. Strength is diminished on the left to 4 out of 5 in both upper and lower extremities with the extensors noted to be weaker than the flexors. The deep tendon reflexes are 2+ on the left and absent on the right. Sensation is grossly intact. LABORATORY DATA: Labs from [2-26] at [Hospital 1514] Hospital showed the sodium of 137, potassium of 5.3, chloride 102, bicarbonate 28, BUN 21, creatinine 1.3, which is up from 1.1 on the [Known lastname ] prior. Glucose is 106, hematocrit done on [3-4], showed a white count of 9.9, hematocrit of 29.2, platelet count 491,000, MCV 90, differential showed 59% neutrophils, 32% lymphocytes, 4% monocytes, 4% eosinophils. Alkaline phosphatase was 106, AST 26, ALT 41, albumin 2.2, total bilirubin 0.2. Urinalysis was done, which was negative. Total cholesterol was 155, triglycerides 157, HDL 30, LDL 92. The EKG done at [Hospital 1514] Hospital on [3-4], showed the patient to be in normal sinus rhythm at a rate of 78 beats per minute. There was a normal axis with normal intervals. There were Qs in lead 3, as well as in leads V1 and V2. There were T-wave inversion in leads V1 through V3 and biphasic T waves in AVL and V6. HOSPITAL COURSE: This is an 81-year-old female with documented severe coronary artery disease including left main disease, had been transferred to [Hospital1 190] for repeat evaluation for either a high-risk CABG versus a high-risk PCI. She had chest pain free three [Known lastname ] prior to her transfer. #1. CARDIAC: As already stated, the patient had severe coronary artery disease. She was continued on her Lopressor, although at a different dose than at the outside hospital. She as started on Lopressor 50 mg p.o.t.i.d. The Nitropatch was continued as was the ACE inhibitor, aspirin, and sublinguals as necessary. Calcium channel blocker was discontinued on admission at it was felt that the other medications could be titrated upwards for blood pressure control. The Lovenox was converted to a heparin drip until a definitive decision was made regarding the treatment plan. After arrival to the floor, the patient experienced an episode of left hand pain, which she stated was not like her previous anginal episodes. It did not respond to nitroglycerin and it was not associated with any EKG changes. It responded well to 2 mg morphine subcutaneously. On the early morning of the third hospital [Known lastname ], the patient again experienced left hand pain. Her pain was eventually relieved after receiving morphine, Darvocet and Serax. The following hospital [Known lastname ] the patient was noted to have significant left neck pain with point tenderness over the left trapezius and paraspinal muscles. It was felt that the arm discomfort may be secondary to possible neck pathology and not to her underlying severe coronary artery disease. Therefore, cervical spine x-rays were obtained. The results of these x-rays are still pending at this time. In regards to definitive treatment of the patient's severe coronary artery disease, CT surgery and the cardiology teams are still working out a decision to determine whether the patient would be best served by a PCI versus CABG. Both procedures hold a high risk in this patient. A third option is medical management of her coronary artery disease with symptomatic improvement of her left arm pain, which may in fact be neuropathic and musculoskeletal in nature. At the time of this discharge summary, the decision as to whether or not to intervene on this patient is still to be determined. Blood pressures have ranged from the 120 to 160 range while admitted here. The high blood pressures are most often noted when the patient is in pain. Heart rate has mainly been in the 50s with decreases in rate to the 40s while sleeping. The beta blocker was decreased to 50 mg b.i.d. Nitroglycerin patch was converted to p.o. nitrates and at this time she is on Isordil 10 mg p.o.t.i.d. In addition, her ACE inhibitor has been titrated up from 5 mg to 10 mg p.o.q.d. The BUN and creatinine, as well as the potassium have been watched closely with the titration of her ACE inhibitor as she was noted to have a slight bump in her creatinine with elevated potassium at the outside hospital when she was started on the ACE inhibitor. At the time of this discharge summary, she appears to be tolerating the ACE inhibitor well with the creatinine currently at 1.0 and the potassium at 5.4. She has been maintained on a low potassium diet. #2. PULMONARY: The patient has bibasilar crackles noted on admission. She had been requiring two liters of oxygen both during the [Known lastname ] and at night. Room-air saturations done on [2181-3-12] showed the patient to be saturating at 87% and 90% on room air and in the low to mid 90s on two liters. It is felt that she may have a slight element of failure. At the time of this discharge summary, we are attempting slight diuresis to improve the patient's oxygen status. She has received Lasix 40 mg p.o. times one dose. She will not be put on a standing dose of Lasix. #3. RENAL: As already stated, the patient's creatinine was somewhat elevated when she first arrived at 1.3. It has decreased to 1.0 as of [2181-3-13]. We are watching her creatinine closely and we bave titrated her ACE inhibitor as already described. The potassium has ranged from the upper 4's to 5.4 while admitted. She is being kept on a low potassium diet. #4. GI/INFECTIOUS DISEASE: The patient had a previous history of possible cholecystitis at the outside hospital. She had good response to antibiotics, and she was treated for greater than 10 [Known lastname ] while at the outside hospital. Upon arrival here, she was afebrile with a normal white count and a normal differential. Therefore, the antibiotics were not continued at this time. She was continued on the Flagyl for positive C. difficile. The Flagyl was started on [3-4] at the outside hospital. She will be continued on a total of a 14-[Known lastname ] course with Flagyl. At this time we are currently awaiting to see if a repeat C. difficile sample will test positive or if the patient has cleared the toxin. #5. ENDOCRINE: The patient has diabetes. She was having sugars in the 300 range, when she was first admitted on her dose of 5 mg of Glyburide in the morning and 5 mg in the evening. In addition, she was having extremely low a.m. sugars in the 40s and 50s. Therefore, the Glyburide dose was changed around and at this time she is currently on Glyburide 15 mg p.o.q.a.m. with improvement of her [Known lastname ] time sugars into the 200s and her a.m. sugars now in the low 100s. #6: PODIATRY: A podiatry consultation was obtained regarding the patient's chronic right foot ulceration and her inability to ambulate since her bilateral TMAs. They recommendations wound care of wet-to-dry dressings b.i.d. to the ulcers. They found no evidence of tracking to the bone in the ulcers. Regarding to the patient's inability to ambulate, they felt that the patient would require some Achilles lengthening. They felt that this procedure could be done by a local anesthesia. This can be considered when the patient is more stable from her cardiac issues. For now the patient is going to be continued on local wound care only. DISPOSITION: At the time of this discharge summary we are still awaiting definitive decision as to whether the patient will receive medical management versus PCI versus CABG for her coronary artery disease and pain syndrome. The results of this decision will be dictated in an addendum. CONDITION ON DISCHARGE: Stable. MEDICATIONS: (As of [2181-3-13]. 1. Lopressor 50 mg p.o.b.i.d. 2. Lisinopril 10 mg p.o.q.d. 3. Enteric coated aspirin 325 mg p.o.q.d. 4. Isordil 10 mg p.o.t.i.d. 5. Flagyl 500 mg p.o.t.i.d. 6. Glyburide 15 mg p.o.q.a.m. 7. Heparin drip. 8. Nitroglycerin sublingual p.r.n. 9. Tylenol 650 mg p.o.q. [5-19] h.p.r.n. 10. Serax 15 mg p.o.q.h.s.p.r.n. 11. Darvocet N 50 one to two tablets p.o.q.4h.p.r.n. DISCHARGE DIAGNOSIS: 1. Coronary artery disease. 2. Hypertension. 3. Diabetes mellitus. 4. C. difficile. 5. Chronic right foot ulcers. [Doctor First Name 475] [Initials (NamePattern4) ] [Last Name (NamePattern4) 474], M.D. [MD Number(1) 9632] Dictated By:[Last Name (NamePattern1) 38860] MEDQUIST36 D: [2181-3-13] 13:10 T: [2181-3-13] 14:07 JOB#: [Job Number 38861]	[ "41071", "41401", "4240", "25000" ]
Admission Date: [2138-7-23] Discharge Date: [2138-8-3] Date of Birth: [2107-9-13] Sex: M Service: MEDICINE Allergies: Gadavist / lisinopril Attending:[First Name3 (LF) 3913] Chief Complaint: hypotension, tachycardia Major Surgical or Invasive Procedure: Left IJ central line placement History of Present Illness: This is a 30 year-old Male with a PMH significant for non-alcoholic steatohepatitis (NASH), impaired glucose tolerance, presumed non-ischemic cardiomyopathy (LVEF 45% with mild global left ventricular hypokinesis), subclinical hypothyroidism with recently diagnosed [Location (un) 5622] chromosome negative (cytogenetics hypodiploid) pre-B cell acute lymphoblastic leukemia who is day 13 s/p hyperCVAD part B admitted for rectal pain and low grade temperatures in the setting of neutropenia. . The patient was initially started on chemotherapy in the ALL consortium trial but subsequently developed a dural venous sinus thrombosis on the right side on MRA/MRV imaging. Neuro-Oncology was consulted and recommended heparinization and he was removed from the study at that point. He was transitioned to Lovenox 80 mg SC Q12H on [2138-7-10]. On serial imaging, the sinus thrombosis in the right sigmoid and sagittal sinuses appeared stable and the patient started hyperCVAD part A on [2138-6-16]. During therapy, neutropenic fever was treated with empiric Cefepime, Vancomycin changed to Daptomycin, Micafungin and Metronidazole. Culture data and imaging at that time was reassuring, however, there was some concern for a line infection and his central catheter was removed and the tip culture was negative. He completed hyperCVAD part A on [2138-7-11] and was discharged home at that time. He was re-admitted for hyperCVAD part B on [2138-7-14] and was discharged on [2138-7-19]; his only complication that admission was an episode of atrial fibrillation with rapid ventricular reponse to the 130s, responsive to beta-blockers and without clear source. He had spontaneous conversion to sinus rhythm. He received IT cytarabine on [7-21] without issues, CSF fluid was unremarkable. . The patient was re-admitted on [2138-7-23] with febrile neutropenia and recurrent peri-rectal pain. The patient was assessed in clinic and was found to have low grade temperatures to the 99.5F range and tenderness in the peri-rectal area with radiation to the right groin in the setting of neutropenia (WBC 0.14, ANC 0 - 7% neutrophils and no bands) and he received IV Zosyn in clinic before admission. On [2138-7-24], he reported some dizziness, nausea and constipation for 24-hours. He had ongoing rectal pain with some mild streaking on the toilet paper with bowel movements and pain with defecation that resolved following these BMs. Past Medical History: 1. Non-alcoholic steatohepatitis (diagnosed in [Country 2784] in [2133]-[2134] via liver biopsy. LFTs resolved within one year of addressing metabolic concerns and with cod-liver oil supplementation) 2. Impaired glucose tolerance 3. History of chronic bronchitis (last pneumonia in [2135], resolved with antibiotics) 4. Folliculitis (recently required Doxycycline) 5. Subclinical hypothyroidism (diagnosed in the setting of depression, fatigue with elevated TSH, normal thyroxine) . Social History: The patient was born in [Country 11150] and moved to [State 622] for educational purposes at age 21 years and stayed there for 7-years. He moved to [Country 2784] for 2 years following that and has been in [Location (un) 86] for the last 10-11 months for post-doc work at the [University/College ]-Smithsonian Institute. He is a doctor of philosophy in astronomy. He denies ever smoking and consumed alcohol [1-27] times weekly (social use only). He is sexually active with women only and had recent negative STI testing. Family History: Paternal grandmother died in her mid 50s of PVD and CAD. Mother with type 2 diabetes mellitus and HTN. Mother with thyroid disorder (hypothyroidism). Physical Exam: Admission Exam: VS: 99.0, 120/80, 92, 20, 100RA GEN: AAOx3, NAD, lying in bed flat, uncomfortable appearing HEENT: PERRLA, EOMI, MMM, no thrush,or visible lesions NECK: supple, no LAD, no JVD CVS: RRR, split S2, no MRG appreciated LUNGS: CTAB ABD: soft, NT, ND, NABS ext: 2+ pulses, no c/c/e External Rectal exam- patient has no visible external lesions or ulcerations in his perirectal area. No rectal exam was performed as he is neutorpenic Skin: no rashes Back- no visible lesions or rashes. No tenderness to palpation of the posterior vertebral column neuro: CN 2-12 intact, strength 5/5 in UE and LE bilat. Discharge Exam: VSS, afebrile Gen: A+Ox3 HEENT: PEERLA, EOMI, MMM, no thrush or visible lesions CV: RRR, no MRG Lungs: CTAB Abd: Soft, nt nd Extremities: 2+DP puses bilateraly, warm and well perfused, no edema Skin: dry, no visible rashes Pertinent Results: ADMISSION LABS [2138-7-23] 03:35PM PLT COUNT-85# [2138-7-23] 10:45AM UREA N-9 CREAT-0.8 SODIUM-142 POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13 [2138-7-23] 10:45AM estGFR-Using this [2138-7-23] 10:45AM ALT(SGPT)-151 AST(SGOT)-37 LD(LDH)-180 ALK PHOS-72 TOT BILI-1.1 [2138-7-23] 10:45AM WBC-0.14# RBC-2.97 HGB-8.9* HCT-26.8* MCV-90 MCH-29.9 MCHC-33.1 RDW-16.4* [2138-7-23] 10:45AM NEUTS-7* BANDS-0 LYMPHS-86* MONOS-0 EOS-7* BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [2138-7-23] 10:45AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [2138-7-23] 10:45AM PLT SMR-VERY LOW PLT COUNT-47# MICU Course labs Hct [7-25]: 19.4, (2 units PRBC transfusion given), [7-26]: 25.1, [7-27]: 23.2 Plt [7-25]: 23, (2 units FFP given) [7-26]: 35, 7/1:49\ WBC [7-25]: 0.1, [7-27]: 2.2 (42% neutrophils) Creatinine [7-25]: 3.7 --> [7-26]: 3.2 --> [7-27]: 1.8 Micro: [2138-7-24]: B GLucan <31- NEGATIVE [2138-7-24]: Aspergillus Galactomannan Antigen 0.1- NEGATIVE Blood culture [7-23], [7-25], [7-26]- NEGATIVE Urine culture [7-24]- NEGATIVE Discharge Labs: [2138-8-3] 12:00AM BLOOD WBC-2.9 RBC-2.83* Hgb-8.8* Hct-24.4* MCV-86 MCH-31.1 MCHC-36.0* RDW-15.1 Plt Ct-477* [2138-8-3] 12:00AM BLOOD Neuts-83.2* Lymphs-11.7* Monos-4.8 Eos-0.2 Baso-0 [2138-8-3] 12:00AM BLOOD PT-10.6 PTT-31.1 INR(PT)-1.0 [2138-8-3] 12:00AM BLOOD Glucose-97 UreaN-20 Creat-0.8 Na-141 K-4.2 Cl-108 HCO3-25 AnGap-12 [2138-8-3] 12:00AM BLOOD ALT-73* AST-33 AlkPhos-65 TotBili-0.5 [2138-8-3] 12:00AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.2 Imaging: CXR [2138-7-23]: Cardiomediastinal contours are normal. The lungs are clear. There is no evidence of pneumonia or pleural effusion. Brief Hospital Course: Mr. [Known lastname 112418] is a 30yo M w/ PMH of Ph- pre B Cell ALL, nonischemic cardiomyopathy, who presented with febrile neutropenia leading to severe sepsis and acute renal failure requiring ICU stay which resolved upon blood counts improving and underwent his next round of HyperCVAD part A with IT treatments without complication. #ALL- patient has recent diagnosis of ALL and has undergone multiple cycles of treatment with hypercvad. He was at his nadir at the time of admission despite being on neupogen and was febrile without source. After his counts returned, he underwent his next round of HyperCVAD part A with IT treatment without complications. -He will follow-up with Dr. [Last Name (STitle) ] and requires Vincritstine treamtent on day 11 -Pt to restart neupogen on discharge #Neutropenic fever: Patient was admitted with febrile neutropenia and rectal symptoms. He was started on broad spectrum antibiotics however he continued to be febrile and rigor. He developed hypotension in the setting of this despite being on maintenance IV fluids and went into renal failure with oliguira and was transferred to the ICU where he was given large boluses of fluids and did not require pressors with return of his kidney function. A fter his counts improved he was no longer febrile. He completed a 7 day course of Meropenem and was switched to ciprofloxacin for prophylaxis at the time of discharge given his severe infection during his last neutropenic period. -Ciprofloxacin was started #Acute renal failure- patient went into acute renal failure at the beginning of his hosptialization and his Cr bumped to 3.7. Renal was consulted and felt that it was due to hypoperfusion from hypotension. This resolved with fluids and his Cr returned to baseline after a couple of days. #Dural sinus thrombosis- patient has known dural sinus thrombosis. He was on lovenox at home and was being transufsed with platelts while his counts were low in order to continue anticoagulation. He complained of postLP like headache on admission and repeat MRI of his head showed improved recanulization of the thrombus. He was continued on his lovenox during his stay and his headahce improved. -continuing lovenox Pending labs/studies: None Medications started: -ciprofloxacin- antibiotic to try to prevent infections -atovaquone- antibiotic to prevent lung infection -senna- as needed for constipation Medications changed: None Medications stopped: None Follow-up needed for: 1. Follow-up with Dr. [Last Name (STitle) ] as per below 2. You will need to follow-up with ophthalmology as an outpatient to discuss your blind spots Medications on Admission: 1. Enoxaparin Sodium 90 mg SC Q12H 2. Acyclovir 400 mg PO Q8H 3. Carvedilol 3.125 mg PO BID 4. Calcium carbonate 500 mg calcium (1,250 mg) PO daily 5. Multivitamins 1 tab PO daily 6. Pantoprazole 40 mg PO Q24H 7. Simethicone 80 mg PO QID PRN gas/bloating 8. Docusate sodium 100 mg PO BID 9. Polyethylene Glycol 17 g PO daily PRN constipation 10. Zolpidem Tartrate 5 mg PO HS PRN insomnia 11. Filgrastim 300 mcg SC Q24H 12. Oxycodone 5 mg PO Q4H PRN pain 13. Ondansetron 4 mg ([1-27] pills) PO every 6-8 hours as needed for nausea Discharge Medications: 1. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours). Disp:10 syringes Refills:0 2. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 3. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas/bloating. 8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. 11. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 12. filgrastim 300 mcg/0.5 mL Syringe Sig: One (1) injection Injection once a day. 13. ondansetron 4 mg Tablet, Rapid Dissolve Sig: [1-27] Tablet, Rapid Dissolves PO every 6-8 hours as needed for nausea. 14. atovaquone 750 mg/5 mL Suspension Sig: Two (2) doses PO once a day. Disp:60 doses Refills:0 15. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:60 Tablet(s) Refills:0 16. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:60 Tablet(s) Refills:0 17. fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Acute lymphocytic Leukemia Dural sinus thrombosis Severe sepsis Acute Kidney Injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 112418] [Last Name (Titles) ] were admitted to the hosptial because you had fevers while your blood counts were very low (neutropenic fever). You were treated with IV antibiotics and for a time the infection had caused your blood pressure to be low which temporarily injured your kidneys so you were transferred to the ICU, and this has all since resolved after your counts returned to [Location 213]. It is still not known what the source of your infection was. Because you were so sick with your infection you will need to be on prophylactic (preventative) antibiotics after you leave (see below). After your counts improved and you were looking well it was decided to start another round of your chemotherapy which you underwent and tolerated without problem. [Name (NI) ] complained of some worsening of the blind spots in your eyes. Unfortunately we were not able to get ophthalmology to see you while you were here and you should make a follow-up appointment with them as an outpatient. For your internal hemmoroid it will be important to make sure you do not get constipated. We have added an additional stool softener to your list of as needed medications. Transtional Issues: Pending labs/studies: None Medications started: -ciprofloxacin- antibiotic to try to prevent infections -atovaquone- antibiotic to prevent lung infection -senna- as needed for constipation Medications changed: None Medications stopped: None Follow-up needed for: 1. Follow-up with Dr. [Last Name (STitle) ] as per below 2. You will need to follow-up with ophthalmology as an outpatient to discuss your blind spots #If you develop a fever you need to call the office## Followup Instructions: Department: HEMATOLOGY/BMT When: [Last Name (STitle) ] [2138-8-4] at 1 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 7779], MD [Telephone/Fax (1) 3237] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/BMT When: [Hospital Ward Name ] [2138-8-4] at 1 PM With: [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 9574], NP [Telephone/Fax (1) 3237] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: HEMATOLOGY/BMT When: FRIDAY [2138-8-8] at 1 PM With: [First Name11 (Name Pattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern1) ], RN [Telephone/Fax (1) 3241] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "0389", "99592", "5845", "2762", "2449" ]
Admission Date: [2133-7-6] Discharge Date: [2133-7-28] Date of Birth: [2075-1-11] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 598] Chief Complaint: Lyphoma care, transfer from [Hospital ] Hospital then pneumoperitoneum due to gastric perforations Major Surgical or Invasive Procedure: Brain biopsy Exploratory Laparotomy for gastric perforation History of Present Illness: Mr [Known lastname 34578] is a 58yoM with a history of B-cell non-Hodgkin's Lymphoma who presented to [Hospital3 934] Hospital on [2133-6-26] with fever and hypotension. He recently had developed bad mucositis [1-14] round 3 of CHOP, and had some difficulty swallowing. He was found to have a LUL cavitating lesion, was started on Zosyn and voriconazole and admitted to the ICU. He was not intubated. A BAL was done and showed mold, with suspicion of Aspergillus (outside record does not state why aspergillus suspected). He improved on zosyn/voriconazole, and repeat CXR on [7-2] showed improvement in LUL infiltrate, but large right sided pleural effusion. Thoracentesis was performed and 1.5L fluid was drained. Pt's course was also complicated by hypernatremia up to Na+ 160, resistant to treatment. MRI of the brain was ordered, and showed among other findings increased uptake in the pituitary stalk, concerning for pituitary involvement with diabetes insipidus. MRI also significant for multiple lesions in leptomeningeal and posterior parietal compartments, involvement of cerebellum. Given possible infectious process, it was decided that an LP should be done, but because of risk of herniation pt was transferred to [Hospital1 18]. The patient states that he is overall doing well. He does have a cough that is sometimes productive and feels SOB. He denies recent fevers, chills, or night sweats. Denies specific pain. No N/V. Has diarrhea but states that this is a chronic problem, no [Name2 (NI) ] or mucous. He does not feel confused. Since he has been in [Hospital1 18], he has received Methotrexate x 2 days and last [Hospital1 ] level today was 0.13 and high dose dexamethasone that has been tapered to 8mg Qday. He was also diagnosed with b/l DVT and an IVC filter was placed. During a routine CXR on [2133-7-19] he was found to have a fair amount of pneumoperitoneum bellow the diaphragm, this study was repeated on [7-21] and the findings were unchanged. Of note this was his first x-ray since his CT scan on [7-8] which was negative for pneumoperitoneum. Today he denied abdominal pain,nausea, emesis SOB, CP, night sweats chills or hematochezia. His last BM was this am. However he complains of fatigue and weakness. He had an ECHO in [2133-5-26] per report gross nl with mild left ventricular hypertrophy and estimated EF of 60%. Past Medical History: - Non-hodgkin's lymphoma, on CHOP, followed by Dr [First Name (STitle) ] with 3/8 cycles completed - Diabetes insipidus - Hypernatremia [1-14] diabetes insipidus - Hypothyroidism - Anemia of chronic disease - Aspergillus pneumonia - Adrenal insufficiency - Hypokalemia - Pleural effusion - Hypertension - Thrush - Hyperlipidemia - Coronary artery disease Social History: Married. Lives w wife. [Name (NI) 1139]: [2-13] cigars/day x 30 years, quit [4-22]. EtOH: rare. Previously employed by USPS. Family History: Grandparents w DM2, no fam hx thyroid or endocrine problems Physical Exam: Admission: GENERAL: NAD HEENT: AT/NC, PERRL, membranes slightly dry, oral thrush NECK: Supple, no lymphadenopathy CARDIAC: Regular rate and rhythm, 2/6 systolic murmur on left sternal border RESPIRATORY: crackles in bilateral lung bases, no wheezes ABDOMEN: Normoactive bowel sounds, soft, non tender, non distended and without hepatosplenomegaly. SKIN: Warm, dry, and intact without rash, petechiae or bruise. EXTREMITIES: No edema, cyanosis, or clubbing Neuro: A+Ox3, no focal deficits although some problems with cerebellar testing. Trouble with finger to nose test at end of pointing. Pertinent Results: Admission labs: [2133-7-6] 05:45PM FIBRINOGE-809* [2133-7-6] 05:45PM PT-12.6 PTT-22.6 INR(PT)-1.1 [2133-7-6] 05:45PM PLT SMR-NORMAL PLT COUNT-203 [2133-7-6] 05:45PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-OCCASIONAL MACROCYT-3+ MICROCYT-1+ POLYCHROM-1+ OVALOCYT-1+ TEARDROP-OCCASIONAL [2133-7-6] 05:45PM NEUTS-87* BANDS-1 LYMPHS-3* MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-1* NUC RBCS-1* [2133-7-6] 05:45PM WBC-12.6* RBC-3.05# HGB-9.5# HCT-29.9# MCV-98 MCH-31.2 MCHC-31.8 RDW-24.4 [2133-7-6] 05:45PM ALBUMIN-3.0* CALCIUM-8.8 PHOSPHATE-3.7 MAGNESIUM-1.9 [2133-7-6] 05:45PM ALT(SGPT)-127* AST(SGOT)-99* LD(LDH)-461* ALK PHOS-178* TOT BILI-0.2 [2133-7-6] 05:45PM estGFR-Using this [2133-7-6] 05:45PM GLUCOSE-88 UREA N-16 CREAT-1.1 SODIUM-145 POTASSIUM-4.6 CHLORIDE-115* TOTAL CO2-21* ANION GAP-14 [2133-7-7] 12:00AM FIBRINOGE-701* [2133-7-7] 12:00AM PT-12.5 PTT-22.8 INR(PT)-1.0 [2133-7-7] 12:00AM PLT COUNT-200 [2133-7-7] 12:00AM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-1+ MACROCYT-2+ MICROCYT-OCCASIONAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL STIPPLED-1+ MACROOVAL-OCCASIONAL [2133-7-7] 12:00AM NEUTS-78* BANDS-3 LYMPHS-10* MONOS-7 EOS-1 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 NUC RBCS-3* [2133-7-7] 12:00AM WBC-12.2* RBC-2.88* HGB-9.2* HCT-27.9* MCV-97 MCH-32.1* MCHC-33.1 RDW-24.0* [2133-7-7] 12:00AM b2micro-3.6* [2133-7-7] 12:00AM ALBUMIN-2.9* CALCIUM-8.7 PHOSPHATE-3.8 MAGNESIUM-2.0 URIC ACID-2.1* [2133-7-7] 12:00AM ALT(SGPT)-124* AST(SGOT)-86* LD(LDH)-449* ALK PHOS-178* TOT BILI-0.2 [2133-7-7] 12:00AM GLUCOSE-64* UREA N-18 CREAT-0.9 SODIUM-143 POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-23 ANION GAP-14 [2133-7-7] 12:00AM GLUCOSE-64* UREA N-18 CREAT-0.9 SODIUM-143 POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-23 ANION GAP-14 MRI [2133-7-6]: There is a 1.5 x 1.4 cm area of abnormal signal intensity, appears hypointense on T1 and hyperintense on T2 and FLAIR sequences, appears bright on diffusion-weighted sequence with corresponding low ADC values. Diffuse homogeneous enhancement is seen within the lesion on the postcontrast scans. There are multiple nodular and linear areas of leptomeningeal enhancement in bilateral cerebellar hemispheres, right parietal cortex, and the optic chiasm. There is no hydrocephalus or midline shift. The ventricles and sulci are normal in caliber and configuration. No acute intracranial hemorrhage or infarction is seen. Intracranial flow voids appear normal. IMPRESSION: Nodular areas of enhancement seen in the right periventricular white matter and involving the optic chiasm. Multiple other linear and nodular areas of leptomeningeal enhancement are seen in bilateral cerebellar hemispheres and in the right parietal lobe. Given the clinical history of non-Hodgkin's lymphoma, imaging findings suggest lymphomatous involvement of the CNS. CT abdomen [7-7]: FINDINGS: A Port-A-Cath terminates in the superior vena cava. Coronary artery calcifications are present. A stent is present in the left anterior descending coronary artery. The heart is at the upper limits of normal size. There is no pericardial effusion. An enlarged subcarinal lymph node measures up to 22 x 16 mm in axial dimensions (3:27). A left upper mediastinal lymph node measures 11 mm in diameter. A right upper paratracheal lymph node measures 25 x 18 mm (3:14); an adjacent one measures 8 mm. Small-to-moderate pleural effusion is present on the right, free flowing and of low density. A trace effusion is present on the left. In the left upper lobe, there is a large cavitating mass with a thick irregular enhancing rim. The lesion measures 73 x 52 mm in axial dimensions and is contiguous with bronchovascular thickening that tracks towards the hilum. The patient has mild-to-moderate emphysema as well. An ill-defined nodule along the left major fissure has a base measuring up to 13 mm with a height of 5 mm (3:31). Mild interstitial changes are noted in the periphery of the left lower lobe. In the right lung, there are a number of ill-defined irregular pulmonary nodules, the majority of which are pleural-based. These show avid enhancement as well in most cases. A representative nodule along the right lower lobe medial pleural surface measures 14 x 10 mm in diameter. These nodules are non-specific. There is also a more patchy ill-defined consolidative and ground-glass opacity in the right lower lung suggesting atelectasis or perhaps infectious or inflammatory pneumonitis. This is also a focal band-like opacity in the left lower lobe suggestive of atelectasis. CT OF THE ABDOMEN: Within the liver, there are several well-defined hypodense lesions. All of these are in the left lobe (3:43 and 45). The largest measures 13 mm in diameter and is low in density, suggestive of a simple cyst. These are too small to entirely characterize, however, but are probably benign. The gallbladder, pancreas, spleen and right adrenal appear within normal limits. There is a widespread infiltrative abnormality throughout the central retroperitoneum that fully encases the aorta and inferior vena cava, although these are patent. It encases bilateral duplicated main renal arteries as well as the left renal vein and small lumbar vessels. It tracks superiorly and closely approaches the splenic vein and infiltrates the retroperitoneal fat, which shows increased attenuation that obscures the left adrenal gland. An extensive, more dense central mesenteric mass measuring approximately 82 x 46 mm in axial dimensions (3:71) encases but does not splay or narrow multiple mesenteric arteries and veins passing through it. There is an aneurysm of the lower abdominal aorta, with rim calcification and thrombus measuring up to 32 x 28 mm in axial dimensions. There is also a fusiform aneurysm of the right common iliac artery with peripheral calcification and thrombus of 29 mm in diameter. These are fully encased by mostly hypoenhancing infiltrative soft tissue, although immediately anterior to the lower aorta, a rim of enhancing tissue that measures 24 x 7 mm in axial dimensions (3:79) is also noted and may represent an area of persistent lymphoma. Scattered diverticula are present throughout the colon. The bladder is substantially distended. Each kidney demonstrates moderate hydronephrosis with surrounding fat stranding and ureters pass through the region of high attenuation. Although it is possible that hydronephrosis is secondary to bladder distention, the possibility that the ureters are blocked by retroperitoneal fibrosis associated with malignancy should be considered. The upper left ureter, upstream of the area of more dense area of retroperitoneal infiltarion, shows enhancement that may be inflammatory or potentially due to malignant infiltration. CT OF THE PELVIS: There is an expansile nearly occlusive thrombus in the left common femoral vein. The external and common iliac veins do not appear involved with thrombus but are probably narrowed somewhat by the presence of the retroperitoneal mass. A deep inguinal lymph node on the left measures 24 x 13 mm in axial dimensions (3:108). A left external iliac node measures 14 x 22 (3:100). A deeper pelvic sidewall lymph node of 15 x 25 mm (3:97) is also noted, worrisome for active lymphoma. The prostate is small with calcifications. The seminal vesicles are unremarkable. Vascular calcifications are widespread. There is no ascites. BONE WINDOWS: There are no suspicious lytic or blastic lesions. Mild degenerative changes are present along the lower lumbar spine. A small sclerotic focus along the right iliac crest is nonspecific but most likely due to a small bone island. Lower thoracic interspaces are mildly narrowed and irregular with small anterior osteophytes. [2133-7-19] CXR New pneumoperitoneum highlights the presence of ascites. The large left upper lobe abscess has not grown, but continues to cavitate and there may be a new small nodule in the right mid lung just above the elevated right hemidiaphragm. Moderate right pleural effusion largely posterior has increased. There is no pulmonary edema or other widespread pulmonary abnormality. Heart size is normal and there is no evidence of mediastinal venous engorgement. A right subclavian infusion port ends in the mid SVC. Findings were discussed by telephone with Dr. [First Name (STitle) ] at the time of this dictation. Brief Hospital Course: Mr [Known lastname 34578] is a 58yoM with a history of B-cell non-Hodgkin's Lymphoma who presented to an OSH with fever and hypotension, found to have CNS lesions and a cavitating lung infiltrate, transferred to [Hospital1 18] for further care. Since he has been in [Hospital1 18], he has received Methotrexate x 2 days and last [Hospital1 ] level today was 0.13 and high dose dexamethasone that has been tapered to 8mg Qday. He was also diagnosed with b/l DVT and an IVC filter was placed. During a routine CXR on [2133-7-19] he was found to have a fair amount of pneumoperitoneum below the diaphragm, this study was repeated on [7-21] and the findings were unchanged. Of note this was his first x-ray since his CT scan on [7-8] which was negative for pneumoperitoneum. A surgical consult was called and given the new finding of pneumoperitoneum, he was taken urgently to the operating room for exploration of a potential GI tract perforation. Several holes were found in the stomach in the operating room, and these were repaired. Please refer to Dr.[Name (NI) 34579] operative dictation for additional details. He had a feeding j-tube placed at this time as well. Post-operatively, he was admitted to the Trauma ICU for further care. On POD 1, he remained stable after his procedure, continuing to make slow improvements. His NGT remained to low continuous wall suction. He was restarted on his heparin drip, leucovorin and Vitamin A were added to his regimen per his oncology team. He was dosed with stress dose steroids for the OR and this was weaned per protocol. On POD 2, he was transfused one unit of PRBCs for a downward trending Hct to 24. This was done in the setting of a device malfunction causing him to receive 22,000 units of Heparin in a bolus dose instead of the usual basal rate. After identification of the problem, he was reversed with Protamine 50 mg and a head CT was performed to ensure no evidence of intracranial bleed -- it was negative. Tube feeds through the J-tube were started at 10 cc/hr. On POD 3, Mr. [Known lastname 34578] was on goal tube feeds, he was started on oxycodone and tylenol and his hydrocortisone taper was continued. He was hemodynamically stable and recovering well; he was transferred out to the floor. On POD 4, his steroid taper was discontinued. Due to peristent low NGT output and patient preference, his NGT was removed. He remained afebrile with stable vital signs. On POD 5, Mr. [Known lastname 34578] developed relatively sudden onset tachycardia to the 120s and hypotension to a systolic of 70s. He was fluid resuscitated with several IVF boluses and his pressures were stabilized. A CXR done at the time showed significant amount of free air -- over the amount one would normally expect as residual from the laparotomy four days ago. He was transferred back to the ICU for further care and started on pressors to maintain his [Known lastname ] pressure. A meeting was held with Dr. [Last Name (STitle) ], the critical care team and the family. The family expressed preferences to make the patient DNR/DNI but not to withdraw care -- but also not to escalate. He was maintained on pressors until he could be appropriately weaned with the decision to refrain from turning pressors back on should the need arise. It was also decided to refrain from further lab draws. On POD 6, his pressor wean was continued and he was started on a morphine drip for comfort. He remained tenous but overall hemodynamically stable. Mental status waxed and waned through the day with several periods of lucency. On POD 7, another family meeting was held. His DNR/DNI status was continued. The family expressed preference for home hospice and decisions were made to make arrangements for discharge on POD 8 ([7-28]) for hospice care. Unfortunately, on POD 8, [2133-7-28] Mr. [Known lastname 34580] vitals began trending down and it was agreed that he may not survive an hour long trip to home hospice. At 10:50 pm [2133-7-28] Mr. [Known lastname 34578] passed away in his room with his family by his side. Death was confirmed by 2 minutes of no spontaneous respiration or pulse. Pupils were not reactive. The family did not want an autopsy. Death certificate was signed. Medications on Admission: Medications (confirmed per d/c summary from OSH and pt): - Tylenol 650mg PO q4 PRN pain - Heparin SQ 5000 units tid - Voriconazole 300mg PO q12 - Lorezepam 0.5mg PO q4 PRN anxiety - Prednisone 10mg PO qdaily - Procrit 40,000 units on Thursday - Allopurinol 300mg PO daily - Zosyn 3.375g IV q6h - Nystatin swish and swallow - Omeprazole 40mg PO daily - Potassium Chloride 40mEq PO daily - HCTZ 12.5mg PO daily - Levoxyl 50mcg PO daily - Viscous lidocaine 2% solution PRN mouth pain Home meds discontinued at outside hospital (confirmed with patient): - metoprolol XR 25mg PO BID - lipitor 40mg PO daily - multivitamin 1 tab PO daily Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Aspergillus pneumonia Diabetes insipidus Hydronephrosis [1-14] ureter compression from lymphoma Lymphoma with brain involvement (#### type of lyphoma pending) Left common femoral deep vein thrombosis, s/p IVF filter placement Gastric Perforation Discharge Condition: pt expired Discharge Instructions: Pt expired Followup Instructions: Pt expired [First Name8 (NamePattern2) ] [Name8 (MD) ] MD [MD Number(2) 601] Completed by:[2133-7-29]	[ "2724", "41401", "V4582", "412", "3051", "5119", "5180", "2449", "4019" ]
Admission Date: [2173-4-28] Discharge Date: [2173-5-6] Date of Birth: [2131-8-9] Sex: F Service: MED HISTORY OF PRESENT ILLNESS: A 41-year-old obese woman with asthma who had never previously been intubated prior to admission but with poor compliance with medications and poor follow-up, who called 911 with progressive shortness of breath at home in the setting of upper respiratory infection x 2-3 days. En route to the Emergency Room, the patient received 2 nebulizers of albuterol. In the Emergency Room, the patient was noted to be afebrile, heart rate was 106, systolic blood pressure 172, saturating 98 percent on room air. The patient was given Solu-Medrol 125 mg IV as well as Atrovent and albuterol nebulizers in the Emergency Room, as well as Combivent. Her saturations initially improved to 100 percent on room air. The patient's respiratory status progressively got worse with desaturations of 84 percent on room air, also with increasing agitation, increasing respiratory rate, and attempted to stand and was agitated. The patient was, therefore, emergently intubated in the Emergency Room for inability to ventilate effectively and hypoxia. The patient had oxygen saturations in the 40 percent range for about 1 minute due to prolonged intubation. The patient was then brought to the Medical Intensive Care Unit for further management. In the Medical Intensive Care Unit, the patient was continued on ventilator and intubated until [5-1] when she was extubated successfully. The patient was then transferred to the Medicine Floor on [5-2] in stable condition. PAST MEDICAL HISTORY: Asthma diagnosed at age 1 with multiple prior admissions. Followed by Dr. [Last Name (STitle) ] of Pulmonology. In [3-27], FEV1 was 88 percent predicted. Heart murmur. Migraines. History of rheumatic fever with mild tricuspid regurgitation. Menorrhagia. Breast reduction surgery [80] years ago. Ethmoid sinus abscess. Gingivitis. Tooth infection. ALLERGIES: No known drug allergies. MEDICATIONS AT HOME: Note the patient reports poor compliance. 1. Albuterol nebulizer as needed. 2. Flovent 220 mcg 2 puffs 2 times a day. 3. Lamisil 250 mg every day. 4. Serevent 50 mcg 2 times a day. 5. Theophylline 300 mg 2 times a day. SOCIAL HISTORY: Works in retail store. Lives in [Location 686]. Denies alcohol, drug or tobacco use. PHYSICAL EXAMINATION: Upon admission to the Medical Intensive Care Unit: General, intubated, sedated, and diaphoretic. Vital signs, temperature 98.2 degrees, axillary, blood pressure 164/85, heart rate 126, and 100 percent saturation on the ventilator. HEENT, pupils were equally round and reactive to light, anicteric. Endotracheal tube in place. Neck, no jugular venous distention or lymphadenopathy, supple. Heart, tachycardic with no murmurs appreciated. Lungs, diffuse wheezing, poor air movement, and no dullness to percussion. Abdomen, obese, normal active bowel sounds, soft, nontender, and nondistended. No hepatosplenomegaly appreciated. Extremities with trace edema bilaterally. No clubbing or cyanosis. Neurological, sedated, spontaneously moving all extremities. DIAGNOSTICS ON ADMISSION: BUN and creatinine 14/1.0. ABG, pH 7.23, pCO2 68, pO2 131 on a nebulizer before intubation and then at intubation 7.02/115/426. White blood count 10.5, hematocrit 39, and platelets 321. RADIOGRAPHIC STUDIES: Chest x-ray with no pneumothorax. HOSPITAL COURSE: The patient was managed in the Intensive Care Unit upon admission until [5-2]. The patient was extubated on [5-1]. Pulmonary. Respiratory failure/asthma. The patient with an acute severe asthma attack requiring intubation in the Emergency Room. The patient was eventually weaned from the ventilator effectively and extubated on [5-1]. The patient was maintained on Solu-Medrol in the Emergency Room as well as in the Medical Intensive Care Unit as well as nebulizers around the clock. Upon arrival to the Medicine Floor, the patient had been started on prednisone taper, which was continued throughout her stay as well as at the time of discharge. The patient was also maintained on albuterol and Combivent, which were switched over from nebulizers to metered-dose inhalers. The patient's respiratory status remained very stable and on the Medicine Floor, she saturated in the high 90s to 100 percent on room air. This included excellent oxygen saturations with ambulation. Acid base. The patient was in severe respiratory acidosis upon admission to the Medical Intensive Care Unit. This improved markedly with ventilator management, and her arterial blood gas measurements came to within normal limits. Mental status upon extubation as well as 1 day on the Medicine Floor, the patient seemed quite slow to answer questions. This was thought to be related to the patient's sedation while on the ventilator. However, there was a question of anoxic brain injury. The patient's mental status continued to improve on the Medicine Floor. The patient's primary care physician [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 3403] [Last Name (NamePattern1) 1968] came to see the patient and reported that the patient's mental status was at her baseline. This includes somewhat odd affect. The patient remained neurologically intact without signs and symptoms of any CNS process. Thyroid stimulating hormone, RPR, and vitamin B12 were checked as reversible causes of dementia, and these were all within normal limits. The patient's mental status continued to improve throughout her hospital stay and was at baseline at the time of discharge. However, with concern over possible anoxic brain injury, an MRI/MRA was ordered for the patient as an outpatient and scheduled for [5-11]. Ophthalmology. The patient complained of blurry vision in the left eye, also with bilateral conjunctival injections/hemorrhages. Ophthalmology was consulted and found the patient's ophthalmological exam to be within normal limits with no evidence of acute process. They believe that the conjunctival injections were related to traumatic intubation and Intensive Care Unit course. Anemia, microcytic. The patient's iron studies were close to within normal limits, plan outpatient follow-up, the patient's hematocrit remained stable. Prophylaxis. The patient maintained on a proton pump inhibitor in Intensive Care Unit and then switched to an H2 blocker for GI prophylaxis on the Medicine Floor. The patient maintained on subcutaneous heparin for DVT prophylaxis as well as the bowel regimen. The patient is full code. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Home health services. DISCHARGE DIAGNOSES: Status asthmaticus. Asthma. Anemia. DISCHARGE MEDICATIONS: 1. Combivent 4 puffs 4 times a day. 2. Ranitidine 150 mg 2 times a day. 3. Metoclopramide 10 mg with meals and at night. 4. Fluticasone 4 puffs 2 times a day. 5. Salmeterol 14 mcg 2 times a day. 6. Albuterol metered dose inhaler every 4 hours as needed. 7. Prednisone taper for over 8 additional days. 8. Loratadine 10 mg every day as needed. FOLLOW-UP: The patient with outpatient MRI/MRA scheduled for [5-11]. The patient with outpatient follow-up scheduled with Dr. [Last Name (STitle) 976], who was taking over for her primary care physician [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) 3403] [Last Name (NamePattern1) 1968]. [First Name11 (Name Pattern1) 122] [Last Name (NamePattern1) 11159], [MD Number(1) 11160] Dictated By:[Last Name (NamePattern1) 4959] MEDQUIST36 D: [2173-6-1] 17:33:19 T: [2173-6-3] 00:12:07 Job#: [Job Number 94556]	[ "51881", "2762", "2859" ]
Admission Date: [2155-12-7] Discharge Date: [2155-12-10] Service: Medicine CHIEF COMPLAINT: Gastrointestinal bleed and melena. HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old Russian-speaking gentleman with terminal metastatic prostate cancer, atrial fibrillation (on Coumadin), and inferior vena cava syndrome who presented with one day of melanotic stool at [Hospital ] Rehabilitation facility and a blood pressure of 68/40. According to the patient's daughter, he has been in his usual state of health over the past several days without any nausea, vomiting, hematemesis, abdominal pain, or bright red blood per rectum. The patient has had approximately two weeks of constipation and has had weight loss over the past several months. He denies chest pain, shortness of breath, and lightheadedness. He denies a history of gastrointestinal bleed. He does not drink alcohol. He does not take aspirin or nonsteroidal antiinflammatory drugs. The patient and the patient's daughter did not know his Coumadin dose and did not know if there had been any recent changes. In the Emergency Department, the patient's INR was found to be 14. His hematocrit was 20. A nasogastric lavage was negative for blood or coffee-grounds material. PAST MEDICAL HISTORY: 1. Terminal metastatic prostate cancer with metastases to the liver and bone and extensive pelvic and inguinal lymphadenopathy. Status post chemotherapy in [2155-7-8]. 2. Atrial fibrillation (on Coumadin). 3. Inferior vena cava syndrome. 4. History of congestive heart failure. MEDICATIONS ON ADMISSION: 1. Coumadin. 2. Iron. 3. Prednisone 20 mg once per day 4. Fentanyl 150-mcg patch q.72h. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient was transferred from [Hospital ] Rehabilitation. No alcohol. No tobacco. He is a retired chemist. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed the patient's temperature was 95.3 degrees Fahrenheit, his blood pressure was 113/59, his heart rate was 85, his respiratory rate was 17, and his oxygen saturation was 98% on room air. In general, the patient was a pale Russian-speaking gentleman. Alert and oriented times three. In no acute distress. Smelled melanotic. Head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light. The sclerae were anicteric. The oropharynx was clear. The mucous membranes were slightly dry. The neck was supple. Cardiovascular examination revealed a regular rate and rhythm. The lungs were clear to auscultation bilaterally but decreased inspiratory effort. The abdomen revealed bilateral small masses in the lower quadrants. No tenderness on palpation. No distention. Rectal examination revealed guaiac-positive black stool. Skin examination revealed a maculopapular erythematous rash in the inguinal and pelvic regions. Extremity examination revealed 2 to 3+ bilateral lower extremity pitting edema. Neurologic examination revealed the patient was alert and oriented. Able to move all four extremities; however, weak throughout slightly greater in the lower extremities. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory data revealed the patient's white blood cell count was 7.2, his hematocrit was 20, and his platelets were 245. INR was 13.9. Sodium was 137, potassium was 4.9, blood urea nitrogen was 51, and his creatinine was 1.4. Urinalysis was cloudy with moderate leukocyte esterase, large blood, positive nitrites, and greater than 50 white blood cells. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed a normal sinus rhythm at a rate of 85, with left axis deviation, and nonspecific lateral T wave changes. A chest x-ray showed low lung volumes. No definite congestive heart failure. Small bilateral pleural effusions with atelectasis at the lung bases. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. UPPER GASTROINTESTINAL BLEED ISSUES: In the Emergency Department, the patient received 3 units of packed red blood cells and 4 units of fresh frozen plasma. With the rapid volume resuscitation, the patient's blood pressure improved to 110/60. He was also given 10 units of vitamin K subcutaneously, and his Coumadin was discontinued. The patient's bleeding quickly receded, and his hematocrit remained stable after correction of his INR. The patient was transferred to the Medical Intensive Care Unit for volume resuscitation and management of his upper gastrointestinal bleed. The patient was seen by the Gastroenterology Service and underwent an urgent upper endoscopy which revealed esophagitis and diffuse ulcerative gastritis which was felt to be the likely cause of the patient's gastrointestinal bleed in the setting of a supratherapeutic INR. The patient was placed on a twice per day proton pump inhibitor and was started on sucralfate for treatment of his gastric ulcerations. The patient was transferred out of the Medical Intensive Care Unit on [12-8] after his hematocrit had been stable for over 24 hours. On transfer to the floor, the patient's hematocrit was monitored twice per day and continued to remain stable. The patient was to be discharged on twice per day proton pump inhibitor. In addition, his prednisone will be decreased to 15 mg to see if he tolerates it froma pain standpoint/symptomatic relief for his prostate ca. If he does tolerate it then we can cont to taper very slowly over several weeks as this may contribute to an increased risk of gastrointestinal bleeding. If he does have increased symptoms it shoudl be continued. The patient's Coumadin should not be restarted as he has had a very high risk of recurrent bleeding. 2. HYPOTENSION ISSUES: The patient was initially extremely hypotensive with a blood pressure of 68/40. The patient received rapid volume resuscitation. His blood pressure responded well throughout his hospital stay. He had low normal systolic and diastolic blood pressures without any symptoms. On the day of discharge, his blood pressure was in the 90s systolic/40s diastolic. 3. ATRIAL FIBRILLATION ISSUES: The patient was admitted on Coumadin. His Coumadin was discontinued due to his gastrointestinal bleed and increased risk for recurrent bleeding. His Coumadin should not be restarted as an outpatient. 4. URINARY TRACT INFECTION ISSUES: The patient has terminal metastatic prostate cancer. He was most recently admitted to [First Name8 (NamePattern2) 1495] [Hospital ] Medical Center where he was found to have mild hydronephrosis and a creatinine in the low 2 range. His urologist (Dr. [Last Name (STitle) 54118] knows the patient well and felt that ureteral stents were not indicated in this patient until he has complete obstruction or becomes septic. During the last 24 hours of his hospital stay, the patient was producing approximately 40 cc to 50 cc of urine per hour. On the day of discharge, his creatinine was 1.3. The patient also developed a urinary tract infection with Pseudomonas which was resistant to fluoroquinolones and aminoglycosides. The patient was started on intravenous Zosyn and was to complete a 14-day course of Zosyn therapy. In addition, the patient had a peripherally inserted central catheter placed for intravenous antibiotics. 5. METASTATIC PROSTATE CANCER ISSUES: After a discussion with the patient's primary urologist (Dr. [Last Name (STitle) 54118], it was discovered that the patient was in the terminal stage of the prostate cancer. There were no further treatments for his prostate cancer. The patient was placed on 20 mg of prednisone daily by Dr. [Last Name (STitle) 54118] for symptomatic relief in end-stage prostate cancer. If the patient tolerates it,the dose will be tapered as it was felt the patient's risk of gastrointestinal bleed is increased by his continued use of steroids. The patient was to follow up with Dr. [Last Name (STitle) 54118] as an outpatient in one to two weeks. 6. ORAL THRUSH ISSUES: The patient was found to have oral thrush and was started on Nystatin swish-and-swallow. 7. GROIN RASH ISSUES: The patient was felt to have a candidal intertriginous infection on the groin and was started on miconazole and Nystatin powders. 8. INFERIOR VENA CAVA SYNDROME: The patient had a significant amount of bilateral lower extremity and scrotal edema which was felt to be due to his inferior vena cava syndrome. The patient's legs should be elevated when possible. 9. CODE STATUS ISSUES: The patient's code status was addressed with his daughter ([Name (NI) 54119]) who is his health care proxy. She has had discussions with her father, and he knows that he has prostate cancer. She felt that he would not fully understand a code discussion, but clearly noted that he would not want any heroic measures taken should his heart stop beating or should he stop breathing. At this time, he was made do not resuscitate/do not intubate. It was determined that pressors would not be used as well. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE STATUS: To [Hospital ] Rehabilitation. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to complete his prednisone taper very slowly - to start with a drop to 15mg and reassess symptoms. 2. The patient was instructed to follow up with his outpatient primary care physician (Dr. [Last Name (STitle) ] in one to two weeks. 3. The patient was instructed to follow up with his outpatient urologist (Dr. [Last Name (STitle) 54118] in one to two weeks. DISCHARGE DIAGNOSES: 1. Upper gastrointestinal bleed. 2. Ulcerative gastritis. 3. Acute anemia requiring blood transfusion. 4. Hypovolemic shock. 5. Elevation INR to 14. 6. Metastatic prostate cancer to the liver and bone. 7. Inferior vena cava syndrome. 8. Atrial fibrillation. 9. Pseudomonas urinary tract infection. MEDICATIONS ON DISCHARGE: 1. Dilaudid 2 mg by mouth q.4h. as needed. 2. Fentanyl 150-mcg patch q.72h. 3. Nystatin swish-and-swallow. 4. Miconazole powder. 5. Sucralfate 1 gram by mouth four times per day (for 14 days). 6. Prednisone 15 mg for seven days; and then reassess for further taper per sx. 7. Zosyn 2.25 grams q.6h. (for 14 days). 8. Protonix 40 mg by mouth twice per day. [Name6 (MD) 2415] [Last Name (NamePattern4) 3474], M.D. [MD Number(1) 3475] Dictated By:[Last Name (NamePattern1) 54120] MEDQUIST36 D: [2155-12-10] 13:04 T: [2155-12-10] 13:05 JOB#: [Job Number 54121]	[ "42731", "5990", "4280", "2851" ]
Admission Date: [2161-9-22] Discharge Date: [2161-9-29] Date of Birth: [2087-3-2] Sex: M Service: CSU This dictation is done for the cardiothoracic service. HISTORY OF PRESENT ILLNESS: Mr. [Name13 (STitle) ] is a 74-year-old man admitted to an outside hospital on [9-17] with a 2-week history of dyspnea on exertion and fatigue which these symptoms had increased over the previous 2-3 days prior to admission. No chest pain or associated nausea or vomiting prior to the onset of symptoms. He had exercised on a treadmill for 60 minutes per day and was able to walk up of a flight of stairs with ease. He was transferred [Hospital ] [Hospital ] [First Name (Titles) ] [Last Name (Titles) ] for cardiac catheterization which revealed three-vessel disease. He was then referred to cardiothoracic surgery for coronary artery bypass grafting. PAST MEDICAL HISTORY: Significant for CVA in [2-/2160] with residual fine motor deficit in the right hand, status post right CEA in [2-/2160], abdominal aortic aneurysm 4.5 cm by CAT scan, PVD, diabetes mellitus type 2, currently taking no medicine well controlled with exercise and diet, and status post GI bleed, hypertension and left subclavian artery stenosis. SOCIAL HISTORY: Retired engineer, widowed, lives alone. Remote tobacco use, quit 14 years ago. No alcohol use. MEDICATIONS PRIOR TO ADMISSION: Zestril 10 mg once daily, Plavix 75 mg once daily, aspirin 81 mg once daily, Lipitor 20 mg once daily, Corgard 40 mg once daily, hydrochlorothiazide 25 mg once daily. ALLERGIES: No known drug allergies. LABORATORY DATA: Prior to admission, white count 5.8, hematocrit 33.9, platelets 149, sodium 135, potassium 3.8, chloride 97, CO2 of 28, BUN 33, creatinine 1.1, glucose 126, PT 32, INR 1.1. As stated previously his cardiac catheterization showed a three-vessel disease with 60 percent LAD lesion, 50 percent left circumflex lesion and 60 percent ostial RCA lesion. Patient has reported a EF of 60 percent with trace MR and mild TR by an echo done at the [Hospital3 29718]. PHYSICAL EXAM: Neurological: Alert and oriented times three, moves all extremities, follows commands. Pulmonary: Clear to auscultation bilaterally. Cardiac: Regular rate and rhythm. Abdomen is soft, nontender, nondistended, normoactive bowel sounds. Extremities are warm. No edema. No varicosities, positive spider veins. HOSPITAL COURSE: Following cardiac cath and CT surgery consult, the patient was seen by the Stroke service to evaluate for risk of perioperative stroke and on [9-23], he was brought to the operating room where he underwent coronary artery bypass grafting. Please see the OR report for full details. In summary, the patient had a CABG times four with the LIMA to the LAD, saphenous vein graft to the RCA, saphenous vein graft to OM-3 with a jump graft to OM-2. His bypass time was 90 minutes with a cross-clamp time of 64 minutes. He tolerated the operation well, was transferred from the operating room to the cardiothoracic intensive care unit. At the time transfer, the patient was A paced at 80 beats per minute. He had a mean arterial pressure of 76 with a CVP of 15. He had propofol at 20 mcg/kg/minimal and Neo- Synephrine at 0.3 mcg/kg/hour. The patient did well in the immediate postoperative period. His anesthesia was reversed. He was weaned from the ventilator and successfully extubated however following extubation, the patient became acutely anxious and required reintubation. Following reintubation, the patient was begun on a Precedex infusion following which he his anxiety stabilized and he was able to follow commands. He was again weaned to C-PAP and the following morning successfully extubated. Throughout this period, the patient remained hemodynamically stable. On postoperative day three, the patient was noted to have periods of atrial fibrillation which were treated with beta blockers as well as IV amiodarone. Ultimately, the patient converted back to normal sinus rhythm. He remained hemodynamically stable throughout this period. On postoperative day four, the patient's temporary pacing wires were removed, his Foley catheter was removed. He was changed from IV amiodarone to oral amiodarone and he was transferred to the floor for continuing postoperative care and cardiac rehabilitation. Over the next several days, the patient had an uneventful postoperative course. His activity level was advanced with the assistance of the nursing staff as well as physical therapist and on postoperative day five, it was decided that the following day the patient would be ready for discharge to rehabilitation center. VITAL SIGNS At the time of this dictation, the patient's physical exam is as follows. Vital signs: Temperature 97, heart rate 67 sinus rhythm, blood pressure 150/76, respiratory rate 24, O2 sat 93 percent on room air. LABORATORY DATA: White count 7.9, hematocrit 31, platelets 171, PT 14, PTT 86.6, INR 1.3, sodium 141, potassium 3.5, chloride 101, CO2 of 31, BUN 32, creatinine 1.2, glucose 118. PHYSICAL EXAM: Neurologically alert and oriented times three, moves all extremities, follows commands, slight left upper extremity weakness, residual from an old CVA. Respiratory: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, S1-S2 with no murmur. Sternum is stable. Incision with Steri-Strips, open to air, clean and dry. Abdomen is soft, nontender, nondistended with normal active bowel sounds. Extremities are warm, well-perfused with one plus edema. Right leg saphenous vein graft harvest site with Steri-Strips, open to air, clean and dry. DISCHARGE MEDICATIONS: Aspirin 325 mg once daily, Colace 100 mg b.i.d., Percocet 5/325 1-2 tablets q. 4-6 hours p.r.n., Imdur 60 mg once daily, Zantac 150 mg once daily, metoprolol 50 mg b.i.d., amiodarone 400 mg b.i.d. times 1 week then 400 mg once daily times 1 week then 200 mg once daily times 1 month, captopril 25 mg t.i.d., potassium chloride 20 mEq b.i.d., Lipitor 20 mg once daily, Lasix 20 mg b.i.d. CONDITION AT DISCHARGE: Good. DISPOSITION: He is to be discharged to rehabilitation at [Location (un) 582] in [Location (un) 620]. DISCHARGE DIAGNOSES: CAD status post coronary artery bypass grafting times four with the LIMA to the LAD, saphenous vein graft to the RCA, saphenous vein graft to OM-2 with a jump to OM-3. Hypertension. Diabetes mellitus type 2. Chronic renal insufficiency. Right CEA. CVA with left sided upper extremity weakness. TURP. AAA measuring 4.5 cm. Skin cancer. PVD. FOLLOW UP: Patient is to have follow-up with Dr. [Last Name (STitle) 42883] in [2-10] weeks, with Dr. [Last Name (STitle) 5293] in [2-10] weeks, and with Dr. [Last Name (STitle) ] in 4 weeks. [Name6 (MD) ] [Name8 (MD) ], M.D. [MD Number(2) 5897] Dictated By:[Last Name (NamePattern4) 1718] MEDQUIST36 D: [2161-9-28] 17:53:39 T: [2161-9-28] 22:04:30 Job#: [Job Number 42884]	[ "41401", "9971", "42731", "25000", "4019", "2720" ]
Admission Date: [2178-2-25] Discharge Date: [2178-2-27] Date of Birth: [2095-4-15] Sex: F Service: MEDICINE Allergies: Lisinopril Attending:[Last Name (NamePattern1) 1167] Chief Complaint: complete heart block s/p RHC Major Surgical or Invasive Procedure: [2-25] Cardiac catheterization [2-25] Temporary transvenous pacemaker placement [2-26] Temporary transvenous pacemaker removal [2-26] DDD Pacemaker placement History of Present Illness: Mrs. [Known lastname 39070] is a 82 year old woman who presents with complete heart block s/p right/left heart catheterization. She initially presented with worsening dyspnea on exertion, new LBBB and a recent stress echo revealing a depressed LVEF of 25% without evidence of ischemia. She was referred for right and left heart catheterization for further evaluation of her cardiomyopathy. Cath did not show any obstructive coronary disease. Right heart catheterization was notable for normal right and left sided filling pressures. During Swan-Ganz catheter placement into the PCW position, the patient developed asystole which resolved with atropine and chest thump to a junctional rhythm at 30 bpm. A temporary transvenous RV pacing wire was placed and set at 50 bpm; she was transferred to the CCU for further management. Past Medical History: 1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: Hypertension (controlled with weight loss) New cardiomyopathy, LVEF 25% New LBBB Hypothyroidism Pneumonia as a child with recurrent right lung empyema drained multiple times (patient reports having scarring and residual incomplete lung expansion) GERD [2152] Bladder Cancer s/p resection Anemia Osteopenia Spinal stenosis s/p laminectomy L4/S1 and spinal fusion L5/S1 '[74] Scoliosis Peripheral neuropathy with numbness of her feet Hx of esophagitis, dysphagia Urinary incontinence Bilateral cataracts Recent episode of bronchitis treated with antibiotics Osteoarthritis s/p Appendectomy Resection of ovarian cyst Bilateral rotator cuff repair [2175] right knee replacement; [2176] left knee replacement Social History: No history of tobacco, alcohol or illicit drug abuse. Retired public health nurse. Husband won [Name2 (NI) 14959] prize in physics but is now disabled with dementia & living in nursing home, causing recent stress. Family History: Mother died at age [Age over 90 ], although she developed heart failure in her 80s. Father died of a CVA related to World War I gassing. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM Tm: 97.5??????F, Tc: 97.5??????F, HR: 50, BP: 102/48(64), RR: 18, SpO2: 97% RA GENERAL: WDWN female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. sclerae anicteric. PERRLA, EOMI. conjunctivae were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: supple with [Doctor Last Name ] a waves CARDIAC: bradycardic, variable S1, normal S2. No m/r/g. No thrills, lifts. No S3 or S4. PMI located in 5th intercostal space, midclavicular line LUNGS: CTAB, no crackles, wheezes or rhonchi. Resp were unlabored, no accessory muscle use. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No C/C/E. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 1+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 1+ PT 2+ NEURO: CN II-XII intact DISCHARGE EXAM Tm: 99.3??????F, Tc: 97.2??????F, HR: 64 (34-84), BP: 105/61(72), RR: 20, SpO2: 97% RA GENERAL: WDWN female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. sclerae anicteric. PERRLA, EOMI. conjunctivae pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: supple, JVP 9 cm CARDIAC: nl S1, S2, no M/R/G appreciated. No thrills, lifts. No S3 or S4. PMI located in 5th intercostal space, midclavicular line LUNGS: CTAB, no crackles, wheezes or rhonchi. Resp were unlabored, no accessory muscle use. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No C/C/E. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 1+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 1+ PT 2+ NEURO: CN II-XII intact, strength and sensation equal and intact bilaterally Pertinent Results: # CARDIOLOGY [2-25] Cardiac Cath (Preliminary Report) COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated no angiographically apparent flow-limiting disease. The LMCA, LAD, LCx, and RCA had no angiographically apparent disease. 2. Resting hemodynamics revealed normal left and right sided filling pressures. 3. The case was complicated by complete heart block requiring temporary ventricular pacing. FINAL DIAGNOSIS: 1. No angiographically apparent flow-limiting coronary artery disease. 2. Normal left and right sided filling pressures. 3. Case complicated by complete heart block requiring temporary pacemaker placement. [2-25] TTE Conclusions: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe global left ventricular hypokinesis (LVEF = 25-30 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Moderate to severe left ventricular systolic dysfunction. Moderate mitral regurgitation. Impaired left ventricular relaxation pattern. [2-27] TTE **********REPORT PENDING************** # LABORATORY DATA - Admission Labs [2178-2-25] 02:16PM BLOOD CK(CPK)-179 [2178-2-25] 02:16PM BLOOD CK-MB-7 cTropnT-<0.01 [2178-2-25*] 02:16PM BLOOD WBC-3.4 RBC-3.83* Hgb-12.1 Hct-34.8* MCV-91 MCH-31.5 MCHC-34.6 RDW-13.7 Plt Ct-216 [2178-2-25] 02:16PM BLOOD Neuts-59.7 Lymphs-30.3 Monos-6.5 Eos-2.1 Baso-1.4 [2178-2-25] 09:00AM BLOOD PT-12.8 INR(PT)-1.1 [2178-2-25] 02:16PM BLOOD Glucose-98 UreaN-19 Creat-0.9 Na-136 K-4.6 Cl-104 HCO3-25 AnGap-12 [2178-2-25] 02:16PM BLOOD Calcium-8.4 Phos-3.9 Mg-2.1 [2178-2-25] 02:16PM BLOOD TSH-1.5 [2178-2-25] 02:16PM BLOOD Free T4-1.8* - Discharge Labs [2178-2-27] 05:29AM BLOOD WBC-5.4 RBC-3.88* Hgb-12.0 Hct-35.5* MCV-92 MCH-31.0 MCHC-33.8 RDW-13.6 Plt Ct-164 [2178-2-27] 05:29AM BLOOD Glucose-107* UreaN-20 Creat-1.0 Na-134 K-4.0 Cl-104 HCO3-24 AnGap-10 [2178-2-27] 05:29AM BLOOD ALT-35 AST-26 [2178-2-27] 05:29AM BLOOD Calcium-8.2* Phos-3.8 Mg-1.8 # IMAGING [2-27] CXR (PA/Lat) **********REPORT PENDING************** Brief Hospital Course: Mrs. [Known lastname 39070] is a 82 year old woman with new LBBB and non-ischemic cardiomyopathy of unclear etiology who presented with complete heart block s/p right/left heart catheterization and is now s/p DDD pacemaker placement [2-26]. # CHB: Patient had a repeat episode of AVblock while temporary pacer wires were being pulled yesterday; a permanent DDD pacer was then placed. Patient remained in sinus rhythm with LBBB. EP interrogated pacer on morning of discharge; no issues. f/u CXR showed no pneumothorax. She received her last dose of vancomycin prior to discharge on [2-27] and will be taking one dose of clindamycin as outpatient on [2-28]. She has a f/u with Dr. [First Name (STitle) 437] in 1 week. # PUMP: Patient has a non-ischemic cardiomyopathy with EF 25%, etiology unclear. She also has a component of desynchrony from her LBBB that decreases her LV ability to contract effectively. She was continued on valsartan 40mg daily and metoprolol xl 25mg daily. She walked prior to discharge without lightheadedness. # CORONARIES: [2178-2-25] cardiac catheterization showed no obstructive coronary disease. She was continued on aspirin 81mg daily # Dysarthria: Patient stated on admission that she feels like she is unable to pronounce her words properly and is having difficulty speaking. She denies any word-finding difficulty, and states that it is purely a vocalization problem. [Name (NI) ] that it is improving and has a normal neuro exam with no focal deficits. These symptoms continued to improve until discharge without intervention. She did not receive head imaging. # Hypothyroidism: Most recent TSH 1.5, FT4 1.8. Continued levothyroxine 112mcg daily. # Osteopenia: Continued calcium/vit D supplementation. # DVT Prophylaxis: Patient received heparin products during this admission. Medications on Admission: aldactone 12.5mg [Hospital1 ] allopurinol 150mg qod aspirin 81mg daily calcitriol 25mcg daily colace 100mg prn coreg 12.5mg [Hospital1 ] diovan 40mg daily folic acid 1mg daily iron 325mg daily lasix 80mg [Hospital1 *] lopid 600mg daily nitro 0.4mg prn plavix 75mg daily prilosec 20mg daily zocor 10mg daily vitamin d 800mg daily B12 monthly procrit 60,000 q2weeks Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. calcium carbonate-vitamin D3 Oral 6. multivitamin Tablet Sig: One (1) Tablet PO once a day. 7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO three times a week. 8. Fish Oil Oral 9. melatonin Oral 10. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day as needed for heartburn. 11. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:30 Tablet Extended Release 24 hr(s)* Refills:2 12. clindamycin HCl 300 mg Capsule Sig: Two (2) Capsule PO once a day for 1 days. Disp:2 Capsule(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: # Complete heart block # Left bundle branch block # Non-ischemic cardiomyopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You are being discharged from [Hospital1 1170]. You were admitted to the hospital because of worsening difficulty breathing with exertion, new Left Bundle Branch Block and a recent stress echo revealing a depressed contraction of your heart without evidence of ischemia. During a right heart cath you had complete heart block and you needed a pacing wire placed. During removal of that wire your heart was beating very slowly. The wire was replaced and you ultimately received a pacemaker. During you admission, some of your medications were changed, you should take the following medications when leavign the hospital: - metoprolol XL 25mg (ongoing) - clindamycin for 1 day after discharge Please note that if you become lightheaded or dizzy or have chest pain you should call your doctor and/or return to the emergency room. Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [2178-3-2] at 3:00 PM With: DR. [First Name8 (NamePattern2) ] [Doctor Last Name ] [Telephone/Fax (1) 62] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Department: SENIOR HEALTH When: TUESDAY [2178-3-3] at 3:00 PM With: [Doctor First Name ] MAIBOR [Telephone/Fax (1) 719] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Department: RADIOLOGY When: THURSDAY [2178-3-5] at 7:30 AM With: ULTRASOUND [Telephone/Fax (1) 327] Building: CC CLINICAL CENTER [Location (un) ] Campus: WEST Best Parking: [Doctor First Name ]. GARAGE Department: GERONTOLOGY When: FRIDAY [2178-3-13] at 10:30 AM With: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], RNC [Telephone/Fax (1) 719] Building: LM [Hospital Unit Name ] [Location (un) ] Campus: WEST Best Parking: [Hospital Ward Name ] Garage	[ "9971", "4019", "2449", "53081" ]
Admission Date: [2108-10-3] Discharge Date: [2108-10-10] Date of Birth: [2044-4-1] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: This 64-year-old white female has a history of hypertension and hyperlipidemia and has had four months of increasing exertional jaw and tooth pain. She reports mandibular and subglossal sharp pain and varying levels of exertion, now occurring with moderate ambulation. She has no associated symptoms, but notes occasional sweats associated with anxiety. She denies nausea, vomiting, presyncope or syncope. She had an exercise tolerance test with inferior lateral reversible defects and was sent to the Emergency Room for cardiac catheterization and was pain free on admission. PAST MEDICAL HISTORY: Significant for a history of hypertension, hypertension of hypercholesterolemia, status post total abdominal hysterectomy and bilateral salpingo- oophorectomy, status post cholecystectomy, status post appendectomy, history of anxiety. MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o. once daily Hydrochlorothiazide 25 mg p.o. once daily Diovan 80 mg p.o. once daily Norvasc 10 mg p.o. once daily Lipitor 10 mg p.o. once daily Serax 15 mg p.o. prn Prozac 20 mg p.o. once daily. ALLERGIES: No known allergies. SOCIAL HISTORY: She is married, does not smoke, does not drink alcohol. FAMILY HISTORY: Unremarkable. REVIEW OF SYSTEMS: As above. PHYSICAL EXAMINATION: She is a well-developed well-nourished white female in no apparent distress. Vital signs are stable, she is afebrile. HEENT examination: Normocephalic, atraumatic, extraocular movements intact, oropharynx benign. Neck supple with full range of motion and no lymphadenopathy or thyromegaly. Carotids 2 plus and equal bilaterally without bruits. Lungs were clear to auscultation and percussion. Cardiovascular examination: Regular rate and rhythm. Normal S1 and S2 with no rubs, murmurs or gallops. Abdomen soft and nontender with positive bowel sounds and no masses or hepatosplenomegaly. Extremities without clubbing, cyanosis or edema. Pulses were 2 plus and equal bilaterally throughout. Neurological exam was nonfocal. HOSPITAL COURSE: She was admitted and on [2108-10-4] she underwent cardiac catheterization, which revealed her left main had a twenty percent lesion, her LAD had a seventy percent hazy lesion after the diagonal one. Left circumflex had diffuse disease proximally with a total occlusion after the small OM2. RCA had one hundred percent proximal occlusion. She had an echocardiogram, which revealed an ejection fraction of fifty-five percent, mild hypokinesis of the basilar inferior wall and one to two plus MR. Dr. [First Name (STitle) ] [Last Name (Prefixes) ] was consulted and on [2108-10-5] the patient underwent a coronary artery bypass graft times three with LIMA to the LAD, reverse saphenous vein graft to the OM and RCA. Cross clamp time was seventy-seven minutes, total bypass time one hundred nineteen minutes. She was transferred to the CSRU in stable condition on Neo-Synephrine and propofol. She was extubated her postoperative night and she had a lot of chest tube output and required aggressive diuresis on postoperative day one. Postoperative day three her Foley was discontinued, her chest tubes were discontinued and she was transferred to the floor in stable condition. On postoperative day four her epicardial pacing wires were discontinued and on postoperative day five she was discharged to home in stable condition. MEDICATIONS ON DISCHARGE: Lasix 20 mg p.o. b.i.d. for seven days Zantac 150 mg p.o. b.i.d. for one month Aspirin 325 mg p.o. once daily Percocet one to two p.o. q.4-6h prn pain Plavix 75 mg p.o. once daily Lipitor 10 mg p.o. once daily Prozac 20 mg p.o. once daily Serax 10 mg p.o. three times daily prn Lopressor 50 mg p.o. b.i.d. Iron 325 mg p.o. once daily Vitamin C 500 mg p.o. b.i.d. Ibuprofen 600 mg p.o. q.8h prn Potassium 20 mEq p.o. b.i.d. for seven days. LABS ON DISCHARGE: Hematocrit 25.2, white count 10,900, platelets 184,000, sodium 141, potassium 3.9, chloride 108, carbon dioxide 25, BUN 16, creatinine 0.9, blood sugar 96. DISCHARGE DIAGNOSES: Hypertension, hypercholesterolemia, anxiety, coronary artery disease. DI[Last Name (STitle) 408]E PLANS: She will be followed by Dr. [First Name (STitle) 216] in one to two weeks, Dr. [Last Name (STitle) ] in two to three weeks and Dr. [Last Name (Prefixes) ] in four weeks. [Doctor Last Name ] [Last Name (Prefixes) ], M.D. [MD Number(1) 1288] Dictated By:[Last Name (NamePattern1) 18588] MEDQUIST36 D: [2108-10-10] 16:30:29 T: [2108-10-11] 00:25:13 Job#: [Job Number 96765]	[ "41401", "4019", "2720" ]
Admission Date: [2122-1-19] Discharge Date: [2122-1-29] Date of Birth: [2078-11-14] Sex: M Service: MEDICINE Allergies: Phenobarbital Attending:[First Name3 (LF) 5827] Chief Complaint: abdominal distension Major Surgical or Invasive Procedure: none History of Present Illness: This is a 42 year old man with multiple sclerosis, Bipolar DO, hypothyroidism, who was admitted on [1-19] from nursing home because he was found to have increasing abdominal distention over past few days, which patient says he has noticed for past few weeks. In the ED, patient was found to have marked small-bowel and colonic dilatation on imaging. NG tube was placed and drained 1 litre of bilious/brown fluid on presentation, and drainage continued throughout MICU stay. He was also febrile to 101 in ED and was started on ciprofloxacin and metronidazole (for bowel pathogens) which were continued. He was admitted to MICU for marked hypertension and transient respiratory distress that resolved with supplemental oxygen. His blood pressure was controlled with IV hydralazine, but this may have precipitated a truncal rash that developed later during the day. He also received agressive IV fluid hydration for total of 4 litres. Creatinine improved from 1.5 on admission to 0.9. Patient was evaluated by surgical service and GI consult team and the consensus is currently [Last Name (un) 3696] syndrome secondary to autonomic neuropathy from multiple sclerosis. He spiked another fever at 10:30am to 101.5 and blood cx, urine cx, and stool cx were sent. Leukocytosis has resolved. He continues to have marked abdominal distention and some tenderness in peri-umbilical region. He had one large, liquid stool today. Rectal tube was placed with only minimal stool drainage since. Patient says he has not tried to eat for several weeks due to vomitting and diarrhea. He has been NPO since admission. Past Medical History: 1) Multiple sclerosis, Secondary Progressive MS. followed by Dr. [Last Name (STitle) 8760]. Had been on copaxone but no longer (ended on [6-/2121]) also had been on pulse steroids. Wheelchair bound with significant cognitive dysfunction. 2) Bipolar disorder, on lithium 3) Hypothyroidism 4) Childhood seizure disorder 5) Hypertension 6) Obesity 7) Hyperlipidemia Social History: Lives at [Hospital ] Care Center [Hospital1 1501]. He is divorced with no children. No alcohol or smoking history. No illicit drug use history. Family History: non-contributory Physical Exam: Vitals:T:100.9, BP:150/78 (150s-180s/90s-110s), HR 111, RR:19, Sat:97% on 3LNC I/O: 4 litres IV fluids in, Out 4770 LOS (~2L NG tube), 600 NG tube output over last 8 hours. GEN: Well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, dry mucous membranes, 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 clear anteriorly, no W/R/R ABD: Soft, very distended, tender to palpation in epigastrium, no rebound or guarding, tympanetic to percussion diffusely, diminished bowel sounds EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. ? Intranuclear ophthalmoplegia. Otherwise CN II - XII grossly intact. Moves arms, moves toes. Patellar hyper-reflexia and tremors with plantar reflex testing, upgoing toes bilaterally, + clonus. SKIN: Pustular truncal rash, mostly over shoulders Pertinent Results: [2122-1-19] 04:30PM GLUCOSE-143* UREA N-21* CREAT-1.5* SODIUM-134 POTASSIUM-4.5 CHLORIDE-93* TOTAL CO2-26 ANION GAP-20 [2122-1-19] 04:30PM ALT(SGPT)-20 AST(SGOT)-18 ALK PHOS-70 AMYLASE-323* TOT BILI-0.6 [2122-1-19] 04:30PM LIPASE-32 [2122-1-19] 04:30PM cTropnT-0.01 [2122-1-19] 04:30PM ALBUMIN-5.0* CALCIUM-10.7* PHOSPHATE-3.9 MAGNESIUM-3.7* [2122-1-19] 04:30PM TSH-1.0 [2122-1-19] 04:30PM WBC-17.3* RBC-5.86 HGB-18.2* HCT-52.8* MCV-90 MCH-31.1 MCHC-34.6 RDW-13.7 [2122-1-19] 04:30PM NEUTS-86.5* BANDS-0 LYMPHS-8.1* MONOS-4.7 EOS-0.4 BASOS-0.2 [2122-1-19] 04:30PM PLT SMR-NORMAL PLT COUNT-421 [2122-1-19] 04:30PM PT-14.7* PTT-27.4 INR(PT)-1.3* Brief Hospital Course: #) Pseudocolonic obstruction-- This was thought to be likely [3-7] neuropathy from MS, but GI infection was considered given fever, leucocytosis, and diarrhea. He was initially admitted to the MICU and surgery and GI were consulted. Lactate trended downward, and stool cultures were negative. C diff was neg x 2. Abdominal distention improved and his leukocytosis resolved. An NGT was placed for decompression. He was transferred to the floor after overnight observation. He received neostigmine on [1-22], and by [1-24] his symptoms were improving and the NGT was removed. He began eating and having regular bowel movements, and by [1-28] colonic dilatation had totally resolved on KUB. Laxatives such as lactulose or enulose were recommended to be avoided as they may cause gas and thus more abdominal discomfort. #) Fever/leukocytosis. His WBC was 17.3 on admission but his leukocytosis resolved within 2 days and he defervesced. C diff neg x 2. Stool cx neg. Campylobacter neg. Blood cx from [1-22] with 1/4 pan-sensitive staph aureus and Vanco was started on [1-23] that was changed to nafcillin [1-24]. Urine cx showed no growth. Further surveillance blood cultures were negative, with cultures from [1-24] and [1-25] still pending. He will complete a course of nafcillin for 2 weeks (last day [2122-2-5]). #) Hypertension: He was on lasix and metoprolol as outpatient. Metoprolol was continued but lasix was held due to copious urine output and the need to retain hydration due to hypernatremia. #) Hypernatremia: Na increased to 150 on [1-22] but improved to 141 [1-24] AM s/p D5W and stayed in the normal range after he began to take POs. #) Seizure disorder: Depakote was continued. #) Bipolar disorder: Depakote and lithium were continued. A lithium level measured during his hospitalization was normal (0.5) #) Hyperlipidemia: Zocor was continued. #) Hypothyroidism: levothyroxine was continued. #) Multiple sclerosis: he is not on treatment currently but this may be re-evaluated as an outpatient with his neurologist, Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 8760]. Medications on Admission: 1) Aspirin 81 daily 2) Lasix 20 mg daily 3) Lithium 300 [Hospital1 ] and 600 at night 4) Provigil 200 mg twice daily 5) Colace 100 twice daily 6) Oxybutynin 5 mg twice daily 7) Amantadine 100 twice daily 8) Bupropoion 200 mg SR twice daily 9) Depakote 500 mg PO daily 10) Levothyroxine 88 mcg daily 11) Celexa 40 mg daily 12) Enulose 13) Calcium carbonate/Vit D 600/400 two tabs daily 14 Albuterol 2 puff q6 PRN 15) Baclofen 20 mg daily 16) Fluticasone nasal spray 1 spray twice daily 17) Metoprolol 50 mg twice daily 18) Simvastatin Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Lithium Carbonate 300 mg Capsule Sig: Two (2) Capsule PO QHS (once a day (at bedtime)). 4. Modafinil 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 6. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Amantadine 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Bupropion 200 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 9. Divalproex 500 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Celexa 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. Calcium Carbonate-Vit D3-Min 600-400 mg-unit Tablet Sig: Two (2) Tablet PO once a day. 13. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 14. Baclofen 20 mg Tablet Sig: One (1) Tablet PO once a day. 15. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [Hospital1 ] (2 times a day). 16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 18. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. . 19. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) g Intravenous Q4H (every 4 hours) for 1 weeks. Discharge Disposition: Extended Care Facility: [Hospital6 4657] - [Location 1268] Discharge Diagnosis: Primary: colonic pseudo-obstruction Secondary: multiple sclerosis, bipolar disorder, hypertension, seizure disorder, hypothyroidism Discharge Condition: good, stable, eating a regular diet, having daily soft bowel movements, afebrile, with some residual abdominal discomfort Discharge Instructions: You were admitted with symptoms of colonic obstruction. You received consults by the surgery and gastroenterology services, and you received a medication called neostigmine to help relieve the obstruction. With conservative measures, your symptoms improved until your colon was normal size by x-ray and you were able to tolerate a regular diet and have regular bowel movements. Your abdominal discomfort may take a couple more weeks to fully resolve. You may take stool softeners to help you have bowel movements but you should avoid lactulose or enulose as they may cause gas and thus more discomfort. If you stop having bowel movements or are unable to keep down food or liquid, call your doctor. One of your blood cultures was positive for an organism called Staph aureus. You will continue IV antibiotics for 1 more week through your PICC line, and then the PICC line may be removed. Followup Instructions: Follow up with your doctors at your [Name5 (PTitle) ] nursing facility. Blood cultures from [1-24] and [1-25] were pending at the time of discharge; your doctors [Name5 (PTitle) ] follow up on the results of these. You have an appointment with [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 17744], a PA at your neurologist's (Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 8760]) office, on [2122-3-19] at 10:45am. You may call his office at [Telephone/Fax (1) 8302] with any questions or if you would like to try to schedule an earlier appointment.	[ "2760", "4019", "2449" ]
Admission Date: [2175-7-19] Discharge Date: [2175-7-25] Date of Birth: [2175-7-19] Sex: M Service: NB HISTORY: Baby boy [Known lastname 7739] was a 2.17 kg product of a 34-week gestation born to a 33-year-old G2, P1 mom. Prenatal screens: A positive, antibody negative, RPR nonreactive, rubella immune, and GBS unknown. This pregnancy was complicated by cervical shortening. There was preterm labor and premature rupture of membranes. Mom was admitted to [Hospital3 3765] and was treated with betamethasone and then transferred to [First Name4 (NamePattern1) 3867] [Last Name (NamePattern1) ] [First Name (Titles) ] [Last Name (Titles) ]. She was betamethasone complete prior to delivery. The infant was born vaginally with Apgars of 9 and 9. PHYSICAL EXAMINATION: Birth weight was 2.170 kg, 25 to 50th percentile; head circumference 30 cm, 25th percentile; length 43 cm, 25th percentile. Very molded head with bruising of scalp. Anterior fontanel open and flat. Red reflex present bilaterally. Palate intact. Neck supple. Clavicles intact. Lungs clear bilaterally. CARDIOVASCULAR: Regular rate and rhythm. No murmurs. Femoral pulses 2+ bilaterally. ABDOMEN: Soft with active bowel sounds. No masses or distention. GENITOURINARY: Normal preterm male. Testes palpable bilaterally. Anus patent. Spine midline without dimple. Hips stable. NEUROLOGIC: Good tone, normal suck and gag. Moves all extremities equally. SKIN: Pink and slightly ruddy. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: The infant has been stable in room air throughout hospital course without issues. CARDIOVASCULAR: The infant has had stable cardiovascular status. FLUIDS AND ELECTROLYTES: Birth weight was 2.170 kg. The infant was initially started ad lib feeding on special care or breast milk 20 calorie. He continued ad lib feeding with a minimum of 80 cc per kg per day, taking in adequate amounts with good urination and stooling. At the time of discharge, he was taking ad lib volumes of breast milk 24 cal/oz and breast feeding. His discharge weight is 2.105 kg. GASTROINTESTINAL: Peak bilirubin was on day of life 5 of 12.1/ 0.4. He was treated with phototherapy. His bilirubin on the day of discharge was 10.6/0.3. HEMATOLOGY: Hematocrit on admission was 53. The infant has not required any blood transfusions. His blood type is O+ Cooms negative. INFECTIOUS DISEASE: CBC and blood culture obtained on admission. CBC was benign and blood cultures have remained negative. The infant did not receive any antibiotics during this course. NEUROLOGIC: The infant has been appropriate for gestational age. SENSORY: Hearing screening was performed with automated auditory brain stem responses and the infant passed. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To home. NAME OF PRIMARY PEDIATRICIAN: Dr. [Last Name (STitle) ]. Telephone No. [Telephone/Fax (1) 69339]. CARE RECOMMENDATIONS: 1. Continue ad lib feeding breast milk or Similac 24 calorie. 2. Medications: Not applicable. 3. Car seat position screening test was performed for 90- minute screen and the infant passed. 4. State newborn screens have been sent per protocol on [2175-7-22]. 5. Immunizations received: The infant has received Heb B on [2175-7-25]. 6. He will need a rebound bilirubin drawn on [2175-7-26]. DISCHARGE DIAGNOSES: Preterm infant born at 34 weeks. Rule out sepsis. Mild hyperbilirubinemia status post circumcision. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 48738], MD [MD Number(2) 55708] Dictated By:[Last Name (NamePattern1) ] MEDQUIST36 D: [2175-7-24] 22:11:22 T: [2175-7-25] 00:13:08 Job#: [Job Number 69340]	[ "7742", "V053", "V290" ]
Admission Date: [2142-12-13] Discharge Date: [2142-12-21] Date of Birth: [2110-2-13] Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 3006] Chief Complaint: Left thumb amputation while at work Major Surgical or Invasive Procedure: -Left thumb replantation -Left thumb arterial anastamotic revision -Left thumb leech therapy -Left infra-clavicular pain catheter placement History of Present Illness: 32yo RHD male with left thumb amputation through the proximal phalanx. Occurred at work with a large press / cutting machine used to divide rubber. No LOC or other injuries. Tetanus UTD. Transferred from [Hospital ] with distal tip on ice. Past Medical History: Anxiety Addiction Social History: Single, machinist, [12-3] ppd smoker, [12-3] EtOH'ic drinks/d, former opiate abuse, currently on suboxone, weekly marijuana Family History: Denies Physical Exam: Left thumb stump with moist gauze, no bleeding, sharp injury just proximal to IP joint.No injury to remainder of hand Pertinent Results: [2142-12-14] 03:49AM BLOOD WBC-5.9 RBC-2.95* Hgb-9.0* Hct-26.5* MCV-90 MCH-30.4 MCHC-33.9 RDW-12.2 Plt Ct-184 [2142-12-14] 11:28AM BLOOD WBC-8.5 RBC-2.74* Hgb-8.5* Hct-24.8* MCV-91 MCH-30.8 MCHC-34.1 RDW-12.2 Plt Ct-188 [2142-12-14] 07:46PM BLOOD WBC-7.4 RBC-2.14* Hgb-6.6* Hct-19.5* MCV-91 MCH-30.6 MCHC-33.7 RDW-12.1 Plt Ct-193 [2142-12-15] 01:38AM BLOOD Hct-22.6* [2142-12-15] 04:31AM BLOOD WBC-7.8 RBC-2.45* Hgb-7.5* Hct-21.4* MCV-87 MCH-30.7 MCHC-35.1* RDW-14.2 Plt Ct-115* [2142-12-15] 08:56AM BLOOD Hct-23.1* [2142-12-15] 02:46PM BLOOD WBC-7.2 RBC-2.63* Hgb-8.0* Hct-23.0* MCV-87 MCH-30.3 MCHC-34.7 RDW-14.3 Plt Ct-146* [2142-12-15] 10:05PM BLOOD Hct-22.0* [2142-12-16] 03:05AM BLOOD WBC-6.2 RBC-2.38* Hgb-7.3* Hct-21.0* MCV-88 MCH-30.5 MCHC-34.7 RDW-14.0 Plt Ct-153 [2142-12-17] 12:04AM BLOOD WBC-6.6 RBC-2.49* Hgb-7.4* Hct-21.8* MCV-88 MCH-29.9 MCHC-34.1 RDW-13.9 Plt Ct-154 [2142-12-17] 06:15AM BLOOD Hct-24.5* [2142-12-18] 05:00AM BLOOD WBC-8.2 RBC-2.87* Hgb-8.7* Hct-24.9* MCV-87 MCH-30.2 MCHC-34.9 RDW-14.7 Plt Ct-181 [2142-12-20] 05:23AM BLOOD WBC-9.7 RBC-2.79* Hgb-8.7* Hct-24.3* MCV-87 MCH-31.1 MCHC-35.6* RDW-14.8 Plt Ct-265 [2142-12-14] 03:49AM BLOOD PT-12.3 PTT-32.2 INR(PT)-1.1 [2142-12-14] 03:49AM BLOOD Plt Ct-184 [2142-12-14] 11:28AM BLOOD Plt Ct-188 [2142-12-14] 07:46PM BLOOD Plt Ct-193 [2142-12-15] 04:31AM BLOOD PT-13.4* PTT-27.3 INR(PT)-1.2* [2142-12-15] 04:31AM BLOOD Plt Ct-115* [2142-12-15] 02:46PM BLOOD PT-12.0 PTT-28.1 INR(PT)-1.1 [2142-12-15] 02:46PM BLOOD Plt Ct-146* [2142-12-15] 10:05PM BLOOD PTT-27.6 [2142-12-16] 03:05AM BLOOD PT-12.1 PTT-28.2 INR(PT)-1.1 [2142-12-16] 03:05AM BLOOD Plt Ct-153 [2142-12-17] 12:04AM BLOOD PT-11.8 PTT-33.4 INR(PT)-1.1 [2142-12-17] 12:04AM BLOOD Plt Ct-154 [2142-12-18] 05:00AM BLOOD Plt Ct-181 Brief Hospital Course: 32 yo RHD male with left thumb traumatic amputation at work and anxiety disorder that persisted as a problem for the entire hospital stay. [2142-12-13] - Admitted to OR (with left infraclavicular pain catheter in place) for left thumb replant. Post-op to PACU for observation, pain control, Subcutaneous heparin / toradol / ASA / heparin soaked sponge to nail bed. [2142-12-14] - Taken back to OR for left thumb arterial anastamotic revision. Post-op to PACU on same meds. Later changed to IV Heparin 500 units / hour. Began leech therapy to left thumb. HCT was 19.5. Ordered two units of PRBC to be transfused. Type and crossmatch was pending. Called to bedside later that evening for patient becoming unresponsive and hypotensive. Received fluid bolus, albumin, 1 dose of neosynephrine. Heparin IV changed to 250 units / hour. Leeches changed to Q6 hours. Received 4 units of PRBC. Doppler pulses stable. Pain control still an issue / Acute pain service on board. [2142-12-15] to [2142-12-17] - Transferred to SICU. Received two more units of PRBC. Stable. Held leech therapy for "venous stress test". Passed. Did not become congested and maintained doppler pulse. [2142-12-18] - Transferred to CC6. Pain catheter removed started on PO dilaudid, acute service signed off. Pain continues as uncontrolled. The acute pain service asked us to call the chronic pain service. [2142-12-19] - Leech therapy restarted for congested thumb. Thumb pinked up within an hour of the leech placement. Oozing persisted so Leeches changed to Q6 hours. Pain still an issue despite Dilaudid 14mg Q3hours pen. [2142-12-20]- Morning HCT stable @ 24.3. One more leech added then stopped again for "venous stress test" Called secondary to patient wanting to leave AMA. Team member spoke with the patient for an hour, he became calm. Pain service changed to Dilaudid 16 mg Q3 hours. [2142-12-21] - AF, VSS. Tol PO, ambulating independently, pain management regimen in place. Awaiting cast placement. Stable to be discharged. Medications on Admission: Clonidine, alprazolam Discharge Medications: 1. clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for anxiety / insomnia. 2. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day as needed for anti-platelet / analgesia for 1 months. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for prophylaxis after leech therapy for 10 days. 5. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for infection prophylaxis following amputation for 10 days. 6. alprazolam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for anxiety. 7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours) as needed for pain for 2 months. 8. hydromorphone 8 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain for 2 weeks. Discharge Disposition: Home With Service Facility: [Hospital1 ] VNA Discharge Diagnosis: -Left thumb traumatic amputation -Status post left thumb replantation -Status post left thumb arterial anastamotic revision -Anxiety Disorder Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. FALL PRECAUTIONS - Take extra care to protect thumb in uncontrolled environments (snow, ice, crowds, etc..) Discharge Instructions: -Keep left hand elevated on pillows -Keep left hand warm at all times -Wear left protective cast at all times, except for visiting nurse dressing changes. Keep clean and dry -Refrain from smoking, consuming caffeine (coffee, soda, tea, chocolate, etc..) -Dressing changes [Hospital1 ]. Clean thumb gently with saline. Dress thumb loosely with xeroform strips longitudinally / gauze in the same manner leaving distal tip visible so that the patient can check capillary refill. Pad hand / forearm. Replace bivalved cast / splint. Patient may soak the thumb in warm water / peroxide (1:1 solution) as tolerated for 10 min to remove dried blood prn. Physical Therapy: -Out of bed w/ assist at least four times a day -Left upper extremity: Non weight bearing - Protect left thumb at all times by wearing splint / cast. Be cautious in uncontrolled environments (snow, ice, crowds, etc..) Treatments Frequency: Visiting Nurse - [Hospital1 ] dressing changes to left thumb. Clean gently with saline, wrap thumb loosely with xeroform and gauze leaving distal tip exposed to check capillary refill. Pad hand / forearm. Replace splint / cast. Followup Instructions: -Provider: [Name10 (NameIs) ] XRAY (SCC 2) Phone:[Telephone/Fax (1) 1228] Date/Time:[2142-12-28] 3:00 -Provider: [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 25538], [MD Number(3) 1240]:[Telephone/Fax (1) 1228] Date/Time:[2142-12-28] 3:20 -Follow-up with the Chronic Pain Clinic, call [Telephone/Fax (1) 1652] for appointment -Follow-up with Dr. [Last Name (STitle) 91987]. Call him today upon returning home to set up plan. Ask him about starting "subutox" in place of suboxone. Completed by:[2142-12-21]	[ "2851", "3051" ]
Admission Date: [2154-3-14] Discharge Date: [2154-3-20] Service: CSU HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old male without a history of coronary artery disease who reports dyspnea on exertion and shoulder discomfort with exertion, and these symptoms resolve with rest. He had a stress echocardiogram on [2154-3-13] which revealed EKG changes and hypokinesis and akinesis in the inferior wall. His cath on [3-14] showed severe 3-vessel disease. His LAD was 90% occluded, D1 was 80%, left circumflex was 90%, and RCA was 90% occluded. He was therefore referred for coronary artery bypass surgery. PAST MEDICAL HISTORY: Hyperlipidemia. PAST SURGICAL HISTORY: Appendectomy in [2090]. ALLERGIES: He has no known drug allergies. MEDICATIONS AT HOME: Lipitor 10 mg daily, aspirin 81 mg daily, calcium, and a multivitamin daily. SOCIAL HISTORY: He lives in [Location 620] with his wife. [Name (NI) ] retired 1 year ago from sales. He drives. He uses no assistive devices. He is very active. He quit smoking in [2116]. He has a 40-pack-year history. He has 3 alcoholic drinks per year. FAMILY HISTORY: His father died of a MI at the age of 87. REVIEW OF SYSTEMS: Negative except for the symptoms stated in the HPI. PHYSICAL EXAMINATION ON ADMISSION: Height is 5 feet 7 inches. Weight is 177.5 pounds. Vital signs reveal a heart rate of 78, sinus rhythm, BP of 143/72, respirations of 15. In general, he was lying flat in bed in no acute distress. Neurologically, he was alert and oriented x 3, appropriate, nonfocal. Cranial nerves II through XII were intact. His lungs were clear to auscultation bilaterally. His heart rate was regular in rate and rhythm. Positive S1 and S2. No clicks, rubs, murmurs, or gallops. His abdomen was soft, nontender, and nondistended. Round with positive bowel sounds. His extremities were warm and well perfused. Negative edema or varicosities. His pulses were 2+ throughout, and he had no carotid bruits. PREOPERATIVE LABORATORY DATA: White blood count was 9.4, hematocrit was 37.7, and platelets were 252. Sodium was 138, potassium was 3.7, chloride was 105, bicarbonate was 24, BUN was 26, creatinine was 0.9, and blood glucose was 164. PT of 13.3, PTT of 28.3, and INR of 1.1. ALT of 17, AST of 25, amylase of 72, total bilirubin of 0.6, albumin of 3.8, alkaline phosphatase of 122. RADIOLOGIC STUDIES: His preoperative chest x-ray showed no evidence of acute cardiopulmonary disease. It did show some small calcified subcentimeter lung nodules at the left base. The cardiac catheterization results were mentioned in the HPI. HOSPITAL COURSE: After obtaining consent for bypass surgery from the patient he was brought to the operating room the next (on [2154-3-15]) and underwent coronary artery bypass graft x 4 with a LIMA to the LAD, a saphenous vein graft to diagonal, a saphenous vein graft to the OM, a saphenous vein graft to the RCA. The patient tolerated the procedure well with a total cardiopulmonary bypass time of 148 minutes. He had a mean arterial pressure in transfer to CSICU of 68, CVP of 23, PA diastolic of 21, PA mean of 25, it was 92 A paced. He was being titrated on Neo-Synephrine and propofol en route to the unit. Later that day propofol was weaned. The patient became less sedated. As he became alert and awake his ET tube was removed. His was following all commands and moving all extremities. He was neurologically intact. On postoperative day 1, he appeared to be doing well. He was hemodynamically stable. Beta blockade and diuretics were started per protocol. His PA catheter was removed, and he was transferred to the telemetry floor. On postoperative day #2, the patient appeared to be doing well. He had some rales in the left base. Otherwise, his physical exam was unremarkable. His mediastinal chest tube was removed. On postoperative day #3, all remaining chest tubes were removed. As well as his epicardial pacing wires and his Foley were removed. His physical exam was now unremarkable. He no longer had rales in his lungs. His O2 saturation was improved since yesterday when it was 95 at 5 liters. He continued to get out of bed and ambulate well. Throughout his postoperative course he was being seen by physical therapy, and they were assessing his status and getting him out of bed and improving his activity level. On postoperative day #4, his magnesium was repleted. His lungs did appear to have some inspiratory wheezes and crackles bilaterally (right greater than left). The patient was encouraged to continue using inspiratory spirometry. On postoperative day #5, the patient was at level 5 activity level. He appeared well enough to go home. He was hemodynamically stable. He still had some scattered rhonchi but was discharged with Lasix and to continue to be diuresed for a week. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: He was discharged to home with VNA services. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Status post coronary artery bypass grafting x 4 on [3-15], [2153]. 3. Hypercholesterolemia. MEDICATIONS ON DISCHARGE: Potassium chloride 10-mEq capsules 2 capsules b.i.d., Colace 100 mg p.o. b.i.d., aspirin 81 mg p.o. daily, atorvastatin 50 mg p.o. daily, Lasix 20 mg p.o. b.i.d., Lopressor 50 mg p.o. b.i.d., ibuprofen 600 mg p.o. q.6h. p.r.n. (for pain), albuterol inhaler 2 puffs q.i.d. p.r.n. (for shortness of breath or wheezing). DISCHARGE FOLLOWUP: The patient was recommended to follow up with Dr. [Last Name (STitle) 70] in 4 to 6 weeks, and with Dr. [Last Name (STitle) 3142] in 1 to 2 weeks, and with Dr. [Last Name (STitle) 5293] in 1 to 2 weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 5662], [MD Number(1) 5663] Dictated By:[Last Name (NamePattern1) 11830] MEDQUIST36 D: [2154-4-17] 14:11:34 T: [2154-4-18] 16:23:45 Job#: [Job Number 60548]	[ "41401", "2724", "4019" ]
Admission Date: [2178-9-26] Discharge Date: [2178-10-5] Date of Birth: [2119-2-9] Sex: F Service: Neurosurgery HISTORY OF PRESENT ILLNESS: Patient is a 59-year-old woman with complex medical history, who awoke this morning with left sided weakness and a left ptosis. Reports hitting her head the day prior to admission after reaching for something in a cabinet and hit her head on the right. Felt fine until today with this, then had awoke with this left sided weakness. No nausea, vomiting, or headache. No diplopia. PHYSICAL EXAMINATION: She is afebrile. Heart rate is 94, blood pressure 117/70, respiratory rate 20, and sats 99%. Patient is lethargic, needing to repeat herself during the examination with no diplopia and no drift on the right. Sensation is grossly intact to light touch. Her strength is 5-/5 on all muscle groups on the right side. She has 0/5 in the left upper extremity except for a grasp which is 3. Her lower extremities are [4-20] on the right, and her left is 3 in the IP, 3+ in the quads, 3+ in the hams, 3+ in the AT, and 3 in the gastroc. Reflexes are 2+ in the upper extremities. Her toes are downgoing and she has a flaccid left upper extremity. PAST MEDICAL HISTORY: 1. Type 1 renal tubular acidosis. 2. Ischemic cardiomyopathy with an EF of 25%. 3. CAD status post a right stent in [2178-2-14]. 4. COPD. 5. Asthma. 6. Anxiety. 7. Depression. 8. Osteoporosis. 9. GERD. 10. Colitis. 11. Status post TAH/BSO. 12. Cholecystectomy. ALLERGIES: Demerol which causes a rash. HOSPITAL COURSE: Patient was admitted and had a head CT which showed a 2.5 cm x 12.2 cm right subdural hematoma with 1 cm midline shift. The patient was taken emergently to the OR for evacuation of the subdural hematoma. She underwent a right craniotomy for evacuation of the subdural hematoma. She was monitored in the recovery room postoperative. She was alert, awake, oriented. EOMs are full. Face is symmetric. Continued to have left sided weakness with 3 in the deltoid, 4 in the grasp, 4 in the biceps, 4+ in the triceps. Right side was [4-20]. Her IPs were 4+. She remained neurologically stable in the PACU. Was monitored and began on salt tablets for a low sodium level of 129 in the recovery room. She was on a 750 cc fluid restriction. She was transferred to the SICU for close neurologic monitoring postoperatively, and on [9-29], she was transferred to the regular floor. Her drain was removed. Her head CT showed good evacuation of the subdural hematoma. The patient began having episodes of diarrhea, and on [9-30], stools for Clostridium difficile was sent which came back positive. GI was consulted, and patient was begun on p.o. Flagyl for Clostridium difficile colitis with a rise in white count up as high as 52. Currently, her white count is 31.8, hematocrit is 35.9, platelets of 485. INR is 1.5. Her last sodium was 137, potassium was 3.2. Her BUN and creatinine of 38 and 1.2. Her vital signs have been stable. She continues to have diarrhea, although is slowing down. GI felt that she would be well treated with just p.o. Flagyl as the diarrhea which increased, will get worse. She can have p.o. Vancomycin added. She was started on a low residue diet. Incision has been clean, dry, and intact. Her staples will be removed before discharge. She will be discharged to rehabilitation with follow up with Dr. [Last Name (STitle) 1132] in one month with a repeat head CT and with the GI service in two weeks' time. DISCHARGE MEDICATIONS: 1. Ipratropium bromide one nebulizer q.6h. prn. 2. Albuterol nebulizer q.6h. prn. 3. Sodium bicarb 1300 mg p.o. q.d. 4. Metronidazole 500 mg p.o. t.i.d. 5. Miconazole powder 2% topically q.i.d. 6. Sodium chloride tablets 2 grams p.o. b.i.d. wean as tolerated. 7. Insulin sliding scale. 8. Lansoprazole 15 mg p.o. q.d. 9. Captopril 25 mg p.o. t.i.d. 10. Levothyroxine 88 mcg p.o. q.d. 11. Lamictal 750 p.o. b.i.d. 12. Furosemide 100 mg p.o. b.i.d. CONDITION ON DISCHARGE: Stable. FOLLOW-UP INSTRUCTIONS: She will follow up with Dr. [Last Name (STitle) 1132] in one month with repeat head CT and two weeks with GI service for her Clostridium difficile colitis. [Name6 (MD) ] [Last Name (NamePattern4) ], M.D. [MD Number(1) 1133] Dictated By:[Last Name (NamePattern1) 344] MEDQUIST36 D: [2178-10-5] 09:04 T: [2178-10-5] 09:02 JOB#: [Job Number 107633]	[ "2761", "4280", "4241", "496", "V5861" ]
Admission Date: [2172-9-30] Discharge Date: [2172-10-8] Date of Birth: [2092-7-20] Sex: F Service: MEDICINE Allergies: Aspirin / Shellfish / Mushroom Flavor Attending:[First Name3 (LF) 2641] Chief Complaint: hip pain Major Surgical or Invasive Procedure: none History of Present Illness: 80 y/o w/ DM2, HTN, HLD, and CAD, presents after a mechanical fall at home. 4 days prior to admission, she was getting out of bed and slided on her back/buttocks to the ground. She denied lightheadedness or dizziness preceeding fall, did not lose consciousness, and denied head strike. She was on the floor for 4 hours, and was helped back to chair with the help of EMS. Since the fall she has been having pain in her right hip. Over the past two days she made almost no urine. She also endorses intermittent chest pain for the past 1-2 weeks, which she attributed to indigestion. Pt denied SOB, HA, N/V/D, weakness, presyncope, recent sickness, or [First Name3 (LF) ] contact. There has been no medication changes. Initial ED vitals: 98 68 130/44 16 98%. Labs notable for CK [Numeric Identifier 14452], trop 0.15, Cr 6.6 (baseline 1.2), BUN 73, K 6.1. ECG showed peaked T waves in the anterior leads. She received 10 units of IV insulin, 1 amp D50, 1 amp bicarbonate, and 30g kayexalate. Foley catheter placed with little to no urine output. 2L of NS given, but urine output still minimal. Bilateral hip x-rays were negative for fracture, CXR negative for acute intrathoracic process, and renal ultrasound did not show hydronephrosis or nephrolithiasis. She also received oxycodone/acetaminophen 5/325mg once for pain. ED reports CP is reproducible on exam. Vitals prior to transfer 98.0 F 114/38, 63, 16 100% RA. On arrival to the MICU, Pt's VS were 97.2, 69, 195/71, 21, 98% on RA. Her K improved with kayexelate, insulin, bicarb. She has received total of 6L IVF, but has not picked up UOP. She is only putting out 10 cc per hour. Her CXR remains clear, and she is maintaining O2 sats. She does have LE edema, and she was transferred out to medicine for continued management of her rhabdo and [Last Name (un) ]. On transfer, her vitals were 97.5 142/45 61 13 98%RA. Currently, on the floor, the pt does not c/o pain or SOB. She is comfortable and eager to ambulate. Most recent labs: K 4.7, HCO3 21, Cr 6.5. Past Medical History: 1. Coronary artery disease (history of single vessel coronary artery status post acute coronary syndrome in [7-31], cardiac catheterization showed 100% LAD occlusion at the first diagonal branch, which was treated with a placement of overlapping Cypher stents) 2. Hyperlipidemia 3. Hypertension: Fairly well controlled on medication (at times incompliant per PCP [Name Initial (PRE) 14453]) 4. Diabetes: Type II 5. Osteoarthritis 6. Obesity 7. Cellulitis: L-foot [9-/2160], R-leg [6-/2162] 8. Cataracts: s/p L-eye cataract removal Social History: Pt lives with husband at home. - Tobacco: denies - Alcohol: social - Illicits: denies Family History: [Name (NI) ] - unclear hx 2 brothers CAD [Name (NI) 6419] sides diabetes, type II Denies family history of cancer or anemia. Physical Exam: Physical Exam on admission: Vitals: 97.2, 69, 195/71, 21, 98% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear 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, no flank tenderness on percussion GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or 1+ pitting edema in LE bilaterally, several cutaneous wounds over left shin ([1-29] recent injury), tenderness on deep palpation over right hip Physical Exam on discharge: Vitals: T 98.3, BP 150/42 (150s-180s)/(40s-70s), HR 57, RR 18, O2Sat 100%RA FBG: 160 (3H), 202 (4H), 191 (3H), 145 (15L) I: 0.88 L, O: 2.9 L (net: approximately -2L) General: Alert, oriented, no acute distress Neck: supple, JVP was not appreciated 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, no flank tenderness on percussion, no CVA tenderness GU: No Foley cathether Ext: warm, well perfused, 2+ pulses, no clubbing, no cyanosis, 2+ pitting edema in hands and lower extremities to the knees b/l, slightly improved from yesterday, several dressed cutaneous wounds over left shin ([1-29] recent injury) Skin: ecchymoses on R forearm Neuro: AAOx3. Cranial nerves II-XII intact. 5/5 strength in deltoids, TAs b/l. 4+/5 strength in IPs b/l. No asterixis. Pertinent Results: Labs on admission: [2172-9-30] 12:15PM BLOOD WBC-8.8# RBC-3.83* Hgb-11.1* Hct-36.3 MCV-95 MCH-29.0 MCHC-30.6* RDW-13.6 Plt Ct-252 [2172-9-30] 12:15PM BLOOD Glucose-100 UreaN-73* Creat-6.6# Na-139 K-6.1 Cl-105 HCO3-24 AnGap-16 [2172-9-30] 12:15PM BLOOD ALT-314* AST-821* LD(LDH)-1287* CK(CPK)-[Numeric Identifier 14452]* AlkPhos-85 Amylase-70 TotBili-0.3 [2172-9-30] 09:48PM BLOOD CK-MB-91* MB Indx-0.2 cTropnT-0.14* [2172-9-30] 06:53PM BLOOD cTropnT-0.15* [2172-9-30] 12:15PM BLOOD CK-MB-90* MB Indx-0.2 cTropnT-0.15* [2172-9-30] 09:48PM BLOOD Calcium-8.2* Phos-5.6* Mg-2.2 [2172-10-1] 04:06AM BLOOD Type-ART Temp-35.9 Rates-/2 pO2-94 pCO2-40 pH-7.35 calTCO2-23 Base XS--3 Intubat-NOT INTUBA [2172-9-30] 10:06PM BLOOD Type-[Last Name (un) ] pH-7.26* Comment-GREEN TOP [2172-10-1] 04:06AM BLOOD Lactate-0.9 [2172-9-30] 10:06PM BLOOD Lactate-1.9 [2172-10-1] 04:06AM BLOOD freeCa-1.07* [2172-9-30] 10:06PM BLOOD freeCa-1.03* [2172-9-30] 05:25PM URINE Color-DKAMBER Appear-Cloudy Sp [Last Name (un) ]-1.017 [2172-9-30] 05:25PM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR [2172-9-30] 05:25PM URINE RBC-23* WBC-3 Bacteri-FEW Yeast-NONE Epi-5 [2172-9-30] 05:25PM URINE CastGr-4* CastHy-4* Urine sediment ([2172-9-30]): + muddy brown casts BILAT HIPS (AP,LAT & AP PELVIS) ([2172-9-30]): IMPRESSION: No evidence of acute fracture or dislocation. CHEST (PA & LAT) ([2172-9-30]): IMPRESSION: No acute intrathoracic process. RENAL U.S. ([2172-9-30]): IMPRESSION: Grossly normal study, specifically with no hydronephrosis or nephrolithiasis. CHEST (PORTABLE AP) ([2172-10-1]): IMPRESSION: Little overall change. Slight mediastinal widening likely due to patient positioning. CHEST (PORTABLE AP) ([2172-10-1]): Lungs are clear. Heart size is top normal. Large hiatus hernia is chronic. No pleural abnormality. Labs on discharge: [2172-10-8] 07:25AM BLOOD WBC-8.8 RBC-3.25* Hgb-10.0* Hct-29.3* MCV-90 MCH-30.8 MCHC-34.2 RDW-14.0 Plt Ct-379 [2172-10-8] 07:25AM BLOOD Glucose-102* UreaN-96* Creat-6.8* Na-140 K-3.7 Cl-99 HCO3-25 AnGap-20 [2172-10-8] 07:25AM BLOOD Calcium-8.4 Phos-6.0* Mg-2.0 Brief Hospital Course: Patient is a 80 y/o woman with h/o DM2, HTN, HLD, and CAD who presented with hyperkalemia and [Last Name (un) ] in the setting of recent mechanical fall and elevated CK, concerning for rhabdomyolitis. Active Issues: # Acute kidney injury: Pt presented with Cr 6.1, with last Cr 1.2 in [2172-3-27]. The cause of her [Last Name (un) ] was likely multifactorial. Her FeUrea of <10% at presentation in the s/o diuretic use is c/w prerenal kidney injury, likely [1-29] decreased PO intake in the days prior. She developed toxic ATN secondary to rhabdomyolysis in s/o fall with elevated CK. Her rhabdomyolysis was possibly worsened by her simva 80mg (she has been stable on simva 80 since [2168]). The continued use of potentially renal toxic medication (i.e., lisinopril) likely exacerbated her kidney injury. Pt was initially oliguric in the ICU averaging around 10 cc/hr after receiving seven liters of NS. However, once she reached the floor she had a rapid resumption of her renal function and was able to avoid the placement of a dialysis catheter. She was likely in post-ATN diuresis on discharge, averaging nearly negative 2 L per day of UOP. In the setting of [Last Name (un) ] ACE-inhibitor, HCTZ and metformin was held. Simvastatin was held out of concern for worsening of muscle breakdown. Pt did recieve one dose of allopurinol for an elevated uric acid of 8.1. # Metabolic acidosis: Pt's bicarb was closely monitored for concern of metabolic acidosis. It trended down to a nadir of 12 on [2172-10-2]. She received multiple ampules of sodium bicarb and was then placed on a sodium bicarb drip with appropriate response. Her bicarb was WNL and stable on discharge. # Hyponatremia: Pt became hyponatremic after the sodium bicarb drip with significantly increased dependent edema. She had no pulmonary edema. In the setting of her [Last Name (un) ], she was most likely unable to reabsorb sodium efficiently with her injuried tubules, precipitating a hypervolemic hyponatremia. After discontinuation of her sodium bicarb gtt, her hyponatremia resolved. # Hyperkalemia: She likely developed hyperkalemia in the setting of rhabdomyositis and [Last Name (un) ]. There were peaking T-waves in ED, but no change compared to 1/[2171]. Pt was given calcium, glucose/insulin, kayxelate and 6L NS in the ICU. Once on the floor, initial potassium was 5.4, for which she reiceved a dose of kayexalate, after which her potassium was WNL and stable. # Anemia: Pt's anemia was most likely dilutional in nature, given her fluid intake greater than urine output. Her hematocrit was trended and monitored on this admission. # Chest pain: Pt has a history of CAD s/p LAD stenting in [2165]. However, her history is atypical for ACS. Chest pain was completely resolved once she arrived on the floor. Per ED signout, pain was reproducible on palpation. Cardiac enzymes mildly elevated, but stable, with troponin 0.15, MB 20, confounded by poor renal clearance. Chest pain was most likely related to indigestion (see Hiatal hernia section below). # HTN: Pt presented with BP 208/66, likely in the setting of [Last Name (un) ] and fluid overload. Lisinopril and hydrochlorothiazide were held given [Last Name (un) ], with continuation of metoprolol tartrate 25 mg qid. She was also discharged on amlodipine 5 mg daily. # DM2: Pt has documented DM2, on metformin 1g/d. Last A1c 7.3 in [2172-3-27]. Metformin was held in light of elevated creatinine and pt was placed on a humalog sliding scale and lantus 15 units at bedtime. # HLD: Pt was stable on simvastatin 80 mg since [2168]. Pt denied possibility of overdose. Simvastatin was held because of concern for muscle breakdown. Pt will be started on atorvastatin 40 mg as outpatient. # Hiatal hernia: Pt has a retrocardiac opacity concerning for hiatal hernia per CXR report. She also complains of heart burn. However, pt is not on treatment for GERD despite close PCP [Name Initial (PRE) 4939]. She may need outpatient follow-up to make sure not secondary to other etiology. Pt was treated empirically with famotidine initially and then omeprazole on this admission. Transitional Issues: -Pt takes care of [Name Initial (PRE) ] husband and [Name2 (NI) ] daughter, and was unable to do so during her illness. She will need support with family coping. -Pt was DNR/DNI on this admission. -Pt will follow up with Nephrology in early Novemeber -Pt will need Chem10 checked every other day for the first week at rehab, then twice a week until discharge. Please call Dr. [Last Name (STitle) ] with any worsening of her renal function. Medications on Admission: DIAZEPAM - 5 MG [Hospital1 ] HYDROCHLOROTHIAZIDE - 25 mg daily INSULIN GLARGINE [LANTUS] - 35 units sc qam LISINOPRIL - 20 mg daily METFORMIN - 500 mg [Hospital1 ] METOPROLOL SUCCINATE [TOPROL XL] - 100 mg daily NITROGLYCERIN [NITROSTAT] - 0.3 mg PRN SIMVASTATIN - 80 mg daily CYANOCOBALAMIN - 1,000 mcg daily FERROUS SULFATE [IRON (FERROUS SULFATE)] - 325 mg daily Discharge Medications: 1. diazepam 5 mg Tablet Sig: One (1) Tablet PO twice a day. 2. insulin glargine 100 unit/mL Solution Sig: One (1) Subcutaneous once a day: please take 15 units at bedtime. 3. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 4. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual once a day as needed for chest pain. 5. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. ferrous sulfate 300 mg (60 mg iron) 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. Disp:30 Capsule, Delayed Release(E.C.)(s) Refills:2 8. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 9. sliding scale Please see attached humalog sliding scale Discharge Disposition: Extended Care Facility: [Hospital6 459] for the Aged - MACU Discharge Diagnosis: Primary: Rhabdomyolysis Acute kidney injury Secondary: Diabetes Mellitus Coronary Artery 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: Dear Mrs. [Known lastname 4223], It was a pleasure to take care of you during your admission at the [Hospital1 69]. You were admitted for hip pain following your fall at home. We ran a number of blood and imaging tests during your admission. Due to muscle breakdown from when you fell down, your kidneys stopped making urine. We treated you with fluids and medications to adjust the level of electrolytes in your body. We considered starting dialysis when you were not making much urine, but you kidney's responded to our treamtment and you did not require any dialysis. You are now ready for discharge to a rehab facility. Please follow up with Dr. [Last Name (STitle) ] one to two weeks after dicharge from your rehab facility. MEDICATION CHANGES STARTED OMEPRAZOLE 20 MG DAILY STARTED AMLODIPINE 5 MG DAILY STARTED HUMALOG SLIDING SCALE STOPPED SIMVASTATIN 80 MG STOPPED HCTZ 25 MG DAILY STOPPED LISINOPRIL 20 MG DAILY STOPPED METFORMIN 500 MG TWICE A DAY CHANGED LANTUS TO 15 UNITS AT BEDTIME Followup Instructions: Name: [Last Name (LF) ],[First Name7 (NamePattern1) ] [Initial (NamePattern1) ] [Last Name (NamePattern4) 4094]: INTERNAL MEDICINE Location: [Hospital3 249] [Hospital1 ]/EAST Address: [Location (un) ], E/CC-6, [Location (un) ],[Numeric Identifier 2260] Phone: [Telephone/Fax (1) 250] Please discuss with the staff at the facility the need for a follow up appointment with your PCP when you are ready for discharge Department: WEST [Hospital 2002] CLINIC When: WEDNESDAY [2172-10-28] at 1:30 PM With: [Doctor Last Name ] [First Name8 (NamePattern2) 251] [Name8 (MD) ], MD [Telephone/Fax (1) 721] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage	[ "5845", "2762", "2761", "2767", "2859", "25000", "4019", "2724", "41401" ]
Admission Date: [2150-4-3] Discharge Date: [2150-4-8] Date of Birth: [2119-9-1] Sex: F Service: MEDICINE Allergies: Vancomycin Attending:[First Name3 (LF) 896] Chief Complaint: Abdominal pain, fever Major Surgical or Invasive Procedure: Transesophageal Echocardiogram History of Present Illness: 30 F w/ HTN, IDDM c/b gastroparesis, w/ several admits for DKA, p/w nausea/vomiting and abdominal discomfort for the past several days. She was recently discharged [3-30] for w/u hypotension and 2 falls at home which were thought to be [3-18] medication nonadherence. She was sent to ED by her PCP [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] today because her mother reported [Name (NI) 2270] had been having fevers to 103 at home around 7pm, with nausea, vomiting abominal pain and new severe flank pain. She asked her to present to ED for evaluation of pyelonephritis or other infection. . In the ED VS: 82 169/93 20 100 % RA. Her emesis in the ED appeared as dark coffee-ground material, although she was guiaic negative from below. Her physical exam was unremarkable and labs were notable for HCT of 25 that decreased to 22 on repeat a few hours later. In the ED she was started on a pantoprazole drip and GI was curbsided who did not leave formal recs but mentioned scoping patient if she were to become hemodynamically unstable. . On the floors, pt is somnolent and uncomfortable appearing. She is vomiting coffee-ground like dark material into emesis basin. She reports onset of sx 7pm yesterday and feeling in her USOH prior . Review of systems: (+/-) Unable to obtain given patient's somnolence. Past Medical History: 1. Type 1 diabetes mellitus complicated by peripheral neuropathy, followed by [Last Name (un) ]. 2. Multiple admissions for DKA (last at [Hospital3 3583] in [2-21]) 3. Depression. 4. History of perirectal abscess. 5. Eating disorder, bulimia. 6. Bacterial overgrowth 7. Chronic Renal failure of Unknown Etiology (baseline 1.3-1.8 since [1-/2150]) Social History: Lives with her parents and brother and sister-in-law. [Name (NI) 1403] as a CNA at an [Hospital3 ] facility in [Location (un) 3320]. Usually works [8-16], sometimes picks up extra shifts. No smoking, occasional alcohol (1-2 drinks per week), no drug use. Family History: PGF died of MI in his early 70s. Physical Exam: On admission: VS: afebrile 181/91 91 SaO2 97% RA GEN: somnolent F arousable to voice and touch and would follow all commands but would intermittently fall asleep during the interview; did not flinch to pain with ABG or [Month/Day (3) ] draws. AOx1 ('[Known firstname 2270]') HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: CTAB no crackles or wheezes Abd: soft, NT, +BS. no g/rt. neg HSM. neg [Doctor Last Name 515] sign. Extremities: wwp, no edema. DPs, PTs 2+. Skin: poor nail hygeine and macerated fingertips c/w chronic wretching Neuro/Psych: CNs II-XII intact. symmetric strength in U/L extremities. DTRs 2+ BL (biceps, achilles, patellar). sensation grossly intact. cerebellar fxn intact (FTN). gait deferred. following all commands. . On discharge: AF HR 60s-80s BP 160s/90s 94% on RA A&Ox3; lungs with diminished bs at bases but otherwise clear ambulating without difficulty Pertinent Results: ADMISSION LABS: [2150-4-2] 10:35PM WBC-9.7# RBC-3.11* HGB-9.4* HCT-25.4* MCV-80* MCH-30.3 MCHC-38.0* RDW-12.9 [2150-4-2] 10:35PM NEUTS-88.6* LYMPHS-7.0* MONOS-3.7 EOS-0.2 BASOS-0.5 [2150-4-2] 10:35PM PLT COUNT-198 [2150-4-2] 10:35PM GLUCOSE-173* UREA N-31* CREAT-1.4* SODIUM-136 POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-24 ANION GAP-18 [2150-4-2] 10:35PM ALT(SGPT)-27 AST(SGOT)-35 ALK PHOS-86 AMYLASE-37 TOT BILI-0.3 [2150-4-2] 10:35PM LIPASE-20 [2150-4-2] 10:46PM LACTATE-1.1 [2150-4-3] 01:40AM URINE COLOR-Yellow APPEAR-Clear SP [Last Name (un) 155]-1.015 [2150-4-3] 01:40AM URINE [Month/Day/Year 3143]-LG NITRITE-NEG PROTEIN-500 GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [2150-4-3] 01:40AM URINE RBC-21-50* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [2150-4-3] 01:40AM URINE UCG-NEGATIVE [2150-4-3] 06:44PM TYPE-ART PO2-65* PCO2-32* PH-7.45 TOTAL CO2-23 BASE XS-0 [2150-4-3] 05:09PM LD(LDH)-536* CK(CPK)-468* AMYLASE-29 TOT BILI-0.5 [2150-4-3] 05:09PM HAPTOGLOB-112 STUDIES: [4-3] CXR: Diffuse bilateral opacities most consistent with pulmonary edema. Although most frequently due to congestive heart failure, the differential diagnosis for pulmonary edema is broad and includes central nervous system disorders, sensitivity reaction, aspiration, and hemorrhage. [4-3] KUB: Non-obstructive bowel gas pattern with NG tube visualized with the tip in the stomach. [4-4] TTE: No echocardiographic evidence of endocarditis. EF 60-65%. Normal regional and global biventricular systolic function. The valves are well seen without significant regurgitation making endocarditis unlikely. . [4-8] TEE: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. A central line is seen in the SVC/right atrium without evidence of overlying thrombus/vegetation. Overall left ventricular systolic function is normal (LVEF>55%). The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 42 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. There is a trivial/physiologic pericardial effusion. IMPRESSION: Trace aortic regurgitation with normal valve morphology. [Month/Year (2) ] culture: [4-2], [4-3] MSSA in [3-18] bottles [Date Range ] culture [4-4] and thereafter: NGTD Urine culture: negative . Renal U/S: IMPRESSION: Echogenic kidneys concerning for diffuse parenchymal kidney disease. No stones, perinephric collection or hydronephrosis noted. . Discharge labs: [2150-4-8] 05:18AM [Month/Day/Year 3143] WBC-6.4 RBC-2.97* Hgb-8.6* Hct-24.2* MCV-81* MCH-29.0 MCHC-35.6* RDW-12.9 Plt Ct-208 [2150-4-8] 05:18AM [Month/Day/Year 3143] ESR-92* [2150-4-7] 05:40AM [Month/Day/Year 3143] Ret Aut-1.1* [2150-4-8] 05:18AM [Month/Day/Year 3143] Glucose-87 UreaN-34* Creat-2.2* Na-140 K-3.8 Cl-107 HCO3-26 AnGap-11 [2150-4-7] 05:40AM [Month/Day/Year 3143] ALT-14 AST-16 LD(LDH)-321* AlkPhos-67 TotBili-0.2 [2150-4-8] 05:18AM [Month/Day/Year 3143] Calcium-8.5 Phos-3.6 Mg-2.4 [2150-4-3] 01:40AM [Month/Day/Year 3143] %HbA1c-10.0* eAG-240* [2150-4-8] 05:18AM [Month/Day/Year 3143] CRP-48.5* Brief Hospital Course: 30 F w/ IDDM c/b gastroparesis and HTN p/w n/v and coffee-ground emesis concerning for UGIB. In the MICU, patient was transfused 1U PRBC with hematocrit remaining stable and stool guaiac negative. She was seen by GI who felt that the NG return showed brown, not coffee-ground emesis and deferred endoscopy given hemodynamic and hematocrit stability. Her MICU course was otherwise notable for respiratory distress attributed to possible aspiration in the setting of her emesis. She required a non-rebreather to keep up her sats in the morning, but was quickly weaned to 3L nasal canula. [Month/Day/Year ] cultures were significant for coag positive S. aureus. Patient was started on vancomycin and zosyn for broad coverage. A TTE was done which was read with a low likelihood of endocarditis. Stool cultures, urine cultures negative to date. Influenza swab was negative. NGT was clamped and removed prior to call out to the floor. Finally, patient presented with [Last Name (un) ]- FeNa was 0.21% consistent with a prerenal process. Renal was consulted. . Pt was transferred to the floor on [4-5]. On the floor, issues were managed as follows: # MSSA Bactermia: MSSA grew in [3-18] bottles on [2-25]. Surveillance cultures were negative. From prior hospitalization, [Month/Year (2) ] culture from [3-28] was negative. the bacteremia was thought to be [3-18] PIV. No vegetations were seen on TTE. Vancomycin was initially started. ID was consulted on HD #4 and recommended TEE, which was performed on [4-8] and showed no vegetation. PICC line was placed. Patient was discharged to complete 14-days of cefazolin 2g q8h. Outpatient MRI order was entered for [2150-4-17] with plans to obtain BUN/Cr prior to study. . # Hypoxia: Initial CXR showed pulmonary edema. Pt was on non-rebreather in the ICU. She was treated for HAP initially with Vancomycin/Zosyn. There was also concern for aspiration pneumonia given aspiration history, however radiographs were not consistent with this diagnosis. On HD #4, zosyn and vancomycin were discontinued. Pt was weaned from oxygen and was ambulating comfortably on room air prior to discharge. . # ? GI bleeding: Treated as above in the ICU. On the floor, the patient had no further episodes of nausea/vomiting. Hct was stable. Pantoprazole 40 mg PO BID was continued but stopped prior to discharge. Aspirin was held initially, restarted upon discharge. . # Acute on chronic kidney injury: Creatinine increased to 3.1 from baseline of ~ 1.4. Renal was consulted and felt the clinical picture and urine sediment were most consistent with ATN. Medications were renally dosed. Cr improved to 2.2 and BUN to 34 from a peak of 45. . # HTN: On the floor, [Month/Day/Year ] pressure was managed with verapamil 40 mg q8h, which was uptitrated to 120 mg q8h. Lisinopril was held due to acute kidney injury. [Month/Day/Year ] pressures were consistently 160s-170s/80s-90s. Plans were for her to see her PCP in [Name9 (PRE) 702] to restart lisinopril and uptitrate BP medications as necessary. Patient was discharged on 360 mg ER Verapamil. . # IDDM: A1C = 10%. Lantus eventually uptitrate to 20 U (home dose). Gabapentin was renally dosed. Diabetic diet was ordered. . # Hypothyroidism: TSH slightly elevated but normal free T4. Continued Levoxyl 75 mcg qday. . # Depression/anxiety: Continued home risperdal, fluoxetine. . Transitional Issues: - BP control: likely restart lisinopril as Cr normalizes; titrate verapamil as needed - MRI back: Ordered for [2150-4-17]; BUN/Cr to be drawn prior to study (concern for osteomyelitis given MSSA bacteremia) - 2 weeks cefazolin (finishes [2150-4-17]) - improved DM control Medications on Admission: ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Capsule - 1 Capsule(s) by mouth qweekly once a week for 8 weeks, then start [2139] units daily FLUOXETINE -40 mg Capsule - 2 Capsule(s) by mouth daily FUROSEMIDE - (Dose adjustment - no new Rx) (On Hold from [2150-3-13] to unknown for Cr increased to 2.0) - 40 mg Tablet - 1 Tablet(s) by mouth qday GABAPENTIN [NEURONTIN] - 400 mg Capsule - 3 Capsule(s) by mouth twice a day INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 100 unit/mL Cartridge - 20units/ day once a day INSULIN GLULISINE [APIDRA] - (Prescribed by Other Provider) - 100 unit/mL Cartridge - per sliding scale as needed LEVOTHYROXINE - (Dose adjustment - no new Rx) - 25 mcg Tablet - 2 Tablet(s) by mouth DAILY (Daily) LISINOPRIL - (Prescribed by Other Provider) (On Hold from [2150-2-20] to unknown for [3-18] elevated Cr) - 10 mg Tablet - Tablet(s) by mouth METOCLOPRAMIDE - (Prescribed by Other Provider) (Not Taking as Prescribed: not taking) - 5 mg Tablet - 1 Tablet(s) by mouth before meals RISPERIDONE - (Prescribed by Other Provider: [Name Initial (NameIs) 16471]) - 0.5 mg Tablet - 0.5 (One half) Tablet(s) by mouth HS (at bedtime) Carvedilol 12.5 mg PO BID Medications - OTC ASPIRIN [ASPIR-81] - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - Tablet(s) by mouth CALCIUM CARBONATE-VIT D3-MIN - (Prescribed by Other Provider) - 600 mg-400 unit Tablet - 1 Tablet(s)(s) by mouth twice a day ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 2,000 unit Capsule - 1 Capsule(s) by mouth qday start daily after you finish the 8 weeks replacement LOPERAMIDE [IMODIUM A-D] - (OTC) - 2 mg Tablet - 1/2-1 Tablet(s) by mouth morning of diarrhea and up to 4 times per day as needed MULTIVITAMIN WITH IRON-MINERAL [CENTRUM] - (Prescribed by Other Provider) - 400 mcg-162 mg-18 mg-300 mcg-250 mcg Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. cefazolin 1 gram Recon Soln Sig: Two (2) grams Intravenous every eight (8) hours for 10 days: Last day of antibiotics is [2150-4-17]. Disp:30 doses Refills:0 2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY (Daily). 4. Lantus 100 unit/mL Solution Sig: Twenty (20) Units Subcutaneous once a day. 5. risperidone 0.25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO every twelve (12) hours. 7. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1) Tablet PO once a day. 8. Vitamin D 2,000 unit Capsule Sig: One (1) Capsule PO once a day. 9. Apidra 100 unit/mL Solution Sig: 1-12 Units Subcutaneous TID w/ meals: Sliding scale insulin. 10. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 11. multivitamin Tablet Sig: One (1) Tablet PO once a day. 12. verapamil 120 mg Cap,Ext Release Pellets 24 hr Sig: Three (3) Cap,Ext Release Pellets 24 hr PO once a day. 13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:14 Adhesive Patch, Medicated(s) Refills:0 14. Work excuse Please excuse [Known firstname 2270] [Known lastname 12997] from work between the dates of [2150-4-3] to [2150-4-17]. She was an inpatient at [Hospital1 18] from [2150-4-3] to [2150-4-8] and requires IV medication until [2150-4-17]. Thanks. 15. Outpatient Lab Work Please draw Chem7 on [2150-4-15] so that renal function is known prior to MRI. Thanks. These should be faxed to Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] at [Hospital 18] [Hospital 191] clinic. Discharge Disposition: Home With Service Facility: critical care systems Discharge Diagnosis: Primary: MSSA Bacteremia Acute on chronic kidney disease Acute on chronic diastolic CHF Hypertension . Secondary: Insulin dependent diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure caring for you at the [Hospital1 827]. You were admitted for nausea, vomiting, and fever. There was concern that you had gastrointestinal bleeding when you were vomiting, though this is not certain. [Hospital1 ] cultures showed that you had bacteria in your [Hospital1 ] - called staphylococcus aureus. For this infection, you will need to complete 2 weeks of antibiotics and you will need an MRI to rule out infection in your back (since you had persistent back pain). You had an echo, which ruled out infection of your heart valves. Also, we worked to bring your [Hospital1 ] pressure under better control though it was still high. Your kidneys showed acute dysfunction, but the function began to improve after you were transferred out of the intensive care unit. . We made the following changes to your medications: We HELD Lisinopril because of kidney dysfunction; you will likely restart this medication after meeting with Dr. [Last Name (STitle) ] We INCREASED Verapamil to better control your [Last Name (STitle) ] pressure; Dr. [Last Name (STitle) ] may decrease the dose of this medicine as lisinopril is restarted We STARTED lidocaine patch for back pain We STARTED Cefazolin to treat your bacteremia; you will complete 14-days of antibiotics; last day is [2150-4-17]. . Your follow-up information is listed below. You will need an MRI of your thoracic and lumbar spine to rule out osteomyelitis in your spine within the next 2 weeks. You need to have [Month/Day/Year ] tests of your kidney function performed prior to this study. Followup Instructions: Department: [Hospital3 249] When: FRIDAY [2150-4-10] at 10:20 AM With: [First Name8 (NamePattern2) 2878] [First Name8 (NamePattern2) 26] [Last Name (NamePattern1) 2879], MD [Telephone/Fax (1) 250] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "5845", "2851", "4280", "5859", "2449" ]
Admission Date: [2187-4-13] Discharge Date: [2187-4-18] Service: CHIEF COMPLAINT: Hypotension and hypothermia. HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old woman with a history of metastatic transitional cell carcinoma, and bilateral hydronephrosis, chronic renal insufficiency, and right infiltrating ductal carcinoma who presented to the Emergency Department after being found down by family members. At that time, the patient was noted to be both hypotensive and hypothermic. Per Emergency Department report, she apparently had fallen 24 hours to 36 hours before being found and was unable to rise secondary to weakness. She denied any loss of consciousness or focal pain. On initial presentation, the patient was alert, weak, conversant, but hypothermic with a rectal temperature of 92.9. She was bradycardic into the 40s with a blood pressure of 118/42. PAST MEDICAL HISTORY: 1. Transitional cell carcinoma with metastatic disease to the liver and pelvis, bilateral hydronephrosis. 2. Right infiltrating ductal carcinoma of the breast diagnosed in [2186-5-30], status post lumpectomy and radiation therapy. Chemotherapy was discontinued at the patient's request. 3. Hypertension. 4. Hypercholesterolemia. 5. Hypothyroidism after ablation. 6. Chronic renal insufficiency. 7. Macular degeneration. 8. Status post left total hip replacement in [2180]. 9. Bilateral hydronephrosis (as previously described). 10. Anemia. 11. Nephrolithiasis. MEDICATIONS ON ADMISSION: (At home) 1. Nadolol 40 mg p.o. b.i.d. 2. Diovan. 3. Ferrous sulfate. 4. Lipitor. 5. Epogen. ALLERGIES: Allergy to ASPIRIN and CODEINE. SOCIAL HISTORY: The patient lives alone at home. She has a heavy tobacco use history, but quit more than 20 years ago. She denies ethanol use. PHYSICAL EXAMINATION ON PRESENTATION: Initial physical examination was as follows; temperature of _____, pulse of 55, blood pressure of 96/43, respiratory rate of 16, oxygen saturation of 100% on 3 liters nasal cannula. She was an elderly-appearing, thin, chronically ill-appearing woman in no acute distress. Her head, eyes, ears, nose, and throat examination was significant for bilateral irregular post surgical pupils. Her mucous membranes were dry. Her neck was supple. No lymphadenopathy was noted. Her lungs were clear to auscultation bilaterally. Her heart was regular but bradycardic. Normal first heart sound and second heart sound. No third heart sound or fourth heart sound were noted; however, there was a 2/6 systolic murmur at the apex and a 2/6 systolic murmur at the base. Her abdomen was soft, nontender, and nondistended, with inguinal lymphadenopathy. Her extremities were without clubbing, cyanosis or edema. She had chronic venous stasis changes in her shins bilaterally. On neurologic examination, she was awake and oriented to person only. PERTINENT LABORATORY DATA ON PRESENTATION: Admission laboratory studies were as follows; white blood cell count of 26, hematocrit of 34.1, platelets of 339. On her white blood count, there was left shift with 92% polys, 3% bands, 3% lymphocytes, 2% monocytes. Sodium of 143, potassium of 4.6, chloride of 106, bicarbonate of 15, blood urea nitrogen of 57, creatinine of 2 (up from a baseline of 1.4), blood glucose of 75. RADIOLOGY/IMAGING: Electrocardiogram showed sinus bradycardia with normal axis, first-degree anterior vesicular block delay with an increased QTc of 515. A chest x-ray was unrevealing. A head CT without contrast did not show any acute intracranial pathology. HOSPITAL COURSE: The patient was initially admitted to the Medical Intensive Care Unit for pressor support, as the patient had previous advanced directive of do not resuscitate/do not intubate. By hospital day four, the patient was weaned off pressors; however, she subsequently developed left upper extremity paralysis and a leftward gaze and was unresponsive. At that time, the family decided to make the patient comfort measures only with antibiotics and intravenous fluids to be continued. Under the guidance of palliative care, a morphine drip was started to make the patient more comfortable. The patient expired on [2187-4-18]. DISCHARGE DIAGNOSES: 1. Transitional cell carcinoma. 2. Cerebrovascular accident. 3. Sepsis. [First Name11 (Name Pattern1) 312] [Initials (NamePattern4) ] [Last Name (NamePattern4) 313], M.D. [MD Number(1) 314] Dictated By:[Last Name (NamePattern1) 9348] MEDQUIST36 D: [2187-7-3] 16:19 T: [2187-7-4] 12:30 JOB#: [Job Number 104595]	[ "0389", "5849", "2859", "4019", "2720" ]
Admission Date: [2136-3-25] Discharge Date: [2136-4-1] Date of Birth: [2056-12-31] Sex: M Service: CARDIOTHORACIC Allergies: Morphine / Indocin / Iodine; Iodine Containing / Mucomyst Attending:[First Name3 (LF) 1283] Chief Complaint: 2 episodes of congestive heart failure Major Surgical or Invasive Procedure: Mitral Valve Replacement(tissue) and RF MAZE procedure via Right Thoracotomy [2136-3-26] History of Present Illness: 79 y/o male with h/o CABGx5/Asc. Aortic and Hemi-Arch replacement in [2132] who has had multiple episodes of congestive heart failure with hospitilizations recently. Echo performed at that time revealed Mitral Regurgitation. More recently repeat echo revealed severe MR w/ dilated LA. Cardiac cath also confirmed MR along with patent grafts from prior CABG. He presented for surgical management for his Mitral Regurgitaion. Past Medical History: Coronary Artery Disease/Asc. Aortic Aneurysm s/p CABGx5/Asc. Aortic Replacement/Hemi-Arch [2132] Atrial Fibrillation since [12-1] (on Coumadin) Hypertension Hypercholesterolemia Congestive Heart Failure IMI [2114] GI Bleed/Ulcer [2109] Amaurosis fugax R. [6-1] Peripheral Vascular Disease Abd. Aortic Aneurysm s/p Repair in 1007 w/ L. Iliac repair Malaria [2075] Seasonal Allergies Deviated Septum Skin Cancer (face) s/p removal s/p L. ext. carotid ligation Social History: Lives with wife. Retired [Name2 (NI) 15068] Officer. Quit smoking in [2109] after 80pk/yr hx. Drinks ETOH rarely. Family History: Mother died of MI at 55 Father and Brother w/ AAA Physical Exam: VS: 80Irreg 17 R144/76 L128/72 5'8" 175# General: Sitting in NAD Skin: Sl. ruddy chest HEENT: PERRL, EOMI, Non-icteric Neck: Supple, FROM, -JVD Chest: CTAB -w/r/r w/ well-healed sternal scar Heart: Irregular rhythm w/ 2/6 SEM Abd: Soft, NT/ND, +BS w/ healed abd. scar Ext: Warm, well-perfused [1-30]+ edema w/ healed mult. harvest incision BLE Neuro: Non-focal, MAE, A&O x 3 Pertinent Results: [2136-3-25] 02:23PM BLOOD WBC-6.6 RBC-5.10 Hgb-15.6 Hct-43.7 MCV-86 MCH-30.6 MCHC-35.7* RDW-15.2 Plt Ct-220 [2136-3-29] 02:53AM BLOOD WBC-8.2 RBC-4.23* Hgb-13.2* Hct-36.7* MCV-87 MCH-31.2 MCHC-35.9* RDW-15.4 Plt Ct-99* [2136-3-25] 02:23PM BLOOD PT-15.5* PTT-30.4 INR(PT)-1.4* [2136-3-29] 02:53AM BLOOD PT-13.7* PTT-31.8 INR(PT)-1.2* [2136-3-25] 02:23PM BLOOD Glucose-99 UreaN-20 Creat-1.3* Na-137 K-7.1* Cl-101 HCO3-24 AnGap-19 [2136-3-29] 02:53AM BLOOD Glucose-91 UreaN-14 Creat-0.9 Na-135 K-3.8 Cl-100 HCO3-27 AnGap-12 [2136-3-29] 02:53AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.1 [2136-3-28] 04:37PM BLOOD freeCa-1.08* [2136-3-25] 07:32PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG [2136-3-25] 07:32PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-<1 Echo [3-26]: PRE-CPB: The left atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is moderately depressed. Resting regional wall motion abnormalities include infero septal, inferoir and inferolateral walls. EF is 30 %. The mitral valve leaflets are moderately thickened. There is mild mitral valve prolapse of the posterior leaflet. Severe (4+) mitral regurgitation is seen. Systolic flow reversal seen in the pulmonary vein. POST-CPB: Well-seated bioprosthetic valve in the mitral position, with trace MR and no paravalvular leak. There is no LVOT obstruction. The post-bypass EF is now 35-40% on inotropic support. CXR [3-28]: No pneumothorax. Improvement in right lower lobe opacification. Brief Hospital Course: Mr. [Known lastname 64525] was initially seen in clinic and was admitted prior to surgery secondary to Coumadin use. He stated he discontinued Coumadin on [3-22] and was started on Heparin along with two Vitamin K when admitted. He also underwent full pre-operative work-up. His lab work, including INR, was suitable for surgery and was brought to the operating room on [2136-3-26] where he underwent a Mitral Valve Replacement and RF MAZE procedure via Right thoracotomy. Please see op note for surgical details. Following the procedure he was transferred to the CSRU in stable condition with Inotropic support and Amiodarone. Later on op day patient was weaned from sedation and awoke neurologically intact. He was then extubated. He was weaned off of all Inotropes by post-op day one and required Nitro for hypertension (which was weaned off by POD#2). On post-op day two he had multiple hypoxic events with decrease in his O2 saturations and PaO2. He underwent a bronchoscopy for a therapeutic aspiration. Multiple mucus plugs were aspirated from RUL/RLL. Post Bronch it was noted his gag response had not returned and a bedside evaluation was performed. He passed the swallow study and eventually advanced to a regular diet without problems. [Name (NI) ] on post-op day two his chest tubes were removed. Mr. [Known lastname 64525] was recovering well post-operatively and transferred to the cardiac step-down unit on post-op day three. He continued to remain on amiodarone for atrial fibrillation and Coumadin was started. Physical therapy followed patient during his post-op period for strength and mobility. On post-op day 6 he was doing well, but required further physical therapy rehabilitation. His INR was above 1.3 and was discharged against medical advice on Amiodarone and Coumadin. He was informed that should not leave because his INR was not theraputic. However, after a long discussion , he wished to leave. He will follow-up in 4 weeks and earlier with his PCP and Cardiologist. Medications on Admission: Lisinopril 5mg qd, Cardizem 240mg qd, Digoxin 0.25mg qd, Lasix 40mg qd, Albuterol INH prn, Coumadin 5mg/4mg (alternating) with last dose of 2mg on [2136-3-22] Discharge Medications: 1. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:60 Tablet(s) Refills:2 2. Aspirin EC 81 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 3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:60 Capsule(s) Refills:2 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:30 Tablet(s) Refills:2 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 7. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:90 Tablet(s) Refills:2 8. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime for 1 doses. Disp:1 Tablet(s) Refills:1 Discharge Disposition: Home With Service Facility: [Hospital1 11485] VNA Discharge Diagnosis: Mitral Regurgitation s/p Mitral Valve Repalcement Atrial Fibrillation s/p RF MAZE procedure Hypertension Hypercholesterolemia Congestive Heart Failure Discharge Condition: good Discharge Instructions: Can take shower. Wash icisions with water and gentle soap. Do not take bath. Do not apply lotions, creams, ointments, or powders. Do not drive for 1 month. Do not lift more than 10 pounds for 2 months. If you develop a fever greater than 101.5 or notice drainage from your incision, please contact the office immediately. [Last Name (NamePattern4) 2138]p Instructions: Dr. [Last Name (Prefixes) ] in 4 weeks Dr. [Last Name (STitle) 64526] in [1-30] weeks Dr. [Last Name (STitle) 64527] in [3-2] weeks Dr. [Last Name (STitle) ] in [1-30] weeks Completed by:[2136-4-1]	[ "4240", "42731", "4280", "V4581", "4019", "412" ]
Admission Date: [2100-8-1] Discharge Date: [2100-8-6] Date of Birth: [2036-5-31] Sex: M Service: SURGERY Allergies: Codeine Attending:[First Name3 (LF) 1384] Chief Complaint: Bleeding liver mass Major Surgical or Invasive Procedure: None History of Present Illness: 64M, known chronic hepatitis/hepatomegaly, presented to [Hospital3 5365] ED 2 days ago with acute onset of abdominal pain and full body discomfort and an episode of "blacking out". Patient was in usual state of health until that time, and went to [Hospital3 5365]. Was hypotensive in the 80s, responded to 2L of IVF. Had some dry heaves, but no nausea/vomitting/ hematemesis. No brbpr or hematochezia. No fevers, chills, sweats, CP or SOB. Reports about 10lb wt loss over the past 2 months. Had hct of 32, got 2U of prbcs. no hct since that time. Past Medical History: Hep C, ?hep B, htn, ptsd, fibromyalgia, emphysema (can walk multiple flights of stairs), fairly clean cath in [3-5] (60% RCA stenosis) Social History: remote h/o of IVDU/cocaine (Denies any currently), no ETOH, 50pk year tobacco, current 1 ppd. Homeless, living with a friend now. Family History: N/C Physical Exam: 98.7 79 99/60 13 99%RA NAD AOx3 RRR CTAB w/ scattered wheezes mild distension, hepatomegaly, tender lower ab only to deep palpation, no signs of varices no c/c/e, +2 distal pulses Pertinent Results: On Admission: [2100-8-1] WBC-11.1* RBC-3.44* Hgb-10.7* Hct-30.8* MCV-90 MCH-31.0 MCHC-34.6 RDW-14.0 Plt Ct-220 PT-12.2 PTT-23.1 INR(PT)-1.0 Glucose-97 UreaN-23* Creat-0.7 Na-137 K-4.4 Cl-105 HCO3-25 AnGap-11 ALT-41* AST-60* AlkPhos-77 TotBili-0.5 Albumin-3.5 Calcium-8.7 Phos-2.6* Mg-2.0 Iron-150 [2100-8-1] calTIBC-252* Ferritn-336 TRF-194* [2100-8-1] HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-POSITIVE HAV Ab-NEGATIVE HCV Ab-POSITIVE [2100-8-1] CEA-1.1 AFP-13.9* On Discharge: [2100-8-6] WBC-6.7 RBC-3.87* Hgb-12.3* Hct-34.3* MCV-89 MCH-31.7 MCHC-35.7* RDW-14.2 Plt Ct-249 PT-12.7 PTT-26.3 INR(PT)-1.1 Glucose-89 UreaN-12 Creat-0.6 Na-137 K-4.3 Cl-101 HCO3-29 AnGap-11 ALT-46* AST-56* AlkPhos-120* TotBili-1.2 Brief Hospital Course: 64 y/o male initially transferred from OSH to the SICU. Triple phase CT scan was performed on his abdomen. -Segment VIII 4.0 x 3.9 x 4.0-cm heterogeneously enhancing liver mass is concerning for a hepatoma. -No change in hemoperitoneum, with no evidence of active extravasation. -Subtle focus of arterial enhancement in segment VI, also concerning for malignancy. -Tumor/ thrombus in middle hepatic vein. -Mesenteric stranding and thick walled colon, likely from third spacing. Varices. He received 3 units of RBC's for the bleeding from the right lobe of the liver. His Hct remained stable following the transfusions. Patients' main complaint was pain, most notably in shoulders and upper back. He was initially given oxycodone with fair effect and switched to dilaudid which appeared to provide better pain relief. Patient was seen by the GI service while in house, and an attempt was made to obtain EGD. He was unable to tolerate conscious sedation, and in fact became agitated with administration of Versed. The patient will be scheduled for an outpatient EGD and potentially for liver biopsy to assess status of the hepatitis C and evidence of cirrhosis as this has not been done in the past. Patient underwent nuclear bone scan which reports: No scintigraphic evidence of osseous metastases. Degenerative changes in the lower lumbar spine, mid thoracic spine, right sternoclavicular joint and right knee. He was also seen by Hepatology service who will follow, and if patient wishes to pursue interferon therapy at some point, they will become involved. Patients case was presented at Radiologic rounds and the decision was made to offer patient chemoembolization as this was not felt to be resectable. He will return to Dr [Last Name (STitle) 9411] clinic in 2 weeks and also has GI follow-up scheduled. Medications on Admission: atenolol 50', percocet, trazadone, omeprazole Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:2 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: Hemoperitoneum s/p bleeding mass in liver concerning for hepatoma Discharge Condition: fair Discharge Instructions: Please call Dr.[Name (NI) 670] office [Telephone/Fax (1) 673] if you have abdominal pain, fever more than 101, chills, nausea, vomiting, blood in stool Do not lift anything heavier than a gallon of milk, no heavy labor until cleared by Dr [First Name (STitle) ] Followup Instructions: Follow up with Dr. [First Name (STitle) ] [Telephone/Fax (1) 673] on [8-20] at 3:20 [Name6 (MD) 1948] [Last Name (NamePattern4) 1949], MD Phone:[Telephone/Fax (1) 463] Date/Time:[2100-8-26] 11:00 EUS (ST-4) GI ROOMS Date/Time:[2100-8-26] 11:00 Completed by:[2100-8-6]	[ "4019", "3051" ]
Admission Date: [2194-6-13] Discharge Date: [2194-6-18] Service: HISTORY OF PRESENT ILLNESS: The patient is a [Age over 90 ]-year-old man with a history of peptic ulcer disease, coronary artery disease, status post myocardial infarction in [2179] as well as [2193], temporal arteritis, who presented with melenas and chest pain. The patient reported melanotic stools times 5 since 4 p.m. on the day prior to admission. No hematemesis or hematochezia. Stools were loose. The patient had a history of melena in [2192-5-14]. The patient also reported being lightheaded, fatigued with an increase in his ch set discomfort for which he was taking sublingual nitroglycerin with relief. On the a.m. of presentation, the symptoms persisted; the patient contact[Name (NI) ] his PCP who sent him to the [Name (NI) ]. In the ED, the p was found to have a hematocrit of 22.9 decreased from a baseline of 32 to 38. He was given IV Protonix, IV fluids, and transfused the first of 2 units of packed red blood cells. Gastroenterology was consulted. The patient initially had an EKG with slight inferior changes while the patient was pain free. The patient then had an episode of [9-23] substernal chest pain in the ED with 3 to [Street Address(2) 94587] changes in V3 to V4. PAST MEDICAL HISTORY: Significant for upper gastrointestinal bleed in [2192-5-14]. An esophagogastroduodenoscopy showed an ulcer in the pylorus and chronic gastritis, coronary artery disease, status post myocardial infarction in [2179] and [2193], benign prostatic hypertrophy, history of temporal arteritis, pemphigoid, history of anemia, history of small bowel volvulus, status post appendectomies, status post inguinal hernia repair x2, history of colonic polyps, and sigmoid diverticulosis. ALLERGIES: THE PATIENT HAS NO KNOWN DRUG ALLERGIES. MEDICATIONS: The patient was on: 1. Celebrex. 2. Aspirin. 3. Prednisone. 4. Atenolol. 5. Imdur. 6. Nitroglycerin p.r.n. SOCIAL HISTORY: He is a retired physician, [Name Initial (NameIs) 2447]. Remote tobacco history. Social alcohol use, which is infrequent. Married with 1 son. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON ADMISSION AS FOLLOWS: VITAL SIGNS: Vital signs of 98.9 temperature, blood pressure 128/80, pulse 72, respiratory rate of 13, and oxygen 100% on 3 liters. GENERAL: The patient appeared comfortable. HEENT: Examination was unremarkable except for pale conjunctiva, dry mucosa. LABORATORY DATA: Significant for the hematocrit of 23 as stated above, a potassium of 5.3, a BUN 78. Initial CK was 107 with an MB of 6 and a troponin of 0.02. INR was 1.0. Urinalysis was unremarkable. As stated above, the patient had 2 EKGs and the second of which showed 2 to [Street Address(2) 5366] changes in V3 to V6. Chest x-ray showed no acute cardiopulmonary process, so the patient was admitted to the hospital. CONCISE SUMMARY OF HOSPITAL COURSE AS FOLLOWS: GI: The patient was felt to likely have another bleeding ulcer as the etiology of his melanotic stools and anemia. The patient had a history of Helicobacter pylori in the past that was treated. The patient was felt to require EGD to evaluate for recurrent infection as well as ongoing bleeding. The patient was initially admitted to the ICU. Gastroenterology was consulted. The patient was taken for EGD on [6-13], which showed a deep antral ulcer, no acute bleeding. The ulcer was injected. The patient was initially continued on IV b.i.d. Protonix. Hematocrits were followed and the patient was maintained on 2 peripheral IV's at all times, and aspirin was held. The patient has another episode of melanotic stool. On [2194-6-14], he was taken for another EGD, at that time which showed the ulcer was not bleeding. As a result, the patient was felt to be stable for discharge to home from a GI perspective with continuation of the b.i.d. Protonix. The patient to follow up for a repeat endoscopy in 8 weeks as an outpatient. Cardiac: Cardiac enzymes had been significant for elevated troponin on admission. Cardiology was contact[Name (NI) ] who did not recommend cardiac catheterization or coronary artery bypass graft. The patient initially received heparin and was restarted on aspirin, which was approved by GI as long as the patient had serial hematocrits. The patient was transfused to keep the hematocrit above 30. He was restarted on atenolol. The patient was also on Imdur for a longer-acting vasodilator effect. The patient had a couple of episodes of further chest pain during the admission but had no further EKG changes. Pulmonary: The patient had some desaturations to 70's and 80's with ambulation without improvement with oxygen with ambulation, but at this time the patient was completely asymptomatic and the patient's oxygen saturation recovered spontaneously to the high 90's on room air with rest. As a result, this was felt to possibly be not reflective of the patient's pulmonary status, but reflective of some peripheral vascular changes with ambulation. The patient was not felt to need inpatient workup and will follow up with PCP as an outpatient. Hematology: The patient with acute blood loss anemia, received a total of 4 units of packed red blood cells, had serial hematocrits while on heparin gtt and was transfused to keep the hematocrit above 30. Musculoskeletal: The patient was restarted on his prednisone for polymyalgia rheumatica and temporal arteritis. DISCHARGE DIAGNOSES: Gastric ulcer. Gastrointestinal bleed. Demand ischemia, elevated troponins, and EKG changes in the setting of acute blood loss anemia. DISCHARGE MEDICATIONS: 1. Nitroglycerin sublingual. 2. Prednisone 5 mg p.o. daily. 3. Atenolol 25 mg p.o. q. p.m., 50 mg p.o. q. a.m. 4. Protonix 40 p.o. b.i.d. 5. Aspirin 325 mg. 6. Isosorbide mononitrate. DISCHARGE FOLLOWUP: Follow up with Cardiology on [Last Name (LF) 2974], [6-20], at 9:15 a.m. The patient's primary cardiologist is Dr. [Last Name (STitle) 104122]. Dr. [Last Name (STitle) 104122] was not available so the patient followed up with Dr. [Last Name (STitle) 11378]. The patient also followed up with Dr. [Last Name (STitle) ] for outpatient endoscopy on [8-21] at 12:30 p.m. and the patient was suggested to pursue cardiac rehabilitation in 4 to 6 weeks. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], [MD Number(1) 5825] Dictated By:[Last Name (NamePattern1) 8160] MEDQUIST36 D: [2194-8-1] 12:24:02 T: [2195-5-15] 13:09:19 Job#: [Job Number 94529]	[ "41071", "2859", "41401" ]
Admission Date: [2140-5-6] Discharge Date: [2140-5-11] Date of Birth: [2067-7-16] Sex: M Service: MEDICINE Allergies: Pollen Extracts / Benzodiazepines Attending:[First Name3 (LF) 1148] Chief Complaint: suicide attempt Major Surgical or Invasive Procedure: Intubation for airway protection History of Present Illness: 72 YOM who presents after suicide attempt. He was found unresponsive by wife this am with an empty bottle of temazepam at his side. He was given 2 of narcan by EMS without any improvement. Recent hx of suicidal expression and was admitted to [Hospital Unit Name 153] in [5-/2139] for similar episode. Intubated in ED for respiratory protection. Apparently has been haveing increasing depression over last couple of months in regards to failing health (Prostate CA, bad knees, hearing loss). He is being transferred to the [Hospital Unit Name 153] for observation of respiratory status overnight since the half-life of flumazenil is about [11-24] the half life of temazepam (8-25h). . Med list from EMS: cipro, sulfa, flomax, tamazepam, flurazepam. His wife is searching at home for any additional medications. . In the ED: - intubated for respiratory protection - UTox and STox only showed benzodiazepines -> Toxicology consult came by to see him and decided not to administer flumazenil out of concern for benzodiazepine withdrawl or of unmasking an underlying seizure disorder. - administered charcoal - while in the ED -> he was hypotensive while on propofol -> changed to etomidate bolii for sedation - he was bradycardiac in the ED to 48 (while at CT scanner) -> but otherwise has been in the 50s -> his wife is checking at home for additional medications. - CT Head: negative for ICH (wet read) - EKG: NSR - 2 PIVs Past Medical History: 1. Prostate cancer s/p brachytherapy on [2138-5-19]. s/p TURP 2. appendectomy 3. b/l hernia 4. tendonitis 5. Recurrent major depression - since early [2112] analyst on and off since [2102], Dr. [First Name8 (NamePattern2) 20180] [Last Name (NamePattern1) 7739], who practices out of [Hospital1 8] ([Telephone/Fax (1) 94591] 6. Recurrent UTIs Social History: Born in NY. Moved to [Location (un) 86] area as child when his father began Ophthalmology training. Only child of married parents. Mo and Fa died of medical illness in the [2102]'s or 80's. Pt said he began medical training but dropped out when he felt it was too difficult. Later went to grad school for Master's in French Lit. Worked "on and off" (not clear what field) but had problems working consistently due to mental illness. Married; has adult children and 1 granddaughter. . Denies any hx of frank substance abuse and reports that he drinks ETOH only very rarely now. However, he does admit that for some period in the past, he took a cocktail of "valium, alprazolam, and a small amount of vodka" each night to help him sleep. Says he no longer does this as he quit drinking ETOH many yrs ago. Denies any abuse of his Restoril but does say he has occasionally had to take a double dose to get to sleep. Family History: noncontributory Physical Exam: Vitals: T:94.4 P:61 BP:105/72 R: SaO2:100% General: Sedated, intubated HEENT: Pupils pinpoint. OP with ET tube Neck: supple, no JVD Pulmonary: Lungs: good air movement bilaterally Cardiac: RRR, nl. S1S2 Quiet heart sounds Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Neurologic: -mental status: Cannot assess -cranial nerves: cant assess -motor: normal bulk, strength and tone throughout. No abnormal movements noted. -sensory: cant asses. Pertinent Results: [2140-5-10] 07:35AM BLOOD WBC-8.5 RBC-3.99* Hgb-13.4* Hct-38.4* MCV-96 MCH-33.6* MCHC-34.9 RDW-13.0 Plt Ct-245 [2140-5-10] 07:35AM BLOOD Glucose-108* UreaN-7 Creat-0.7 Na-139 K-3.7 Cl-102 HCO3-29 AnGap-12 [2140-5-6] 11:30AM BLOOD CK(CPK)-222* Amylase-102* [2140-5-6] 11:30AM BLOOD CK-MB-6 cTropnT-<0.01 [2140-5-10] 07:35AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.2 [2140-5-6] 11:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG urine culture ngtd . Head CT: IMPRESSION: No evidence of intracranial hemorrhage or mass effect. . CHEST AP: The endotracheal tube has been advanced with the tip now approximately 5 cm above the carina. Nasogastric tube is well positioned within the stomach. The appearance of the chest is otherwise stable compared to one and a half hours earlier. . CXR: IMPRESSION: No active pulmonary disease. Brief Hospital Course: 72yo male admitted after benzo overdose in suicide attempt. In the ED, he was intubated for airway protection. His UTox and STox only showed benzodiazepines. Toxicology consult came by to see him and decided not to administer flumazenil out of concern for benzodiazepine withdrawl or of unmasking an underlying seizure disorder. He recieved charcoal. He briefly became hypotensive while on propofol -> changed to etomidate for sedation. He was bradycardiac in the ED to 48 (while at CT scanner) which resolved. He had a prolonged QTc (520) which also resolved back to normal. His CT Head was negative for ICH. . In the [Hospital Unit Name 153], he was monitored and then extubated on [5-7]. He was given 3 days of ceftriaxone for a UTI. Psych saw him and felt that he may not leave AMA and needed in patient psych admission. He did not require any benzos for withdrawal nor any haldol for agitation; on morning of admit he did get 2mg ativan for some anxiety. Believe major depressive disorder; recommend avoiding restarting benzos in his treatment protocol. His TSH was normal, orthostatics were normal. Restarted tamsulosin for BPH as well; patient able to void independently without foley. Medications on Admission: temazepam proscar flomax Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): Until patient regularly ambulating. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Haloperidol 2 mg Tablet Sig: One (1) Tablet PO QID PRN (). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Bismuth Subsalicylate 262 mg Tablet, Chewable Sig: One (1) Tablet PO TID (3 times a day) as needed. 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO BID (2 times a day). 8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Discharge Disposition: Extended Care Discharge Diagnosis: Benzodiazepine overdose Suicide attempt/ideation Depression Urinary tract infection Discharge Condition: Stable Discharge Instructions: Patient admitted after suicide attempt with benzodiazepine overdose. Please have patient see doctor or return to the hospital if develops increased depression, suicidal language, signs of benzo withdrawal such as tremulousness, tachycardia, hypertension. Followup Instructions: Once you are discharged from a psych facility, please arrange a follow up appointment with your primary care doctor in [12-26] weeks ([First Name8 (NamePattern2) ] [Last Name (NamePattern1) 2903] [Telephone/Fax (1) 15863]).	[ "5990", "42789" ]
Admission Date: [2145-12-9] Discharge Date: [2145-12-12] Date of Birth: [2082-8-5] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[First Name3 (LF) 10293] Chief Complaint: Melena Major Surgical or Invasive Procedure: EGD with banding of esophageal varices [2145-12-9]. History of Present Illness: Mr. [Known firstname ] [Known lastname 90095] is a 63-year-old gentleman with Hep-C cirrhosis and multifocal HCC. About 3 years ago, he underwent treatment with pegylated interferon and Ribavirin for 6 months, and did not respond to it. He had to reduce his dose at 4-1/2 months secondary to anemia, and he was told he had genotype 2. He is status post a right lobe TACE on [2145-5-29] followed by RFA to a segment II/III lesion on [2145-8-4]. A left lobe TACE was subsequently performed on [2145-8-6] for residual disease. The patient has portal vein infiltration from his HCC and known portal hypertension evidenced by Grade I esophageal varices seen on recent EGD. The patient was in his normal state of health until Saturday when he had increasing pain in his midepigastric area. He described the pain as sharp, radiated to the back, and was worse with deep breaths, and with laying on his left side. He had some relief with dilaudid, but he says that the pain was worse and different than his normal RUQ pain. The pain was not associated with eating, nor did he describe it as reflux pain. The patient says that the pain continued until Sunday when he felt a "popping" sensation in the same distribution as the pain. He said that the pain actually improved then, but then on Monday he developed dark, black, tarry stool. The patient continued to have black, tarry, large quantity stools on Wednesday, but then the patient's stools returned to a brown color. The patient denied hematemesis, nausea, reflux, BRBPR, lightheadedness, dizziness, orthostasis. He does take intermittent Ibuprofen. He is not on prophylactic nadalol or propranolol. The patient was admitted directly from clinic to the MICU for urgent EGD for possible variceal bleed. On arrival to the MICU, the patient was afebrile with normal BP, HR. Past Medical History: Past Oncologic History: Mr. [Known lastname 90095] is a 63-year-old man with cirrhosis who was found to have multiple liver lesions suspicious for HCC on screening ultrasound [2145-4-9]. MRI [2145-4-16] demonstrated a cirrhotic liver with a 4.2 cm mass in segment II and a bilobed 5.5 cm mass in segment VIII. He underwent TACE to the right lobe of the liver on [2145-5-28]. His post Tace course was notable for fever, significant and prolonged RUQ pain, mild nausea, urinary retention and constipation in the setting of narcotics to treat his pain. On [2145-7-26], he started on a clinical trial 08-256 involving RFA plus or minus sorafenib. The patient underwent RFA to a segment II/III lesion on [2145-8-4]. He also underwent CT/ultrasound-guided biopsy at that time. Imaging was notable for a previously noted right adrenal nodule which was shown to have increased in size to 25 x 15 mm, suspicious for metastasis. Notation was also made of interval increase in size of remaining foci of arterial enhancing lesions within the liver. These findings were reviewed in Tace Imaging Conference and it was recommmended that the patient undergo TACE. Following TACE, the patient will be set up for bx and RFA of his adrenal nodule. Consideration will be given to sorafenib in the near future. He received his first TACE to the left lobe and to two targeted branches to the Segment 4 in the right lobe and the hepatic dome. He had discomfort at the end of the procedure (he has previously had epigastric and left shoulder pain related to his RF and RUQ and right shoulder pain from his TACE - both of these might be expected post-procedure). He got Versed/Fentanyl for moderate sedation, Toradol during the case, and had significant nausea at the end of the procedure for which he got additional Zofran and a dose of Haldol. The procedure itself went well. He received Diludid PCA complicated by constipation and nausea. PMHx: - Gallstones, s/p cholecystectomy in early [2133] complicated by a collapsed lung and "nicked" diaphragm. - hx of IV drug abuse - cirrhosis (bx performed during cholecystectomy in early [2133] b/c of abnormal liver findings) Presumed [12-30] Hep C 3a, viral load > 1 million [2145-2-26]. Complicated by 'fogginess' and difficulty multi-tasking improved on rifaxamin after trial of lactulose. Treated with interferon x 4 doses in [2141] without response. HIV negative. - kidney stones as per pt report - HepBsAB + but HBsAG negative. - Hep C 3a positive, viral load > 1 million [3-9] Social History: (As per previous notes). Married. Lives with wife and adult daughter and young grandson. Smokes [11-29] pack/day. Smoked 25+ pack year. Sober x 25 years. Prior heavy drinker. Worked as contractor/carpenter on [Hospital3 ] until [2144]. Quit IV drug use at age 49. Family History: Father with CAD. DM in his sister and grandparents. 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, TTP in RUQ, minimal mid-epigastric tenderness, hepatomegaly, splenomegaly, no ascites appreciated 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 At discharge: VS: 97.4, HR 55 (50s - 80s), BP 116/66, RR 18, 96% on RA 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, wheezes on the right side, rales, ronchi Abdomen: soft, distended, TTP in RUQ, minimal mid-epigastric tenderness, hepatomegaly, splenomegaly, no ascites appreciated GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact Pertinent Results: Admission labs: [2145-12-9] 08:49PM GLUCOSE-96 UREA N-14 CREAT-0.7 SODIUM-134 POTASSIUM-5.1 CHLORIDE-103 TOTAL CO2-23 ANION GAP-13 [2145-12-9] 08:49PM ALT(SGPT)-99* AST(SGOT)-140* ALK PHOS-159* AMYLASE-88 TOT BILI-1.1 [2145-12-9] 08:49PM LIPASE-14 [2145-12-9] 08:49PM ALBUMIN-3.3* CALCIUM-8.7 PHOSPHATE-4.1# MAGNESIUM-1.8 [2145-12-9] 08:49PM NEUTS-68.2 LYMPHS-19.5 MONOS-8.0 EOS-3.0 BASOS-1.3 [2145-12-9] 08:49PM NEUTS-68.2 LYMPHS-19.5 MONOS-8.0 EOS-3.0 BASOS-1.3 [2145-12-9] 08:49PM PLT COUNT-101* [2145-12-9] 08:49PM PT-13.4* PTT-25.1 INR(PT)-1.2* [2145-12-9] 12:10PM UREA N-14 CREAT-0.7 SODIUM-137 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-27 ANION GAP-11 [2145-12-9] 12:10PM estGFR-Using this [2145-12-9] 12:10PM WBC-6.6 RBC-3.98* HGB-13.5* HCT-36.8* MCV-92 MCH-34.0* MCHC-36.8* RDW-13.6 [2145-12-9] 12:10PM WBC-6.6 RBC-3.98* HGB-13.5* HCT-36.8* MCV-92 MCH-34.0* MCHC-36.8* RDW-13.6 [2145-12-9] 12:10PM PLT COUNT-103* [2145-12-9] 12:10PM GRAN CT-4830 Discharge labs: [2145-12-12] 07:25AM BLOOD WBC-5.0 RBC-3.58* Hgb-11.7* Hct-33.1* MCV-93 MCH-32.6* MCHC-35.3* RDW-13.2 Plt Ct-106* [2145-12-12] 07:25AM BLOOD PT-14.2* PTT-30.0 INR(PT)-1.3* [2145-12-12] 07:25AM BLOOD Glucose-98 UreaN-10 Creat-0.6 Na-136 K-4.2 Cl-103 HCO3-28 AnGap-9 [2145-12-12] 07:25AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.8 [2145-12-9] EGD: Esophagus: Protruding Lesions [3-3] cords of grade [12-31] varices were seen in the lower third of the esophagous. None of the varices were bleeding. 3 [Month/Day (3) ] were successfully placed. Stomach: Mucosa: Severe diffuse portal hypertensive gastropathy was noted through the stomach. No gastric varices were seen. No evidence of any active bleeding in the stomach. Duodenum: Normal duodenum. Impression: Esophageal varices Abnormal mucosa in the stomach Otherwise normal EGD to third part of the duodenum Recommendations: follow up with the inpatient liver team Continue the Octreotide drip Additional notes: The attending was present for the entire procedure. FINAL DIAGNOSES are listed in the impression section above. Estimated blood loss = zero. No specimens were taken for pathology Brief Hospital Course: ASSESSMENT/PLAN: This is a 63 yo M with Hep C cirrhosis c/b HCC invading the portal vein s/p TACE and RFA who presents from clinic with evidence of recent upper GIB concerning for variceal bleed. ACTIVE ISSUES: 1. UPPER GI BLEED: Patient was admitted to the MICU given concern for variceal bleeding and was taken urgently for EGD, which demonstrated [3-3] cords of grade II-III varices in his lower esophagus. Three [Month/Day (1) ] were successfully deployed. He did not require any blood transfusions. His hct remained stable throughout hospitalization. He was initially kept on IV PPI and octreotide drip. He did well and was transitioned to a PO PPI and nadolol. He was also discharged on two weeks of a sucralfate slurry and a soft diet for one week. 2. INTUBATION: The patient required intubation to complete EGD. The patient was intubated with ETT without any complications and he was kept intubated overnight due to high dose of analgesics he got during procedure. He was extubated without event and was called out of MICU. Patient did not require any further oxygen. 3. CIRRHOSIS: The patient has Hep C cirrhosis c/b varices and ? encephalopathy in the past. He was continued on lactulose and started on ceftriaxone. He was discharged home on ciprofloxacin 500 mg twice a day to complete a seven day course and will take ciprofloxacin 250 mg daily thereafter for prophylaxis. 4. HCC: Patient will continue treatment as per outpatient providers. CHRONIC/INACTIVE ISSUES: 1. Insomnia: Continued home dose lorazepam. TRANSITIONAL ISSUES: 1. Patient will have CBC checked as outpatient. Will follow-up with PCP. 2. HCC: Has follow-up scheduled with oncology. Medications on Admission: HYDROMORPHONE - 2 mg Tablet - one Tablet(s) by mouth every 6 hrs as needed as needed for pain LACTULOSE - (Prescribed by Other Provider) - 10 gram/15 mL Solution - 5 ml by mouth once a day LORAZEPAM - 0.5 mg Tablet - [11-29] Tablet(s) by mouth q4-6 as needed for nausea, insomnia, or anxiety RANITIDINE HCL - (Prescribed by Other Provider) - 150 mg Tablet - one Tablet(s) by mouth once day as needed for prn SORAFENIB [NEXAVAR] - 200 mg Tablet - 2 Tablet(s) by mouth twice a day TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - 18 mcg inhalations via 2 inhalations daily Discharge Medications: 1. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 2. lactulose 10 gram/15 mL Syrup Sig: Ten (10) ML PO twice a day: Please titrate to 2 - 3 bowel movements per day. . Disp:QS 1 month mL Refills:2 3. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for anxiety, insomnia, or nausea. 4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: Two (2) inh Inhalation once a day. 5. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days. Disp:8 Tablet(s) Refills:0 8. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day: After you complete course of 500 mg [Hospital1 ]. Start once days in 4 days. . Disp:30 Tablet(s) Refills:2 9. sucralfate 100 mg/mL Suspension Sig: One (1) gram PO four times a day for 14 days. Disp:QS 14 days mL Refills:0 10. Outpatient Lab Work [2145-12-15] Please check CBC Fax results to: Dr. [Last Name (STitle) ] Phone: [Telephone/Fax (1) 6142], Fax: [Telephone/Fax (1) 61423] Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Upper gastrointestinal bleed, esophageal varices SECONDARY: Hepatocellular carcinoma, hepatitis c cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to participate in your care Mr. [Known lastname 90095]. You were admitted to the hospital for an EGD because of concern you are bleeding in your GI tract. You had a procedure called an EGD - we found that you had large veins in your esophagus called varices. The liver doctors [First Name (Titles) ] [Last Name (Titles) ] around your varices so that they would not bleed. Please make the following changes to your medications: 1. START nadolol 20 mg daily 2. START ciprofloxacin 500 mg daily for 4 days. When you complete the 4 day course, you will take 250 mg daily thereafter. 3. START protonix 40 mg [Hospital1 ] 4. START sucralfate 1 mg by mouth four times a day for 2 weeks 5. INCREASE lactulose - 2 - 3 doses per day, titrate to 2 - 3 bowel movements per day Please see below for your follow-up appointments. Followup Instructions: Please call to make an appointment with your primary care doctor this week. You need to have your blood count checked (CBC) this week. Please call to make an appointment with Dr. [First Name (STitle) ] within the next several weeks. Department: RADIOLOGY CARE UNIT When: TUESDAY [2145-12-14] at 9:30 AM [Telephone/Fax (1) 446] Building: De [Hospital1 ] Building ([Hospital Ward Name 121] Complex) [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: RADIOLOGY When: TUESDAY [2145-12-14] at 11:00 AM With: CAT SCAN [Telephone/Fax (1) 327] Building: CC CLINICAL CENTER [Location (un) ] Campus: WEST Best Parking: [Street Address(1) 592] Garage Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [2145-12-22] at 10:00 AM With: [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 2502], MD [Telephone/Fax (1) 22] Building: SC [Hospital Ward Name 23] Clinical Ctr [Location (un) 24] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage	[ "4168" ]
Admission Date: [2198-9-6] Discharge Date: [2198-9-10] Date of Birth: [2128-4-7] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 30] Chief Complaint: Cellulitis of the nose Major Surgical or Invasive Procedure: None History of Present Illness: 70 Russian M without any medical history presents w/ cellulitis of the nose. Pt reports that he noticed a small area of redness on the tip of his nose yesterday. Today, the redness had spread to his entire nose. He endorses + Diffuse myalgias and chills, +loss of appetite, that his nose feels numb and there is a pressure sensation in the area of his nose. However, he denies headache, LH/dizziness, eye pain, visual difficulities, rhinorrhea, epitaxsis, sore throat, URI/cough, sick contacts, insect bite. He also denies CP/palp/SOB/abd pain/n/v/d/c/melena/brbpr/dysuria/weakness/paresthesias. In the ED, initial vs were: T 98.4 P BP R 16 O2 sat 99% on RA. EKG wnl. CXR clear. Patient was given a dose of IV unasyn. Past Medical History: s/p Appy L ear cellulitis 10 yrs ago L inguinal hernia + PPD [2193] (17 mm), for which he refused to take INH; pt believes it's due to childhood BCG vaccine h/o vertigo Social History: Social hx: Retired. Previously worked as health aid for elderly. Immigrated from [Country 532] in [2184]. Lives at home with his wife. Eats according to his blood type. -Tob: Quit ~30yrs ago. 45 pack-year history -EtOH: Occasional, red wine -Illicits: None Family History: Father died of a CVA, had hypertension and diabetes. Mother still alive, but quiet ill with dyslipidemia and hypertension. Three younger siblings, one with heart issues, another with thyroid disease and nephrolithiasis. Two daughters, one with thyroid disease. Granddaughter with IBD. No cancers or diabetes in the family. Physical Exam: VS:T 102.3, BP 130/70, HR 80, RR 18, sat 96% on RA Gen:NAD, appears stated age, cooperative HEENT:Nc/AT, PERRLA, conjunctiva not-injected, no eye swelling or pain with movement. EOMI, anicteric, +erythema and swelling of the nose up to the forehead and ending at the nasolabial folds. No pus/bleeding or other rash. +slight TTP of nose. No rhinorrhea, OP clear. Ears without external tenderness or rash. Neck: supple, no LAD, no JVP Cor:s1s2 rrr no m/r/g Pulm:b/l ae no w/c/r Abd:+bs, soft, NT, ND Extrem:no c/c/e 2+pulses Skin:as above, no other rashes appreciated Neuro:non-focal Pertinent Results: 139 101 9 -------------< 110 4.5 28 1.1 WBC-8.5 RBC-4.43* HGB-14.1 HCT-39.8* MCV-90 MCH-31.8 MCHC-35.4* RDW-12.8 PLT COUNT-268 NEUTS-77.5* LYMPHS-17.2* MONOS-4.3 EOS-0.7 BASOS-0.3 URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG CXR: IMPRESSION: No acute cardiopulmonary process. CT ORBITS: 1. Mild subcutaneous edema and venous engorgement of the nose consistent with the clinical impression of nasal cellulitis. No evidence of orbital cellulitis. 2. Body deformity involving the left third molar, which may be post-surgical. 3. Mild sinus disease as described above. Brief Hospital Course: Mr. [Name14 (STitle) 15381] is a 70 year old male without significant PMH presenting with nasal and periorbital cellulitis, requiring brief stay in the MICU for hypotension/sepsis. . A/P: Pt is a 70 y.o male with no significant PMH who presents with nose cellulitis extending near his eyes and sx of eye pressure, but no abnormal eye findings on physical exam. . #Facial/nose cellulitis: Pt has episodes of rigors and temp spikes. Does not have h/o MRSA or risk-factors for comm-acquired MRSA or hosp-acquired MRSA. However, given extension of erythema near eyes, was empirically rx for MRSA and other pathogens seen in periorbital cellulitis during this hospitalization. Although pt w/o signs of ocular involvement currently, he did complain of eye pressure bilaterally. Given this, a CT of orbits was obtained and was negative for orbital cellulitis. Transthoracic echo was also obtained during this hospitalization and was remarkable for mild mitral valve thickening. Patient was treated as an inpatient with IV vanco & Unasyn, however did develop hypotension which was initially unresponsive to several liters of IVF while on the floor. He was then transferred to the ICU for presumed sepsis, and his BP stabilized after recieving ~10L of IVF. He did not require pressors and was not intubated. BCx were negative upon transfer to the ICU, and are still negative to date. He was also placed briefly on Clindamycin in addition to his Vanc/Unasyn given hypotension for a period of time, however clinically improved and was eventually transferred back to the floor. Given the improvement in the patient's symptoms after several days, it was determined that the patient would be sent home on a regimen of PO Augmentin given his low risk for MRSA. The patient was to continue Mupirocin ointment to his nares for 5 days upon discharge. ENT was consulted regarding this patient's care and was ok with this plan. The patient was given a follow up appointment with ENT 1 week after discharge. . # PPx: subq heparin, bowel regimen . # Code: presumed FULL Medications on Admission: None Discharge Medications: Augmentin 875/125mg PO BID x 10 days Mupirocin 2% ointment to nares [Hospital1 ] x 5 days Discharge Disposition: Home Discharge Diagnosis: Facial Cellulitis Discharge Condition: Stable and improved. Resolving cellulitis Discharge Instructions: You were admitted for a bacterial infection of the skin of your nose. You were treated with antibiotics. Because your blood pressure became low, you were monitored in the intensive care unit, where your blood pressure improved with IV fluids. You were then transferred back to the floor after you were stable. It is very important that you continue to take the oral antibiotics as prescribed. You should follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 39], [First Name3 (LF) ] ear-nose-throat specialist, on [2198-10-4] at 11:15AM. Your echocardiogram did not show any abnormal findings that would require interventions. Please report to the Emergency Room if you develop eye pain, fevers, chills, severe lightheadedness, chest pain, severe shortness of breath, nausea, vomiting, or any other concerning symptoms. Followup Instructions: Please follow-up with Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 39], [First Name3 (LF) ] ear-nose-throat specialist, on [2198-10-4] at 11:15AM on the [Hospital Unit Name ], [Location (un) ]. A Russian interpreter has already been scheduled for your. Call [Telephone/Fax (1) 41] if you have questions about your appointment. Please follow-up with your primary care provider, [Last Name (NamePattern4) ]. [First Name8 (NamePattern2) ] [Doctor Last Name ] on [2198-11-16] at 1:00pm. Please call [Telephone/Fax (1) 250] if you have questions regarding your appointment. Completed by:[2198-9-11]	[ "0389" ]
Admission Date: [2173-5-1] Discharge Date: [2173-5-5] Date of Birth: [2141-1-3] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 70850] Chief Complaint: Labor Reason for [Hospital Unit Name 153] transfer: Hypotension Major Surgical or Invasive Procedure: vaginal delivery History of Present Illness: 32 y/o F with hx of tetralogy of fallot, surgically repaired at age 3, admitted to L&D at 39w3d days in labor. On arrival to L&D she denied any cardiac symptoms. She had a cards consult which determined she was safe to push, has a normal EF. Past Medical History: 1. Tetralogy of Fallot, s/p repair at age 3 at [Location (un) 80622] hospital, [Country 14635]. Per records had a VSD closed with a dacron patch, excision of hypertrophied muscles in the crista supraventricularis and opening of a hypoplastic pulmonary annulus. Subsequent echo studies have shown (by report) mild PS and mild to mod PR with mild RV dilation. Followed by Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] at [Hospital ] [Hospital3 ]'s adult congenital heart disease clinic. 2. 1 episode of VT at age 14 s/p exercise OBHx: G1P0 MedHx: - Tetrology of Fallot s/p repair at age 3 as above SurgHx: cardiac surgery, as above Social History: Denies tobacco, EtOH or illicit substances. Prior to pregnancy pt went to yoga several times a week as well as used the elliptical trainer ~2x/wk. Family History: MGM w/ an "enlarged heart". Otherwise non-contributory for SCD, arrhythmia or CAD. Physical Exam: On arrival to L&D: Vitals - T:97.3 BP:106/76 HR:82 RR:16 CV: 2/6 SEM at LSB Gen: NAD, mildly uncomfortable with ctx Abd: soft, gravid, no TTP, EFW 8# by [Last Name (un) 23291] SVE: deferred, [4-/2153]/BBOW in triage FHT: 120/mod var/+accels/no decels --> category I Toco: q 5-6 min Exam on arrival to [Hospital Unit Name 153]: Vitals: T:96.3 BP:108/71 P:91 R:20 O2:98% room air General: Alert, pleasant, oriented, no acute distress but mildly anxious HEENT: Sclera anicteric, MM dry, OP clear, no tonsillary hyperemia or exudate Neck: supple, no appreciable JVD or LAD Lungs: CTAB, no wheezes, rales, rhonchi CV: RRR, normal S1 + S2. Pronounced holosystolic murmur most prominent at left USB. No rubs or gallops Abdomen: Soft, insensate to pressure while anesthetized. Bowel sounds present. No organomegaly or pulsatile masses. Ext: warm, well perfused, 2+ pulses, no cyanosis or edema. Cap refill not assessed given fingernail paint Neuro: AAOx3. Speech fluent, thought process clear. Moving upper extremities freely. Can move lower extremities though relatively weak in setting of epidural analgesia. Pertinent Results: [Hospital Unit Name 153] admission labs: [2173-5-1] 02:26AM BLOOD WBC-9.5 RBC-4.28 Hgb-13.3 Hct-39.9 MCV-93 MCH-31.1 MCHC-33.3 RDW-12.9 Plt Ct-228 [2173-5-1] 10:29PM BLOOD WBC-25.7# RBC-3.37 Hgb-10.6* Hct-31.0* MCV-92 MCH-31.3 MCHC-34.0 RDW-12.9 Plt Ct-194 [2173-5-1] 10:29PM BLOOD Neuts-93.9* Lymphs-3.7* Monos-2.2 Eos-0.1 Baso-0 [2173-5-1] 10:29PM BLOOD PT-12.7 PTT-30.6 INR(PT)-1.1 [2173-5-3] 04:14AM BLOOD Fibrino-718* [2173-5-1] 10:29PM BLOOD Glucose-87 UreaN-11 Creat-0.7 Na-135 K-4.0 Cl-104 HCO3-20* AnGap-15 [2173-5-1] 10:29PM BLOOD Calcium-8.2* Phos-4.0 Mg-1.8 Cardiac enzymes: [2173-5-1] 10:29PM BLOOD CK(CPK)-374* [2173-5-1] 10:29PM BLOOD CK-MB-16* MB Indx-4.3 cTropnT-0.09* [2173-5-2] 05:02AM BLOOD CK(CPK)-285* [2173-5-2] 05:02AM BLOOD CK-MB-11* MB Indx-3.9 cTropnT-0.02* [2173-5-2] 12:13PM BLOOD CK(CPK)-287* [2173-5-2] 12:13PM BLOOD CK-MB-9 cTropnT-0.02* Urine: [2173-5-1] 01:19AM URINE Color-Straw Appear-Hazy Sp [Last Name (un) ]-1.008 [2173-5-1] 01:19AM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG MICRO: [5-2] BCx: pending [5-2] UCx: negative [5-3] BCx: pending STUDIES: [5-1] CXR: Heart is mildly enlarged. Mediastinum within normal limits. Lungs are clear. Multiple leads project over the chest. IMPRESSION: Probably no active disease in the chest. [5-4]: TTE: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60%). There is a small paramembranous ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with borderline normal free wall function. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: Ms [Known lastname ] was admitted to L&D in active labor. She had a spontaneous vaginal delivery. Her labor was uncomplicated. her delivery was complicated by 2nd degree laceration and uterine atony. She received 100 mcg cytotec PR, 0.2 mg methergine IM, and 40 units of pitocin IV. The total estimated blood loss was 500cc. The uterotonics controlled the vaginal bleeding but shortly after delivery the patient experienced palpiations. She became hypotensive with nadir BP of 57/33. She received a total of 1000 mcg of phenylephrine over the following several hours, divided into several 100 and 200 mcg boluses. Her BP subsequently stabilized with systolic readings in the 100-110s. Her symptoms resolved. She was admitted to the [Hospital Unit Name 153] postpartum for continued monitoring. . # Hypotension: Likely [1-5] hypovolemia, given blood loss during delivery and conservative IV fluid resuscitation in setting of known structural cardiac abnormalities. Cardiology was consulted and felt that the patient could tolerate IV fluids, to which her blood pressure responded well. She did not require phenylephrine after arriving in [Hospital Unit Name 153]. No evidence of volume overload on CXR, and no peripheral signs of right heart failure. No signs of SIRS/sepsis, as patient is afebrile, with normal WBC this morning. Cardiogenic etiology also thought possible, given elevated cardiac enzymes, but less likely. She had a TTE to evaluate for new wall motion abnormalities which showed only stable mild pulmonary artery systolic hypertension (see attached report). The on-call physician at the patient's cardiology practice ([Location (un) 86] Adult Congenital Heart Disease clinic) was contact[Name (NI) ] and made aware of the events. The patient was hemodynamically stable upon transfer to the postpartum floor. On the postpartum floor her vitals remained normal and she denied symtoms of palpitations/chest pain. . # Palpitations/chest pain/Tetralogy of Fallot: ECG abnormal in setting of repaired tetralogy but generally unchanged from prior, but had no ischemic changes. Cardiac enzyme elevation (troponins peaked at 0.09) was likely [1-5] demand ischemia in setting of hypotension, tachycardia, vasopressors. Tachycardia likely [1-5] hypovolemia as above, +/- anxiety. Subjective palpitations and tachycardia both improving with IV fluids and reassurance. . # Vaginal bleed s/p spontaneous vaginal delivery: patient had moderate lochia postpartum and her fundus remained firm. Her hematocrit decreased from 39.9 on admission to 22.6 postpartum. She received two units of packed RBCs and her Hct improved to 27.3, with follow-up Hct stable at 27.0. Medications on Admission: Medications (home): PNV Metamucil . Medications (on transfer): oxytocin Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain for 2 weeks. Disp:30 Tablet(s) Refills:0 2. breast pump Sig: [12-5] three times a day: Pt s/p ICU admission, low milk supply. Disp:1 Refills:0 3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every [3-9] hours for 2 weeks. Disp:30 Tablet(s) Refills:0 Discharge Disposition: Home Discharge Diagnosis: s/p fullterm vaginal delivery postpartum hemorrhage anemia hypotension s/p Tetralogy of Fallot repair Discharge Condition: good Discharge Instructions: follow printed instructions Followup Instructions: 6 wks within 2 wks with cardiologist [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] Completed by:[2173-5-10]	[ "2851", "4168" ]
Admission Date: [2129-10-14] Discharge Date: [2129-10-24] Date of Birth: [2066-4-17] Sex: M Service: [Last Name (un) ] HISTORY OF PRESENT ILLNESS: This patient is a 63-year-old man with past medical history significant for diverticulitis and ventral hernia repair with mesh who presented to the ER at 2 a.m. with 12 hours of abdominal distention, nausea, vomiting x1, and pain, which the patient described as being more like fullness. He denied any fever or chills, chest pain, or shortness of breath. These symptoms have not happened previously. PAST SURGICAL HISTORY: Notable for a colostomy and colonic resection in [2119] for perforated diverticulitis, which was subsequently reversed and a ventral hernia repair with mesh in [2127]. The patient has also had a right total hip replacement. PAST MEDICAL HISTORY: Ankylosing spondylitis. ALLERGIES: The patient has no known drug allergies. CURRENT MEDICATIONS: 1. Hydrochlorothiazide 12.5 mg. 2. Toprol 50 mg. 3. Diovan 80 mg. 4. Piroxicam 20 mg for arthritis and the ankylosing spondylitis. SOCIAL HISTORY: The patient smokes one to two cigarettes per week and is a social drinker. PHYSICAL EXAMINATION ON ADMISSION: Temperature 99.2 degrees, pulse 86, blood pressure 125/99, respiratory rate 16, and saturating at 97 percent on room air. Lungs are clear to auscultation bilaterally. Heart is regular rate and rhythm. Abdomen is soft and somewhat distended with diffuse mild tenderness. The patient has no rebound. No evidence of hernia. Rectal examination is without masses and guaiac negative. LABORATORY DATA: On transfer from the outside hospital, white count 17.6, hematocrit of 48.1. Chem-7 within normal limits, although notation is made of a creatinine of 1.2. HOSPITAL COURSE: The patient was seen and examined by Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] and Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. The initial plan on his presentation was to place a nasogastric tube, make the patient n.p.o., hydrate with IV fluids, and attempt nonoperative management depending on the patient's clinical course. Later on that evening, however, it was felt that the patient was appearing to have developed a complete obstruction and the patient was taken to the operating room for an exploratory laparotomy and extensive lysis of adhesions. Please refer to the operative note by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 57554] for more details on that operation. Due to the patient's history of ankylosing spondylitis and a very difficult intubation, postoperatively, the patient was transferred to SICU where he had a stable course without significant incident. On postoperative day two, [2129-10-16], the patient was transferred to the floor. Vital sings were stable. Breath sounds continued to be somewhat coarse. Physical examination was otherwise unremarkable. The patient's wound was noted to be clean, dry, and intact. The patient was encouraged to ambulate as much as possible and was given aggressive pulmonary toilet with regards to incentive spirometer use and early ambulation. Pain control was managed with the patient- controlled analgesia pump. On [2129-10-18], it was noted that the patient's condition continued to improve. Note was made of slight erythema at the left margin of his incision and the abdomen was otherwise soft. No focal tenderness. Due to the patient's improving clinical status, the nasogastric tube was discontinued on [2129-10-18] and his diet was advanced to sips and clear liquids. The Foley was taken out and the patient continued to improve. On [2129-10-19], the patient continued to improve, although it was noted that he felt a slight bloating sensation even on the clear sips and the patient's diet was not advanced further that day. Late in the evening of [2129-10-19], in fact at 12:30 a.m. on [2129-10-20], house staff was called to see the patient for a ten-beat run of ventricular tachycardia on the telemetry monitor. The patient was also complaining of left shoulder pain that was focal and nonradiating. The patient denied diaphoresis or shortness of breath, although he did have a slight episode of nausea prior to the event. Note was made of a significantly elevated blood pressure to 190/100, other vital signs were unremarkable. The patient was given a 1 mg of morphine sulfate for pain control and an increased dose of intravenous Lopressor. The patient's blood pressure came down to 180/102. The patient was alert, somewhat anxious, and was not diaphoretic. Heart was regular rate and rhythm. Lungs were clear to auscultation. A 12-lead EKG was performed and no change was appreciated from his EKG of [2129-10-15]. Other measures initiated at that time were to restart the patient on his home dose of Diovan, increase his IV Lopressor dose to 10 mg q.6 h. He was started on aspirin 325 mg and was given an order for Nitro paste as necessary and electrolyte check in the morning. Results of stat chemistry showed a low magnesium of 1.4; this was appropriately repleted; and on recheck, the patient's magnesium rebounded to 2.6. The patient was once again made n.p.o., although the NG tube was not replaced. Throughout the day of [2129-10-20], the patient continued to do well and tolerated limited p.o. intake. After being initially n.p.o. that morning, he was seen and examined by the attending once again. After this hypertensive event, his blood pressures had stabilized to 165/91. His cardiac enzymes were negative for infarction. The patient's diet was gradually advanced; and on [2129-10-23], the patient was given a regular diet, which he tolerated well. Also on [2129-10-23], the patient had one bowel movement, which was considered an encouraging sign of return of bowel function. He was transitioned to entirely oral medicines. The patient continued to do well throughout the day. On [2129-10-24], the patient was once again feeling very well. His abdominal examination was reassuring. The incision was noted to be clean, dry, and intact. It was decided to discharge the patient home in good condition. DISCHARGE MEDICATIONS: The patient was discharged home on his customary cardiac regimen of 50 mg Toprol XL q.d., 80 mg of Diovan q.d., and 12.5 mg of hydrochlorothiazide q.d. DISCHARGE INSTRUCTIONS: The patient was given instructions to return to see Dr. [Last Name (STitle) ] in one week for removal of the staples. DISCHARGE DIAGNOSES: Partial small bowel obstruction. Ankylosing spondylitis. Postoperative hypotension. Postoperative volume depletion. Acute hypertensive crisis. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) ], [MD Number(1) 13137] Dictated By:[Doctor Last Name 55789] MEDQUIST36 D: [2129-10-24] 14:00:28 T: [2129-10-25] 02:55:53 Job#: [Job Number 57555]	[ "9971", "4019" ]
Admission Date: [2162-12-16] Discharge Date: [2162-12-21] Date of Birth: [2093-4-22] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamides) / Betadine / Iodine Attending:[Last Name (NamePattern1) 1561] Chief Complaint: tracheomalacia Major Surgical or Invasive Procedure: right thoracotomy posterior tracheobronchoplasty with marlex History of Present Illness: 69M with progressive shortness of breath over last 6 months, who was noted to have tracheomalacia by functional bronchoscopy. He had a tracheal stent placed, with good result and now presents for definitive repair. Past Medical History: PVD s/p right fem-[Doctor Last Name ] BPG, right femoral stent HTN CAD s/p angioplasty x2. Last stress test normal (6 months ago) GERD tracheomalacia cataract surgery carpal tunnel syndrome s/p release Social History: +cigs (45 pack years, quit 20 yrs ago) 1 beer/day Retired pool worker Family History: Father colon ca, mother pacemaker Physical Exam: Well appearing, NAD NC/AT, PERRLA CTA bilat RRR, no murmurs soft NT ND no CCE, palp DP's Pertinent Results: [12-19] CXR: No evidence of pneumothorax following right-sided chest tube removal. Brief Hospital Course: [12-16]: OR, right thoracotomy & tracheoplasty (see op note). well tolerated. [12-17]: transferred to floor after o/n ICU observation [12-18]: epidural catheter removed. [12-19]: chest tube removed. [12-21]: tolerating regular diet, pain controlled on PO percocet, sats 93% on 4 liters. DC home on O2 via nasal cannula. Medications on Admission: flomax 0.4', Avapro 150', ECASA 81', Protonix 40', Lorazepam 0.5', Amitriptyline 25qhs, [Doctor First Name ]" Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:75 Tablet(s) Refills:0 2. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: scrip #2. Disp:75 Tablet(s) Refills:0 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 17 doses: continue until [2163-1-6]. Disp:17 Tablet(s) Refills:0 4. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO every 4-6 hours as needed for secretions. Disp:250 ML(s) Refills:2 5. Other medications Continue all of your preop medications: flomax, avapro, aspirin, protonix, ativan, elavil & [Doctor First Name 130]. Take colace twice a day while using percocet. 6. Home oxygen Continuous home O2 via nasal cannula @ 2-6 liters/min to maintain sats > 93% & Pulse-dose oxygen delivery system. Discharge Disposition: Home With Service Facility: [Hospital1 11485] VNA Discharge Diagnosis: tracheomalacia PVD s/p mult bypass surgeries HTN COPD/emphysema GERD cataracts Discharge Condition: good Discharge Instructions: Diet as tolerated. No bathing (showers okay - pat wound dry), no lifting objects heavier than a gallon of milk & no driving while using narcotics. You should drink plenty of water & take colace twice a day to prevent constipation while using narcotics. Contact your MD if you develop shortness of breath, fevers > 101, redness about your surgical sites, or if you have any questions/concerns. Followup Instructions: Provider: [Name10 (NameIs) ],[First Name4 (NamePattern1) ] [Last Name (NamePattern1) ] [Telephone/Fax (1) 170] Follow-up appointment should be in 2 weeks Completed by:[2163-1-20]	[ "4019", "53081" ]
Admission Date: [2128-5-31] Discharge Date: [2128-6-5] Date of Birth: [2056-12-7] Sex: F Service: MEDICINE Allergies: Penicillins / Erythromycin Estolate / Xylocaine Attending:[First Name3 (LF) 2024] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 71 yo woman with metastatic breast cancer to spine, femur p/w acute dyspnea. Pt was in USOH until this afternoon, when she developed sudden dyspnea @ 3pm. She was not exerting herself during this period. She reports sitting in a chair at the time of onset. Pt's caregiver [Name (NI) 653] her daughters. The pt was hesitant to go to the hospital without her daughters. However, she became progressively more dyspneic over the next hour and EMS was called. Of note she had recent admit [Date range (1) 40693] for dyspnea, thought to be [1-23] PNA (and a possible aspiration event), treated with cefpodoxime/flagyl. . On arrival to the [Name (NI) ], pt was initially afebrile (though eventually spiked to 101.6), BP 180s/110s, hr 120s-140s, rhonchi on exam, given ntg slx1, started on nitro gtt and given lasix 40 mg iv X1 (UOP 750cc). Pt initially placed on BIPAP, but was weaned off to a NRB. However, while getting CT, as below, pt transiently required BIPAP, which was again taken off before being transferred to [Hospital Ward Name 516]. Otherwise w/u in the ED included: EKG ST @128 bpm, lad, twi I, avl, std v4-6. CXR: Perihilar vascular congestion, cephalization of the pulmonary vasculature. CTA negative for PE or consolidation, though evidence of pulmonary edema and large bilateral pleural effusions as well as increased right hilar lymphadenopathy. CT abd showed multiple liver metastases (new since [1-28]), increasing bilateral adrenal thickening - mets vs hypertrophy, small amount of ascites, mild anasarca. CT head checked in case of the need for anti-coagulation, showed mass at R cranial vertex. Labs sig for wbc 15.5, hct 32.2, plt 492, Na 126, cl 87, ck 155, ck-mb 4, tpn 0.02. BNP 4491. Other than nitro and lasix, pt given asa 325 mgx1, levoflox 750 mg x1, vanc 1 gm x1, tylenol 650 pr, dilaudid 1 mg x1, oxycontin 280 mg x1. Past Medical History: Onc history: Left breast cancer diagnosed in [2124-6-20] with three positive nodes and underwent lumpectomy followed by Cytoxan and Adriamycin. In [2126-3-22] she was diagnosed with a vetebral metastatic lesion and at the same time was also diagnosed with colorectal cancer for which she underwent excision. Has also been on gemtricitabine. Right pathologic proximal femur fracture s/p ORIF [2128-4-8], s/p XRT -Goiter with hypothyroidism -Hypertension -Anxiety disorder -Lymphedema left arm -Rectal cancer Social History: lives alone with caregiver during day, former tob and etoh, 2 daughters Family History: Father died at 73 of coronary artery disease and mother died at 97. Physical Exam: Temp 95.3 oral BP 122/66 Pulse 82 Resp 16 O2 sat 99% 6 L NC Gen - anxious, but no acute distress HEENT - extraocular motions intact, anicteric, mucous membranes moist Neck - no JVD, no cervical lymphadenopathy Chest - rales throughout CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops Abd - Soft, nontender, nondistended, with normoactive bowel sounds Extr - trace edema b/l. 2+ DP pulses bilaterally Neuro - Alert and oriented x 3 Skin - No rash Pertinent Results: EKG ST @128 bpm, lad, twi I, avl, std v4-6. . [2128-5-31] 05:30PM BLOOD WBC-15.5# RBC-3.42 Hgb-10.3* Hct-32.7* MCV-96 MCH-30.1 MCHC-31.4 RDW-21.4* Plt Ct-492# [2128-6-5] 12:02AM BLOOD WBC-9.6 RBC-3.24 Hgb-10.3* Hct-30.6* MCV-94 MCH-31.7 MCHC-33.7 RDW-20.0* Plt Ct-370 [2128-5-31] 05:30PM BLOOD Neuts-63 Bands-4 Lymphs-13* Monos-18* Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-1* [2128-6-1] 04:25AM BLOOD PT-14.0* PTT-26.0 INR(PT)-1.2* [2128-5-31] 05:30PM BLOOD Glucose-252* UreaN-9 Creat-0.8 Na-126* K-4.4 Cl-87* HCO3-24 AnGap-19 [2128-6-5] 12:02AM BLOOD Glucose-137* UreaN-16 Creat-0.7 Na-127* K-4.4 Cl-89* HCO3-26 AnGap-16 [2128-6-5] 12:02AM BLOOD Glucose-137* UreaN-16 Creat-0.7 Na-127* K-4.4 Cl-89* HCO3-26 AnGap-16 [2128-5-31] 05:30PM BLOOD CK(CPK)-155* [2128-6-1] 12:03AM BLOOD ALT-13 AST-81* CK(CPK)-215* AlkPhos-348* Amylase-30 TotBili-0.3 [2128-6-1] 04:25AM BLOOD CK(CPK)-178* [2128-6-1] 12:03AM BLOOD Lipase-9 [2128-5-31] 05:30PM BLOOD CK-MB-4 proBNP-4491* [2128-5-31] 05:30PM BLOOD cTropnT-0.02* [2128-6-1] 12:03AM BLOOD CK-MB-8 cTropnT-0.18* [2128-6-1] 04:25AM BLOOD CK-MB-8 cTropnT-0.16* [2128-6-3] 02:28AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.4 [2128-6-4] 12:04AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.4 Cholest-190 [2128-6-5] 12:02AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.3 [2128-6-4] 12:04AM BLOOD Triglyc-132 HDL-60 CHOL/HD-3.2 LDLcalc-104 [2128-6-2] 05:41AM BLOOD Osmolal-259* [2128-6-1] 04:25AM BLOOD CEA-29* [2128-6-1] 12:03AM BLOOD CA27.29-77* [2128-5-31] 05:42PM BLOOD Lactate-2.5* [2128-6-1] 01:10AM BLOOD Lactate-1.3 . [5-31] CT Head w/o Contrast: NON-CONTRAST HEAD CT: There is a hyperdense ill-defined 3.2 x 1.9 cm mass at the right frontovertex that appears to be extra-axial in location with slight mass effect on the subjacent cortex and minimal subfalcine herniation (approximately 5 mm of midline shift). No other intracranial mass is identified. [Doctor Last Name ]-[Known lastname ] matter differentiation is preserved and there is no evidence of acute hemorrhage or major vascular territorial infarct. No hydrocephalus. A 1 cm destructive osseous lesion at the right frontal calvarium is seen (2:11), likely a metastasis. There is also a well-defined lytic lesion of the left parietal calvarium, at the vertex (2:26) which may represent a prominent arachnoid granulation, or could represent metastasis in this patient with extensive metastatic breast cancer. The visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: 1. Hyperdense extra-axial mass at the right cranial vertex may represent dural metastasis or meningioma. There is minimal mass effect and 5 mm of subfalcine herniation. No evidence of intracranial hemorrhage or major vascular territorial infarct. 2. Destructive osseous lesion at the right frontal calvarium is likely a metastatic lesion. 3. Possible metastasis versus prominent arachnoid granulation at the left parietal vertex. Findings were conveyed to the ED dashboard at the time of the exam, and discussed with the MICU team. NOTE ADDED IN ATTENDING REVIEW: Unusual constellation of findings, as above. Given the known extensive metastatic disease, including epidural involvement in the lumbar spine, the right craniovertex extra-axial lesion, which crosses the midline and may breach the superior sagittal sinus, likely represents a dural metastasis. However, incidental meningioma remains a possibility as these may occur with increased frequency in patients with breast cancer. The well-defined, scalloped left parietovertex lesion is most suggestive of an incidental "giant" pacchionian (arachnoid) granulation. The lytic "punched out" lesion, in the region of the right pterion, has a most unusual appearance. This includes peripheral low-attenuation (measuring negative [Doctor Last Name ], suggestive of fat) as well as central stippled calcification or ossification, with no associated soft tissue component. This could represent an unrelated hemangioma or, less likely (given the calcification), epidermoid. However, lytic breast metastasis with residual bone fragments, remains a concern. If further evaluation is necessary (unclear, given current clinical scenario), comparison with any previous cross-sectional study, as well as MRI (including post-contrast, fat-suppressed sequences) may be of help. . [5-31] CTA and CT torso TECHNIQUE: Multidetector helical scanning of the chest, abdomen and pelvis was performed prior to and following the administration of IV contrast (130 cc IV Optiray). Coronal, sagittal and multiple oblique reformats were performed of the chest as well as coronal and sagittal reformats of the abdomen and pelvis. CTA OF THE CHEST: There is no evidence of pulmonary embolism. The heart is moderately enlarged with no evidence of pericardial effusion. There is no evidence of aortic dissection. Large mediastinal and hilar lymph nodes are noted including a 2 x 2.7 cm pretracheal lymph node (3A:29), and two right hilar lymph nodes measuring up to 1.5 cm each. The bronchi are patent to the subsegmental level. Diffuse perivascular ground-glass opacification of the lungs is consistent with pulmonary edema. There are moderate bilateral pleural effusions, measuring simple fluid density, with associated atelectasis. No definite consolidations are seen. Geographic airspace opacity along the left upper lobe is relatively unchanged since [2128-1-22] and consistent with post-radiation changes. No pathologically enlarged axillary lymph nodes are seen. CT OF THE ABDOMEN: Multiple enhancing masses are seen within the liver, new since [2128-1-22] and consistent with metastases from patient's known metastatic breast cancer. The largest lesions include a 3 x 2.5 cm lesion in the right lobe (3B:107). A 2.7 x 2.5 cm lesion of the inferior and posterior aspect of the right lobe (3B:123) and an ill-defined 3 x 3 cm lesion in the inferior aspect of the left lobe (3B:116). The adrenal glands are thickened bilaterally, increased since [2128-1-22], also concerning for metastases. The spleen, pancreas and gallbladder are unremarkable. A non-enhancing exophytic cyst of the left kidney is again noted. The kidneys enhance and excrete contrast normally. The aorta is of normal caliber throughout. Intra- abdominal small and large bowel loops are unremarkable. Increased stranding within the mesentery and soft tissues consistent with anasarca. Duodenal diverticulum is again noted. CT OF THE PELVIS: The patient is status post sigmoid resection. Post-surgical changes of the anastomotic site are stable with no extraluminal air identified. This area is not well distended to evaluate for recurrence. No free fluid or lymphadenopathy within the pelvis. Foley catheter is seen within the bladder. BONE WINDOWS: Again seen are diffuse sclerotic metastases throughout the lumbar spine and pelvis with a stable L1 compression fracture status post vertebroplasty. Multiplanar reformats confirm the above findings. IMPRESSION: 1. No evidence of pulmonary embolism. 2. Moderate pulmonary edema and bilateral pleural effusions. 3. Increasing mediastinal and right hilar lymphadenopathy. 4. Stable radiation changes in the left upper lobe. 5. Progression of disease with new liver metastases and bilateral adrenal enlargement suggestive of metastasis. 6. Diffuse osseous metastases with no evidence of new fractures. 7. Anasarca. . [5-31] CXR FINDINGS: The patient is in lordotic and slightly leftward rotated position. A right central venous catheter is identified with tip overlying the expected region of the distal SVC. There is mild cephalization of the pulmonary vasculature which may be consistent with mild pulmonary edema. There is a stable appearing dextroscoliosis of the thoracolumbar spine. There is a right-sided pleural effusion which is unchanged in size. There is no evidence of a right pleural effusion. The sclerotic appearance of several lower thoracic vertebral body is stable corresponding to sclerotic metastasis on prior studies. IMPRESSION: 1. Perihilar congestion and cephalization of the pulmonary vasculature consistent with congestive heart failure. 2. Blunting of the left costophrenic angle is consistent with either effusion or atelectasis and is stable. 3. Again identified is sclerotic foci and vertebroplasty material from patient's known metastatic disease to the spine. . [6-1] CXR Moderately severe pulmonary edema and small-to-moderate pleural effusions, right greater than left, have increased since [5-31]. Mild cardiac enlargement has increased. Tip of the right subclavian line projects over the superior cavoatrial junction. No pneumothorax. . [6-2] MRI Brain HEAD MRI TECHNIQUE: Multiplanar T1, T2, diffusion-weighted, and post-gadolinium sequences were obtained. FINDINGS: An 8 x 9 mm ring-enhancing lesion is present within the right occipital lobe with an adjacent 9 x 10 mm more homogeneously enhancing lesion within the left occipital lobe, both consistent with metastatic disease. Additionally, a previously identified dural-based mass, predominantly located at the cranial right-sided vertex with midline extension to involve the left- sided vertex appears to have mild amount of homogeneous enhancement in association with thickening of the dura and dural enhancement, also suggestive of a dural metastatic lesion. Two osseous lesions, one within the inner table of the right frontal bone with extension to an extradural location and the second within the posterior high vertex of the parietal bone with inner table erosion and adural extension are also likely consistent with osseous metastatic disease. Increased T2 and FLAIR signal abnormalities within the cerebral periventricular deep [Known lastname ] matter are compatible with chronic small vessel infarction. There is no evidence of hydrocephalus, shift of normally midline structures, or acute infarct. No abnormal areas of restricted diffusion are identified surrounding the parenchymal lesions. There is mild mucosal thickening of the maxillary sinuses bilaterally, likely inflammatory in origin. IMPRESSION: Findings most consistent with bilateral occipital, subdural, and osseous right frontal and left parietal metastatic lesions. Coincident meningiomas accounting for the vertex dural lesions is an alternative diagnosis. . [6-3] MRI spine: FINDINGS: There are areas of low signal identified predominantly in C2, C4, C5, T1, T2, and T3 vertebral bodies indicative of sclerotic metastasis. There is no evidence of spinal cord compression or epidural mass identified. There is no evidence of intrinsic spinal cord signal abnormalities. Multilevel degenerative changes are seen from C3-4 to C6-7 without spinal stenosis. IMPRESSION: Sclerotic metastatic disease in the visualized cervical vertebral bodies without epidural mass or spinal cord compression. No evidence of intrinsic spinal cord signal abnormalities. THORACIC SPINE: TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the thoracic spine were obtained. Comparison was made with the previous MRI examination of [2127-6-23]. FINDINGS: Again diffuse sclerotic metastasis is seen in the thoracic vertebral bodies. As seen on the previous lumbar spine MRI of [2128-3-7], there is a pathologic fracture of L1 vertebra visualized with retropulsion. There is mild spinal stenosis seen at that level. In the thoracic region at T9 and T10 level, mild epidural soft tissue changes are seen with mild-to-moderate spinal stenosis. There is no obvious spinal cord compression seen on the T2 axial images, however. There is no evidence of intrinsic spinal cord signal abnormalities seen. IMPRESSION: Bony metastatic disease with low signal intensities indicative of sclerosis. Chronic pathologic fracture of L1 with retropulsion and mild spinal stenosis which appears to be secondary to epidural disease at T9 and T10 level which can be better evaluated with gadolinium-enhanced MRI if clinically indicated. No spinal cord compression seen. . [6-1] ECHO: Conclusions: The left atrium is mildly dilated. The estimated right atrial pressure is 0-5mmHg. Left ventricular wall thickness and cavity size are normal. There is focal hypokinesis of the distal half of the inferior wall. The remaining segments contract well. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([12-23]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [2128-4-20], new regional left ventricular systolic dysfunction is now seen c/w CAD and the severity of mitral regurgitation has increased. The estimated pulmonary artery systolic pressure is lower. A large left pleural effusion is similar (was present but not reported). CLINICAL IMPLICATIONS: Based on [2127] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Brief Hospital Course: A/P: 71 yo woman with metastatic breast cancer to spine, femur p/w acute dyspnea . Dyspnea: Pt with evidence of pulmonary edema on exam/imaging, responsive to nitro gtt in the ED. Elevated bnp. No evidence of PE despite risk factors. No clear PNA but underlying parenchymal changes, fever, bandemia. In regards to trigger for flash pulm edema, CEs positive for NSTEMI with rate related changes on ECG. No baseline LV dysfunction or valvular disease on recent echo but new murmur concerning for MR. [First Name (Titles) ] [Last Name (Titles) 10718] appeared to occur in setting of significant HTN, ? related to medication effect (missed toprolXL, recently started on ritalin). - Her dyspnea had resolved by discharge. It appeared to have been caused by ? flash pulmonary edema in the setting of hypertension and NSTEMI. Unclear which precipitated which but her blood pressure was well-controlled on dishcarged and she had no further episodes while in-house. . NSTEMI: Troponin elevated but trending down, at risk for CAD given left chest wall XRT, h/o hypertension. Not a candidate for heparin/IIbIIIa inhibitors given CNS pathology. Started on aspirin, continued on beta blockade, nitro gtt overnight. Nitro gtt stopped prior to transfer from ICU to OMED. - she was continued on metoprolol and this was increased w/ goal HR < 70 - lisinopril was also started prior to d/c - Dr. [Last Name (STitle) 30938] was emailed and she will follow-up with him as an outpatient . HTN: [Month (only) 116] have missed her toprol dose on the day of admission. BP initially controlled with nitro gtt but this was weaned before she was transferred to OMED and her BP was well-controlled w/ toprol and the additional of lisinopril. . leukocytosis/fever: ? pulm source, no other localizing s/s. Blood sent/urine sent and negative. Cont levoflox for empiric 7 day course (day 1=[5-31]). Also given new MR murmur and indwelling portacath concern for endocarditis, she had a TTE that was not concerning for endocarditis although it did show slightly worsened MR. . metastatic breast CA: Recently began treatment with Velban [2128-5-7]. Now with evidence on imaging concerning for mets to head, new mets to liver and elsewhere in abd. She was given the news of the spread of her disease and an MRI was performed of her brain and spine. She started whole brain radiation while inpatient ([6-3]) and will continue this as an outpatient per Dr. [Last Name (STitle) ]. - prednisone taper per Dr. [Last Name (STitle) ]. . s/p ORIF of right pathologic femur fracture: Pt recently discharged home from rehab. Has been ambulating with walker. Plan for ortho f/u as out-pt. C/S PT/OT. . hypothyroidism: cont home synthroid . anxiety: cont home ativan . ppx: ppi, BR, pneumoboots, holding heparin given brain mets . FEN: HH diet, replete lytes . acccess: PIV, port . comm: Daughter [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]/HCP, [Telephone/Fax (1) 109222] (work)/[Telephone/Fax (1) 109223] (cell) . FULL CODE Medications on Admission: Oxycontin 280 mg q8h. oxycodone 20 mg - 30 mg q3h. p.r.n. Colace prn Senna prn Ativan 1 mg q4h prn ritalin 2.5 mg daily levothyroxine 25 mcg daily ibuprofen prn sertraline 50 mg daily toprol 12.5 mg daily omeprazole 20 mg 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. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Seven (7) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). 3. Oxycodone 5 mg Tablet Sig: 20-30 mg PO Q3H (every 3 hours) as needed for pain. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for anxiety or insomnia. Disp:30 Tablet(s) Refills:0 7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:90 Tablet(s) Refills:2 8. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:30 Tablet Sustained Release 24 hr(s) Refills:2 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:2 Tablet(s) Refills:0 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heartburn. 15. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:15 Tablet(s) Refills:2 16. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): through [6-9], then 1 tab 3 times per day through [6-16], then 1 tab 2 times per day through [6-24] then per Dr. [Last Name (STitle) 724]. Disp:100 Tablet(s) Refills:0 17. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [12-23] Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:1 INH Refills:0 18. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) patch Topical once a day: place patch, remove after 12 hours. Wait 12 hours before placing the next patch. Disp:30 patches Refills:2 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: NSTEMI Pulmonary Edema HTN Urinary Tract Infection SIADH Metastatic Breast Cancer Hypothyroidism Anxiety Discharge Condition: Hemodynamically stable. Ambulatory with a walker. Discharge Instructions: You were admitted with shortness of breath from pulmonary edema. The pulmonary edema was likely caused by high blood pressure, a small heart attack and worsening of your mitral valve function. It is very important that you have good blood pressure control (goal <120/80). You should also follow a low-fat, low cholesterol, low-salt diet. . Please seek medical attention immediately if you develop fever, chills, nausea, vomiting, shortness of breath, chest pain or any other concerning symptoms. . We made some changes to your medicines. We stopped your Ritalin. We increased your toprol dose to 25 mg per day. We added a blood pressure medication call lisinopril to your regimen. You will take an antibiotic called levofloxacin for two more days. A steroid was added to your regimen for the lesions in your brain. Please follow the schedule that we have written out for you on how to take the steroids. We added a lidoderm patch to your regimen for your pain. We gave you an inhaler to use when you have shortness of breath. Followup Instructions: 1) You are scheduled to have radiation therapy on [5-19] and [6-9] at 10:00 am. Dr. [First Name8 (NamePattern2) 324] [Last Name (NamePattern1) ]. Tel ([Telephone/Fax (1) 8082]. . 2) You have an appointment w/ Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 724] (Neuro-Oncology) on [2128-6-21] at 2:00 pm. Tel ([Telephone/Fax (1) 6574]. . 3) You have an appointment with Dr. [First Name4 (NamePattern1) 122] [Last Name (NamePattern1) ] (cardiology) on [2128-6-24] at 10:40 am. Tel ([Telephone/Fax (1) 10085]. . Then following appointments are already scheduled for you: Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 3260], [MD Number(3) 1240]:[Telephone/Fax (1) 22] Date/Time:[2128-6-18] 10:00. This appointment will also be with Oncologist Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ]. Provider: [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 4425], RN Phone:[Telephone/Fax (1) 22] Date/Time:[2128-6-18] 10:30	[ "5990", "486", "4019", "2449", "41071", "4280" ]
Admission Date: [2172-6-25] Discharge Date: [2172-7-2] Date of Birth: [2091-10-7] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Gold Salts Attending:[First Name3 (LF) 613] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: Intubation, central venous line placement History of Present Illness: Ms. [Known lastname ] is a 80 y/o Spanish-speaking female with h/o MI in [2-/2172] (in setting of urosepsis), RA on steroids, HTN, recent UTI on levaquin, ? lung disease, who presents with AMS at rehab. . Per reports, patient was in USOH at 7am this morning when patient was evaluated by [Hospital1 1501] staff. Per daughter, who last spoke with patient at 10am, patient was alert and conversant however noticed that her words were slurred. Was apparently also nauseous. Later this PM, pt vomited and was noted to have desatted. She then was noted to be lethargic and less responsive. . Patient was then transferred to [Hospital1 18] ED for further evaluation. On arrival to ED, patient's vitals were 101.2 92 133/50 19 100% NRB. Code stroke was called and patient was evalauted by neuro who left that AMS was [1-8] toxic/metabolic causes. NCHCT was completed and was unremarkable. . Given level was consciousness, ABG was completed and showed significant hypercarbia with pCO2 of 100. Patient was started BiPAP however SBPs dropped to 73/49. CPAP was then tried and SBPs remained in 120s and MS improved. Patient was also given 1 dose of CTX for UTI as well as 1000cc of fluid. Lactate was noted be 1.0. Pt has positive UA and mild leukocytosis. Given tenuous mental status, patient was admitted to MICU. Prior to transfer, VS were afebrile HR 76 BP 105/41 RR 17 SpO2 92% on Cpap (PEEP 5mmHg). . In MICU, pt was minimally responsive to sternal rub. Review of systems: (+) Per HPI: chest pain (per dtr) . Past Medical History: - ? Lung disease with "CO2 retention"- severe restrictive disease - ? Sleep Apnea - CAD, sp CABG, s/p STEMI in [2-/2172] w/ 2 BMS to the RCA and RBL - S/p DVT w/ lupus anticoag (was on coumadin but had GI bleed on [2-/2172] in the setting of supra-therapeutic INR) - L retinal vein occlusion - Chronic anemia - diastolic dysfunction w/ EF of 75% - Bioprosthetic mitral valve seen on echo [6-/2172] - Moderate TR - Moderate pulmonary HTN - frequent UTIs and urosepsis - [Hospital3 ], h/o VRE (pseudomonas) - RA - HL - HTN - hypothyroidism - TKR Social History: daughter reports patient has lived at [Hospital3 2558] since hospitalization in [Month (only) 958]. She does not have dementia or cognitive impairment at baseline. - Tobacco: past h/o heavy smoking - Alcohol: none Family History: NC Physical Exam: Vitals: 96.8 79 113/72 12 91% on CPAP General: minimally responsive to sternal rub only HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: cool, tready pulses, multiple ecchymoses . Pertinent Results: ON ADMISSION: - ABG (prior to NIPPV): 7.22/100/82/43 - Lactate: 1.0 - UA: 11 WBC, Mod Leuk, Few Bact Outside Labs: from [2172-6-24] <-- [2172-6-19] - WBC 12.8 <-- 15.8 - Neuts: 70.5% - Lymphs: 19.6% - Hct 40.2 - Plt 265 - Na 138 - K 3.9 - Cl 91 - Co2 34 <-- 35 - BUN 26 - Cr 1.1 <-- 1.0 - Glucose 136 - Ca 8.6 . Discharge Labs: [2172-7-2] 06:05AM BLOOD WBC-9.6 RBC-3.77* Hgb-9.5* Hct-30.8* MCV-82 MCH-25.2* MCHC-30.9* RDW-17.0* Plt Ct-207 [2172-7-2] 06:05AM BLOOD Glucose-105* UreaN-23* Creat-1.1 Na-145 K-4.2 Cl-104 HCO3-37* AnGap-8 [2172-7-2] 06:05AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.1 [2172-6-26] 03:35AM BLOOD TSH-2.7 [2172-7-1] 05:47AM BLOOD Ferritn-69 Micro: - [2172-6-25]: URINE CULTURE-PENDING . Images: - CT HEAD: (prelim read) No acute intracranial hemorrhage or mass effect. White matter hypodense areas- likely non-spf; consider MR if not CI to exclude acute infarction. - CTA Head and Neck: (prelim read) Atherosclerotic disease at the common carotid bifurcations- pending review of reformations to assess the extent of stenosis. Focal prominence at the junction of the A1 and A2 on the right may relate to confluence; however, to be reviewed on ref. to exclude a small incidental aneurysm. ( se 3, im 246) No obvious flow limiting stenosis, occlusion or obvious aneurysm. Final read pending all the 3D reformations. - CXR: [2172-6-25] Lung volumes are quite low, making it difficult to determine if there really is pulmonary vascular congestion or just vascular crowding and whether there is atelectasis or consolidation at the base of the left lung. Heart size is top normal. No pneumothorax. - CXR: [2172-6-30] FINDINGS: As compared to the previous radiograph, the patient has been extubated. The nasogastric tube has also been removed. The right-sided subclavian vein catheter is in unchanged position. Also unchanged are the external pacemaker leads. Unchanged alignment of the sternal wires, unchanged position of the valve replacement. The pre-existing signs of mild-to-moderate pulmonary edema, combined to a retrocardiac and left basal atelectasis as well as to a left pleural effusion are unchanged. A previously described right pleural effusion is no longer visible. There is no evidence of newly appeared focal parenchymal opacities Echo showed "mild symmetric LVH with normal global and regional biventricular systolic function. Mildly thickened mitral bioprosthesis with normal function. Moderate tricuspid regurgitation. Moderate pulmonary hypertension." . AS PER [Hospital3 ] REC: [2172-4-3] CT- pelvis: this was done for evaluation of hip replacement. - Showed extensive diverticulosis w/out diverticulitis. Urinary bladder significantly distended. There is a small ventral hernia in the region of the pelvis that contains small bowel loops and extensive vascular calcification. No other comments on urinary tract system. Brief Hospital Course: 80 y/o F with history of recurrent UTIs, MI, RA on steroids who presents with sudden onset altered mental status in setting of fever and positive UA found to have hypercarbia (Pc02: 100) requiring bipap and subsequent intubation. #. Acute on Chronic Hypercapnia: Severe hypercarbia with pCO2 to 100. Felt to be secondary to baseline obstructive disease in setting of hypoventilation from significant AMS from recieiving tramadol and quinolone and a UTI. Pt initially failed NIPPV from mental status standpoint and was intubated. Started CTX/Azithromycin for CAP, however broadened to linezolid (VRE history) and cefepime. Able to be weaned from ventilator, was diursed with IV Lasix gtt. Weaned off the vent to room air. Had episodes of hypotension that were fluid responsive in the MICU. Urine culture grew [Last Name (LF) 100098], [First Name3 (LF) ] patient was narrowed to cefepime only. Her respiratory status improved greatly. Patient will follow up with pulmonary clinic. 2. Altered Mental Status/Somnolence: CT head unremarkable, EKG unremarkable, sedating meds were limited. Likely related to pain medication, levofloxacin she received plus UTI. Improved with treatment of UTI and holding these medications. #. Hypotension: Transiently after receiving sedation. Normal lactate, EKG. NICOM showed fluid responsiveness and was given IVF's. Got subclavian CVL which was removed after PICC placed. #. Urinary tract infection: Has h/o VRE in urine per daughter. Recurrent UTI with prior urosepsis in [12/2171] requiring intubation at [Hospital6 ]. UCx grew out Pseudomonas Cipro resistant (was treated with Levaquin as outpt before admission), intermediate Gent, otherwise sensitive. Will be treated with a 14 day course of Cefepime. She will also follow up with ID in the outpatient for other possible management of her resistant UTIs. # CHF/CAD: s/p MI in 03/[2171]. EKGs unremarkable. Recent Echo shows EF: 75%. Roughly equal to negative fluid balance during entire length of stay. Now on 2 liters O2, saturating well. Continued ASA, plavix, atorvastatin, beta blocker, and restarted lasix at 40 mg daily and should be uptitrated back to home regimen as patient is tolerating. # ARF: Creatinine increased from 1 to 1.3 in setting of starting captopril and diuresis. Patient was normotensive on floor and captopril was being held, so this was stopped prior to discharge. She was placed back on her regimen as above. # Shakiness/Weakness: Patient complaining of shakiness. Normal neuro exam. Appeared to be secondary to significant deconditioning. She will be discharged back to rehab. # Rheumatoid Arthritis: On chronic steroids. Given 50 mg stress dose of Hydrocortisone initially. Continued prednisone 10mg # Hypothyroidism: continued levothyroxine # GERD: continued pantoprazole # Communication: Patient and Family: daughter [Name (NI) 15359]: [Telephone/Fax (1) 100099] # Code: Was full, then pt stated she wanted to be DNR/DNI, not receive NIPPV either. Medications on Admission: (per [Hospital3 ] records) - ASA 81 - Plavix - Levaquin 500 mg x 5 days (started [6-23]) - Lasix 40mg [Hospital1 ] (as of [6-23], was on 20mg at 2PM and 40mg at 6PM prior to this) - Lipitor 80 mg - pantoprazole 40 mg - Tramadol 50 mg TID PRN - gabapentin 300 mg [Hospital1 ] - levothyroxine 25 mcg daily - Toprol XL 100 mg daily - Remeron 15 mg qhs - KCL 20 meq daily - prednisone 10 mg daily - folic acid 1mg - MVI - lidoderm patch to right hip - colace . Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day): Continue until patient is ambulatory. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. cefepime 2 gram Recon Soln Sig: Two (2) Grams Injection Q12H (every 12 hours) for 7 days. 12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for yeast infection. 14. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold for sbp < 100. 15. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for yeast. 16. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 17. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain: 12 hours on and 12 hours off. 19. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [Hospital3 2558] - [Location (un) ] Discharge Diagnosis: Primary: Hypercarbic respiratory failure Pseudomonas UTI Metabolic encephalopathy 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: You were admitted for altered mental status and found to have a urinary tract infection. Your carbon dioxide in your blood was very high, which can cause signficant sleepiness. You were ultimately intubated to correct this problem. [Name (NI) ] received antibiotics for your infection and you improved. You should continue all of your medications with the following important changes: 1. Continue Cefepime 2 grams every 12 hours. Last day [2172-7-9] 2. Decrease lasix to 40 mg daily and should uptitrate by your primary care doctor as needed 3. STOP Tramadol as this may have been why you were so sleepy 4. Decrease metoprolol to 37.5 mg twice per day Followup Instructions: Department: MEDICAL SPECIALTIES When: MONDAY [2172-7-13] at 1:30 PM With: DR. [Last Name (STitle) 51373]/DR. [Last Name (STitle) ] [Telephone/Fax (1) 612] Building: [Hospital6 29] [Location (un) ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage Please arrive at 1:00pm for this appointment. Department: INFECTIOUS DISEASE When: WEDNESDAY [2172-8-19] at 3:00 PM With: [First Name8 (NamePattern2) 1955] [Last Name (NamePattern1) ], MD [Telephone/Fax (1) 457] Building: LM [Hospital Unit Name ] [Hospital 1422] Campus: WEST Best Parking: [Hospital Ward Name ] Garage Please call our registration department at [Telephone/Fax (1) 10676] to update your demographic information before your appointments. [First Name5 (NamePattern1) ] [Last Name (NamePattern1) ] MD [MD Number(2) 617]	[ "51881", "5845", "486", "5990", "412", "V4582", "V4581", "4280", "32723", "4168", "2724", "4019", "2449", "53081" ]
Admission Date: [2184-8-12] Discharge Date: [2184-8-18] Service: MEDICINE Allergies: Antihistamines Attending:[First Name3 (LF) 898] Chief Complaint: fatigue, weakness, and red/dark stools x2-3wk Major Surgical or Invasive Procedure: EGD [2184-8-13] History of Present Illness: Mr. [Known lastname ] [Age over 90 ]yo man with a history of extensive peripheral vascular disease, CAD, metastatic prostate CA, who presents w/ fatigue, weakness, and red/dark stools x2-3wk. He reports loose red/dark stools on at least a daily basis. No abd pain, N/V. No prior [Last Name (un) ] known. No lightheadeness, CP, or SOB. Pt??????s son encouraged pt to seek care, so he was brought to ED for further eval. In ED, afebrile, HR 60s, SBP 100s (baseline 110-130s). Hct 21, then 14 on repeat, though no interim blood loss (? Hct 14 spurious value). Guaiac +. Pt being admitted to MICU for further eval & tx of GIB. Of note, pt also started on cefazolin for possible LLE cellulitis. Past Medical History: 1. CAD: IMI and complete heart block prior to CABG in [2169-12-30]. 2. Complete heart block in [2169], s/p PPM 3. Atrial fibrillation 4. Mitral valve abnormality with thrombus; on Coumadin since [2168]. 5. TIA's in [2167]. 6. Right CVA in [2176-8-30]. 7. Hypertension. 8. Hypercholesterolemia. 9. Prostate cancer diagnosed in [2169-2-27]; treated with Lupron/Premarin. 10. Peptic ulcer disease greater than 50 years ago. 11. Spinal stenosis with disk disease. 12 Herpes zoster. 13. Venostasis disease. 14. Peripheral vascular disease; followed by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1476] since [2175]. PAST SURGICAL HISTORY: 1. CABG times four with left leg vein on [2170-1-1] byDr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], at [Location (un) 511] [Hospital ] Hospital. 2. Left CEA in [2176-5-30] by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1476]. 3. Right CEA with Dacron patch angioplasty in [Month (only) ] of2000 by Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) 1476]. 4. Status post right BKA to RLE 5. L SFA occlusion, tx??????d w/ angioplasty & stent on [2183-11-5]. Social History: patient lives with his wife. [Name (NI) ] gets around in wheelchair. He does not smoke cigarettes. He occasionally drinks alcohol. Family History: nc Physical Exam: ENT: pale sclerae. ABDOMEN: Soft. LYMPH NODES: Exam is negative in the supraclavicular and axillary region. NECK: Supple without masses. EXTREMITIES: R BKA; LLE w/ skin brkdown over shin & medial malleoulus-->stage II ulcer, erythema surrounding lesion. Pertinent Results: [2184-8-12] 07:55PM BLOOD WBC-15.0# RBC-2.35# Hgb-6.4# Hct-21.0# MCV-89 MCH-27.2# MCHC-30.4# RDW-14.0 Plt Ct-398 [2184-8-13] 06:28AM BLOOD WBC-14.4 RBC-3.51# Hgb-10.3# Hct-30.6# MCV-87 MCH-29.2 MCHC-33.6# RDW-14.2 Plt Ct-282 [2184-8-13] 02:00PM BLOOD Hct-26.7 [2184-8-14] 03:43AM BLOOD WBC-13.2* RBC-3.57* Hgb-10.0* Hct-32.5* MCV-91 MCH-27.9 MCHC-30.7* RDW-14.5 Plt Ct-227 [2184-8-15] 05:58AM BLOOD WBC-11.2* RBC-3.52* Hgb-10.2* Hct-30.8* MCV-88 MCH-28.9 MCHC-33.0 RDW-14.6 Plt Ct-227 [2184-8-16] 05:35AM BLOOD WBC-9.3 RBC-3.57* Hgb-10.0* Hct-31.0* MCV-87 MCH-28.0 MCHC-32.3 RDW-14.7 Plt Ct-261 [2184-8-17] 05:15AM BLOOD WBC-9.7 RBC-3.63* Hgb-10.3* Hct-32.2* MCV-89 MCH-28.3 MCHC-31.9 RDW-14.8 Plt Ct-245 [2184-8-18] 09:50AM BLOOD WBC-9.3 RBC-3.59* Hgb-10.1* Hct-32.0* MCV-89 MCH-28.2 MCHC-31.7 RDW-14.8 Plt Ct-278 [2184-8-12] 07:55PM BLOOD PT-31.9* PTT-31.4 INR(PT)-3.3* [2184-8-13] 06:28AM BLOOD PT-24.4* INR(PT)-2.4* [2184-8-13] 02:00PM BLOOD PT-19.1* PTT-30.5 INR(PT)-1.8* [2184-8-14] 03:43AM BLOOD PT-17.8* PTT-36.2* INR(PT)-1.6* [2184-8-15] 05:58AM BLOOD PT-17.6* PTT-30.7 INR(PT)-1.6* [2184-8-18] 09:50AM BLOOD PT-15.3* PTT-36.4* INR(PT)-1.4* [2184-8-12] 07:55PM BLOOD Glucose-109* UreaN-40* Creat-1.5* Na-136 K-4.7 Cl-104 HCO3-22 AnGap-15 [2184-8-13] 06:28AM BLOOD Glucose-107* UreaN-33* Creat-1.3* Na-138 K-4.4 Cl-107 HCO3-20* AnGap-15 [2184-8-15] 05:58AM BLOOD Glucose-100 UreaN-36* Creat-2.1* Na-137 K-3.6 Cl-106 HCO3-20* AnGap-15 [2184-8-16] 05:35AM BLOOD Glucose-99 UreaN-32* Creat-1.8* Na-137 K-3.3 Cl-106 HCO3-21* AnGap-13 [2184-8-18] 09:50AM BLOOD Glucose-145* UreaN-18 Creat-1.3* Na-140 K-3.6 Cl-108 HCO3-23 AnGap-13 [2184-8-12] 07:55PM BLOOD CK(CPK)-51 [2184-8-12] 07:55PM BLOOD cTropnT-0.03* [2184-8-13] 06:28AM BLOOD Albumin-3.1* [2184-8-14] 03:43AM BLOOD PSA-107.6* [2184-8-12] 09:12PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG Culture: [8-12] Ucx negative. Bcx negative x2 [8-14] Wound Culture MRSA [8-16] H.pylori negative Imaging: [8-13] EGD: Findings: Esophagus: Normal esophagus. Stomach: Mucosa: Erythema, erosion and ulceration of the mucosa were noted in the antrum. Duodenum: Mucosa: Erosion, erythema, and ulceration of the mucosa with contact bleeding were noted in the anterior bulb. Impression: Erythema, erosion and ulceration in the antrum Erosion, erythema, and ulceration in the anterior bulb Otherwise normal EGD to second part of the duodenum Recommendations: Routine post procedure orders Please start [Hospital1 ] PPI. Continue to trend HCT. Brief Hospital Course: [Age over 90 ]yo man w/ multiple medical problems including metastatic prostate cancer (to bone), afib on coumadin, CAD, who p/w fatigue & weakness in setting of red/dark stools x2-3wk. Found to have hct 21, down from low to mid-30s. Stool guaiac positive. # GIB: The pt was transfused a total of 5 units pRBCs and his HCT stabalized. PPI therapy was initiated. Serial HCTs were followeded initial q6 hours and then less frequently. The GI service was consulted and an EGD was performed; no clear source for bleeding was identified. The pt's anticoagulation was revered with Vit K and FFP pre-procedure. An EGD was performed on [8-13] which was significant for Erythema, erosion and ulceration in the antrum. Erosion, erythema, and ulceration in the anterior bulb. Otherwise normal EGD to second part of the duodenum. Biopsies were not taken due to contact bleeding. [Name2 (NI) ]-procedure, the patient's HCT remained stable throughout the remainder of his hospital course. H.pylori serologies were drawn and were negative. . # CAD: The pt has a remote hx of IMI. He did not demonstrate any sxs of ischemia during this admission. The pt's home atenolol was intially held in the setting of unstable plasma volume. The pt's home Plavix and Coumadin (pt not on ASA at home) were held as well given the drop in HCT with presumed GI bleed. Post-EGD, the HCT remained stable and he was restarted on his plavix and coumadin upon discharge without events. He will be bridged at discharge with lovenox. #Afib/CHB: The pt is s/p PPM. His Coumadin was held and his anticoagulation reversed for the acute bleed. The pt's BB and diltiazem were also held. Once stabilized, he was restarted on all his home medications without difficulty. # PVD: The pt is s/p RLE BKA and bilateral CEA. At admission, his skin was warm, well perfused, though some stage 2 ulcers on LLE (L medial malleolus & L shin); Cipro and nafcillin were started for a question ulcer infection, possible with Pseudomonas. The vascular surgery and wound services were consulted and followed the pt's progress. No e/o osteo, local cellulitis. A wound culture was positive for MRSA and given the sensitivities, the cipro and nafcillin were d/c and the patient was started on Bactrim DS for a full 14 day course. Patient scheduled for 2wk follow-up with Dr. [Last Name (STitle) ]. # Prostate CA: mets to bones. Continued on premarin, flomax Code: FULL (confirmed by MICU team) Medications on Admission: ATENOLOL - 25 mg qpm ATORVASTATIN 10 mg tabs Tablet(s take one pill a day;two pills on Mon/Wed/Friday CONJUGATED ESTROGENS [PREMARIN] ?????? 3.75 mgevery morning DILTIAZEM HCL [DILTIA XT] - 120 mg once a day SPIRONOLACTONE - 12.5 mg every evening TAMSULOSIN - 0.4 mg once daily WARFARIN - (- 2 mg Tablet - qd, last dose [2183-11-2] pre angiogram Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Conjugated Estrogens 0.625 mg Tablet Sig: Six (6) Tablet PO QAM (once a day (in the morning)). 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day for 6 weeks. Disp:84 Tablet, Delayed Release (E.C.)(s) Refills:0 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 14 days. Disp:56 Tablet(s) Refills:0 8. Lovenox 120 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous once a day for 10 days. Disp:10 syringes Refills:0 9. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day: Hold if SBP<100 or HR<60. Discharge Disposition: Home With Service Facility: [Hospital1 ] senior life Discharge Diagnosis: Upper gastrointestinal bleed Discharge Condition: Stable in good condition Discharge Instructions: You were admitted to the hospital because of upper gastrointestinal bleeding that had manifested as red/dark stools. In the Emergency Department you were noted to have a very low red blood cell count, likely because of this bleeding. Because of this concern for gastrointestinal bleeding you were admitted to the Medical ICU for observation. While in the ICU, you were seen by the Gastroenterologists who did an upper endoscopy which showed some erosions in the mucosa of your stomach but no active bleeding or deep ulcers. Because your red blood cell count was low, you were given 5 units of red blood cell tranfusion. You did not have any further bleeding or decreases in your red blood cell count and were deemed stable for discharge on [8-18]. You were seen by the Vascular surgeons while you were in the hospital for your left lower leg ulcers. A culture was done of the ulcer because of surrounding redness. The culture grew out a bacterial MRSA. You will be treated with bactrim for this bacteria for a full 14 day course. You were taken off of your home Diltiazem and Spironolacton because of blood pressure. You should have your blood pressure checked by the visiting nurse service and followed up with your primary doctor to address adding this medication back. You will be taking a new medication, Lovenox which is a daily injection as well a Bactrim, which is an antibiotic for your leg ulcers. The Bactrim will be a 14 day course. Call your primary doctor or go to the Emergency Room if you have any persistent fevers, any sudden weakness, any blood in your stool or very dark/black stools. Followup Instructions: Follow-up with your new primary care provider, [Name10 (NameIs) 39063] [Name8 (MD) 106250], MD Phone:[Telephone/Fax (1) 250] Date/Time:[2184-9-1] 3:00 Follow-up with your Vascular [Last Name (LF) 5059], [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2184-9-9] 2:30	[ "2851", "42731", "4019", "2720", "V4581", "V5861" ]
Admission Date: [2136-11-24] Discharge Date: [2136-12-5] Date of Birth: [2089-5-3] Sex: M Service: NEUROLOGY Allergies: Etoposide Attending:[First Name3 (LF) 8850] Chief Complaint: Seizure. Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [Name14 (STitle) ] is a 47 y/o man with a PMH of GBM s/p resection, radiation, ongoing chemo (with Avastin and carboplatin; last cycle this past tuesday), and seizures who presents after a prolonged seizure this morning. According to his wife, he had a 2 minute seizure last night that involved right facial twitching and inability to talk. Afterwards, he returned to his baseline and was able to walk and talk. This morning, a few minutes before 6, his wife felt him kick her on the couch. He was unable to talk, his right face was twitching, his tongue was going up and down and his right arm was rhythmically going up and down. He couldn't open his eyes and was not alert. This was noted to be different than his previous seizures as he is usually alert. His wife proceeded to stand him up and walked him by supporting his weight, she says this usually helps break his seizures, but he wouldn't come out of his unresponsive state. She then noted that the seizure (including the right face twitching, right arm jerking and tongue movements) lasted about 3 hours. He was taken to an OSH where he was intubated for airway protection as well as given Ativan, Dilantin and Dexamethasone. He was then transferred to [Hospital1 18] for further care. Past Medical History: PAST ONCOLOGIC HISTORY: (1) a stereotaxic brain biopsy by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. on [2135-6-17], (2) s/p gross total surgical resection by [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], M.D. on [2135-6-22], (3) received involved-field cranial irradiation with temozolomide to [2135-7-11] to [2135-8-22], (4) started Nuvigil on [2135-7-12] and stopped on [2135-9-5], (5) s/p 2 cycles of adjuvant temozolomide at 200 mg/m2/day x 5 days since [2135-9-24], (6) s/p 2 cycle of XL-184, which was started on [2135-11-25], (7) s/p hospitalization from [2136-1-20] to [2136-1-22] after a seizure causing non-fluent aphasia, (8) had 3 cycles of bevacizumab (5 mg/kg on [2136-2-28] and 10 mg/kg on [2136-3-13] in cycle 1, 10 mg/kg in cycle 2, 15 mg/kg in cycle 3, and 12.5 mg/kg in cycle 4), (9) had adverse abdominal reaction (pain and inability to tolerate food) with Etoposide which he last received approximately 10 days ago ([2136-6-24]), (10) But after stopping etoposide on [2136-6-24], his cramping and nausea improved by [2136-6-26]. He was admitted to the Hospitalist Service on [2136-6-27] for preparation for a colonoscopy. He was found to be neutropenic on [2136-6-28] with WBC at 1.2 and ANC at 467. His colonoscopy had to be with held. He was started on filgastrim 480 mcg subcutaneous daily on [2136-6-28]. On [2136-6-29], his WBC was 1.7 and his ANC was 969. He had his colonoscopy on [2136-6-29] without problem. (11) Currently on bevacizumab and carboplatin. PAST MEDICAL HISTORY: Arthritis GERD Hashimoto's thyroiditis Glaucoma Raynaud's syndrome s/p shoulder surgery Seizures Sigmoid diverticulosis Rectal bleed from hemorrhoids Social History: He lives at home with wife and denied tobacco, drugs, or alcohol abuse. Family History: His father has hypertension. His mother died of a left frontal lobe astrocytic tumor. He has 2 sisters and a brother; one sister has hypertension. He has 3 children and they are all healthy. Physical Exam: Physical Examination At The Time Of Admission: GENERAL: Awake, alert, NAD [Date Range 4459]: Sclerae anicteric, no conjunctival injection, oropharynx clear CARDIOVASCULAR: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops PULMONARY: CTA bilaterally, no wheezes, rhonchi, rales ABDOMEN: Positive BS, soft, NTND abdomen EXTREMITIES: No lower extremity edema bilaterally NEUROLOGICAL EXAMINATION: Mental status: Awake and alert, flattened affect. He was oriented to person, place, and date. He had decreased attention, perseverates with saying days of week backwards. There was no dysarthria, but stuttering speech, plus mild anomia Cranial Nerves: Right pupil: 7mm-->5mm, left pupil fixed at 6mm and non-reactive. Right homonymous hemianopsia. Extraocular movements intact bilaterally. Mild ptosis of left eyelid with right esotropia. Mild flattening of right nasolabial fold. Hearing intact to finger rub bilaterally. Motor: Normal bulk and tone bilaterally. Right pronator drift. [Doctor First Name ] Tri [Hospital1 ] WE FE FF IP H Q DF PF TE R 5- 5- 5- 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch throughout. +extinction on double stimulation with touch to left face and right side. Reflexes: 2+ and symmetric throughout. Gait: deferred. Physical Examination On Discharge: VITAL SIGNS: Temperature 97.7 F, blood pressure 130/80, pulse 73, repsiration 18, and oxygen saturation 96% in room air. GENERAL: AAOx3, conversant [Hospital1 4459]: Left pupil enlarged, minimally reactive CARDIOVASCULAR: RRR, S1+S2, no m/r/g PULMONARY: CTAB ABDOMEN: Soft, non-tender, non-distended, with psotive bowel sounds EXTREMITIES: No clubbing, cyanosis, or edema NEUROLOGICAL EXAMINATION: His Karnofsky Performance Score is 60. He is awake, alert, and able to follow commands. His language is fluent with good comprehension. His short-term recall is fine. Cranial Nerve Examination: His pupils are equal and reactive to light, 4 mm to 2 mm bilaterally. But the left pupil is sluggish direct light reflex. Extraocular movements are full; there is no nystagmus. Visual fields are full to confrontation in OD but his OS has no light perception. His face is symmetric. Facial sensation is intact bilaterally. His hearing is intact bilaterally. His tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: There is slight pronation of his right hand. His muscle strengths are [5-9] at all muscle groups, except for 4+/5 strength in right handgrip. His muscle tone is normal. His reflexes are 2- and symmetric bilaterally. His knee jerks are 2-. His ankle jerks are absent. His toes are down going. Sensory examination is intact to touch and proprioception. Coordination examination does not reveal appendicular dysmetria. Gait and stance are deferred. Pertinent Results: Adm labs: [2136-11-26] 08:40AM BLOOD WBC-4.0 RBC-3.51* Hgb-12.0* Hct-35.7* MCV-102* MCH-34.2* MCHC-33.6 RDW-18.3* Plt Ct-122* [2136-11-26] 08:40AM BLOOD Glucose-80 UreaN-10 Creat-0.6 Na-141 K-3.8 Cl-103 HCO3-27 AnGap-15 [2136-11-25] 02:54AM BLOOD ALT-47* AST-34 AlkPhos-72 TotBili-0.3 [2136-11-24] 12:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG Discharge labs: [2136-12-5] 07:05AM BLOOD WBC-2.3* RBC-2.53* Hgb-9.2* Hct-25.5* MCV-101* MCH-36.5* MCHC-36.2* RDW-17.7* Plt Ct-147* [2136-12-5] 07:05AM BLOOD Glucose-90 UreaN-11 Creat-0.5 Na-139 K-3.7 Cl-106 HCO3-25 AnGap-12 [2136-12-5] 07:05AM BLOOD ALT-38 AST-24 LD(LDH)-268* CK(CPK)-18* AlkPhos-81 TotBili-0.2 [2136-12-5] 07:05AM BLOOD Albumin-3.6 Calcium-9.1 Phos-2.7 Mg-1.9 CXR: IMPRESSION: Bibasilar atelectasis. Support lines in satisfactory position. EEG: IMPRESSION: Very abnormal EEG due to overall voltage reduction with marked interhemispheric asymmetry and exaggerated slowing over the left hemisphere compared to the right with periodic lateralized epileptiform discharging activity from the left posterior quadrant. While some of the voltage asymmetry may represent a breach rhythm there was, in addition, some excess of slowing and periodic lateralized epileptiform discharges from the left hemisphere indicative of more disruptive rhythms and destructive processes involving L>R hemisphere. In addition, the overall slowing and voltage reduction would suggest a diffuse encephalopathy more accentuated over the left than the right. MRI Brain: IMPRESSION: The multifocal foci of lesional enhancement as well as diffuse FLAIR hyperintensity bilaterally has slightly progressed compared with the prior study. Similar to that described on the prior study, in the setting of Avastin treatment, this is again concerning for continued tumor progression. Neck Soft Tissue: The current study demonstrates, on the AP view, preserved airway column, but there is slight deviation of the air column to the right with some narrowing and impinging over the left wall. This might be attributed to slight asymmetric position of the neck, but mass effect cannot be excluded, thus repeated radiograph, or if clinically justified, CT of the neck might be considered. Lateral view demonstrates no evidence of soft tissue swelling. Extensive degenerative changes are demonstrated within the cervical spine. CT Neck: IMPRESSION: No evidence of compression of the airway. NOTE ADDED IN ATTENDING REVIEW: There is a congenital fusion anomaly with C5- C7 "block" vertebral body with rudimentary intervening disc spaces, as well as ankylosis of the posterior elements, particularly at C5-C6 on the right (as on MR examination of [2136-10-30]. There is associated abnormal rotation of these vertebrae, with focal levoscoliosis, and displacement of the laryngeal skeleton and the proximal cervical trachea to the right. It is this displacement, rather than true compression with effacement, that likely accounts for the appearance on the prompting radiographs. CT Head: IMPRESSION: 1. No acute intracranial hemorrhage. 2. Multifocal lesions consistent with tumor in a patient with known glioblastoma multiforme appear overall stable since the prior. 3. Hypodensity in the right frontoparietal lobe is more apparent than on reference CT head of [2136-11-24] and may represent subacute infarct. COMMENT: Dr. [Last Name (STitle) 4539] notified of results by Dr. [Last Name (STitle) ], at 6:15 a.m. on [2136-12-5]. NOTE ADDED IN ATTENDING REVIEW: The hypodense region in right parietovertex subcortical white matter likely corresponds to the vasogenic edema associated with numerous enhancing lesions at this site, well-demonstrated on the interval MR study of [2136-11-26], which had progressed since the prior study of [2136-10-23]. There is no additional finding to suggest interval infarction. Brief Hospital Course: [Known firstname ] [Known lastname 22950] is a 47-year-old man with a past medical history of glioblastoma of left frontal lobe, s/p resection, radiation, ongoing chemotherapy (bevacizumab and irinotecan since [2136-8-15], alternating with 1 cycle of bevacizumab and carboplatin since [2136-9-18], and in combination with cis-retinoic acid 3 weeks on and 1 week off) and seizures, who presents after a prolonged seizure, s/p intubation at outside hospital with admission to neurosurgery ICU [2136-11-24] and transferred to OMED following extubation [2136-11-27]. (1) Neurological Issues: Upon admission, Mr. [Name14 (STitle) 22951] was responding to commands although intubated. Once extubated, he had significant confusion on exam, with difficulty following complex commands and perseveration that has resolved back to baseline. He continued to have occasional seizures with right sided hand an facical twitching which were responsive to ativan. We opted not to continue the dilantin while in house, instead preferring to increase his lacosamide to 100mg TID. He continues on his home Keppra of 1375mg [Hospital1 ] and lamotrigine of 225mg TID. Phenobarbitol was added at 15 mg [Hospital1 ] which was uptitrated to 30mg [Hospital1 ]. He also had a NCHCT that was concerning for some worsening of his edema. In response, we increased the dose of his decadron to 4mg TID, which he has tolerated well. He had an MRI that showed slight progression of his lesions from the previous study. His motor seizures were well controlled under above regimen. Prior to his discharge had episode of significant fatigue and drowsiness preceeded by some vertigo-like complaints, later developed some lip numbness which resolved with PO liquid Ativan. Labs were unremarkable. CT of his head showed hypodensity in the right frontoparietal lobe which is more apparent than on reference CT head of [2136-11-24] and may represent subacute infarct. He was feeling was that his complaints of vertigo, lip numbness, drowsiness are all manifestations of continuing seizure activity. He continued seizure prophylaxis as above and PRN Ativan are recommended. (2) Neck Swelling: Patient developed left sided soft tissue swelling in the neck overnight [2136-12-1]. This was not associated with any pain or symptoms. Neck X-ray showed possible left sided impingement and deviation to the right, which could not differentiate between mass effect versus rotation of the film. He remained clinically stable and swelling resolved by the next morning. A CT neck was pursued which showed no evidence of compression of the airway, just a benign congenital anomaly. (3) Leukopenia: Likely seocndary to chemotherapy. WBC stable at 2-4 range. (4) Thrombocytopenia: He remained stable in the 100a-130s. He was kept off heparin on his home Lovenox. (5) Anemia: Hct on admission 32.1, and remained stable in the high 20s-30s. (6) History of DVT: He continued Lovenox. (7) Constipation: Patient with signficant constipation without a BM for sevaral days on admission. He was put on Colace, senna, Miralax, bisacodyl, and responded well to this with several bowel movements. (8) Anxiety: He has intermittently become agitated and confused at night, requiring prn ativan. He ultimately did not calm down until his wife came in. She stayed with him around the clock and since then, he has been calm. He has repeatedly expressed concerns that he may die. However throughout admission he did quite well on standing and PRN Xanax especially in the presence of his family (9) Hypertension: He has had some high BPs with diastolics in the 100s, but has otherwise been stable from a cardiovascular standpoint. We have not made any adjustment in his blood pressure medications. Medications on Admission: Accutane 20mg PO BID Alprazolam 0.5mg PO BID Brimonidine 0.15% drops 1 gtt OU [Hospital1 ] Dexamethasone 4mg PO BID Dorzolamide-Timolol (Cosopt) 2%-0.5% drops 1 drop OU [Hospital1 ] Enoxaparin 60mg SC BID Lacosamide 50mg PO BID Lamotrigine 225mg PO TID Latanoprost (Xalatan) 0.005% 1 drop OU daily Levetiracetam 1375mg PO TID Omeprazole E.C. 20mg PO daily Ondansetron 8mg PO q8h PRN Sulfamethoxazole-Trimethoprim 800-160mg 1 tab PO M-W-F Armour thyroid 45mg PO daily Tropicamide 1% 1 gtt OS daily Docusate 100mg PO daily PRN constipation Ergocalciferol (vitamin D2) dose unknown Lratadine 10mg PO daily Simethicone 80mg PO TID PRN gas Discharge Medications: 1. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [Hospital1 ] (2 times a day). 3. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Ophthalmic [Hospital1 ] (2 times a day). 4. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 5. lamotrigine 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): total of 225mg . 6. lamotrigine 25 mg Tablet Sig: One (1) Tablet PO three times a day: total of 225mg . 7. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 10. thyroid (pork) 15 mg Tablet Sig: Three (3) Tablet PO once a day. 11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. loratadine 10 mg Tablet Sig: One (1) Tablet PO daily (). 13. dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 14. Amnesteem 20 mg Capsule Sig: Five (5) Capsule PO BID (2 times a day). 15. tropicamide 1 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day). 16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 19. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 20. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 21. lacosamide 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 22. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for seizures. 23. menthol-cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for sore throat. 24. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 25. phenobarbital 15 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 26. pilocarpine HCl 1 % Drops Sig: One (1) Drop Ophthalmic Q6H (every 6 hours) as needed for glaucoma. 27. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed for gas. 28. Keppra 500 mg Tablet Sig: 2.75 Tablets PO three times a day. 29. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for HA. Discharge Disposition: Extended Care Facility: [Location (un) 1036] - [Location (un) 620] Discharge Diagnosis: Primary: Glioblastoma multiforme Seizures Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [Known lastname 22950], You were admitted to the hospital because of seizures. You required a breathing tube which we subsequently removed after you improved. You still have occasional seizures but have overall improved from your initial seizure. We have made the following changes to your medications: STARTED: Pilocarpine eye drops as needed STARTED: Oxycodone as needed for pain STARTED: Cephacol lozenge as needed STARTED: Lacosamide 100mg by mouth three times daily STARTED: Alprazolam 0.5mg by mouth thrice daily as needed STARTED: Bactrim 1 SS tab 3x/week STARTED: Insulin sliding scale STARTED: Phenobarbitol 30 mg PO BID STARTED: Colace STARTED: Senna STARTED: Miralax STARTED: Bisacodyl STARTED: Isotretinoin 100mg by mouth twice daily STARTED: Ondansetron 4mg IV every 8 hours as needed for nasuea CHANGED: Dexamethasone to 4mg by mouth 3 times daily CHANGED: Lorazepam IV to Lorazepam by mouth as needed for seizures STARTED: Simethicone as needed for gas STARTED: Tylenol as needed for pain You should continue all other medications. Followup Instructions: Please make an appointment to follow up with your outpatient neuro-oncologist. Also, please keep the following appointment with Ophtho: Name: Dr [First Name8 (NamePattern2) 1692] [Last Name (NamePattern1) ], MD Specialty: Ophthalmology When: Thursday [12-13] at 1pm Location: [State 51252] [Last Name (NamePattern1) 79237], [Location (un) 86], MA Phone: [Telephone/Fax (1) 82288] Completed by:[2136-12-6]	[ "2875", "4019", "53081" ]
Admission Date: [2172-11-13] Discharge Date: [2172-12-17] Date of Birth: [2172-11-13] Sex: M Service: HISTORY OF PRESENT ILLNESS: Baby [Name (NI) ] [Known lastname 47502] was born at 28 weeks gestation to a 17 year old, Gravida II, Para I, now II woman. Prenatal screens were blood type A positive, antibody negative, Rubella immune, RPR nonreactive, hepatitis surface antigen negative and group B strep unknown. This pregnancy and an ultrasound, which showed subchorionic hematoma. The mother was admitted to [Hospital1 188] on [2172-10-24] at approximately 25 weeks gestation with vaginal bleeding. An ultrasound at that time showed low amniotic fluid levels, suggesting premature rupture of membranes. She began leaking amniotic fluid after that. She Betamethasone. On the day of delivery, the mother presented with increasing abdominal tenderness. A cesarean section was performed for concerns of chorioamnionitis. The infant emerged with spontaneous cry but poorly sustained respiratory effort. Apgars were seven at one minute and eight at five minutes. The infant required intubation in the delivery room at approximately ten minutes of age. The infant's birth weight was 1,235 grams; 75th percentile. Birth length was 37 cms, 50th percentile. Birth head circumference 27 cms, 50 to 75th percentile. PHYSICAL EXAMINATION: The admission physical examination reveals a premature infant, non dysmorphic. Anterior fontanel soft and flat. Positive bilateral red reflex. Palate intact. Grunting, flaring and retracting present with inspiratory crackles and poor air movement throughout. Normal S1 and S2 heart sounds, no murmurs. Pulses +2. Abdomen soft, no hepatosplenomegaly. Testes were descended bilaterally. Normal phallus. Patent anus. Normal hip examination and age appropriate tone and reflexes. HOSPITAL COURSE: 1.) Respiratory status: The infant was intubated in the delivery room. He required three doses of Surfactant. He weaned to nasopharyngeal continuous positive airway pressure on day of life four and, after several attempts, he successfully weaned to nasal cannula oxygen on day of life 29. He is currently on nasal cannula oxygen 200 cc flow at 50 to 70% oxygen. His respiratory rate ranges 30 to 80 breaths per minute. He has mild subcostal retractions. He was treated with caffeine citrate for apnea of prematurity from day of life four to day of life 15. He currently has zero to two episodes of apnea and/or bradycardia in a 24 hour period. 2.) Cardiovascular status: The infant required Dopamine for blood pressure support for the first 48 hours of life and has remained normotensive since that time. He has had a persistent grade one to two over six systolic ejection murmur at the left sternal border. His electrocardiogram and chest x-ray and four extremity blood pressures were all within normal limits. He was seen by [Hospital3 1810] cardiology service on [2172-12-15] and evaluation was that this was an innocent murmur, requiring no follow-up. 3.) Fluids, electrolytes and nutrition status: Enteral feeds were begun on day of life five. He advanced without difficulty to full volume feeds by day of life 11 and calories were then increased to his current level of 30 calories per ounce of Premie Enfamil with added ProMod. Feedings are all by gavage with a total fluid of 130 cc per kg per day. At the time of discharge, his weight is 2,090 grams. His length is 43.5 cms and his head circumference is 29.5 cms. 4.) Gastrointestinal status: The infant was treated with phototherapy for physiologic hyperbilirubinemia from day of life number one until day of life number 11. His peak bilirubin occurred on day of life number 5 and was a total of 5.7, indirect 0.4. There are no other gastrointestinal issues. 5.) Hematology. The infant received one transfusion of packed red blood cells on [2172-12-6] for a hematocrit of 25.8. He has not had a follow-up hematocrit since that time. His blood type is A positive. His DAT is negative. 6.) Infectious disease status: The infant was started on Ampicillin and Gentamycin at the time of admission for sepsis suspected. He completed 14 days of antibiotics for presumed sepsis. His blood cultures and cerebrospinal fluid cultures remained negative from that time. He has remained off antibiotics since that time. On [12-17] patient had a low grade fever to 100 that prompted delay in transefr for an additional delay. he remains afebrile and well appearing. The fever appears to have been environmentall induced. 7.) Neurology: He had ultrasounds done, the first one on [2172-11-16] which showed bilateral germinal matrix hemorrhage. A repeat head ultrasound on [2172-11-19] was unchanged and then [2172-12-14] at 30 days of age, the head ultrasound showed the resolving germinal matrix hemorrhage and no evidence of periventricular leukomalacia. 8.) Sensory: Audiology: The infant has not yet had a hearing screen done but one is recommended prior to discharge. Ophthalmology: The eyes were examined most recently on [2171-12-17], revealing immaturity of the retinal vessels but no retinopathy of prematurity as of yet. A follow-up examination should be scheduled for the week of [2172-12-30]. 9.) Psychosocial: [Hospital1 69] Social Work has been involved with this family. The contact social worker is [Name (NI) 3460] [Name (NI) 38331], [Hospital3 ] beeper #[Numeric Identifier 36245]. The parents have been visiting frequently and very involved in the infant's care. During the Neonatal Intensive Care Unit stay, they are very pleased with the infant's transfer to [Hospital 1474] Hospital as transportation has been a great difficulty for them. The infant is discharged in good condition. The infant is being transferred to [Hospital 1474] Hospital special care nursery for continuing care. The primary pediatrician will be Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], telephone #[Telephone/Fax (1) 43611]. CARE AND RECOMMENDATIONS: Feedings at discharge: Total fluids 130 cc per kg per day, premie Enfamil 30 calories per ounce with added ProMod. The feeding additives are as follows: Four calories per ounce of medium chain triglyceride oil. Polycose two calories per ounce. ProMod [11-19] tsp. per 90 cc of formula. All of those are added to 24 calorie per ounce formula. Fluids are entirely by gavage at this time. MEDICATIONS: Ferinsol 25 mg per 1 mls, the dose is 0.15 cc p.g. q. day. Vitamin E 5 i.u. p.g. q. day. The infant has not yet had a car seat position screening test. The last state screen was sent on [2172-11-26] and was within normal limits. The next state screen is due on [2172-12-25]. The infant has not yet received any immunizations. Recommended immunizations: 1.) Synagis-RSV prophylaxis should be considered from [Month (only) 359] through [Month (only) 547] for infants who meet any of the following three criteria: a.) Born at less than 32 weeks. b.) Born between 32 and 35 weeks with plans for day care during the RSV season, with a smoker in the household or with preschool siblings, or: c.) With chronic lung disease. 2.) Influenza immunization should be considered annually in the fall for preterm infants with chronic lung disease, once they reach six months of age. Before this age, the family and other caregivers should be considered for immunization against influenza to protect the infant. DISCHARGE DIAGNOSES: Prematurity 28 weeks gestation. Status post respiratory distress syndrome. Status post presumed sepsis. Status post hypertension. Resolving bilateral germinal matrix hemorrhage. Apnea of prematurity. Status post physiologic hyperbilirubinemia. Immature retinal vessels. Anemia of prematurity. Heart murmur "innocent". Bronchopulmonary dysplasia. [First Name11 (Name Pattern1) ] [Last Name (NamePattern1) 36142], M.D. [MD Number(1) 36143] Dictated By:[Last Name (NamePattern1) 43006] MEDQUIST36 D: [2172-12-17] 03:31 T: [2172-12-17] 05:33 JOB#: [Job Number 47503]	[ "7742" ]
Admission Date: [2108-2-4] Discharge Date: [2108-2-7] Date of Birth: [2036-7-11] Sex: M Service: NEUROLOGY Allergies: Haldol / Prolixin / Sulfasalazine / Thorazine Attending:[Last Name (NamePattern1) 1838] Chief Complaint: Right sided weakness and dysarthria Major Surgical or Invasive Procedure: None History of Present Illness: Neurology at bedside for evaluation after code stroke activation within: 5 minutes Time (and date) the patient was last known well: 1300 (24h clock) NIH Stroke Scale Score: 6 (on initial exam) t-[MD Number(3) 6360]: No Reason t-PA was not given or considered: Hx of b/l SDH [2100], improvement in symptoms I was present during the CT scanning and reviewed the images instantly within 20 minutes of their completion. NIH Stroke Scale score at 1600 was 6: 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 0 4. Facial palsy: 1 5a. Motor arm, left: 0 5b. Motor arm, right: 1 6a. Motor leg, left: 0 6b. Motor leg, right: 1 7. Limb Ataxia: 2 8. Sensory: 0 9. Language: 0 10. Dysarthria: 1 11. Extinction and Neglect: 0 HPI: [Known firstname ] [Known lastname ] is a 71y M with a history of CAD s/p CABGx2, HTN, DM, b/l SDH in [2100] and paranoid schizophrenia. He presents today s/p fall at his group home with right sided weakness and new dysarthria. At 1300 today, pt was observed by facility supervisor ([Doctor Last Name 8214]) to be dragging his right leg when returning to his room. She asked him if his leg was in pain and he said it was. He was last seen normal at 1215 when they went out to lunch at a restaurant. The supervisor had worked with him earlier that morning and had not noticed any abnormalities. Since [2101], he has used a walker for an unsteady gait. Between 1500 and 1530, the patient had an unobserved fall in his room. He knocked on the wall to get the attention of his nurse. She found him on the floor without any obvious trauma. He could not stand up on his own, so she called EMS. When they arrived and started asking him questions, she noticed that he was slurring his words. At the time, he confirmed weakness in his right arm and leg. He has a bilateral tremor and tardive dyskinesia at baseline, but the tremor appeared worse to her at the time. The patient was brought to the hospital, where his initial vitals were BP 137/87 HR 82 RR 18 O2 90%. A code stroke was called at 1600; the ED calculated NIHSS as 4. On exam, he showed right-sided mild weakness (?face, +drift, +leg drift) and right-sided ataxia. His labs were notable for a Glucose of 372 and a Cr of 2.0 (baseline CKD with b/l Cr ~2.1). He was taken for a non-contrast head CT, which did not show an acute intracranial hemorrhage or acute infarct (see below). We added CT-P and CT-A (see below), which were unrevealing. By 1700, his exam showed increased strength (no more drift) and less ataxia in right arm and leg. His tremors (primarily Left pill-rolling and jaw/[Year (4 digits) ] TD-type movements) persisted. Due to the improvemed exam and more imprortantly the history of prior bilateral subdural hematoma, t-PA was not given. The patient has not had surgery in the last three weeks. As far as his group home worker knows, he does not have a history of stroke (the Right-parietal hypodensity on CT was apparently a silent or undocumented infarct). He had a b/l subdural hematoma after a fall in [2100] that may have been traumatic though unclear. [Name2 (NI) ] did take his Aspirin and Plavix this morning. Past Medical History: # CAD/CHF -- on Lasix, dig, BB, ASA/Plvx --Last echo @OSH ([Hospital1 ]) in [2106-10-18] showed EF of 40%, mild TR and AR. Moderate diastolic dysfunction. - TTE ([2102-7-14])- poor windows. Decreased systolic function could not be quantified. 2+ MR (? underestimated), 3+ TR --[2102-6-9] CABGx2 (SVG->LAD, SVG->OM) and MV Repair (27mm Duran ancore band) - TEE ([6-9] intraop)- EF 25% - TTE ([2102-6-7])- EF 25-30% - TEE ([7-22]): LVEF 30-35% mod global HK, 2+ MR # Hypertension # Hyperlipidemia on statin # Mental retardation # Paranoid schizophrenia on risperdone # Diabetes mellitus. Currently on 75-25 Humalog (6U at 7:30AM and 3U at 4PM) and Lopid # Subdural hematomas [7-22]. Described by Neurosurgery at that time as being chronic, though SDH was found after fall. # h/o MSSA bacteremia # Chronic renal insufficiency. Last CrCl was 54 (Cr 2.1) in [2101]. # Hypothyroidism on Synthroid #Lower GI bleed. Admitted to [Hospital1 ] [Location (un) 620] in [9-/2106] for GI bleed and anemia from internal hemorrhoids. Last colonoscopy in [2105] showed multiple colon polyps and internal hemorrhoids. Social History: Lives at [Location 11292] group home. Has roomate. [First Name4 (NamePattern1) 8214] [Last Name (NamePattern1) 8389] = supervisor ([Telephone/Fax (1) 93356]. Able to dress and shower himself. He does need assisstance with cleaning and cooking. Family History: noncontributory Physical Exam: ADMISSION EXAM: Vitals: T (initially afebrile-->)102.8 BP 137/87 HR 82 RR 18 O2 90% General: Well-appearing, awake, alert. Quiet, but polite and responsive to pointed questions. TD-type jaw movements. Pill-rolling tremor of left index fgr/thumb. Neck: supple, no meningismus. No goiter. No LAD. No bruits appreciated in loud ED. CV: RRR w/o loud M/R/G appreciated in loud ED. Lungs: CTA anteriorly. Non-labored. Abdomen: Soft, NT/ND. Extr: Warm and well-perfused. No edema. Smooth/hairless shins. Dry feet. (PAD-type appearance). Good distal pulses. Neurologic exam: MS: Awake and alert. Oriented to "[Known firstname ] [Known lastname ]" [2107], [Month (only) 956]. Tracks in all directions. Follows most simple commands, but exam is highly limited by motor perseveration on recent tasks. Inattentive to DOWbw (gives fw). Naming intact to all NIHSS items except cactus. Repetion intact to "today is a sunny day in [Location (un) 86]." Fluent, but no spontaneous speech and short responses. CN: II: PERRL. Visual fields grossly full on limited exam (makes saccades to fingers moving on either side of direction of primary gaze, up and down on each side). III, IV, VI: EOMs grossly full and conjugate, no nystagmus (limited exam [1-19] perseveration/inattention). difficult to assess because patient moves gaze. V: symmetrically intact to pinprick V1-V2-V3. VII: difficult to assess due to TD jaw/lip-smacking movements. [Month (only) 116] be weaker on the Left than right, unclear. [Name2 (NI) ] tremor. Speech was mildly dysarthric initially, but improved on re-examination after CT. IX/X/XII: palate elevates symmetrically and [Name2 (NI) ] protrudes midline. Motor: Exam limited by inattention, motor perseveration, ?lack of effort, and tremor. - Right pronates and drifts down initially; on repeat testing, it pronates, but he keeps it up (left does not pronate/fall). Both delts are breakable ([3-22] ?effort) whereas triceps are full ([4-21]) bilaterally. - Initially unable to hold Right leg up against gravity for more than a second or two (left leg holds indefinitely), but improved on re-examination to same as left. Initially decreased tone in Right leg only, but improved on re-examination. Both IPs are breakable ([3-22] ?effort). Cerebellar: Grossly dysmetric FNF and HKS in the Right arm and leg. Left side has tremor, which abated with FNF, no dysmetria. LLE HKS smoother, but exam limited by cooperation/attention. Reflexes: symmetrically brisk, non-pathologic. Right toes mute-to-?up / left toes equivocal-to-?down. Sensory: Pt reports symmetric prinprick and light touch in all extremities. Otherwise limited exam. DISCHARGE EXAM: Able to hold all extremities anti-gravity and against resistance, though has some difficulty understanding all commands. Mild dysmetria bilaterally, right slightly greater than left. Pertinent Results: ADMISSION LABS: [2108-2-4] 04:15PM BLOOD WBC-14.4* RBC-3.27* Hgb-11.3* Hct-32.1* MCV-98 MCH-34.5* MCHC-35.1* RDW-12.5 Plt Ct-211 [2108-2-5] 02:04AM BLOOD Neuts-83.2* Lymphs-10.7* Monos-5.1 Eos-0.7 Baso-0.3 [2108-2-4] 04:15PM BLOOD PT-11.7 PTT-26.9 INR(PT)-1.1 [2108-2-5] 02:04AM BLOOD Glucose-108* UreaN-50* Creat-1.8* Na-142 K-3.8 Cl-105 HCO3-27 AnGap-14 [2108-2-5] 02:04AM BLOOD ALT-11 AST-22 AlkPhos-133* TotBili-0.2 [2108-2-5] 02:04AM BLOOD cTropnT-0.03* proBNP-1866* [2108-2-5] 02:04AM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.4 Mg-2.1 Cholest-103 [2108-2-5] 02:04AM BLOOD Triglyc-76 HDL-32 CHOL/HD-3.2 LDLcalc-56 [2108-2-5] 02:04AM BLOOD TSH-0.49 [2108-2-4] 04:15PM BLOOD Digoxin-0.5* [2108-2-4] 04:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2108-2-4] 04:29PM BLOOD Glucose-372* Na-139 K-4.9 Cl-95* calHCO3-30 DISCHARGE LABS: [2108-2-7] 06:45AM BLOOD WBC-11.9* RBC-2.96* Hgb-10.0* Hct-28.5* MCV-96 MCH-33.8* MCHC-35.2* RDW-12.6 Plt Ct-187 [2108-2-7] 06:45AM BLOOD Glucose-137* UreaN-42* Creat-1.7* Na-135 K-4.5 Cl-98 HCO3-29 AnGap-13 [2108-2-6] 05:10AM BLOOD ALT-8 AST-17 AlkPhos-105 TotBili-0.2 [2108-2-7] 06:45AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.8 IMAGING: CT/CTA/CTP non-con head: 1. no ICH; grey-white appears preserved; equivocal dense L MCA. 2. if CTA performed, IV hydration recommended given the Cr of 2.0. CTA: anterior and posterior circulations patent; calcified atherosclerotic disease of both cavernous internal carotid arteries. CTP: no blood flow, blood volume, or mean transit time asymmetries. CXR: FINDINGS: Frontal and lateral views of the chest were obtained. There are right greater than left upper lobe patchy opacities, raising concern for underlying infection. Patient is status post median sternotomy and CABG. Prosthetic mitral valve is unchanged in appearance. No pleural effusion or pneumothorax is seen. Cardiac and mediastinal silhouettes are grossly stable MRI Brain: IMPRESSION: 1. No acute infarct. Nonspecific FLAIR hyperintense foci as described above. 2. MR angiogram of the head and neck, is suboptimal due to reasons mentioned above. Within this limitation, major arteries are patent without focal flow-limiting stenosis. Please see the prior CT angiogram study for subsequent details. The P1 segment of the right posterior cerebral artery is diminutive in size, with a fetal PCA pattern and prominent posterior communicating artery. 3. Focal prominence of the ACOM complex is likely related to confluence of the arteries. Brief Hospital Course: Mr. [Known firstname ] [Known lastname ] is a 71 year old man with a history of CAD s/p CABG, HTN, DM, bilateral SDH in [2100] and paranoid schizophrenia presenting with right sided weakness and dysarthria. NEURO: On the day of arrival he was noted to be dragging his right leg and was brought to the ED where a Code Stroke was called. He had a CT scan, CTA, and CT perfusion which showed no sign of an infarct, and he rapidly improved on arrival to the [Last Name (LF) ], [First Name3 (LF) ] no tPA was given. He was admitted to the Neurology service, where he underwent an MRI of the brain, which showed no signs of an acute infarct. He did develop a fever of 102.8 shortly after arrival, and was found to have a UTI and pneumonia. His neurologic exam rapidly improved with treatment of these infections, and it was thought that his symptoms were primarily due to this. CV: He has a history of CAD and CHF. His aspirin was continued. Given the initial concern for stroke, his Lasix was held, however was restarted when it was determined that infection was the primary etiology of his symptoms. He had a very slight troponin increase on arrival that was thought to be related to his underlying renal failure. Respiratory: He had a chest x-ray which showed evidence for pneumonia. He was stable on room air. ID: His U/A grew e coli that was sensitive to cephalosporins, and he was started on ceftriaxone, to be transitioned to cefpodoxime as an outpatient, to continue through [2-10]. For his community acquired pneumonia he was started on doxycycline, to be continued through [2-17]. Psych: He was continued on his home regimen of risperdal, zoloft, ativan and neurontin, without incident. Rehab goals: He will not require more than 30 days of rehab. Medications on Admission: Humalog 75/25 (3U at 4:30PM, 6U at 7AM) Aspirin 162 mgs daily (AM) Plavix 75mg daily (AM) Toprol XL 50 mg Daily (PM) Zocor 40 mg daily (PM) Lasix 60 mg (M-F, AM) Lopid 600 mg [Hospital1 ] Digitek 0.0625 mg daily (AM) Kayexalate 40 cc powder (MWF in AM) Neurontin 800 mg [Hospital1 ] Risperdal 0.5mg daily at 8PM Zoloft 100 mg Daily at 8pm Ativan 0.5 mg [Hospital1 ] Tramadol 50 mg PRN q6hrs Ranitidine HCl 300 mg (Daily AM) Synthroid 0.025 mg daily (AM) Colace 100 mg PRN Milk of Magnesia 30 mL PRN every 12 hours Robitussin 2 tsp PRN q4h Simethicone 40 mg TID Tylenol 650 mg PRN q4hrs Vit B12 1000 mg daily (PM) Vitamin D 1200 IU daily (AM) Calcitriol 0.025 mg (MWF in AM) Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 2. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: Three (3) units Subcutaneous 4:30 PM. 3. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: Six (6) units Subcutaneous 7 am. 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO HS (at bedtime). 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day: Give Mon-Fri. 8. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. sodium polystyrene sulfonate 15 g/60 mL Suspension Sig: One (1) dose PO MWF (Monday-Wednesday-Friday). 11. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 12. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. sertraline 50 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 14. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day. 15. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain; home med. 16. ranitidine HCl 300 mg Capsule Sig: One (1) Capsule PO once a day. 17. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 19. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL PO every twelve (12) hours as needed for constipation. 20. simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable PO TID (3 times a day). 21. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever >101. 22. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 23. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Three (3) Tablet PO DAILY (Daily). 24. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO MWF IN AM (). 25. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 10 days: Through [2-18]. Disp:20 Capsule(s) Refills:0 26. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days: Through [2-10]. Disp:6 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [Hospital 11851] Healthcare & Rehabilitation Center - [Location (un) 620] Discharge Diagnosis: Urinary tract infection Pneumonia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you. You were admitted with right sided weakness and slurred speech. You had a CT scan and MRI of the brain, which showed no signs of a stroke. You were found to have a urinary tract infection and a pneumonia, for which you were treated with antibiotics, with clinical improvement. The following medication changes were made: STARTED Doxycycline 100mg [Hospital1 ] to be continued through [2-17] STARTED Cefpodoxime 200mg [Hospital1 ] to be continued through [2-10] If you notice any of the warning signs listed below, please call your PCP or come to the nearest ED for further evaluation. Followup Instructions: Please call [Telephone/Fax (1) 2574] to schedule a follow-up appointment in the [Hospital 878] clinic with Dr. [Last Name (STitle) ] in [3-23] weeks. Please see your PCP within one week of discharge.	[ "5990", "486", "V4581", "40390", "5859", "25000", "V5867", "4280", "2449" ]
Admission Date: [2130-9-12] Discharge Date: [2130-9-15] Date of Birth: [2065-11-30] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 1390] Chief Complaint: Left hip pain s/p pedestrian struck Major Surgical or Invasive Procedure: Aortogram and left iliac angiogram History of Present Illness: 64 M no significant past medical history s/p pedestrian struck. He was walking when was struck by a car at 25 mph, subsequently rolling onto the [Doctor Last Name ] and smashing the windshield. Patient uncertain if LOC, +head trauma. Brought here for further evaluation. In ED, initial vitals stable although dropped pressures to 81/47 at time of evaluation, undergoing fluid and blood resuscitation Past Medical History: -Asthma -Hyperlipidemia -GERD -h/o nephrolithiases Social History: Pt is retired firefighter from [Location (un) ]; lives with wife, [Name (NI) 90299] Family History: Non-contributary Physical Exam: Physical exam: done in IR: [2130-9-12]: Vital signs: bp=115/70, hr=93, resp. rate=18, oxygen saturation 100% CV: RRR RESP: mild wheezing bases ABD: soft, non-tender, non-distended, + bowel sounds Neur: alert and oriented x 3 Ext: Large hematoma left lateral thigh Physical examination on discharge: [2130-9-15] Vital signs: 145/68, hr=100, T=97.5, sat 99% Neuro: alert and oriented x 3, speech clear, no tremors CV: Ns1, s2, s-3 s-4 , no murmurs ABD: Distended, tympanic, non-tender, no masses LUNGS: Clear bil. EXT: Lower ext. warm, + dp bil., firm, ecchymotic left lateral thigh, tender, right thigh soft, non-tender, muscle st. right lower ext. +5/+5, left +3/+5, + sensation lower ext. bil. Pertinent Results: [2130-9-12] 09:31PM HCT-34.9* [2130-9-12] 05:20PM HCT-34.3* [2130-9-12] 01:47PM PH-7.44 COMMENTS-GREEN TOP [2130-9-12] 01:47PM GLUCOSE-135* LACTATE-4.0* NA+-138 K+-3.9 CL--102 TCO2-18* [2130-9-12] 01:47PM freeCa-1.10* [2130-9-12] 01:30PM UREA N-16 CREAT-0.8 [2130-9-12] 01:30PM estGFR-Using this [2130-9-12] 01:30PM LIPASE-27 [2130-9-12] 01:30PM ASA-NEG ETHANOL-29* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [2130-9-12] 01:30PM WBC-9.2 RBC-4.40* HGB-14.2 HCT-40.7 MCV-92 MCH-32.1* MCHC-34.8 RDW-14.4 [2130-9-12] 01:30PM PT-12.7 PTT-25.6 INR(PT)-1.1 [2130-9-12] 01:30PM PLT COUNT-179 [2130-9-12] 01:30PM FIBRINOGE-201 [2130-9-14] 05:00AM BLOOD WBC-7.7 RBC-2.95* Hgb-9.6* Hct-27.7* MCV-94 MCH-32.5* MCHC-34.5 RDW-14.5 Plt Ct-100* [2130-9-14] 02:50AM BLOOD Hct-27.5* [2130-9-13] 10:00PM BLOOD Hct-28.1* [2130-9-13] 06:19PM BLOOD Hct-28.4* [2130-9-14] 05:00AM BLOOD Plt Ct-100* [2130-9-13] 04:10AM BLOOD Plt Ct-154 [2130-9-12] 01:30PM BLOOD PT-12.7 PTT-25.6 INR(PT)-1.1 [2130-9-12] 01:30PM BLOOD Fibrino-201 [2130-9-12] 01:30PM BLOOD UreaN-16 Creat-0.8 [2130-9-12] 01:30PM BLOOD ASA-NEG Ethanol-29* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [2130-9-14] 05:00AM BLOOD WBC-7.7 RBC-2.95* Hgb-9.6* Hct-27.7* MCV-94 MCH-32.5* MCHC-34.5 RDW-14.5 Plt Ct-100* [2130-9-14] 02:50AM BLOOD Hct-27.5* [2130-9-13] 10:00PM BLOOD Hct-28.1* [2130-9-14] 05:00AM BLOOD Plt Ct-100* [2130-9-13] 04:10AM BLOOD Plt Ct-154 [2130-9-12] 01:30PM BLOOD UreaN-16 Creat-0.8 [2130-9-15] 05:00AM BLOOD Hct-25.1* [2130-9-14] 05:00AM BLOOD WBC-7.7 RBC-2.95* Hgb-9.6* Hct-27.7* MCV-94 MCH-32.5* MCHC-34.5 RDW-14.5 Plt Ct-100* [2130-9-14] 02:50AM BLOOD Hct-27.5* [2130-9-14] 05:00AM BLOOD Plt Ct-100* [2130-9-13] 04:10AM BLOOD Plt Ct-154 [2130-9-15] 05:00AM BLOOD Hct-25.1* [2130-9-12]: EKG: Sinus tachycardia. Minor ST-T wave abnormalities. No previous tracing available for comparison [2130-9-12]: Chest x-ray and pelvis: IMPRESSION: Fractures of the left superior and inferior pubic rami. No chest pathology identified, although wide mediastinum is noted. While likely due to tortuosity and possibly lipomatosis, mediastinal vascular injury cannot be excluded in the setting of trauma. Correlate with cross-sectional imaging [2130-9-12]: cat scan of abdomen/chest: Acute left inferior pubic ramus fracture. 2. Left thigh hematoma with potential areas of active extravasation noted within the gluteal musculature. Findings discussed with surgical resident consultant at the time of attending review. 3. 6-mm right lung nodule should have followup CT in 12 months to document stability [2130-9-12]: Cat scan of head: IMPRESSION: Right subgaleal hematoma but no acute intracranial process Brief Hospital Course: Mr. [Known firstname ] was brought to the Emergency Department and admitted to the Acute Care Service on [2130-9-12] after being struck by a motor vehicle traveling at 25 mph. In the ED, the left gluteal hematoma appeared to have extravasation with a concomittant systolic blood pressure drop into the 80s. Therefore, the patient was transfused with 1 unit of PRBCs and given fluid resuscitation with adequate response and SBP to 120s. Interventional radiology was consulted and the patient underwent an aortogram and left iliac angiogram without identification of aneurysm or extravasation. The patient remained hemodynamically stable in the recovery room. The patient was initially managed in the surgical intensive care unit post-procedure and was transferred to the surgical [Hospital1 ] on hospital day #2. Hematocrit levels were monitored and he continued to have a decrease in his hematocrit. His current hematocrit has stablized at 25.0. His foley catheter has been discontinued. He has been evaluated by physical therapy and has been cleared to go home with VNA services His vital signs are stable. He did have an elevation in his blood pressure and heart this morning when he got out of bed, but vital signs returned to [Location 213] when he returned to bed. He is tolerating a regular diet and has not had any problems with voiding. He is preparing for discharge today and will follow up 2-3 weeks with his Primary Care Provider and in 4 weeks with Orthopedic Nurse Practitioner, [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ]. Medications on Admission: Advair diskus IH 1 puff [Hospital1 ] Albuterol sulfate IH 1-2 puffs q 4 hours prn Simvastatin Omeprazole Discharge Medications: 1. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [Hospital1 ] (2 times a day). 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for Pain. Disp:50 Tablet(s) Refills:1 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 6. niferix Sig: 150 mg tablet twice a day. Disp:50 Refills:2 Discharge Disposition: Home With Service Facility: [Location (un) ] VNA Discharge Diagnosis: Left superior and inferior pubic ramus fractures; left flank hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent, walker and cane with assistance Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory -wallker with assistance and cane Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory -wallker with assistance and cane Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [4-17] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: Please call the Orthopedic service to schedule an appointment with the Nurse Practitioner, [First Name5 (NamePattern1) ] [Last Name (NamePattern1) 98176] in 4 weeks. The telephone number for Orthopedics is # [Telephone/Fax (1) 1228]. Follow up with you primary care provider [Last Name (NamePattern4) ] [1-11] weeks to follow for hematocrit check. Completed by:[2130-9-15*]	[ "49390", "2724", "53081" ]
Admission Date: [2152-7-19] Discharge Date: [2152-7-24] Date of Birth: [2095-2-18] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 922] Chief Complaint: angina/DOE/fatigue Major Surgical or Invasive Procedure: [7-19] Bentall procedure (27 mm [Company 1543] Freestyle porcine aortic root/valve)/ repl. hemiarch aorta 26mm Gelweave graft)/ Talon Sternal plating History of Present Illness: 57 year old gentleman with a history of coronary artery disease status post LAD stenting in [2140]. He underwent a stress echo this [Month (only) ] which revealed a dilated ascending aorta and mild aortic stenosis.Last cardiac cath [2143]. Referred for surgical eval. Past Medical History: Past Medical History Coronary artery disease ( s/p LAD stent) Hyperlipidemia Hypertension Obesity Peptic ulcer disease with h/o GI bleed Diabetes mellitus type 2 fatty liver cholelithiasis BPH OSA ( no CPAP) microscopic hematuria/proteinuria periodically ? TIA Past Surgical History: none Social History: Last Dental Exam:18 months ago Lives with:wife Occupation:housekeeping supervisor at [Hospital ] Hosp. Tobacco: Never ETOH: 4-5 drinks per month Family History: mother with CVAs, grandfather with CVA Physical Exam: Pulse: 89 Resp: 20 O2 sat: 99% B/P Right: 146/84 Left: 141/93 Height: 5'6" Weight:295# General:Obese, mildly SOB Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x]anicteric sclera; has no upper teeth, and lower remaining teeth are loose Neck: Supple [x] Full ROM []no JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur- 3/6 SEM radiates softly to carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] obese abd; no HSM Extremities: Warm [x], well-perfused [x] Edema- trace bilat. Varicosities: None [x] Neuro: Grossly intact; nonfocal exam; MAE [5-17] strengths Pulses: Femoral Right: faint Left:faint DP Right: 1+ Left:1+ PT [Name (NI) 167]: 2+ Left:2+ Radial Right: 2+ Left:2+ Carotid Bruit: murmur radiates softly to both carotids Pertinent Results: Intra-Op TEE Conclusions Pre Bypass: There is moderate symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. The aortic arch is moderately dilated. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve is bicuspid. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) central mitral regurgitation is seen. Post Bypass: Patient is AV (later A) paced on phenylepherine infusion (transient epi on seperation from bypass). There is a xenograft in the aortic/sinus position (#29 per report). There is no flow outside of the valve, no AI. Peak gradient 9, mean 3 mm hg at a cardiac output > 7 L/min. Preserved biventricular function LVEF > 55%. Ascending/ hemiarch aortic conduit contours appear intact with laminar flow. Desending aorta intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], MD, Interpreting physician [2152-7-22] 06:39AM BLOOD WBC-8.3 RBC-3.04* Hgb-9.2* Hct-26.5* MCV-87 MCH-30.2 MCHC-34.6 RDW-14.1 Plt Ct-230 [2152-7-22] 06:39AM BLOOD Glucose-97 UreaN-42* Creat-1.3* Na-142 K-3.8 Cl-101 HCO3-31 AnGap-14 Brief Hospital Course: Admitted [7-19] and underwent surgery with Dr. [Last Name (STitle) 914]. Sternal plating done by Dr. [First Name (STitle) ]. Please separate op notes. Transferred to the CVICU in stable condition on titrated insulin, phenylephrine, propofol drips. Extubated after he awoke neurologically intact. Transferred to the floor on POD #1 to begin increasing his activity level. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. The patient did develop left shoulder pain. This was managed with Motrin, neurontin, dilaudid and a lidocaine patch. Shoulder X-ray negative for fracture and at the time of discharge on POD#5 Mr. [Known lastname 37430] was able to move his left upper extremity with very minimal discomfort. He was given arm/shoulder exercises to do at home. He was claered for discharge to home on POD#5 by Dr. [Last Name (STitle) ]. He ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. Medications on Admission: Metformin 500-mg/day ( currently on hold pending labs) amlodipine 5-mg/day lisinopril 5-mg/day metoprolol tartrate 75-mg [Hospital1 ] simvastatin 80-mg/day qhs fenofibrate 160-mg/day Avodart 0.5 mg/day Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). Disp:30 Tablet(s) Refills:2 3. Dutasteride 0.5 mg Capsule Sig: One (1) Capsule PO daily (). Disp:30 Capsule(s) Refills:2 4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:60 Tablet(s) Refills:2 5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:90 Tablet(s) Refills:2 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:90 Capsule(s) Refills:0 8. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:90 Tablet(s) Refills:1 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:75 Tablet(s) Refills:0 10. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. Disp:28 Tablet(s) Refills:0 13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks. Disp:14 Tab Sust.Rel. Particle/Crystal(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 8117] Home Health & Hospice Discharge Diagnosis: aortic aneurysm s/p Bentall/Hemiarch aorta repl. Coronary artery disease ( s/p LAD stent) Hyperlipidemia Hypertension Obesity Peptic ulcer disease with h/o GI bleed Diabetes mellitus type 2 fatty liver cholelithiasis BPH OSA ( no CPAP) microscopic hematuria/proteinuria periodically ? TIA Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Motrin, dilaudid Incisions: Sternal - healing well, no erythema or drainage Edema 1+ bilateral LEs Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [Telephone/Fax (1) 170] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge 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] Tuesday [8-22] @ 1:30 pm Please call to schedule appointments with your Primary Care Dr.[Last Name (STitle) 17863] [Telephone/Fax (1) 11376] in [1-15] weeks Cardiologist Dr. [Last Name (STitle) 1911] in [1-15] 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:[2152-7-24]	[ "41401", "2724", "4019", "25000", "32723" ]
Admission Date: [2199-7-24] Discharge Date: [2199-7-29] Date of Birth: [2144-4-17] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[Known firstname 922] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [2199-7-24] Cardiac Catheterization with IABP placement [2199-7-25] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Diag, SVG to OM to LPDA) History of Present Illness: 55 y/o female with progressive chest pain. EKG changes in ER. Sent for Cardiac Cath. Past Medical History: Hypertension, Hypothyroidism s/p [Doctor Last Name 933] Disease s/p Thyroidectomy, Pre-Diabetes Mellitus Social History: Denies Tobacco. Social ETOH. Married. Family History: Non-contributory Physical Exam: Alert NAD HEENT: PERRL, EOMI Sclera non-icteric Neck: Supple, -JVD, -bruits Lungs: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, well-perfused -edema, left femoral IABP, good pulses throughout Pertinent Results: Cath [7-24]: 1. Selective coronary angiography of this left dominant system revealed left main and two vessel coronary artery disease. The left main coronary artery had a 70% ostial stenosis. The left anterior descending coronary artery had a long 80% stenosis in the proximal vessel and a 99% stenosis in the mid vessel with TIMI II flow. There was a 90% stenosis of a major diagonal branch. The left circumflex artery was the dominant vessel. There was a 60% stenosis of OM1 and an 80% stenosis of the left PDA. The right coronary artery was small and nondominant. 2. Resting hemodynamic measurements revealed mildly elevated right and left sided filling pressures, RVEDP = 12mmhg, and mean PCWP = 15 mmhg. There was no evidence of pulmonary hypertension. The cardiac output and index were preserved at 5.8 and 2.6 respectively. There was moderate systemic hypertension. 3. Left ventriculography was not performed. 4. Intra-aortic balloon pump was placed through the right femoral artery. Echo [7-25]: PRE-BYPASS: A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. There is moderate to severe regional left ventricular systolic dysfunction. Overall left ventricular systolic function is mildly depressed. Resting regional wall motion abnormalities include mid-distal anterior anteroseptal and lateral wall severely hypokinesia . The remaining left ventricular segments are mildly hypokinetic. Overall EF is 30-35%Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There is no aortic valve stenosis. No aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. Intra-aortic balloon pump is in good position in the descending thoracic aorta 3 cm below the left subclavian artery. POST CPB: Global and focal left ventricular systolic function are mildly improved. Ejection fraction os 40-45%. Mitral regurgitation is now trace. IABP confirmed to be in good positon. CXR [7-27]: Marked widening of the postoperative cardiomediastinal silhouette which progressed on [7-25] and 4th has subsequently remained stable consistent with a stable fluid accumulation. There is small left pleural effusion is present. There is no pneumothorax. Bibasilar atelectasis is unchanged. Lungs are otherwise clear. [2199-7-24] 10:15PM BLOOD WBC-11.8# RBC-5.63 Hgb-17.5 Hct-49.9 MCV-89 MCH-31.1 MCHC-35.1 RDW-13.2 Plt Ct-310 [2199-7-25] 03:27PM BLOOD WBC-16.2* RBC-3.94* Hgb-12.3* Hct-34.4* MCV-87 MCH-31.2 MCHC-35.7* RDW-13.1 Plt Ct-174 [2199-7-28] 05:00AM BLOOD WBC-7.9 RBC-3.12* Hgb-9.7* Hct-27.6* MCV-89 MCH-31.1 MCHC-35.2* RDW-13.1 Plt Ct-227 [2199-7-24] 10:15PM BLOOD PT-11.0 PTT-23.0 INR(PT)-0.9 [2199-7-26] 02:44AM BLOOD PT-13.4* PTT-27.6 INR(PT)-1.2* [2199-7-24] 10:15PM BLOOD Glucose-199* UreaN-14 Creat-0.9 Na-134 K-4.8 Cl-97 HCO3-24 AnGap-18 [2199-7-28] 05:00AM BLOOD Glucose-152* UreaN-14 Creat-1.0 Na-132* K-4.1 Cl-94* HCO3-29 AnGap-13 [2199-7-29] 08:00AM BLOOD Calcium-PND Phos-PND Mg-PND Brief Hospital Course: Following patient presentation to the ER with EKG changes suggestive of a acute anterolateral MI, he was brought to for a cardiac catheterization. Cath revealed 70% left main disease with TIMI flow in LAD. A IABP was placed and he was brought to the CCU until surgery. On [7-25] he was brought to the operating room where he underwent a coronary artery bypass graft x 4. Please see operative report for surgical details. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. Post-operatively he required transfusions with platelets, FFP and RBC's for bleeding. He also underwent an echo in the CSRU which ruled out a tamponade. On post-op day one he was weaned from sedation, awoke neurologically intact and extubated. He appeared stable after extubation and later on this day he was transferred to the cardiac surgery telemetry floor. Beta blockers and diuretics were initiated and he was diuresed towards his pre-op weight. His chest tubes were removed on post-op day two. Epicardial pacing wires removed on post-op day four. He continued to recover well with physical therapy helping with strength and mobility. He had stable labs, vital signs and physical exam. Later on this day he was discharged home with VNA services and the appropriate follow-up appointments. Medications on Admission: Aspirin, Atenolol, Levoxyl, Enalapril 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:2 3. Atorvastatin 10 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 for pain. Disp:40 Tablet(s) Refills:0 5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:180 Tablet(s) Refills:1 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:14 Tablet(s) Refills:0 7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:28 Capsule, Sustained Release(s) Refills:0 8. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 9. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:0 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:60 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: [Hospital 119] Homecare Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 PMH: Hypertension, Hypothyroidism s/p [Doctor Last Name 933] Disease s/p Thyroidectomy, Pre-Diabetes Mellitus Discharge Condition: Good Discharge Instructions: [Month (only) 116] take shower. Wash incisions and gently pat dry. Do not take bath. Do not apply lotions, creams, ointments or powders to incisions. Do not drive for 1 month. Do not lift more than 10 pounds for 2 months. If you develop a fever or notice drainage from chest incision, please contact office. Please call to schedule all follow-up appointments. Followup Instructions: Dr. [Last Name (STitle) 914] in 4 weeks Dr. [Last Name (STitle) 911] in [1-25] weeks Dr. [First Name (STitle) ] in [12-24] weeks Completed by:[2199-7-30]	[ "41401", "4019" ]
Unit No: [Numeric Identifier 75192] Admission Date: [2127-9-30] Discharge Date: [2127-10-2] Date of Birth: [2127-9-30] Sex: F Service: NB HISTORY: Baby girl [Known lastname 174] was the 4.39 kg product of a 37 and 5/7 weeks gestation, born to a 19-year-old G1, P0, now 1 mother. PRENATAL SCREENS: O positive, antibody negative, hepatitis B surface antigen negative, Rubella immune, RPR nonreactive, and GBS positive. The mother presented in labor with ruptured membranes at 9 a.m. on [9-29]. Temperature max was 101.2. Three and one-half hours prior to delivery, she was started on ampicillin and gentamicin. She received a combined epidural and spinal anesthesia. ANTENATAL HISTORY: Unremarkable. Maternal history of Chlamydia infection treated last in [2127-1-20]. DELIVERY HISTORY: Infant with fetal tachycardia and nonreassuring fetal heart rate therefore she was delivered via cesarean section. The infant emerged crying. Apgars 7 at one minute, 8 at five minutes. The infant was admitted to the Newborn Intensive Care Unit for further investigation of respiratory distress and sepsis evaluation. PHYSICAL EXAMINATION AT DISCHARGE: Anterior fontanel open and flat with moderate-sized caput, and mild cephalic molding. Normal faces. Breath sounds clear and equal on room air with slight retractions and comfortable respirations. No audible murmur. Well-perfused with normal pulses. Abdomen soft and round with active bowel sounds, drying cord. Normal genitourinary exam. HISTORY OF HOSPITAL COURSE: RESPIRATORY: The patient was admitted to the Newborn Intensive Care Unit with mild respiratory distress, placed on nasal cannula, quickly weaned to room air within the first 12 hours of life and has been stable on room air since that time. The infant had a chest x- ray with low lung volumes and otherwise within normal limits. The infant did have one episode of desaturation following an enteral feeding, requiring some blow-by O2 and has been stable since that time. CARDIOVASCULAR: Has had no issues. FLUID AND ELECTROLYTES: Birth weight was 4.390 kg, discharge weight is 4290 grams. Admission head circumference 34.5 cm. Length 55 cm. The infant was initially started on 60 ml/kg of D10W. Enteral feedings were initiated within the first day of life. The infant is currently ad lib feeding, Enfamil 20 calories, taking in adequate amounts. She had borderline dextrosticks which have improved and are now normal on enteral feeds. GASTROINTESTINAL: Bilirubin on day of life 1 was 8.3/0.3. HEMATOLOGY: Hematocrit on admission was 47.5 and the infant has not required any blood transfusion. INFECTIOUS DISEASE: CBC and blood culture were obtained on admission. CBC was benign with a white count of 14.8, with 58 polys, 2 bands, and a platelet count of 345. She is treated with ampicillin and gentamicin with pending results of a blood culture at 48 hours, to determine length of course. NEURO: The infant has been appropriate for gestational age. Sensory: Hearing screen has not yet been performed, but should be done prior to discharge. CONDITION AT DISCHARGE: Stable. DISCHARGE DISPOSITION: To newborn nursery. NAME OF PRIMARY PEDIATRICIAN: [Location (un) 669] Comprehensive (Dr. [Last Name (STitle) ]. CARE RECOMMENDATIONS: Continue ad lib feeding Enfamil 20 calories. MEDICATIONS: Not applicable. CAR SEAT POSITION SCREENING: Has not yet been performed, but should be done prior to discharge. NEWBORN SCREENING: Not yet sent. IMMUNIZATIONS: The infant has not received any immunizations to date. DISCHARGE DIAGNOSES: 1. A 37 and [5-26] weeker. 2. Large for gestational age. 3. Mild transitional tachypnea of newborn. 4. Rule out sepsis with antibiotics. Dictated By:[MD Number(1) 75193] MEDQUIST36 D: [2127-10-1] 22:42:17 T: [2127-10-1] 23:39:16 Job#: [Job Number 75194]	[ "V053" ]
Admission Date: [2145-8-5] Discharge Date: [2145-8-12] Date of Birth: [2064-4-3] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[First Name3 (LF) 7333] Chief Complaint: ICD fired twice Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 81 y/o male with PMHx CAD s/p CABG x3 in [2125] with ICD implantation in [2142] BIBA due to ICD firing twice at home. The patient was at home at rest when his pacer fired once, then again approximately 5 minutes later. In the ambulance, had runs of VT on and off with ATP. Supposedly, he was pulseless in the ambulance but never lost conciousness. In the ED, initial vitals were HR:80 BP:151/104 Resp:16 O(2)Sat:98%. He had continued runs in and out of VT, then had 1 longer run with hypotension to the 80s. Loaded with amiodarone 600mg IV which increased pressures, then got 150mg PO. Transferred to the CCU for further management. . He does admit to feeling fatigued the past few days. He checks his blood pressures at home and reports his SBP in the 70s to 80s. He denies dizziness or light-headedness at those times. He also reports that his heart has felt "jiggly" recently, lasting about 5 minutes and occurring approximately 6 times a day. He denies any changes to his medications except for his gabapentin, the dose of which has been decreased. He reports no changes in diet and he says he has been compliant with his medications. He does have recurrent anginal type pain including at rest which he attributes to having Prinzmetal's angina. He says he has been worked up numerous times for his chest pain in the past and they all showed no evidence of ischemia. He does take nitroSL which resolves the pain, most recently yesterday. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, 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 paroxysmal nocturnal dyspnea, orthopnea, syncope or presyncope. . In the CCU, the patient denied any symptoms except for palpitations. After review of his EKGs with EP (Dr. [First Name (STitle) 63778] and Dr. [Last Name (STitle) ], it was determined he had a fasicular tachycardia. He was given lidocaine 100mg IV which converted him to sinus rhythm. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: x3 in [2125] - unknown anatomy -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: ICD placed in [2142] due to results of holter monitor 3. OTHER PAST MEDICAL HISTORY: Prostate cancer s/p radiation [2126], cryosurgery [2130] IBS Gastro-esophageal spasms Osteoarthritis COPD Total knee replacement Fractured vertebrae [4-/2145] . Social History: -Tobacco history: quit smoking 33 years ago, smoked 3-4ppd for 34 yrs -ETOH: sober for 47 years -Illicit drugs: denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Mother passed at 79 from CHF, father passed at 65 with lung cancer. Physical Exam: GENERAL: elderly 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. NECK: Supple with JVP of 3cm. no LAD, no carotid bruits, 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: Poor air entry bilaterally with decreased breath sounds. no crackles, wheezes or rhonchi. ABDOMEN: Soft, obese NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 1+ pitting edema bilaterally to mid calf. 2+DP/PT pulses Pertinent Results: [2145-8-5] 06:00PM BLOOD WBC-7.0 RBC-3.71* Hgb-11.0* Hct-34.7* MCV-94 MCH-29.7 MCHC-31.7 RDW-12.9 Plt Ct-178 [2145-8-6] 03:41AM BLOOD WBC-6.8 RBC-3.49* Hgb-10.5* Hct-33.1* MCV-95 MCH-30.1 MCHC-31.7 RDW-13.0 Plt Ct-159 [2145-8-7] 06:00AM BLOOD WBC-6.6 RBC-3.71* Hgb-11.0* Hct-33.8* MCV-91 MCH-29.6 MCHC-32.5 RDW-12.9 Plt Ct-144* [2145-8-7] 11:44AM BLOOD WBC-7.6 RBC-4.00* Hgb-11.6* Hct-36.8* MCV-92 MCH-28.9 MCHC-31.5 RDW-12.9 Plt Ct-153 [2145-8-8] 06:33AM BLOOD WBC-8.4 RBC-3.56* Hgb-10.7* Hct-32.7* MCV-92 MCH-30.0 MCHC-32.7 RDW-12.8 Plt Ct-154 [2145-8-9] 08:40AM BLOOD WBC-8.8 RBC-3.61* Hgb-10.6* Hct-33.1* MCV-92 MCH-29.5 MCHC-32.1 RDW-12.7 Plt Ct-139* [2145-8-10] 09:53AM BLOOD WBC-8.0 RBC-3.26* Hgb-9.8* Hct-29.8* MCV-91 MCH-30.0 MCHC-32.9 RDW-12.8 Plt Ct-146* [2145-8-11] 03:26AM BLOOD WBC-8.6 RBC-3.64* Hgb-11.1* Hct-33.8* MCV-93 MCH-30.4 MCHC-32.8 RDW-12.7 Plt Ct-170 . [2145-8-5] 06:00PM BLOOD Neuts-72.8* Lymphs-17.4* Monos-7.6 Eos-1.8 Baso-0.4 [2145-8-7] 11:44AM BLOOD Neuts-77.0* Lymphs-12.1* Monos-9.0 Eos-1.4 Baso-0.5 [2145-8-9] 08:40AM BLOOD Neuts-84.4* Lymphs-9.5* Monos-5.6 Eos-0.4 Baso-0.1 . [2145-8-5] 06:00PM BLOOD PT-12.7 PTT-28.1 INR(PT)-1.1 [2145-8-6] 03:41AM BLOOD PT-12.3 PTT-29.2 INR(PT)-1.0 [2145-8-7] 06:00AM BLOOD PT-13.4 PTT-28.0 INR(PT)-1.1 [2145-8-7] 11:44AM BLOOD PT-12.9 PTT-26.2 INR(PT)-1.1 [2145-8-9] 08:40AM BLOOD PT-13.2 PTT-29.6 INR(PT)-1.1 [2145-8-10] 09:53AM BLOOD PT-13.6* PTT-28.6 INR(PT)-1.2* [2145-8-11] 03:26AM BLOOD PT-12.8 PTT-27.8 INR(PT)-1.1 . [2145-8-5] 06:00PM BLOOD Glucose-108* UreaN-28* Creat-1.2 Na-138 K-4.5 Cl-98 HCO3-34* AnGap-11 [2145-8-6] 03:41AM BLOOD Glucose-122* UreaN-27* Creat-1.0 Na-135 K-4.9 Cl-99 HCO3-32 AnGap-9 [2145-8-6] 04:35PM BLOOD UreaN-28* Creat-1.2 Na-138 K-5.0 Cl-98 HCO3-33* AnGap-12 [2145-8-7] 06:00AM BLOOD Glucose-94 UreaN-23* Creat-0.9 Na-140 K-4.3 Cl-99 HCO3-33* AnGap-12 [2145-8-7] 11:44AM BLOOD Glucose-114* UreaN-22* Creat-0.9 Na-138 K-4.8 Cl-98 HCO3-33* AnGap-12 [2145-8-8] 06:33AM BLOOD Glucose-121* UreaN-22* Creat-0.9 Na-134 K-4.8 Cl-97 HCO3-32 AnGap-10 [2145-8-8] 04:50PM BLOOD UreaN-22* Creat-1.0 Na-133 K-5.2* Cl-96 HCO3-32 AnGap-10 [2145-8-9] 08:40AM BLOOD Glucose-101* UreaN-28* Creat-1.1 Na-136 K-5.2* Cl-96 HCO3-36* AnGap-9 [2145-8-10] 09:53AM BLOOD Glucose-206* UreaN-29* Creat-1.0 Na-134 K-4.8 Cl-96 HCO3-35* AnGap-8 [2145-8-11] 03:26AM BLOOD Glucose-101* UreaN-33* Creat-1.0 Na-136 K-5.1 Cl-96 HCO3-38* AnGap-7* . [2145-8-5] 06:00PM BLOOD ALT-9 AST-21 AlkPhos-53 TotBili-0.5 [2145-8-6] 03:41AM BLOOD CK(CPK)-76 [2145-8-5] 06:00PM BLOOD Lipase-28 . [2145-8-5] 06:00PM BLOOD cTropnT-0.06* [2145-8-6] 03:41AM BLOOD CK-MB-5 cTropnT-0.05* . [2145-8-5] 06:00PM BLOOD Albumin-4.1 Calcium-9.3 Phos-3.9 Mg-2.0 [2145-8-6] 03:41AM BLOOD Calcium-8.8 Phos-4.4 Mg-2.0 [2145-8-6] 04:35PM BLOOD Calcium-9.2 Phos-3.9 Mg-2.0 [2145-8-7] 06:00AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.9 [2145-8-7] 11:44AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.1 [2145-8-8] 06:33AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.0 [2145-8-8] 04:50PM BLOOD Mg-2.0 [2145-8-9] 08:40AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.0 [2145-8-10] 09:53AM BLOOD Calcium-8.5 Phos-2.6* Mg-1.9 [2145-8-11] 03:26AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.4 . [2145-8-6] 03:41AM BLOOD TSH-1.2 . [2145-8-6] 3:41 am MRSA SCREEN Source: Nasal swab. FINAL REPORT [2145-8-8] MRSA SCREEN (Final [2145-8-8]): No MRSA isolated. . TTE [8-9] LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Normal LV wall thickness and cavity size. Moderate regional LV systolic dysfunction. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal motion consistent with conduction abnormality/ventricular pacing. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. AORTIC VALVE: Moderately thickened aortic valve leaflets. No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. No MVP. Calcified tips of papillary muscles. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor subcostal views. Suboptimal image quality - poor suprasternal views. The patient appears to be in sinus rhythm. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with thinning/near akinesis of the inferior and inferolateral walls, with hypokinesis of the distal lateral wall. The remaining segments contract normally (LVEF = 35 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with regional systolic dysfunction c/w CAD (PDA distribution). Mild mitral regurgitation most likely due to papillary muscle dysfunction. CLINICAL IMPLICATIONS: The left ventricular ejection fraction is <40%, a threshold for which the patient may benefit from a beta blocker and an ACE inhibitor or [Last Name (un) ]. Based on [2141] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Electronically signed by [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 4083], MD, Interpreting physician [Last Name (NamePattern4) ] [2145-8-9] 14:56 Brief Hospital Course: 81 y/o male with PMHx CAD s/p CABG with triple bypass, ICD placement in [2142] who presents from home with 2 shocks from ICD. Found to be in sinus rhythm with first degree av nodal conduction delay with fascicular tachycardia that converted to sinus rhythm with lidocaine IV. . # RHYTHM: Patient was in sinus rhythm with first degree conduction delay as well as left posterior fasicular tachycardia (VT) that evolved into sinus rhythm with one:one conduction with lidocaine 100mg IV once. It was thought his arrhythmia was triggered by the albuterol in his inhalers given it is very responsive to adrenergic stimuli (albuterol, adrenalin, etc). Pacer interrogated by EP on admission and corroborated he had been shocked twice. Sent to floor on [8-7] and had runs of VT and brought back to CCU. He was transitioned from IV amiodarone drip to Amiodarone 400mg po TID. He was stable in CCU and continued to have occasional runs of VT [5-31] sec duration, however this was non-concerning as pt was asymptomatic and episodes are non-sustained. He was started on metoprolol succinate 75mg [Hospital1 ] to inhibit adrenergic stimuli with good rate control and minimizing of his VT. His ICD was interrogated and found to be functionig normally. Pt was followed by EP who will f/u as an outpatient (Dr. [Last Name (STitle) 23246] in [Hospital1 ]). . # CORONARIES: Patient with known coronary disease, s/p CABG with triple bypass in [2125]. Reports a diagnosis of Prinzmetals angina, responsive to nitroSL. Cardiac biomarkers negative on admission. He was continued on aspirin, plavix, statin therapies and did not require nitroSL for any episodes of chest pain. . # PUMP: From OSH echo, has chronic systolic heart failure. No clinical signs of overt heart failure on admission. He was continued on Furosemide 20 mg IV DAILY and spironolactone home dosages. SBP ranged from 80s-130s but averaged in low 110s and carvedilol was not restarted in house given we switched him to metoprolol for better control of his arrhythmia. He was transitioned to lasix 20mg PO daily and tolerated well. # COPD - Stable, will continue current medication regimen of Tiotropium Bromide, Symbicort inhalers. Combivent home inhaler was discontinued for its adrendergic effects, increased use of inhaler per pt likely inititated the runs of VT prior to admission. Medications on Admission: Lasix 20mg daily Plavix 75mg daily Coreg 3.125mg [Hospital1 ] Protonix 20mg daily Celebrex 200mg daily Aspirin 81mg daily Spironolactone 25mg daily Tylenol 1000mg [Hospital1 ] Prednisone 10mg daily Symbicort 2 puffs [Hospital1 ] Gabapentin 600mg daily Magnesium 250mg daily Vitamin B6 Vitamin B12 Folic Acid Simvastatin 20mg daily Lisinopril 2.5mg daily Combivent PRN NitroSL PRN Valium 2mg PRN Discharge Medications: 1. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Take two times a day for 1 month. Then take one times a day. Disp:120 Tablet(s) Refills:2 9. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO BID (2 times a day). Disp:90 Tablet Sustained Release 24 hr(s) Refills:2 10. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. Discharge Disposition: Extended Care Facility: [Hospital1 599] Heathcare of [Location (un) 1887] Discharge Diagnosis: Primary Diagnosis arrythmia: ventricular tachycardia Secondary Diagnosis coronary disease, s/p CABG with triple bypass in [2125] chronic systolic HF COPD GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted after receiving shocks from your ICD. You had episodes of Ventricular tachycardia (an arrhythmia) which were treated with amiodarone, metoprolol, and lidocaine. You will be discharged to rehab with amiodarone and metoprolol. Please make the following changes to your medications: START AMIODARONE 400mg [Hospital1 ] for one month, and then 400 mg daily START Metoprolol Succinate XL 75 mg PO BID STOP Coreg STOP Combivent CONTINUE: Lasix 20mg daily, Plavix 75mg daily, Protonix 20mg daily, Aspirin 81mg daily, Spironolactone 25mg daily, Gabapentin 100mg daily, Simvastatin 20mg daily, Lisinopril 2.5mg daily Your arrhythmia can be triggered by strong emotions (adrenaline) and one of the two medications in your inhalers (albuterol). You should try to avoid those medications unless you necesarily need them. Followup Instructions: F/u Dr [Last Name (STitle) 23246] in [Location (un) 620] in 1 month (([Telephone/Fax (1) 8937]).	[ "4280", "496", "53081", "25000", "2724", "4019", "V4581", "V1582" ]
Admission Date: [2172-4-28] Discharge Date: [2172-5-18] Date of Birth: [2110-5-27] Sex: M Service: CARDIOTHORACIC Allergies: Heparin Agents Attending:[First Name3 (LF) 165] Chief Complaint: Type A Dissection Major Surgical or Invasive Procedure: [2172-4-28] - 1. Emergency repair of type A aortic dissection with replacement of the ascending aorta and hemiarch with a size 26 Gelweave graft. 2. Aortic valve resuspension. [2172-4-29] - Re-exploration for bleeding, status post type A ascending aortic dissection repair. History of Present Illness: 61-year-old man with a history of hypertension presented to the outside hospital after developing anterior substernal chest pain for several minutes in the shower and then felt very weak. He almost passed out and had to lie down in the shower floor for several minutes. He presented by ambulance to the outside hospital and was given 4 baby aspirin prior to arrival. Patient was reportedly hypotensive in the field prior to arrival at the outside hospital. Patient also complained of numbness and weakness in his right arm. Past Medical History: Hypertension Diabetes Colon resection for perforated diverticulitis New Diagnosis': Heparin Induced Thrombocytopenia Renal failure Atrial fibrillation Social History: no tobacco, EtOH, or illicit drug use Family History: unknown Physical Exam: Constitutional: Intubated and sedated on ventilator. Obese. HEENT: Pupils equal, round and reactive to light, Extraocular muscles intact, Normocephalic, atraumatic Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Nontender, Nondistended GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema Skin: No rash, Warm and dry Heme/[Last Name (un) ]/[Last Name (un) ]: No petechiae Pertinent Results: [2172-4-29] ECHO Pt, s/p acute aortic disection with ascending/hemiarch repair. Re-exploration for bleeding, marginal hemodynamics. The patient is receiving epinephrine0.04 ucg/kg/mon Norepinephrine 0.025 ucg/kg/min No atrial septal defect is seen by 2D or color Doppler. Right ventricular chamber size and free wall motion are normal. A mobile density is seen in the aortic arch consistent with an intimal flap/aortic dissection. A mobile density is seen in the descending aorta consistent with an intimal flap/aortic dissection. The descending aortic intimal flap is newly visualized compared to the study from [2172-4-28].The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. A large right pleural efussion is visualized and drained. [2172-4-29] Renal Ultrasound The study is very limited due to body habitus. The right kidney measures 12.0 cm, and the left kidney measures 11.4 cm. There are no gross renal lesions and there is no hydronephrosis. Doppler evaluation was very limited, but there are limited arterial waveforms in each kidney. [2172-5-9] CXR REASON FOR EXAMINATION: Follow up of the patient after aortic dissection surgery, follow up of effusions. COMPARISON: [2172-5-11]. No significant interval change in the left pleural effusion which is small to moderate and small right pleural effusion, the last one potentially increased since the prior study although it might be related to upright position of the patient. Cardiomediastinal silhouette is stable with unchanged appearance of the sutures. The right internal jugular line is at the level of mid SVC. There is no evidence of pneumothorax. There is no evidence of failure. DR. [First Name4 (NamePattern1) 2618] [Last Name (NamePattern1) 2619] Approved: WED [2172-5-13] 2:13 PM Brief Hospital Course: Mr. [Known lastname 41393] was admitted to the [Hospital1 18] on [2172-4-28] via transfer from an outside hospital for surgical management of his type A aortic dissection. He was taken to the operating room where he underwent repair of his type A aortic dissection with resuspension of his aortic valve. Please see operative note for details. Postoperatively he was taken to the intesive care unit for monitoring. The GI service was consulted for assistance as he had blood in his NG tube. A proton pump inhibitor drip was started and he was transfused with improvement in his hematocrit. His chest tube output remained high with hypotension and he was returned to the operating room on [2172-4-29] where he underwent a re-exploration for bleeding. He was again taken back to the intensive care unit for continued care. The nephrology service was consulted for a rising creatinine. As he renal function continued to deteriorate and he was fluid overloaded, CVVH was started. A renal ultrasound was performed which was limited however showed reduced arterial wave forms in the bilateral kidneys. He underwent MRA [5-7] and there was question about the distal extent of the dissection (? involving the renals) and the vascular surgery service was therefore consulted. MRA suggested some compression of Left renal artery but Right renal artery was found to be widely patent. A nuclear scan was done [5-12] to assess for renal artery involvement which was normal. His platelet count had dropped acutely and a HIT antibody was positive and patient was started on Argatroban. Hematology was consulted and subsequent Serotinin Release Assay was negative, leading to the conclusion that the patient did not have HIT syndrome. He reported that he awoke from anesthesia with the right arm weakness. Noncontrast head CT performed [5-8] revealed L frontal subarachnoid hemmorhage, and Neurology was consulted regarding whether anticoagulation may be used in this setting. It was recommended to avoid anticoagulation given the subarachnoid hemmorhage. He was transferred to the step down unit in stable condition. His renal function continued to improve and as of [5-12] he has not been on dialysis and his BUN and creat are coming down and he is making adequate urine on daily lasix. BUN and Creat on [2172-5-18] were 97/6.1. He was traeted with IV vanco and po cipro for enterobacter in his sputum. Iv vanco was d/c'd and he continues on cipro po until [2172-5-22]. He had a brief episode of rapid afib on [2172-5-14] which was treated with amiodarone and has been in SR since. Anticoagulation was not recommednded per Neurology given SAH. He was seen and evaluated by physical and occupational therapy for strength and consitioning and rehab was recommended. On POD#20 Mr. [Known lastname 41393] was cleared for discharge to [Hospital 24759] [Hospital 656] rehab in [Hospital1 3597] MA by Dr. [First Name8 (NamePattern2) ] [Name (STitle) ] Medications on Admission: Pravastatin, amlodipine, metformin Discharge Disposition: Extended Care Facility: [Hospital3 1122] Center - [Hospital1 3597] Discharge Diagnosis: Type A aortic dissection Diabetes Hypertension Heparin Induced Thrombocytopenia Atrial Fibrillation Renal failure requiring hemodialysis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Left - groin wet- dry dressing changes [Hospital1 ] trace pedal edema bilaterally Discharge Instructions: 1) 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 2) Please NO lotions, cream, powder, or ointments to incisions 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4) No driving for approximately one month until follow up with surgeon 5) No lifting more than 10 pounds for 10 weeks 6) 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. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) 766] [2172-6-15] 1:00PM ([Telephone/Fax (1) 1504] Please call to schedule appointments with your Primary Care Dr. [Last Name (STitle) ] in [12-7] weeks [Telephone/Fax (1) 18696]. Please have Dr. [Last Name (STitle) ] recommend a cardiologist for you and be seen in 2 weeks post discharge please call the [Hospital 2793] clinic at [Hospital1 18] to schedule an appointment in 3 weeks [Telephone/Fax (1) 721] Please call and schedule a follow up appointment with Dr. [Last Name (STitle) ] in neurology [Telephone/Fax (1) 657] in [2-6] weeks. You will need a Non- Contrast head CT at [Hospital1 18] prior to your appointment with Dr. [Last Name (STitle) ]. 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:[2172-5-18]	[ "5849", "9971", "5119", "42731", "4019", "25000" ]
Admission Date: [2147-2-24] Discharge Date: [2147-3-2] Date of Birth: [2112-11-14] Sex: M Service: MEDICINE Allergies: Penicillins / Watermelon / Almond Oil / Hydralazine / cefepime Attending:[First Name3 (LF) 603] Chief Complaint: nausea, vomiting, shortness of breath Major Surgical or Invasive Procedure: [2147-2-24] - Central line placement in right IJ [2147-2-24] - Mechanical ventilation History of Present Illness: 34yo M PMHx DM1, ESRD (on HD [Month/Day/Year ]/Thurs/Sat), severe gastroparesis with recurrent admissions for nausea/vomitting (most recent discharge [2147-2-17]), nonischemic cardiomyopathy (EF=30-35%), presenting with nausea, vomiting, and shortness of breath. History was initially obtained from the patient in the emergency department, and subsequently obtained from the patient's girlfriend by the ICU team. . Per ED, the patient reported that 3 days prior to day of admission, he developed nausea and NBNB emesis, consistent with prior episodes of gastroparesis. Symptoms were not initially associated with any fevers/NS/chills, shortnesss of breath, chest pain; beginning 1d prior to admission, he developed worsening pleuritic chest pain, non-exertional, along with shortness of breath and cough. Also reported poorly controlled finger sticks. . Per the patient's girlfriend, the patient has chronic issues with nausea/vomiting from gastroparesis. He was in his usual state of health until Tuesday, when he awoke with shortness of breath prior to dialysis. He felt okay after HD on Tuesday, then developed shortness of breath on Wednesday evening/Thursday morning. He felt better after HD yesterday, but awoke at 5 a.m. today with nausea, vomiting, shortnss of breath. His emesis was profuse and red, but the patient's girlfriend attributes this to red coolaid that he drank last night. No diarrhea. Last BM yesterday per girlfriend. Had mild coughing this morning. No recent travel or sick contacts. Had dental work and was on antibiotics 2-3 weeks ago. The patient's girlfriend is not sure the patient took his usual medications this a.m. but believes he probably did not. No recent med changes per girlfriend. [Name (NI) ] fever/chills. No syncope. +abdominal pain, diffuse, this a.m. No dysuria. No rash. No myalgia/arthralgia. . On presentation to ED initial vital signs were 99.0 113 225/111 28 89% 3LNC. On exam patient was short of breath, appearing fatigued. He became hypoxic, requiring a non-rebreather. On further history taking, he reported that in setting of vomiting he may have aspirated small amount of vomitus. Labs were significant for WBC 11.8 (N87), Hct 29 (baseline 28), Na 131, K 4.2, glucose 678, Anion Gap 21, VBG 7.47/38, lactate 2.0. CXR significant for pulmonary edema (radiology read), felt to be consistent with pneumonia by ED. Patient was albuterol, ipratropium, NTG, labetalol 10 mg IV x 2, morphine, Zofran, vancomycin 1 gm, cefepime 2 gm. He was given succinylcholine, propofol, fentanyl, and midazolam prior to intubation. A central line and OGT were placed. After intubation, the patient reported to have red frothy secretions from ET tube. Vital signs prior to transfer were T 98.5 P 88, BP 160/91 Sat 100% on AC 500mL 22RR 10peep 100%. Past Medical History: - DM type I since age 19, followed at [Last Name (un) ]. Complicated by nephropathy, neuropathy, gastroparesis, retinopathy. Multiple prior hospitalizations with DKA, nausea/vomitting [2-9] gastroparesis - ESRD on HD T/Th/S via right arm fistula @ [Location (un) ] [Location (un) ], dry weight 73kg - Hypertension - Nonischemic cardiomyopathy with EF 30-35% - Anemia: felt to be due to both iron deficiency and advanced CKD - Depression - Pulmonary hypertension - Migraines Social History: -Home: Lives with his GF. Mother lives in the area as well. -Tobacco: trying to quit; has relapsed and smokes 1 pack per week or week and a half -EtOH: previously drank heavily (30-40 drinks/week) but has not used alcohol since [2144-11-14] -Illicits: Denies other drugs. Family History: Paternal GF had DM2 but nobody with DM1. Hypertension in a few family members. Physical Exam: Admission exam: VS: T 98.4 BP 179/98 HR 92 RR 21 Sat 100%/vent Gen: Intubated, sedated. HEENT: Anicteric sclerae. Neck: RIJ in place. Chest: Clear ventilated breath sounds. CV: RRR. Normal s1, s2. No M/G/R. Abd: +BS. Soft. NT/ND. Rectal: Guaiac negative yellowish-brown stool. Ext: WWP. No edema. RUE fistula with good thrill. Neuro: Sedated. PERRL. Moves all extremities. Discharge exam - unchanged from above, except as below: Gen: Awake, interactive, comfortable Neck: supple, no RIJ Chest: CTAB aside from trace crackles in the lung bases bilat Neuro: A&Ox3, no focal neuro defecits Pertinent Results: Admission labs: [2147-2-24] 08:15AM BLOOD WBC-11.8# RBC-3.11 Hgb-9.7* Hct-29.6* MCV-95 MCH-31.1 MCHC-32.6 RDW-13.9 Plt Ct-261# [2147-2-24] 08:15AM BLOOD Neuts-87.4* Lymphs-5.7* Monos-2.7 Eos-3.6 Baso-0.7 [2147-2-24] 02:02PM BLOOD PT-11.7 PTT-31.3 INR(PT)-1.1 [2147-2-24] 08:15AM BLOOD Glucose-678* UreaN-30* Creat-6.4* Na-131* K-4.2 Cl-90* HCO3-24 AnGap-21* [2147-2-24] 08:15AM BLOOD CK-MB-4 cTropnT-0.24* proBNP-GREATER TH [2147-2-24] 02:02PM BLOOD CK-MB-4 cTropnT-0.20* [2147-2-24] 08:15AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.7 [2147-2-24] 08:41AM BLOOD Type-[Last Name (un) ] Temp-37.2 pO2-138* pCO2-38 pH-7.47* calTCO2-28 Base XS-4 Intubat-NOT INTUBA [2147-2-24] 08:41AM BLOOD Lactate-2.0 Discharge labs: [2147-3-2] 05:39AM BLOOD WBC-5.6 RBC-2.82* Hgb-8.7* Hct-25.5* MCV-91 MCH-31.1 MCHC-34.3 RDW-14.1 Plt Ct-229 [2147-3-2] 05:39AM BLOOD Glucose-274* UreaN-40* Creat-10.2# Na-137 K-3.6 Cl-94 HCO3-26 AnGap-21* [2147-3-2] 05:39AM BLOOD Calcium-8.7 Phos-5.0* Mg-1.9 Imaging: CXR [2-24]: Findings most consistent with pulmonary edema. CXR [2-24]: Right internal jugular vascular catheter terminates in the mid superior vena cava, with no visible pneumothorax. Other indwelling devices remain in standard position. Cardiac silhouette is enlarged but has slightly decreased in size, and widespread pulmonary edema has also slightly improved in the interval. Small pleural effusions have apparently slightly decreased in size but positional differences limit comparison. CXR [2-27]: 1. Right internal jugular central line continues to have its tip in the mid SVC. There is worsening bilateral airspace process most likely representing moderate-to-severe pulmonary edema. The heart is enlarged, which could reflect cardiomegaly, although pericardial effusion should also be considered. This is likely a layering left effusion. No pneumothorax is seen. CXR [2-28]: As compared to the previous radiograph, there is a marked improvement with decrease in extent of the pre-existing massive pulmonary edema. The radiograph currently shows only mild signs of fluid overload. Unchanged moderate cardiomegaly without pleural effusions. Mild retrocardiac atelectasis. Unchanged right internal jugular vein catheter. ECHO [2-28]: Mild symmetric left ventricular hypertrophy with mild cavity enlargement and normal regional/global systolic function. Pulmonary artery hypertension. Very small pericardial effusion. Compared with the prior study (images reviewed) of [2147-2-10], the left ventricular cavity is now smaller and systolic function is improved. The estimated PA systolic pressure is now lower. Brief Hospital Course: 34 yo M PMHx DM1, ESRD (on HD [Year (4 digits) ]/Thurs/Sat), severe gastroparesis with recurrent admissions for nausea/vomitting (most recent discharge [2147-2-17]), nonischemic cardiomyopathy (EF previously 30-35%), presenting with nausea, vomiting, admitted to the ICU for respiratory failure. # Respiratory failure: Likely due to pulmonary edema in the setting of CHF exacerbation. Intubated in the ED due to worsening mental status. Extubated on [1-25], and able to saturate well on room air. On the floor he was initially on room air. However, on [2-27], patient became tachypneic and desatted into the 70-80s in the setting of severe HTN to 220/120s. Exam and CXR consistent with flash pulmonary edema. Patient initially on NRB, received urgent dialysis (-3L) and was able to be weaned to nasal cannula, he did not require intubation. His BP was controlled as below and he was transferred back to the floor where he remained on room air until discharge. # Acute on chronic systolic heart failure: Likely caused by severe HTN, with HTN possibly exacerbated by vomiting. Has non-ischemic cardiomyopathy for EF which was previously reported as 30-35%. MI ruled out with serial enzymes. He received extra sessions of hemodyalysis to remove volume, although these were often stopped early because he reported chest pain. A repeat echo showed an improved EF of 55% during this admission. # Alveolar hemorrhage - Bronchoscopy was performed in the [Hospital Unit Name 153] which was concerning for alveolar hemorrhage. This was performed because of blood in his endotracheal secretions. The cause was likely severe hypertension. Serologies were sent for [Doctor First Name ], ANCA and anti-GBM, all of which were negative. He had no further obvious episodes of hemorrhage and had no hemoptysis after leaving the floor. # Hypertension: Patient has severe HTN, on multiple meds in setting of underlying ESRD. He was initially continued on home doses of [Doctor First Name 40899], carvedilol, lisinopril, amlodipine. On the floor, he remianed hypertensive and his [Doctor First Name 40899] patch was increased to 0.3mg/24h. On [2-27], developed BP into 220/120s with flash pulmonary edema. He was transferred to the ICU and started on nitro drip and also received IV labetalol to lower his BP. HTN thought to be related to fluid overload, he improved with an extra session of HD which removed 3L by ultrafultration. Patient has been recently skipping HD sessions and sometimes HD cut short due to crampy chest pain. His carvedilol was changed to labetalol to allow for more room to uptitrate. At discharge, he was on labetalol 300mg q8h with BP in the 160s. We wanted to monitor his BP for another 24 hours after this medication change but the patient insisted on leaving AMA, as described below. # Anemia: Chronic anemia related to ESRD. Transfused one unit during hospitalization. No source of acute bleed was identified aside from mild degree of pulmonary hemorrhage, as discussed below. # ESRD on HD (TuThSa): Renal was consulted and he continued to receive HD as an inpatient. Continued on sevelamer and nephrocaps. Had urgent dialysis on [2-27] for hypertensive emergency and pulmonary edema as described above. # DM1: Initially presented with severe hyperglycemia. Developed hypoglycemia on insulin gtt requiring D20 to maintain normoglycemia. After initial transfer to the floor, he remained hyperglycemic with multiple "critical high" blood sugars requiring additional doses of Lantus. At the time of his second MICU stay, he was again hyperglycemic to the 400s. Anion gap ~16-17, but also with ESRD. PH 7.45 on ABG. Does not make urine, so cannot measure urine ketone. No clear evidence of DKA. Patient restarted on insulin drip and transitioned to subcutaneous insulin once tolerating PO. Josline was consulted and his Lantus dose was increased to 14 units qAM and 12 units qPM. Again, we had hoped to monitor his glucose for longer after the most recent uptitration of his insulin, however he left AMA. #AMA: On [3-2], the patient was still mildly hypertensive to the 160s systolic and his labetalol had just been uptutrated. We had also recently increased his Lantus dose. We wanted to monitor him longer to ensure adequate BP and glycemic control after these medication changes. However, the patient was very frustrated with being in the hospital and chose to leave AMA. He understood and was able to repeat the risks of leaving, including worsening hypertension, fluid accumulation in the lungs, hyperglycemia and DKA and possible death. # Code status this admission: FULL CODE #Transitional issues -Will need BP closely monitored, antiypertensive regimen changed: carvedilol 25mg [Hospital1 ] changed to labetalol 300mg q8h -Will need close monitoring of his blood sugar with uptitration of his Lantus this admission -Dry weight should be re-evaluated so that an appropriate amount of fluid is removed with each HD session -Would likely benefit from outpatient social work given that he is very frustrated and depressed about the state of his health, which may be contributing to his poor compliance. Medications on Admission: - amlodipine 10 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. - aspirin 81 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO DAILY (Daily). - carvedilol 25 mg Tablet [Hospital1 ]: One (1) Tablet PO twice a day. - [Hospital1 40899] 0.2 mg/24 hr Patch Weekly [Hospital1 ]: One (1) Patch Weekly Transdermal QSUN (every Sunday). - insulin glargine 100 unit/mL Solution [Hospital1 ]: Fourteen (14) units Subcutaneous Every morning. - insulin lispro 100 unit/mL Solution [Hospital1 ]: Sliding Scale units Subcutaneous Before meals and before bed - B complex-vitamin C-folic acid 1 mg Capsule [Hospital1 ]: One (1) Cap PO DAILY (Daily). - lisinopril 40 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. - sevelamer carbonate 800 mg Tablet [Hospital1 ]: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). - sertraline 100 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. - hydromorphone 4 mg Tablet [Hospital1 ]: One (1) Tablet PO twice a day as needed for pain. - ondansetron 4 mg Tablet, Rapid Dissolve [Hospital1 ]: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Discharge Medications: 1. amlodipine 10 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. 2. aspirin 81 mg Tablet, Chewable [Hospital1 ]: One (1) Tablet, Chewable PO DAILY (Daily). 3. [Hospital1 40899] 0.3 mg/24 hr Patch Weekly [Hospital1 ]: One (1) Patch Weekly Transdermal QMON (every [Hospital1 766]). Disp:4 Patch Weekly(s) Refills:0 4. insulin glargine 100 unit/mL Solution [Hospital1 ]: Fourteen (14) units Subcutaneous In the morning. 5. insulin lispro 100 unit/mL Solution [Hospital1 ]: Sliding scale units Subcutaneous With meals and at bedtime: Please contnue to use your home sliding scale. 6. B complex-vitamin C-folic acid 1 mg Capsule [Hospital1 ]: One (1) Cap PO DAILY (Daily). 7. lisinopril 40 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. 8. sevelamer carbonate 800 mg Tablet [Hospital1 ]: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. sertraline 100 mg Tablet [Hospital1 ]: One (1) Tablet PO once a day. 10. hydromorphone 4 mg Tablet [Hospital1 ]: One (1) Tablet PO every twelve (12) hours as needed for pain. 11. ondansetron 4 mg Tablet, Rapid Dissolve [Hospital1 ]: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 12. labetalol 300 mg Tablet [Hospital1 ]: One (1) Tablet PO every eight (8) hours. Disp:52 Tablet(s) Refills:0 13. insulin glargine 100 unit/mL Solution [Hospital1 ]: Twelve (12) units Subcutaneous at bedtime. Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: Acute on chronic systolic heart failure Respiratory failure Uncontrolled type 1 diabetes Uncontrolled hypertension Secondary diagnoses: Gastroparesis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [Known lastname 21822], It was a pleasure taking care of you during your admission to [Hospital1 18]. You were initially admitted to the intensive care unit where you were intubated for respiratory failure, thought to be due to an exacerbation of heart failure. You had fluid removed with dialysis and your symptoms improved. After transfer to the medicine floor, your blood pressure was severely elevated and fluid built up in your lungs, for which you were readmitted to the ICU. There, you received IV medications to lower your blood pressure and an insulin drip to control your blood sugar. Your blood pressure and blood sugar improved and were again transferred to the medicine floor. We stopped your carvedilol and added labetalol to help control your blood pressure. We also increased your [Hospital1 40899] patch to 0.3mg/24h. Labetalol was increased to 300mg every 8 hours. We wanted to watch your blood pressure after the most recent change to your medications, but you wanted to leave against medical advice. Please check your BP at home and call your PCP, [Last Name (NamePattern4) ]. [Last Name (STitle) ], or return to the hospital if it is higher than 180/100 or if you have any headache, changes in vision, chest pain or shortness of breath. It is important that you go to each session of dialysis to remove fluid and help control your blood pressure. You will follow up with your nephrologist after discharge at your next dialysis session. Weigh yourself every morning, [Name8 (MD) 138] MD if weight goes up more than 3 lbs. The following changes were made to your medications: START labetalol 300mg by mouth three times per day STOP carvedilol CHANGE [Name8 (MD) 40899] patch 0.3mg/24h change every [Name8 (MD) 766] CHANGE Lantus 14 units in the morning and 12 in the evening Followup Instructions: Department: [Hospital3 249] When: FRIDAY [2147-3-10] at 10:10 AM With: Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] Address: [Location (un) 830] [Location (un) 86], [Numeric Identifier 718] Location: [Company 191] POST [Hospital 894] CLINIC [Telephone/Fax (1) 250] Building: SC [Hospital Ward Name 23] [Hospital Ward Name ] Ctr [Location (un) 895] Central [Hospital ] Campus: EAST Best Parking: [Hospital Ward Name 23] Garage This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [Name10 (NameIs) 616] this visit, you will see your regular primary care doctor in follow up. [Location (un) ] [Location (un) ] Dialysis Center Schedule- Tuesday, Thursday and Saturdays Phone: [Telephone/Fax (1) 5972] Your nephrologist Dr. [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ] will follow up with you for your hospitalization at your next scheduled dialysis day.	[ "51881", "40391", "4280", "4168", "V5867", "311", "3051" ]
Admission Date: [2110-1-21] Discharge Date: [2110-1-28] Service: SURGERY Allergies: Penicillins / Spironolactone Attending:[First Name3 (LF) 2597] Chief Complaint: Gangrene of the right foot Major Surgical or Invasive Procedure: [2110-1-21] Right popliteal to dorsalis pedis artery bypass with non reversed right lesser saphenous vein and angioscopy. History of Present Illness: This 84-year-old gentleman has gangrene involving the lateral aspect of his right foot. He had an arteriogram which showed occlusion of his anterior tib and posterior tibial arteries over a long distance. His peroneal artery was opened but was diseased distally and he reconstituted a small caliber dorsalis pedis artery. Vein mapping showed a saphenous vein patent from the groin to the calf. He had the distal vein harvested for CABG before. Past Medical History: 1. Insulin dependent-diabetes mellitus. 2. Coronary artery disease, three vessel with an ejection fraction of 20-25%; s/p CABG [2103] LIMA-LAD, SVG-OM and SVG-RCA 3. Prostate cancer status post radical prostatectomy [2096], no chemotherapy and no XRT 4. Paget's disease 5. Ulcerative colitis 6. Peripheral vascular disease s/p LLE bypass, left popliteal to DP; [3-12] mild proximal [Month/Year (2) ] stenosis 7. Status post left first toe amputation in [4-4] 8. Right inguinal hernia repair [2099-9-3] 9. Status post left carpal tunnel release in [2088] 10. Right carpal tunnel release in [2100] 11. Status post appendectomy in [2053] 12. CVA to the thalamus 6-8 years ago with no deficit. 13. Cardiomyopathy 14. s/p left 1st toe amputation [1-6] osteomyelitis 15. Left shoulder fracture status post fall [2105] 16. Mild mitral regurgitation, Echo [2106] 17 Mild pulmonary hypertension, Echo [2106] 18. Appendectomy [2054-11-3] 19. LE ulcerations, followed by [Doctor Last Name ] 20. s/p ICD placement in [2103], revision [2105] - unclear reason besides was delaying CABG for 2-3 weeks to get affairs in order Social History: Widowed [2105], retired engineer, does not use alcohol. He quit smoking in [2059] after 15 years of smoking three packs per day while in the Navy, inaddition to cigars and pipes. There is no history of alcohol abuse but drinks several times each week. Family History: Family history notable for brother being a 'blue baby' who died at 26, brother died [1-6] MI at 47. Mothers and sisters with DM. Physical Exam: VS: 98.0 P: 70 BP: 97/62 RR: 20 Spo2: 99% RA Gen: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL CV: RRR, normal S1, S2. No m/r/g. No S3 or S4. Resp: unlabored, no accessory muscle use. mild bibasiler rales Abd: Thin, soft, NT, ND. No HSM or tenderness. Extremities/Skin: bilateral 2 pitting edema with distal erythema; Right leg with 1cm dorsal ulcer about 2-3 mm deep, Left foot with lateral eschar ~5cm wide, appears necrotic, also with dorsal 1cm ulcer. Incisions: RLE open to air with steristrips. Minimal drainage. Incision from knee to ankle. Stage II pressue ulcer to coccyx Pertinent Results: [2110-1-25] 06:30AM BLOOD WBC-7.7 RBC-3.26* Hgb-10.6* Hct-31.6* MCV-97 MCH-32.7* MCHC-33.7 RDW-17.0* Plt Ct-201 [2110-1-24] 04:07AM BLOOD Hct-29.0* Plt Ct-166 [2110-1-23] 04:11AM BLOOD Hct-29.8* Plt Ct-179 [2110-1-22] 04:50AM BLOOD WBC-11.1# Hgb-11.2 Hct-33.6* Plt Ct-232 [2110-1-21] 06:15PM BLOOD Hgb-11.1* Hct-32.9* Plt Ct-222 [2110-1-25] 06:30AM BLOOD Plt Ct-201 [2110-1-25] 06:30AM BLOOD PT-15.2* PTT-33.9 INR(PT)-1.3* [2110-1-24] 04:07AM BLOOD Plt Ct-166 [2110-1-23] 04:11AM BLOOD Plt Ct-179 [2110-1-21] 06:15PM BLOOD PT-14.5* PTT-91.7* INR(PT)-1.3* [2110-1-25] 06:30AM BLOOD Glucose-74 UreaN-27* Creat-1.2 Na-140 K-4.6 Cl-98 HCO3-39* AnGap-8 [2110-1-21] 06:15PM BLOOD Glucose-132* UreaN-22* Creat-1.1 Na-144 K-3.3 Cl-103 HCO3-37* AnGap-7* [2110-1-21] 06:15PM BLOOD ALT-30 AST-32 AlkPhos-140* [2110-1-21] 06:15PM BLOOD CK-MB-4 cTropnT-0.04* [2110-1-22] 04:57AM BLOOD Type-ART Temp-37.7 FiO2-35 O2 Flow-2 pO2-103 pCO2-58* pH-7.42 calTCO2-39* Base XS-10 Intubat-NOT INTUBA Comment-NASAL [Last Name (un) 154] [2110-1-25] 06:30AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.2 [2110-1-21] 04:39PM BLOOD Glucose-160* Lactate-1.9 K-3.2* Portable TEE (Complete) Done [2110-1-21] at 3:32:45 PM FINAL Conclusions: The left atrium is markedly dilated. Moderate to severe spontaneous echo contrast is seen in the body of the left atrium. The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-10mmHg. Overall left ventricular systolic function is severely depressed (LVEF= XX %). The estimated cardiac index is borderline low (2.0-2.5L/min/m2). The calculated myocardial performance index was0.9 (MPI A = 602 ms; MPI B = 330 ms). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity imaging are consistent with Grade III/IV (severe) LV diastolic dysfunction. with severe global free wall hypokinesis. The descending thoracic aorta is mildly dilated. There are three aortic valve leaflets. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Brief Hospital Course: [2110-1-21] Admitted direct via holding room for a scheduled LE bypass, taken to OR and underwent Right popliteal to dorsalis pedis artery bypass with non reversed right lesser saphenous vein and angioscopy. Patient invasive lines (foley, a-line, PA-line, and central line)were placed. Patient tolerated procedure, recovered in the PACU and then transferred to [Hospital Ward Name 121] 5/VICU/telemetry for further observation. Overnight patient had probelms w/ tachycardia-managed w/ IV Metoprolol. Pain managed w/ IV Hydromorphone. [2110-1-22] No acute events. On LE BP pathway. Remains on bed rest. Clears and PO meds re-started. Given Albumin and NS for volume. Electrolytes repleted. Remains VICU. 2/19-20/09 No acute events. Continues LEBP pathway. Diet advanced. Art line and foley d/c'd, central line switched to PIV. Physical therapy evaluation, touch down WB on R, FWD on L. Remains VICU. Pain mananged. Foley replace, unable to void. 2/21-22/09 No acute events. Continues LEBP pathway. had some problems w/ [Name2 (NI) 34279]-given on Bisacodyl and given fleet enema. Became floor status. Pain management still an issue. Having breakthrough pain requiring IV pain medications. [2110-1-27] No acute events. Urine output scant, and unable to take in large po fluids, given IV fluid bolus. Out of bed w/ assist. Pain meds converted to PO. [2110-1-28] Stable overnight. Transferred to Rehab with indwelling foley. Medications on Admission: SQ Heparin Amiodarone 200 mg qd Levothyroxine 112 mcg. qd [Month/Day/Year ] 81 mg po qd Folic Acid 1 1 mg po qd ISS NPH 20 U QAM Eplerenone 25 mg qd Cipro 250 mg [Hospital1 ] Brimonidine 1gtt [Hospital1 ] Lasix 80 IV BID Hydralazine 10 mg po tid Isosorbide dinitrate 10 mg tid eucerin Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic TWICE DAILY (). 7. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO [3-10] H () as needed for pain. 14. Humalog Sliding Scale Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Q6H Humalog Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-60 mg/dL [12-6] amp D50 [12-6] amp D50 [12-6] amp D50 [12-6] amp D50 [12-6] amp D50 61-150 mg/dL 0 Units 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 2 Units 2 Units 2 Units 2 Units 2 Units 201-250 mg/dL 4 Units 4 Units 4 Units 4 Units 4 Units 251-300 mg/dL 6 Units 6 Units 6 Units 6 Units 6 Units > 300 mg/dL 8 Units 8 Units 8 Units 8 Units 8 Units 15. NPH Insulin 24 units with breakfast Discharge Disposition: Extended Care Facility: [Doctor First Name 3548] [Doctor Last Name 3549] Nursing & Rehabilitation Center - [Location (un) 1110] Discharge Diagnosis: PVD w/ Gangrene of the right foot. history of CAD s/p CABG [2103] (LIMA-LAD, SVG-RCA, SVG-OM) history of CVA no deficits history of insulin dependent diabetes history of CHF (EF 20%) history of prostate CA s/p prostatectomy, history of VT arrest s/p ICD placement with 4 firings last year history of hypothyroidism Post-op constipation-treated Post-op hypovelemia- fluid resuscitated Discharge Condition: stable Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [1-7] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [First Name11 (Name Pattern1) 1112] [Last Name (NamePattern4) 2604], MD Phone:[Telephone/Fax (1) 1237] Date/Time:[2110-2-10] 1:20 Provider: [First Name8 (NamePattern2) 278] [Last Name (NamePattern1) ], MD Phone:[Telephone/Fax (1) 3070] Date/Time:[2110-4-1] 11:15 Completed by:[2110-1-28]	[ "25000", "4168", "V4581", "4280" ]
Admission Date: [2128-4-6] Discharge Date: [2128-4-19] Date of Birth: [2089-3-6] Sex: F Service: MED HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old female with a history of [Location (un) 2174] ataxia and cardiomyopathy with ejection fraction of 35 percent and diastolic dysfunction with negative catheterization, atrial fibrillation on Coumadin, and insulin-dependent diabetes mellitus, who was in her usual state of health until 2-3 weeks prior to admission she had episodes of nausea and vomiting. The patient also noted paroxysmal nocturnal dyspnea and orthopnea with a 30-pound weight gain and decreased urine output. She was noted to have an INR of 19.5 on admission. She was given vitamin K and admitted to the Fennard Intensive Care Unit for concern for gastrointestinal bleed. The patient was also found to have nephrotic range proteinuria and elevated LFTs. Echocardiogram revealed depression in her ejection fraction to 20 percent. GI Service was consulted and it suspected that her increasing liver function tests were secondary to ischemic liver injury with paroxysmal atrial fibrillation and hypertension. The Renal Service was consulted and felt her creatinine increase and proteinuria may be secondary to underlying diabetic nephropathy with severe right-sided heart failure. She was initially started on Lasix for her uncompensated congestive heart failure, but her creatinine rose, so she was transferred to the [Hospital Ward Name 517] to initiate nesiritide treatment. PHYSICAL EXAMINATION: Temperature 98.6, heart rate 66-78, blood pressure 125-130/82-91, respirations 20, she is saturating 100 percent on 2 liters nasal cannula. Generally, in mild respiratory distress, alert and oriented x 3. HEENT: Mucous membranes moist. Obese neck. Cardiovascular: Regular rate and rhythm. No murmurs, rubs or gallops. Pulmonary: Bibasilar crackles. Abdomen is soft, nontender, slightly distended, normoactive bowel sounds. Extremities: Show total body 2 plus edema. LABORATORY DATA: White count 14.2, hematocrit 41.7, platelets 417, 93 percent neutrophils, 5 percent lymphocytes, 2 percent monocytes. Sodium 140, potassium 5.1, glucose 140, chloride 105, bicarbonate 20, BUN 20, creatinine 1.1, and magnesium 2. INR is 5.4 and PTT 34.3. ALT is 915, AST 1,311. Troponin T is 0.15, MB index is 3, MB is 12, and CK is 397. Alkaline phosphatase 114 and total bilirubin 3.1. Chest x-ray on [4-7], shows congestive heart failure versus bibasilar atelectasis. Renal ultrasound shows unremarkable left kidney, limited evaluation of the left. No hydronephrosis. Normal echo texture. Echocardiogram shows ejection fraction of 20 percent, severe global left ventricular hypokinesis, severe global right ventricular and free wall hypokinesis, 3 plus TR, mild pulmonary artery systolic hypertension. Abdominal ultrasound shows normal liver echo texture, hepatopetal portal venous flow. HOSPITAL COURSE: Congestive heart failure: The patient with non-ischemic congestive heart failure associated with [Location (un) 2174] ataxia with a recent worsening of her ejection fraction to 20 percent. The patient had mild elevation in her cardiac enzymes, more consistent with atrial fibrillation and hypotension in the [Hospital Unit Name 153]. These enzymes trended down and were not consistent with myocardial infarction. The patient was felt to be at risk for arrhythmia secondary to her severe congestive heart failure and would likely need pacemaker replacement in the future. She was started on a Natrecor drip due to her worsening renal function with Lasix. She was diuresed well with the Natrecor and the Congestive Heart Failure Service followed her while she was in the hospital. After several days of Natrecor diuresis, she was transitioned to Lasix, although her creatinine rose to 2.1 and therefore her Lasix was held for 1 day and her Lasix dose was decreased. Atrial flutter: The patient has evidence of sick sinus syndrome with occasional positives and is very sensitive to beta-blockers. She was started on dofetilide per the Electrophysiology Service in an attempt to convert her to sinus rhythm to improve her congestive heart failure. The patient did convert to sinus rhythm on dofetilide, although her creatinine was unstable and rose to 2.1. Therefore, dofetilide was considered to be a poor antiarrhythmic choice for her. Per the Electrophysiology Service, there were no other antiarrhythmic options and the patient will need to follow up for a flutter ablation and if the flutter ablation is unsuccessful, likely AV node ablation with pacemaker placement. Renal: The patient was in nephrotic range proteinuria, likely due to diabetic nephropathy. The patient's creatinine during her hospitalization rose to 2.1 and her Lasix dose was subsequently decreased. Because of her unstable creatinine dofetilide was felt to be a poor antiarrhythmic for her. Elevated LFTs: There was no clear toxic etiology for increased LFTs. Her hepatitis A virus IgG was positive, although all other hepatitis serologies were negative. Acetaminophen level was negative. This was felt to be either related to transient hypotension in the [Hospital Unit Name 153] versus hepatic congestion from congestive heart failure. During her hospitalization, her LFTs improved. Urinary tract infection: The patient with a positive UA, was treated with levofloxacin. Insulin-dependent diabetes mellitus: The patient was followed by the [Last Name (un) ] Service while an inpatient and started on Lantus which was titrated up, and sliding scale insulin. Depression: The patient was with a history of severe depression with suicide attempts. She was continued on her Paxil and during her hospitalization denied any suicidal or homicidal ideations. [Location (un) 2174] ataxia: The patient was followed by Dr.[Name (NI) 22985] team, the neurogeneticist, and initiated on coenzyme-Q treatment while in hospital. She will continue on this as an outpatient and follow up with her neurologist. DISCHARGE DISPOSITION: Stable. DISCHARGE STATUS: The patient was discharged to home in the care of her husband. DISCHARGE MEDICATIONS: 1. Levothyroxine 25 mcg p.o. q.d. 2. Paroxetine 20 mg p.o. q.d. 3. Pantoprazole 40 mg p.o. q.d. 4. Coenzyme Q-10 600 mg p.o. q.d. 5. Colace 100 mg p.o. b.i.d. 6. Senna 1 tablet p.o. b.i.d. p.r.n. 7. Vitamin E 400 units p.o. q.d. 8. Carvedilol 3.125 mg p.o. b.i.d. 9. Baclofen 10 mg p.o. t.i.d. 10. Coumadin 4 mg p.o. h.s. to be adjusted per INR levels. 11. Magnesium oxide 400 mg p.o. q.d. 12. Digoxin 125 mcg tablet, [11-28] tablet p.o. q.d. 13. Levofloxacin 500 mg p.o. q.d. x 7 days. 14. Humalog sliding scale as directed q.i.d. FOLLOWUP PLANS: The patient is to follow up with Dr. [First Name4 (NamePattern1) ] [Last Name (NamePattern1) ], her neurologist, in the next 1 week. She is to follow up with her primary care provider, [Last Name (NamePattern4) ]. [Last Name (STitle) ], in the next 1-2 weeks. She is to follow up with Dr. [Last Name (STitle) 284] on [2128-5-27] at 3:30 p.m. [Hospital1 882] labs is to draw her INR level on Friday [4-23], and the [Hospital 197] Clinic will call her to change her dose. She is to follow up with Dr.[Name (NI) 22986] nurse educator, [First Name8 (NamePattern2) ] [Last Name (NamePattern1) ], at the [Hospital ] Clinic regarding her new insulin dosing on [4-27] at 5:00 p.m. [First Name11 (Name Pattern1) ] [Last Name (NamePattern4) 2014], MD [MD Number(2) 20382] Dictated By:[Last Name (NamePattern1) 15388] MEDQUIST36 D: [2128-9-12] 13:07:37 T: [2128-9-13] 11:42:33 Job#: [Job Number 22987]	[ "4280", "5849" ]

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